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Esposito AC, Brandt WS, Coppersmith NA, White EM, Chung M, Rujeedawa T, Yoo PS. Learning Environment is the Prevailing Factor in Surgical Residents' Favorite Rotations. JOURNAL OF SURGICAL EDUCATION 2022; 79:1454-1464. [PMID: 35907699 DOI: 10.1016/j.jsurg.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Understand the characteristics of residents' favorite rotations to improve the ability of educators to maximize positive learning experiences. DESIGN Novel cross-sectional survey developed through thematic analysis of focus groups with residents using 4-point Likert scales ranked from "Not at all important" to "Extremely important." SETTING Single university-affiliated urban hospital PARTICIPANTS: Clinical surgical residents BACKGROUND: Resident assessments of learning experiences vary between rotations leading to the development of "favorite" rotations. MATERIALS AND METHODS A novel survey instrument containing 31 characteristics divided into 4 thematic categories was developed following analysis of surgical resident focus groups. Clinical surgical residents were asked how important each characteristic was for determining their favorite rotation on a 4-point Likert Scale from "not at all important" to "extremely important." Two-sided independent sample T-tests were used. RESULTS The response rate was 59% (33/56) with proportional representation of postgraduate levels. Overall, 67% (22/33) of residents reported their favorite rotation was in their preferred specialty, 70% (23/33) reported their favorite rotation required >70 hours per week in the hospital, and 97% (32/33) of residents reported their favorite rotation required <2 days of clinic. Overall, the average ranking of the categories from most to least important was content (mean = 2.84, SD = 0.48), learning environment (mean = 2.67, SD = 0.57), working environment (mean = 2.38, SD = 0.56), and accomplishment (mean = 2.31, SD = 0.57). The only category with a statistically significant difference between junior and senior resident was content with seniors ranking it most important (mean = 3.35, SD = 0.93) compared to junior residents who ranked it least important (mean = 2.21, SD = 1.25), p = 0.01. Personal characteristics such as "Attendings cared about my learning" (mean = 3.56, SD = 0.50) and "I felt good at my job" (mean = 3.45, SD = 0.67), tended to be more important than structural characteristics such as "call schedule" (mean = 2.71, SD = 0.86), "formal didactics" (mean = 2.67, SD = 1.04), and "work-life balance" (mean = 2.70, SD = 0.99). CONCLUSIONS This study demonstrates a novel understanding of the factors that contribute to resident preferences for certain rotations. Junior and senior residents attribute importance differently, which may provide the basis for level-appropriate improvements. Personal factors tended to be more contributory than structural factors, highlighting additional dimensions to examine when considering how to optimize certain rotations.
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Affiliation(s)
- Andrew C Esposito
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Whitney S Brandt
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Erin M White
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Peter S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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2
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Williams J, Thelen AE, Luckoski J, Chen X, George BC. How Do Resident Surgeons Identify Operative Case Complexity? An Analysis of Resident versus Attending Perceptions. JOURNAL OF SURGICAL EDUCATION 2022; 79:469-474. [PMID: 34602380 DOI: 10.1016/j.jsurg.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/28/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Accurate recognition of patient-related complexity of an operation is critical for appropriate surgical decision making. It is not yet understood whether general surgery residents are able to accurately assess the relative complexity of a given operative case. This study investigates the agreement of case complexity ratings between residents and attending surgeons and explores whether resident-related factors correlate with any discordance in perception of patient-related operative complexity. DESIGN Residents and attending surgeons rated the relative complexity of completed cases on a 3 point scale via the SIMPL (Society for Improving Medical Professional Learning) operative assessment smartphone app. Additional trainee demographic data, autonomy ratings, and performance ratings were also obtained from the SIMPL registry for each rated case. Complexity agreement was defined as an equal rating between the resident and attending and assigned a value of zero. Over-estimate ratings were assigned a positive value and under-estimate ratings were assigned a negative value. Trends in complexity agreement were analyzed using descriptive statistics and mixed-effects models. RESULTS A total of 43,179 general surgery cases were rated by 1946 categorical general surgery residents and 1520 attending surgeons between 2015 and 2020. Residents and attendings agreed on case complexity in 63.23% of cases, while the residents overestimated complexity in 13.37% of cases and underestimated complexity in 23.40% of cases. Every level of resident except post-graduate year 2 had similar rates of agreement about the complexity of a procedure, while residents who received a higher autonomy rating were more likely to be in agreement with the faculty raters (OR 1.12, 95% CI 1.06-1.19). CONCLUSIONS The results of this study suggest that general surgery residents inaccurately perceive the patient-related complexity of a given case approximately one third of the time. Greater experience and operative autonomy appear to be associated with higher complexity agreement. Future research into factors influencing perceived case complexity may provide insight into how to best implement new teaching for surgical residents regarding the concept of case complexity.
