Difficulties Faced by General Surgery Residents. A Qualitative Systematic Review

Learning curve analyses in spine surgery: a systematic simulation-based critique of methodologies

BACKGROUND CONTEXT

Various statistical approaches exist to delineate learning curves in spine surgery. Techniques range from dividing cases into intervals for metric comparison, to employing regression and cumulative summation (CUSUM) analyses. However, their inherent inconsistencies and methodological flaws limit their comparability and reliability.

PURPOSE

To critically evaluate the methodologies used in existing literature for studying learning curves in spine surgery and to provide recommendations for future research.

STUDY DESIGN

Systematic literature review.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, and Scopus databases, covering articles from January 2010 to September 2023. For inclusion, articles had to evaluate the change in a metric of performance during human spine surgery across time/a case series. Results had to be reported in sufficient detail to allow for evaluation of individual performance rather than group/institutional performance. Articles were excluded if they included cadaveric/nonhuman subjects, aggregated performance data or no way to infer change across a number of cases. Risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. Surgical data were simulated using Python 3 and then examined via multiple commonly used analytic approaches including division into consecutive intervals, regression and CUSUM techniques. Results were qualitatively assessed to determine the effectiveness and limitations of each approach in depicting a learning curve.

RESULTS

About 113 studies met inclusion criteria. The majority of the studies were retrospective and evaluated a single-surgeon's experience. Methods varied considerably, with 66 studies using a single proficiency metric and 47 using more than 1. Operating time was the most commonly used metric. Interval division was the simplest and most commonly used method yet inherent limitations prevent collective synthesis. Regression may accurately describe the learning curve but in practice is hampered by sample size and model choice. CUSUM analyses are of widely varying quality with some being fundamentally flawed and widely misinterpreted however, others provide a reliable view of the learning process.

CONCLUSION

There is considerable variation in the quality of existing studies on learning curves in spine surgery. CUSUM analyses, when correctly applied, offer the most reliable estimates. To improve the validity and comparability of future studies, adherence to methodological guidelines is crucial. Multiple or composite performance metrics are necessary for a holistic understanding of the learning process.

Defining Practice Readiness in Pediatric Surgery Fellowship: A Qualitative Analysis

INTRODUCTION

While competency-based training is at the forefront of educational innovation in General Surgery, Pediatric Surgery training programs should not wait for downstream changes. There is currently no consensus on what it means for a pediatric surgery fellow to be "practice-ready". In this study, we aimed to provide a framework for better defining competency and practice readiness in a way that can support the Milestones system and allow for improved assessment of pediatric surgery fellows.

METHODS

For this exploratory qualitative study, we developed an interview guide with nine questions focused on how faculty recognize competency and advance autonomy among pediatric surgery fellows. Demographic information was collected using an anonymous online survey platform. We iteratively reviewed data from each interview to ensure adequate information power was achieved to answer the research question. We used inductive reasoning and thematic analysis to determine appropriate codes. Additionally, the Dreyfus model was used as a framework to guide interpretation and contextualize the responses. Through this method, we generated common themes.

RESULTS

A total of 19 pediatric surgeons were interviewed. We identified four major themes from 127 codes that practicing pediatric surgeons associate with practice-readiness of a fellow: skill-based competency, the recognition and benefits of struggle, developing expertise and facilitating autonomy, and difficulties in variability of evaluation. While variability in evaluation is not typically included in the concept of practice readiness, assessment and evaluation were described by study participants as essential aspects of how practicing pediatric surgeons perceive practice readiness and competency in pediatric surgery fellows. Competency was further divided into interpersonal versus technical skills. Sub-themes within struggle included personal and professional struggle, benefits of struggle and how to identify and assist those who are struggling. Autonomy was commonly stated as variable based on the attending.

CONCLUSION

Our analysis yielded several themes associated with practice readiness of pediatric surgery fellows. We aim to further refine our list of themes using the Dreyfus Model as our interpretive framework and establish consensus amongst the community of pediatric surgeons in order to define competency and key elements that make a fellow practice-ready. Further work will then focus on establishing assessment metrics and educational interventions directed at achieving such key elements.

