Can a Structured, Video-Based Cadaver Curriculum Demonstrating Proficiency Enhance Resident Operative Autonomy?

Implementation of an Online Intraoperative Assessment of Technical Performance for Surgical Trainees

INTRODUCTION

Assessment of surgical resident technical performance is an integral component of any surgical training program. Timely assessment delivered in a structured format is a critical step to enhance technical skills, but residents often report that the quality and quantity of timely feedback received is lacking. Moreover, the absence of written feedback with specificity can allow residents to seemingly progress in their operative milestones as a junior resident, but struggle as they progress into their postgraduate year 3 and above. We therefore designed and implemented a web-based intraoperative assessment tool and corresponding summary "dashboard" to facilitate real-time assessment and documentation of technical performance.

MATERIALS AND METHODS

A web form was designed leveraging a cloud computing platform and implementing a modified Ottawa Surgical Competency Operating Room Evaluation instrument; this included additional, procedure-specific criteria for select operations. A link to this was provided to residents via email and to all surgical faculty as a Quick Response code. Residents open and complete a portion of the form on a smartphone, then relinquish the device to an attending surgeon who then completes and submits the assessment. The data are then transferred to a secure web-based reporting interface; each resident (together with a faculty advisor) can then access and review all completed assessments.

RESULTS

The Assessment form was activated in June 2021 and formally introduced to all residents in July 2021, with residents required to complete at least one assessment per month. Residents with less predictable access to operative procedures (night float or Intensive Care Unit) were exempted from the requirement on those months. To date a total of 559 assessments have been completed for operations performed by 56 trainees, supervised by 122 surgical faculty and senior trainees. The mean number of procedures assessed per resident was 10.0 and the mean number per assessor was 4.6. Resident initiation of Intraoperative Assessments has increased since the tool was introduced and scores for technical and nontechnical performance reliably differentiate residents by seniority.

CONCLUSIONS

This novel system demonstrates that an online, resident-initiated technical assessment tool is feasible to implement and scale. This model's requirement that the attending enter performance ratings into the trainee's electronic device ensures that feedback is delivered directly to the trainee. Whether this aspect of our assessment ensures more direct and specific (and therefore potentially actionable) feedback is a focus for future study. Our use of commercial cloud computing services should permit cost-effective adoption of similar systems at other training programs.

Role Reversal Between Trainees and Surgeons: Improving Autonomy and Confidence in Surgical Residents

INTRODUCTION

There are increasing concerns regarding resident autonomy in the context of efficiency, legal ramifications, patient expectations and patient safety. However, autonomy is necessary to develop competent, independent surgeons. Therefore, educational paradigms that maximize opportunities for entrustability without sacrificing patient safety are necessary to ensure adequate training for surgeons.

METHODS

This is a prospective, qualitative study of intraoperative role reversal between surgeons and residents. Using Likert scales and binary questions, preintervention and postintervention surveys were collected, evaluating variables including intraoperative learning, decision making, communication, confidence, autonomy and opportunity for safe struggle. The Mann-Whitney U test was used to analyze results and compare responses between training years.

RESULTS

Thirty-six general surgery residents comprising post-graduate year 1, 2, 4, and 5 acted as primary surgeon in a total of 36 cases. Preoperative knowledge scores were significantly higher in more senior residents (P < 0.001), but all residents had significant improvement in knowledge scores postoperatively (P < 0.001). The knowledge improvement was quantitatively larger for junior versus senior residents. Intraoperative decision making significantly improved after the intervention for all training levels (P < 0.001). 25 intraoperative "rescues" were performed by faculty for failure to progress or unsafe conditions (23 for junior residents, 2 for senior residents). Residents indicated that this intraoperative role reversal improved preparation, confidence, autonomy, and intraoperative communication.

CONCLUSIONS

Intraoperative role reversal between residents and surgeons provides a safe opportunity for maximizing learning and increasing entrustability under direct supervision.