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Affiliation(s)
- Jonathan Williams
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan.
| | - Angela E Thelen
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| | - John Luckoski
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| | - Xilin Chen
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research, Michigan Medicine, Ann Arbor, Michigan
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Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room. Ann Surg 2022; 275:e264-e270. [PMID: 32224741 DOI: 10.1097/sla.0000000000003887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy. BACKGROUND Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome. METHODS In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents. RESULTS In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9). CONCLUSIONS This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.
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Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition, University of Groningen, Groningen, The Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Research and Innovation in Medical Education, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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4
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Senders ZJ, Brady JT, Ladhani HA, Marks J, Ammori JB. Factors Influencing the Entrustment of Resident Operative Autonomy: Comparing Perceptions of General Surgery Residents and Attending Surgeons. J Grad Med Educ 2021; 13:675-681. [PMID: 34721797 PMCID: PMC8527956 DOI: 10.4300/jgme-d-20-01259.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/02/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND General surgery residents may be underprepared for practice, due in part to declining operative autonomy during training. The factors that influence entrustment of autonomy in the operating room are unclear. OBJECTIVE To identify and compare the factors that residents and faculty consider influential in entrustment of operative autonomy. METHODS An anonymous survey of 29-item Likert-type scale (1-7, 1 = strongly disagree, 7 = strongly agree), 9 multiple-choice, and 4 open-ended questions was sent to 70 faculty and 45 residents in a large ACGME-approved general surgery residency program comprised of university, county, and VA hospitals in 2018. RESULTS Sixty (86%) faculty and 38 (84%) residents responded. Faculty were more likely to identify resident-specific factors such as better resident reputation and higher skill level as important in fostering entrustment. Residents were more likely to identify environmental factors such as a focus on efficiency and a litigious malpractice environment as impeding entrustment. Both groups agreed that work hour restrictions do not decrease autonomy and entrustment does not increase risk to patients. More residents considered low faculty confidence level as a barrier to operative autonomy, while more faculty considered lower resident clinical skill as a barrier. Improvement in resident preparation for cases was cited as an important intervention that could enhance entrustment. CONCLUSIONS Differences in perspectives exist between general surgery residents and faculty regarding entrustment of autonomy. Residents cite environmental and attending-related factors, while faculty cite resident-specific factors as most influential. Residents and faculty both agree that entrustment is integral to surgical training.
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Affiliation(s)
- Zachary J. Senders
- Zachary J. Senders, MD, is a General Surgery Resident, Department of Surgery, University Hospitals (UH) Cleveland Medical Center
| | - Justin T. Brady
- Justin T. Brady, MD, is a General Surgery Resident, Department of Surgery, UH Cleveland Medical Center
| | - Husayn A. Ladhani
- Husayn A. Ladhani, MD, is a General Surgery Resident, Department of Surgery, UH Cleveland Medical Center
| | - Jeffrey Marks
- Jeffrey Marks, MD, FACS, is Professor of Surgery and Associate Program Director, General Surgery Residency, UH Cleveland Medical Center, Case Western Reserve University School of Medicine
| | - John B. Ammori
- John B. Ammori, MD, FACS, is Associate Professor of Surgery and Program Director, General Surgery Residency, UH Cleveland Medical Center, Case Western Reserve University School of Medicine
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Granek L, Shapira S, Roth J, Constantini S. Can Good Intraoperative Judgement Be Taught?: Pediatric Neurosurgeons' Pedagogical Approaches to Training Residents on Intraoperative Decision-Making. JOURNAL OF SURGICAL EDUCATION 2021; 78:1492-1499. [PMID: 33814338 DOI: 10.1016/j.jsurg.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore how pediatric neurosurgeons train residents in developing intraoperative decision-making judgement. DESIGN This study used the Grounded Theory Method in its study design. In-depth interviews were conducted with pediatric neurosurgeons about their approaches to training residents in intraoperative decision making. Data was analyzed line-by-line with codes and categories emerging from participants narratives. SETTING & PARTICIPANTS Twenty-six pediatric neurosurgeons from 12 countries were interviewed using video-conferencing technology. RESULTS Pediatric Neurosurgeons used a variety of training approaches that included pre-surgery discussions, didactic communication during surgery, post-surgery debriefing, allowing residents to model and observe their own intraoperative behaviors, using case studies to teach, and ongoing mentorship. In addition, they encouraged residents to ask for help when needed and emphasized the importance of empathy as a surgeon. Challenges to training residents included the notion that decision-making could only be learned through personal experience, the trainee's personality, and an over-reliance on algorithms and standardized medicine. CONCLUSIONS Training neurosurgical residents about intraoperative decision-making appears to be ad-hoc and dependent on both the institution and the availability and willingness of senior surgeons to make this a part of their pedagogy. Surgical departments could use these findings to reflect on their own teaching practices and explore whether they wish to teach these skills more explicitly, and in what ways these skills can be best taught to residents.