Difficulties Faced by Residents and Clues for Solutions: A Qualitative Study

A complex healthcare system often leads to the high variety experiences among medical postgraduate students. This study aims to reveal the difficulties they face during postgraduate education, their consequences, and coping strategies. This is a phenomenological study conducted by using the maximum diversity strategy from purposive sampling methods. Semi-structured interviews were conducted with 10 medical residents from different disciplines, 7 step of thematic analysis was applied. The findings were presented under the headings of challenges, outcomes, and ways of coping in line with the research questions. The sub-themes within the "postgraduate medical education" theme were "learning-teaching processes, educators, educational program, interactions, assessment, and evaluation." The sub-themes in the "culture/climate" theme were "academic environment, disruptive behaviors, rules and procedures, and hierarchy." The difficulties experienced by residents in the "health system" theme were examined under the sub-themes of "health care team, health service delivery, payment for service, patients, and their relatives." The sub-themes in the "specialization" theme were "scope and practices of the specialty area" and "perception of the specialty area." The difficulties in the "time/period" theme were analyzed under (1) senior and (2) junior sub-themes. The consequences of difficulties were examined under the themes of "deterioration in well-being and perception of incompetence." Coping with the difficulties was categorized into individual efforts, not expend effort, and getting support themes. Individual efforts were examined under the sub-themes of "sharing difficulties, communication-interaction, being a problem solver, maintaining well-being, and socializing." Sub-themes of getting support were classified as institutional and psychological. It is necessary to understand the phenomenon of "residents" difficulties'. All parts involved in PGME, should be aware that residents are in early adulthood. They have to recognize internal structural constraints, distinguish between internal and external factors. Solutions should go beyond individual development, systematic design and support mechanisms should be established at both institutional and national levels.

Beyond Accreditation Council for Graduate Medical Education Required Scholarship: The Academic Journey of Plastic Surgery Residents

INTRODUCTION

Research productivity is an important part of required Accreditation Council for Graduate Medical Education scholarship during residency training and critical to trainees who intend to pursue careers in academia. This study aims to determine plastic surgery residents' experiences with and attitudes toward research.

METHODS

Accredited independent (52) and integrated (86) plastic surgery program websites were manually searched for currently active residents' names and email addresses. Identified residents were emailed a survey consisting of 25 questions through Research Electronic Data Capture.

RESULTS

A total of 45 plastic surgery residents responded to the survey request (14.6% response rate). Respondents were 57% female and 43% male, with an average age of 30.7 y. At the time of survey participation, 95% of surgery residents were involved in research endeavors, voluntarily or as part of their residency training. Of the respondents, 13 (32%) previously participated in a research fellowship compared to 28 (68%) respondents who did not. Interestingly, respondents who completed fellowships were 2.84 times (95% confidence interval: 0.52-15.38, P = 0.2269) more likely to intend continuing research endeavors after residency. Participants were most in agreement with statements suggesting their research fellowship benefitted their application in the plastic surgery match process (4 [interquartile range (IQR): 4, 4]), improved their ability to conduct research (4 [IQR: 4, 4]), and helped to better understand medical literature (4 [IQR: 3, 4]).

CONCLUSIONS

Plastic surgery programs' robust research emphasis has a favorable translation into residents' self-perceived understanding of medical literature and clinical knowledge.

Becoming a neurosurgeon in France: A qualitative study from the trainees' perspective

Introduction

The training of neurosurgeons is evolving in a world of socio-professional changes, including the technological revolution, administrative pressure on stakeholders, reduced working hours, geographical heterogeneity, generational changes, to name but a few.

Research question

This qualitative study aimed to explore experiences and feedback of French neurosurgical trainees concerning their training.

Material and methods

The grounded theory approach was used with 23 neurosurgical trainees' interviews. Inclusion was continued until data saturation. Six researchers (an anthropologist, a psychiatrist, and four neurosurgeons) thematically and independently analyzed data collected through anonymized interviews.

Results

Data analysis identified three superordinate themes: (1) The Trainee-Senior Dyad, where the respondents describe a similar bipolarity between trainees and faculty (trainees oscillating between those who fit into the system and those who are more reluctant to accept hierarchy, faculty using an ideal pedagogy while others refuse to help or invest in training); (2) The difficulty to learn (describing pressure exercised on trainees that can alter their motivation and degrade their training, including the impact of administrative tasks); (3) A pedagogy of empowerment (trainee' feelings about the pertinent pedagogy in the OR, ideal sequence to progress, progressive empowerment especially during the shifts, and stress of envisioning themselves as a senior neurosurgeon).

Discussion and conclusion

Respondents emphasize the heterogeneity of their training both intra- and inter-university-hospital. Their critical analysis, as well as the formalization of their stress to become autonomous seniors, can be an important link with the reforms and optimizations currently being carried out to improve and standardize the training of young French neurosurgeons.