How We Do It: Remediation Pathways in a Surgical Simulation Curriculum for Competency Improvement

OBJECTIVE

Validated assessment of procedural knowledge and skills with formative remediation is a foundational part of achieving surgical competency. High-fidelity simulation programs provide a unique area to assess resident proficiency and independence, as well as to assist in identifying residents in need of further practice. While several studies have validated the use of simulation to attain proficiency of specific technical skills, few have validated remediation pathways for their trainees objectively. In this descriptive analysis, we review 2 remediation pathways within our simulation training curricula and how these are used in assessments of resident proficiency.

MATERIALS AND METHODS

Two methods of remediation were formulated for use in high-fidelity simulation labs. One remediation pathway was a summative process, where ultimate judgment of resident competency was assessed through intra-operative assessments of a holistic skill set. The second remediation pathway was a formative "coaching" process, where feedback is given at several intervals along the pathway towards a specific technical skills competence. All general surgery residents are enrolled in the longitudinal, simulation curricula.

RESULTS

Approximately one-third of surgical residents entered into a remediation pathway for either of the high-fidelity simulation curricula. Both residents and faculty expressed support for the summative and formative remediation pathways as constructed. Residents who entered remediation pathways believed it was a beneficial exercise, and the most common feedback was that remediation principles should be expanded to all residents. Interestingly, faculty demonstrated stronger support for the formative coaching feedback model than the summative assessment model.

CONCLUSIONS

Through the complementary use of both formative and summative remediation pathways, resident competence can be enriched in a constructive, nonpunitive method for self-directed performance improvement. Both trainees and faculty express high satisfaction with programs explicitly organized to ensure that skills are rated through a standardized process.

Training the New Generations of Orthopaedic Surgery Residents: Understanding Generational Differences to Maximize Educational Benefit

Most of the current orthopaedic residents are considered Millennials (born between 1981 and 1996) and are often trained by attending surgeons who are from Generation X (born between 1965 and 1980) or the Baby Boomer generation (born between 1946 and 1964). The Generation X orthopaedic surgeons were largely trained by Baby Boomers who were very demanding of their trainees and expected excellence. The Baby Boomers had been inspired, mentored, and trained by the Greatest Generation (born between 1901 and 1927). Baby Boomers took nothing for granted and nothing was given to them on a silver platter. Generation X was trained under these premises and was expected to abide by similar values. Regarding the next generation of residents, current faculty hope to instill the same qualities that had been instilled in them during their training. This value transference sometimes presents a challenge because of the differences in attitudes and perspectives that may exist between Millennial residents and their predecessors regarding work-life balance, teaching styles, the regulation of duty hours, and feedback assessments. These differences require an evolution in the methods of surgical education to optimize the educational benefit and ensure good will and rapport between the generations. Trainees and faculty alike have a responsibility to understand each other's differences and come together to ensure that knowledge, experience, values, and skill sets are effectively passed on to a new generation of orthopaedic surgeons.

A longitudinal cadaver-based simulation curriculum creates sustainable increases in resident confidence and exposure to fundamental techniques: Results of a 5-year program evaluation

INTRODUCTION

For the past five years, our surgical residency program has led a cadaver-based simulation course focused on fundamental surgical maneuvers. This study aimed to quantify the impact of this course on resident exposure to surgical skills and longitudinal impact on resident education.

METHODS

General surgery residents participated in an annual cadaver-based simulation curriculum. Participants completed surveys regarding improvements in knowledge and confidence; these results were stratified between course iterations (P1: 2 years, 2014-15; P2: 3 years, 2016-2018).

RESULTS

Residents reported a sustained increase in knowledge of anatomy and technical dissection, confidence in performing operative skills independently, and exposure to operative skills that were otherwise not encountered in clinical rotations. Junior residents demonstrated an increase in gaining skills they would otherwise not achieve (87% vs. 98%, p = 0.028) and confidence to safely perform these procedures in the clinical setting (94% vs. 100%, p = 0.077).

CONCLUSION

This annual, longitudinal cadaver-based skills course focused on fundamental maneuvers demonstrates a sustained impact in resident and faculty surgical confidence in resident's operative skills as a component of a longitudinal simulation curriculum to enhance competency-based promotion.