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Affiliation(s)
- Leeat Granek
- School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada.
| | - Shahar Shapira
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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6
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Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. Fingerprints of Teaching Interactions: Capturing and Quantifying How Supervisor Regulate Autonomy of Residents in the Operating Room. JOURNAL OF SURGICAL EDUCATION 2021; 78:1197-1208. [PMID: 33358759 DOI: 10.1016/j.jsurg.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/13/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Supervisors and residents agree that entrusted autonomy is central to learning in the Operating Room (OR), but supervisors and residents hold different opinions about entrustment: residents regularly experience that they receive insufficient autonomy while supervisors feel their guiding is not appreciated as teaching. These opinions are commonly grounded on general experiences and perceptions, instead of real-time supervisors' regulatory behaviors as procedures unfold. To close that gap, we captured and analyzed when and to what level supervisors award or restrain autonomy during procedures. Furthermore, we constructed fingerprints, an instrument to visualize entrustment of autonomy by supervisors in the OR that allows us to reflect on regulation of autonomy and discuss teaching interactions. DESIGN All interactions between supervisors and residents were captured by video and transcribed. Subsequently a multistage analysis was performed: (1) the procedure was broken down into 10 steps, (2) for each step, type and frequency of strategies by supervisors to regulate autonomy were scored, (3) the scores for each step were plotted into fingerprints, and (4) fingerprints were analyzed and compared. SETTING University Medical Centre Groningen (the Netherlands). PARTICIPANTS Six different supervisor-resident dyads. RESULTS No fingerprint was alike: timing, frequency, and type of strategy that supervisors used to regulate autonomy varied within and between procedures. Comparing fingerprints revealed that supervisors B and D displayed more overall control over their program-year 5 residents than supervisors C and E over their program-year 4 residents. Furthermore, each supervisor restrained autonomy during steps 4 to 6 but with different intensities. CONCLUSIONS Fingerprints show a high definition view on the unique dynamics of real-time autonomy regulation in the OR. One fingerprint functions as a snapshot and serves a purpose in one-off teaching and learning. Multiple snapshots of one resident quantify autonomy development over time, while multiple snapshots of supervisors may capture best teaching practices to feed train-the-trainer programs.
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Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, the Netherlands.
| | - Mike Huiskes
- Center for Language and Cognition, University of Groningen, Groningen, the Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, the Netherlands
| | - Martin Stevens
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Debbie A D C Jaarsma
- Center for Research & Innovation in Medical Education, University Medical Center Groningen, Groningen, the Netherlands
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7
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Joh DB, van der Werf B, Watson BJ, French R, Bann S, Dennet E, Loveday BPT. Assessment of Autonomy in Operative Procedures Among Female and Male New Zealand General Surgery Trainees. JAMA Surg 2021; 155:1019-1026. [PMID: 32857160 DOI: 10.1001/jamasurg.2020.3021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance The need for trainee sex equality within surgical training has resulted in an appraisal of the training experience in the New Zealand general surgery training program. Objective To investigate the association between trainee sex and surgical autonomy in the operating room in the New Zealand general surgery training program. Design, Setting, and Participants Retrospective cohort study conducted from December 10, 2012, to December 10, 2017, examining all endoscopic, major, and minor procedures performed by all New Zealand general surgery trainees in every training hospital in New Zealand. Main Outcomes and Measures The primary outcome was the level of meaningful autonomy by each New Zealand general surgery trainee (ie, trainee as primary operator without the surgeon mentor scrubbed for the case). Outcomes were compared using multivariable analysis. Results This study included 120 New Zealand general surgery trainees (42 women [35%] and 78 men [65%]) who were analyzed over 279.5 trainee-years (88.5 trainee-years for women and 191.0 trainee-years for men). Included were 119 380 general surgery procedures (17 465 endoscopic, 56 964 major, and 44 951 minor) in 18 hospitals. By the end of the 5-year training program, female trainees had a lower cumulative mean autonomous caseload than male trainees for endoscopic (284.0 [95% CI, 207.0-361.0] vs 352.2 [95% CI, 282.9-421.6], P = .03), major (139.9 [95% CI, 76.7-203.2] vs 198.1 [95% CI, 142.3-254.0], P = .02), and minor (456.3 [95% CI, 394.8-517.9] vs 519.9 [95% CI, 465.6-574.2], P = .007) procedures. Conclusions and Relevance After accounting for differences among trainees, hospital type, number of female and male surgeon mentors at each hospital, and trainee seniority, female trainees performed fewer cases with meaningful autonomy compared with male trainees. These findings support the need for pragmatic solutions to address this bias and further investigations on mechanisms contributing to discrepancies.