Undergraduate Skills Training in Pandemic Times: Where Is the Future of Medical Education?

BACKGROUND

The COVID-19 pandemic forced medical programs to rapidly switch to remote teaching from scratch, impacting hands-on skills training. This study compared the efficacy of a hybrid online format to a regular in-person session for a mandatory surgical skills class.

METHODS

Third-year undergraduate medical students attending the surgical skills class in the winter semester of 2020/21 at the Medical University of Graz were randomly assigned to either the hybrid or in-person class, depending on their course schedule and government regulations. The hybrid class involved online videos, one-on-one peer tutoring, and an Objective Structured Clinical Examination (OSCE). Pre- and post-class self-assessments were conducted to evaluate their theoretical and practical knowledge of a single interrupted suture.

RESULTS

The study included 85 students in the regular in-person class and 50 in the hybrid class. A pre-class assessment revealed higher self-assessments in the hybrid class for theoretical and practical knowledge, but a post-class assessment showed no significant difference. The advantages and disadvantages of both modalities were identified, providing valuable insights for future curriculum development.

CONCLUSIONS

Both teaching modes were effective for undergraduate surgical skills training. This study recommends implementing positive aspects of both the hybrid and in-person formats while recognizing their respective limitations.

Diversity bias in colorectal surgery: a global perspective

There is a specific lack of data on equity and injustices among colorectal surgeons regarding diversity. This study aimed to explore colorectal surgeon’s lived experience of diversity bias with a specific focus on gender, sexual orientation or gender identity and race or religion. A bespoke questionnaire was designed and disseminated to colorectal surgeons and trainees through specialty association mailing lists and social media channels. Quantitative and qualitative data points were analysed. 306 colorectal surgeons responded globally. 58.8% (n = 180) identified as male and 40.5% (n = 124) as female. 19% were residents/registrars. 39.2% stated that they had personally experienced or witnessed gender inequality in their current workplace, 4.9% because of sexual orientation, and 7.5% due to their race or religion. Sexist jokes, pregnancy-related comments, homophobic comments, liberal use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. 44.4% (n = 135) did not believe their institution of employer guaranteed an environment of respect for diversity and only 20% were aware of society guidelines on equality and diversity. Diversity bias is prevalent in colorectal surgery. It is necessary to work towards real equality and inclusivity and embrace diversity, both to promote equity among colleagues and provide better surgical care to patients.

Population Preference of Surgeon's Gender for Surgical Care and Their Attitudes Toward Female Surgeons in Taif, Saudi Arabia

Introduction

One contributing factor that has led to a reduction in the number of females entering the profession of surgery is discrimination against female surgeons. Little is known about the practices, attitudes, and perceptions of the Saudi population toward gender discrimination in the field of surgery. The aim of this study was to assess the practices, attitudes, and perceptions of the Taif population in choosing a surgeon based on their gender.

Materials and methods

An online pretested questionnaire was randomly sent to the participants living in Taif city. Collected data were subjected to scrutiny to check participants' study inclusion criteria. All the data were subjected to statistical analysis by an independent biostatistician. Pearson's chi-square test was used to search for a statistically significant association between categorical variables.

Results

About 49.5% of the participants preferred a surgeon of the same gender when consulting for a non-emergency visit to a surgery clinic, whereas females significantly preferred a female surgeon (p < 0.001). The most common reason to choose surgeons of the same gender was comfort, followed by ease of talking. About 71.8% of the participants preferred female surgeons for ''sensitive'' surgical cases such as genital, obstetric, or sexual disorders, whereas 12.1% preferred male surgeons.

Conclusion

Females have shown progress in the field of surgery, but there is still much to be done to convert the surgical workplace to be more supportive of women so that they contribute their best effort.

Prevalence of burnout syndrome among unmatched trainees and residents in surgical and nonsurgical specialties: a cross-sectional study from different training centers in Palestine

BACKGROUND

Burnout is a psychological syndrome that involves physical, mental, and emotional exhaustion. This study was conducted to determine the prevalence of burnout among unmatched trainees and residents in surgical and nonsurgical specialties in Palestine. Additionally, this study also sought to identify the associated variables and predictors of higher burnout scores.

METHODS

This study was conducted in a cross-sectional design using a questionnaire in the period between October 2020 and March 2021. The questionnaire collected sociodemographic characteristics of the residents and trainees in 18 different training centers/hospitals. The Copenhagen Burnout Inventory was used to determine burnout among the residents and trainees. Pearson's correlations, analysis of variance, Student's t-test, and multiple linear regressions were used to analyze the data.