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Affiliation(s)
- Daniel B Joh
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Bert van der Werf
- Department of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Bridget J Watson
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | - Rowan French
- Department of Surgery, Waikato District Health Board, Hamilton, New Zealand
| | - Simon Bann
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Elizabeth Dennet
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Benjamin P T Loveday
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Royal Melbourne Hospital, Victoria, Australia
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Nguyen C, Thompson-Burdine J, Kemp MT, Williams AM, Rivard S, Sandhu G. High vs. low entrustment behaviors in the operating room. Am J Surg 2020; 221:973-979. [PMID: 33019972 DOI: 10.1016/j.amjsurg.2020.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/05/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Operative experience with an appropriate degree of supervised autonomy is critical to resident training. Progressively greater intraoperative entrustment has been associated with gradually higher levels of resident autonomy. This study attempts to identify consistently observed intraoperative behaviors that are linked with higher resident entrustment. METHODS This qualitative study analyzed observational notes recorded by trained raters who provided entrustment scores for 204 surgical cases at Michigan Medicine from 2015 to 2017. Notes were coded in NVivo12. Thematic analysis was used to identify themes and patterns within the data. RESULTS The analysis generated 144 codes. Codes were clustered into 10 themes. These themes manifested differently in intraoperative behaviors strongly associated with high entrustment versus low entrustment. CONCLUSION This study demonstrates key differences in intraoperative behaviors exhibited by residents and faculty in high and low entrustment interactions. Awareness of behaviors that enhance entrustment can help faculty augment resident learning and enable higher resident operative autonomy.
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Affiliation(s)
- Christine Nguyen
- University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | | | - Michael T Kemp
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Aaron M Williams
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Samantha Rivard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Gurjit Sandhu
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA.
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Chang YT, Lu PY, Lai CS. Disparity of perspectives between teachers and learners on perioperative teaching and learning. BMC MEDICAL EDUCATION 2020; 20:244. [PMID: 32736559 PMCID: PMC7393732 DOI: 10.1186/s12909-020-02172-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/22/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND To build a consensus about learning objectives in the operating room, the aim of the study was to evaluate both surgical teacher and learner perspectives on perioperative teaching and learning in Taiwan. METHODS Twelve main technical and non-technical learning objectives in the operating room were evaluated by learners and surgical teachers in Kaohsiung Medical University Hospital. The learners included postgraduate year (PGY) 1-3 residents (junior learner, JL) and PGY 4-7 residents (senior learner, SL). The definition of learning preferences were recommended learning objectives, and learning load was defined as demands of learning preferences. During the survey, surgical teachers evaluated the learning preferences for the learner, and learners evaluated their learning preferences. The learners also evaluated the learning preferences that the surgical teachers should teach. RESULTS Response rate of the questionnaire was 65.4%. A total of 31 learners and 39 surgical teachers completed the survey. The consensus was that the need to increase the learning loads and ethical issues were the learning preferences for SL, and indications, details of procedure, and teamwork were important to both JL and SL. The teachers intended to set specific learning objectives for different learner levels, including (i) indications, details of procedure, teamwork, and postoperative care for both JL and SL; (ii) preoperative preparation, surgical anatomy, and instrument handling for JL (P = 0.022, 0.021 and 0.006); and (iii) surgical technique, independent practice, clinical reasoning, complications, and ethical issues for SL (P = 0.010, < 0.001, < 0.001, 0.001, 0.011). Resident perspective on learning objectives differed between JL and SL, and there was discrepancy between resident's learning as perceived by teachers, particularly in the JL. CONCLUSIONS Our study revealed significant disparity of perspectives between teachers and learners on perioperative teaching and learning. Surgical teachers should set specific learning objectives for different learner levels, since junior and senior residents have different learning preferences even though both scrub in the same case. Effective communication between teachers and learners has the potential to improve learning experience and create a positive environment in the operating room.
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Affiliation(s)
- Yu-Tang Chang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peih-Ying Lu
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- College of Humanities and Social Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Sheng Lai
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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10
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Shin TH, Naples R, French JC, Khandelwal CM, Rose W, Alaedeen D, Dai J, Lipman J, Rosen MJ, Petro C. Effect modification of resident autonomy and seniority on perioperative outcomes in laparoscopic cholecystectomy. Surg Endosc 2020; 35:3387-3397. [PMID: 32642848 DOI: 10.1007/s00464-020-07780-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited. METHODS Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time. RESULTS Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64-9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p < 0.001, 95% CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p = 0.069, 95% CI 0.99-1.41). CONCLUSION While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.
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Affiliation(s)
- Thomas H Shin
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. .,Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - Robert Naples
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Judith C French
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Warren Rose
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diya Alaedeen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jie Dai
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Lipman
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael J Rosen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Clayton Petro
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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11
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Lane SM, Young KA, Hayek SA, Dove JT, Sharp NE, Shabahang MM, Ellison HB. Meaningful autonomy in general surgery training: Exploring for gender bias. Am J Surg 2020; 219:240-244. [DOI: 10.1016/j.amjsurg.2019.11.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 11/14/2019] [Accepted: 11/24/2019] [Indexed: 10/25/2022]
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12
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Shebrain S, Mahmood G, Munene G, Miller L, Collins J, Sawyer R. The Role of Manual Dexterity and Cognitive Functioning in Enhancing Resident Operative Autonomy. JOURNAL OF SURGICAL EDUCATION 2019; 76:e66-e76. [PMID: 31221607 DOI: 10.1016/j.jsurg.2019.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/26/2019] [Accepted: 06/02/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Autonomy, both operative and nonoperative, is one of the most critical aspects of successful surgical training. Both surgeon and resident share the responsibility of achieving this goal. We hypothesize that operative autonomy is distinct and depends, for the most part, on the resident's manual dexterity, knowledge of, and preparation for the procedure. METHODS Over a period of 4 academic years, between July 2014 and June 2018, a total of 958 Global Rating Scale of Operative Performance evaluations were completed by 32 general and subspecialty faculty surgeons for 35 residents. Elective procedures were evaluated, including 165 (17.2%) by postgraduate year (PGY)1 residents, 253 (26.4%) by PGY2, 199 (20.8%) by PGY3, 147 (15.3%) by PGY4, and 194 (20.3%) by PGY5. The procedures evaluated were: 261 (27.2%) hernia repairs; 178 (18.6%) cholecystectomies; 102 (10.6%) colorectal and anal procedures; 73 (7.6%) vascular procedures; 56 (5.8%) thyroid and parathyroidectomies; 39 (4.1%) foregut (esophagus and stomach) procedures; 38 (4%) skin, soft tissue, and breast; 92 (10%) hepatopancreatic; 20 (2.1%) pediatric procedures; and 99 (10.3%) other procedures including amputations, cardiothoracic, and solid organs procedures. Each resident was scored from 1 to 5 (1 lowest, 5 highest) in each of the following categories of Global Rating Scale of Operative Performance: respect for tissue (RT), time and motion (T&M), instrument handling (IH), knowledge of the instrument (KI), flow of operation (FO) and resident's preparation for the procedure (RP). Resident operative autonomy (ROA) was assessed using the Zwisch scale, a 4-point scale describing faculty supervision behaviors associated with different degrees of resident autonomy (1: Show and Tell, 2: Active Help, 3: Passive Help, and 4: Supervision Only). RESULTS Correlation and ordinal regression analyses were conducted to examine the relationship between ROA and manual dexterity (RT, T&M, IH, and FO), and cognitive functioning (knowledge of instruments and resident preparation). Results indicated a positive correlation between ROA and RT (r = 0.528, p < 0.001), T&M (r = 0.630, p < 0.001), IH (r = 0.597, p < 0.001), KI (r = 0.490, p < 0.001), FO (r = 0.637, p < 0.001), and RP (r = 0.525, p < 0.001). Additionally, there was a weak inverse correlation between ROA and the number of years the surgeon had been in practice (r = -0.127, p = 0.001). The significant predictors of resident autonomy found by the ordinal logistic regression include time and motion (p < 0.001), flow of operation (p < 0.001), and resident's preparation for the procedure (p < 0.001). CONCLUSIONS Resident operative autonomy is a product of shared responsibility between the faculty and resident. However, residents' inherent and/or acquired skills and preparation for the operative procedures play a critical role. Residents should be advised to use available resources such as simulation to augment their skills preoperatively and to enhance their autonomy in the operating room.