RESULTS

The study tool was completed by 250 residents and trainees in surgical and nonsurgical specialties (response rate = 83.3%). Of all participants, 203 (81.2%) reported a moderate-severe degree of burnout in the personal domain, 188 (75.2%) reported a moderate-severe degree of burnout in the work-related domain, and 97 (38.8%) reported moderate-severe degree of burnout in the client-related domain. There was a moderate and positive correlation between personal and work-related burnout scores (Pearson's r = 0.69, p-value < 0.001), and client-related burnout scores (Pearson's r = 0.52, p-value < 0.001). Similarly, there was a moderate and positive correlation between work-related and client-related burnout scores (Pearson's r = 0.57, p-value < 0.001). The multiple linear regression model showed that higher burnout scores were predicted by being married, not having another paid employment, inability to financially support oneself, frequent consumption of tea/coffee, dissatisfied with the training/job, thinking to change the profession, and long working hours.

CONCLUSION

The findings of this study indicated that burnout was highly prevalent among residents and trainees in surgical and nonsurgical specialties in Palestine. Decision-makers in healthcare authorities, hospital managers, professional groups, directors of residency programs, and educators/trainers should consider addressing burnout and improving the well-being of residents and trainees in surgical and nonsurgical specialties in Palestine. Future studies are still needed to determine which interventions could be effective in reducing burnout among residents and trainees in surgical and nonsurgical specialties in Palestine.

The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review

OBJECTIVE

To understand racial bias in clinical settings from the perspectives of minority patients and healthcare providers to inspire changes in the way healthcare providers interact with their patients.

METHODS

Articles on racial bias were searched on Medline, CINAHL, PsycINFO, Web of Science. Full text review and quality appraisal was conducted, before data was synthesized and analytically themed using the Thomas and Harden methodology.

RESULTS

23 articles were included, involving 1,006 participants. From minority patients' perspectives, two themes were generated: 1) alienation of minorities due to racial supremacism and lack of empathy, resulting in inadequate medical treatment; 2) labelling of minority patients who were stereotyped as belonging to a lower socio-economic class and having negative behaviors. From providers' perspectives, one theme recurred: the perpetuation of racial fault lines by providers. However, some patients and providers denied racism in the healthcare setting.

CONCLUSION

Implicit racial bias is pervasive and manifests in patient-provider interactions, exacerbating health disparities in minorities. Beyond targeted anti-racism measures in healthcare settings, wider national measures to reduce housing, education and income inequality may mitigate racism in healthcare and improve minority patient care.

Preoperative concerns of patients undergoing general surgery

OBJECTIVES

This qualitative review aims to provide a clearer understanding of concerns general surgery (GS) patients face in the preoperative period.

METHODS

Medline, CINAHL, PsycINFO and Web of Science were searched for articles describing the preoperative concerns of GS patients. Qualitative and mixed method studies were included. Key quotes were extracted, coded, and thematically analyzed according to Thomas and Harden's methodology.

RESULTS

27 articles were included. Three main themes were generated: (1) lead-up to surgery, (2) postoperative recovery process and (3) standard of care. While waiting for surgery, patients were often shrouded with uncertainty and concerned themselves with the potential impacts of their disease and surgery on their wellbeing and recovery. Furthermore, patients' trust and confidence in Healthcare Professionals (HCPs) was compromised when standard of care was perceived to be deficient, resulting in doubts about HCPs' credibility and capabilities.

CONCLUSION

Patients' preoperative concerns often stem from the uncertainty and unfamiliarity surrounding surgery. To address this, a combination of effective preoperative education, individualised communication and involvement of social support should be considered.

PRACTICE IMPLICATIONS

Preoperative concerns can negatively impact patients and effective interventions will result in a better perioperative experience with fewer negative consequences arising from patients' fear and anxiety.

Teaching Medical Research to Medical Students: a Systematic Review

PHENOMENON

Research literacy remains important for equipping clinicians with the analytical skills to tackle an ever-evolving medical landscape and maintain an evidence-based approach when treating patients. While the role of research in medical education has been justified and established, the nuances involving modes of instruction and relevant outcomes for students have yet to be analyzed. Institutions acknowledge an increasing need to dedicate time and resources towards educating medical undergraduates on research but have individually implemented different pedagogies over differing lengths of time.