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Affiliation(s)
- Saad Shebrain
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan.
| | - Gulrez Mahmood
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Gitonga Munene
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Lisa Miller
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - John Collins
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
| | - Robert Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan
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Park J, Ponnala S, Fichtel E, Tehranchi K, Fitzgibbons S, Parker SH, Lau N, Safford SD. Improving the Intraoperative Educational Experience: Understanding the Role of Confidence in the Resident-Attending Relationship. JOURNAL OF SURGICAL EDUCATION 2019; 76:1187-1199. [PMID: 31255644 DOI: 10.1016/j.jsurg.2019.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/02/2019] [Accepted: 02/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE With recent changes to graduate medical education, the balance between resident autonomy and need for supervision impacts the educational and training experience of residents. The objective of this study was to understand the relationship between the confidence of attendings and residents and their different perspectives of perceived educational experience and autonomy in the operating room (OR). We hypothesized that the attending's confidence in the resident would be an important factor in improving the educational experience and resident's autonomy in the OR. DESIGN Self-reported confidence-rating and operative experience surveys were administered to teams of post-graduate year (PGY 1) through PGY 5 surgical residents and attendings in two temporal sets (Early: Sept-Dec 2015, n = 20; Late: Jan-Apr 2016, n = 22). A second "end-of-year" survey was distributed to residents (n = 9, 37.5% response) and attendings (n = 10, 35% response) asking questions regarding their educational experience and operative experience during the past year. SETTING Large rural teaching hospital. PARTICIPANTS Nineteen general surgery residents (PGY 1 - 5) and 14 general surgery attendings. RESULTS Resident perception of confidence differs from junior to senior residents, and that there was discordance between resident's confidence and skill as perceived by attendings, particularly in senior residents. Results also showed that attending's confidence in residents was positively correlated with attending's perceived educational experience in the OR. Residents and attendings both indicated attending's confidence in residents as an important factor in increasing resident autonomy in the OR, thus the attending's confidence in residents could have a positive impact on resident autonomy and educational experience in the OR. CONCLUSIONS We have demonstrated a relationship between self-confidence for residents and improved confidence from attendings in residents' capabilities. Based on these findings, we would propose identifying methods to expand resident's awareness of surgical situations and develop attending's confidence in residents.
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Affiliation(s)
- Juyeon Park
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Siddarth Ponnala
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Eric Fichtel
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Kian Tehranchi
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Shimae Fitzgibbons
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Sarah Henrickson Parker
- Human Factors Research, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Nathan Lau
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Shawn D Safford
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
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Chen XP, Sullivan AM, Smink DS, Alseidi A, Bengtson JM, Kwakye G, Dalrymple JL. Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability. Ann Surg 2019; 269:1080-1086. [PMID: 31082905 DOI: 10.1097/sla.0000000000002717] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. BACKGROUND Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. METHODS We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. RESULTS We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. CONCLUSION Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.