APPROACH

While individual studies have evaluated the efficacy of these curricula, the evaluations of educational methods and curriculum design have not been reviewed systematically. This study thereby aims to perform a systematic review of studies incorporating research into the undergraduate medical curriculum, to provide insights on various pedagogies utilized to educate medical students on research.

FINDINGS

Studies predominantly described two major components of research curricula-(1) imparting basic research skills and the (2) longitudinal application of research skills. Studies were assessed according to the 4-level Kirkpatrick model for evaluation. Programs that spanned minimally an academic year had the greatest proportion of level 3 outcomes (50%). One study observed a level 4 outcome by assessing the post-intervention effects on participants. Studies primarily highlighted a shortage of time (53%), resulting in inadequate coverage of content.

INSIGHTS

This study highlighted the value in long-term programs that support students in acquiring research skills, by providing appropriate mentors, resources, and guidance to facilitate their learning. The Dreyfus model of skill acquisition underscored the importance of tailoring educational interventions to allow students with varying experience to develop their skills. There is still room for further investigation of multiple factors such as duration of intervention, student voluntariness, and participants' prior research experience. Nevertheless, it stands that mentoring is a crucial aspect of curricula that has allowed studies to achieve level 3 Kirkpatrick outcomes and engender enduring changes in students.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-020-01183-w.

The unspoken reality of gender bias in surgery: A qualitative systematic review

OBJECTIVE

This study was conducted to better understand the pervasive gender barriers obstructing the progression of women in surgery by synthesising the perspectives of both female surgical trainees and surgeons.

METHODS

Five electronic databases, including Medline, Embase, PsycINFO, CINAHL and Web of Science Core Collection, were searched for relevant articles. Following a full-text review by three authors, qualitative data was synthesized thematically according to the Thomas and Harden methodology and quality assessment was conducted by two authors reaching a consensus.

RESULTS

Fourteen articles were included, with unfavorable work environments, male-dominated culture and societal pressures being major themes. Females in surgery lacked support, faced harassment, and had unequal opportunities, which were often exacerbated by sex-blindness by their male counterparts. Mothers were especially affected, struggling to achieve a work-life balance while facing strong criticism. However, with increasing recognition of the unique professional traits of female surgeons, there is progress towards gender quality which requires continued and sustained efforts.

CONCLUSION

This systematic review sheds light on the numerous gender barriers that continue to stand in the way of female surgeons despite progress towards gender equality over the years. As the global agenda towards equality progresses, this review serves as a call-to-action to increase collective effort towards gender inclusivity which will significantly improve future health outcomes.

A Systematic Scoping Review on Pedagogical Strategies of Interprofessional Communication for Physicians in Emergency Medicine

BACKGROUND

Interprofessional communication (IPC) is integral to interprofessional teams working in the emergency medicine (EM) setting. Yet, the coronavirus disease 2019 pandemic has laid bare gaps in IPC knowledge, skills and attitudes. These experiences underscore the need to review how IPC is taught in EM.

PURPOSE

A systematic scoping review is proposed to scrutinize accounts of IPC programs in EM.

METHODS

Krishna's Systematic Evidence-Based Approach (SEBA) is adopted to guide this systematic scoping review. Independent searches of ninedatabases (PubMed, Embase, CINAHL, Scopus, PsycINFO, ERIC, JSTOR, Google Scholar and OpenGrey) and "negotiated consensual validation" were used to identify articles published between January 1, 2000 and December 31, 2020. Three research teams reviewed the data using concurrent content and thematic analysis and independently summarized the included articles. The findings were scrutinized using SEBA's jigsaw perspective and funneling approach to provide a more holistic picture of the data.

RESULTS

IN TOTAL

18,809 titles and abstracts were identified after removal of duplicates, 76 full-text articles reviewed, and 19 full-text articles were analyzed. In total, four themes and categories were identified, namely: (a) indications and outcomes, (2) curriculum and assessment methods, (3) barriers, and (4) enablers.

CONCLUSION

IPC training in EM should be longitudinal, competency- and stage-based, underlining the need for effective oversight by the host organization. It also suggests a role for portfolios and the importance of continuing support for physicians in EM as they hone their IPC skills.

HIGHLIGHTS

• IPC training in EM is competency-based and organized around stages.• IPC competencies build on prevailing knowledge and skills.• Longitudinal support and holistic oversight necessitates a central role for the host organization.• Longitudinal, robust, and adaptable assessment tools in the EM setting are necessary and may be supplemented by portfolio use.