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Affiliation(s)
- Xiaodong Phoenix Chen
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- The Ohio State University, Columbus, OH
| | - Amy M Sullivan
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Douglas S Smink
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Joan M Bengtson
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - John L Dalrymple
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room. J Patient Saf 2019; 15:e90-e93. [DOI: 10.1097/pts.0000000000000608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE The aim of this study is to establish evidence to support the validity of a novel faculty-resident intraoperative assessment tool for entrustment known as OpTrust. BACKGROUND Recently, the landscape of surgical training has been altered, in part, because of resident work-hour changes and increased supervision requirements. To address these concerns, a new model for assessment of teaching and learning in surgical residencies must be anchored on progression through milestones and entrustment. METHODS OpTrust was designed to assess the faculty-resident dyad in the operating room and measure the entrustment exhibited during intraoperative interactions across 5 domains: (i) types of questions asked, (ii) operative plan, (iii) instruction, (iv) problem solving, and (v) leadership by the surgical resident. After initial pilot testing and refinement of OpTrust, 5 individual raters underwent rater training sessions; 49 individual operating room observations were completed based on 28 cases. RESULTS OpTrust, as a tool for assessing intraoperative entrustment, is supported by strong validity evidence. In part, it demonstrates strong interrater reliability across all faculty domains as measured by intraclass correlation 1 (ICC1) (0.81-0.93). For resident domains the results were similar with ICC1 (0.84-0.94). Cronbach alpha was 0.89 and 0.87 for faculty and resident entrustment respectively, signifying the 5 domains could be combined into a single construct of entrustment. A high correlation existed between faculty and resident scores (Pearson r = 0.94, P < 0.001) indicating a strong positive linear relationship between faculty and resident mean entrustment scores across all scale domains. CONCLUSIONS OpTrust successfully assesses behaviors associated with entrustment during intraoperative faculty-resident interactions, and has the potential to be adopted across other procedural-based specialties to promote autonomous training progression.
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See one, do one, teach one: A randomized controlled study evaluating the benefit of autonomy in surgical education. Am J Surg 2019; 217:281-287. [DOI: 10.1016/j.amjsurg.2018.10.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 11/17/2022]
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Hyde GA, Soder BL, Stanley JD, Dart BW, Holcombe JM, Cook RG, Burns RP, Nelson EC. Evaluating Surgery Resident Technical Skills: Intestinal Anastomosis in a Porcine Model. Am Surg 2018. [DOI: 10.1177/000313481808401139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Because work hour restrictions and technological developments such as staplers change the surgical landscape, efficient resident training methods are necessary to ensure surgical quality. This study evaluates efficacy of a porcine skills laboratory for teaching surgery residents to perform handsewn intestinal anastomoses based on a validated subjective tool and novel objective measurements. We hypothesized that resident performance would improve postintervention; junior residents would improve more than the seniors would. This prospective study was completed over a period of four months in 2015. Participants performed standardized two-layer, handsewn, end-to-end small intestine anastomosis in a live porcine model before (pretest) and after (posttest) an educational intervention. The intervention consisted of an instructional module and skills laboratory teaching session by attending surgeons. Participants were evaluated based on objective measurements of the anastomosis and blinded video evaluations using objective structured assessment of technical skills. Twenty-eight residents in a six-year general surgery program started and completed the study. The objective structured assessment of technical skills ratings demonstrated that the whole resident cohort had statistically significant improvement in pre- to posttest scores, 11.16 to 24.59 ( P < 0.001). Junior and senior residents improved independently, 9.59 versus 22.53 ( P < 0.001) and 13.59 versus 27.77 ( P < 0.001), respectively. Finally, the cohort significantly improved in number of full-thickness Lembert sutures (2.36 vs 0.93, P = 0.001) and time to completion (31.28 vs 28.2 minutes, P = 0.046). Anastomotic leak pressure, anastomotic narrowing, and anastomotic tensile strength all trended toward improvement. A structured educational intervention, teaching intestinal anastomosis in a live porcine model produced significant improvement in residents’ technical skills.
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Affiliation(s)
- G. Alan Hyde
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
| | - Brent L. Soder
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
| | - J. Daniel Stanley
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
| | - Benjamin W. Dart
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
| | - Jenny M. Holcombe
- School of Nursing, University of Tennessee at Chattanooga, Chattanooga, Tennessee
| | - Richard G. Cook
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
| | - R. Phillip Burns
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
| | - Eric C. Nelson
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee and
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Williams RG, George BC, Bohnen JD, Meyerson SL, Schuller MC, Meier AH, Torbeck L, Mandell SP, Mullen JT, Smink DS, Chipman JG, Auyang ED, Terhune KP, Wise PE, Choi J, Foley EF, Choti MA, Are C, Soper N, Zwischenberger JB, Dunnington GL, Lillemoe KD, Fryer JP. Is the operative autonomy granted to a resident consistent with operative performance quality. Surgery 2018; 164:566-570. [DOI: 10.1016/j.surg.2018.04.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/20/2018] [Accepted: 04/27/2018] [Indexed: 10/28/2022]
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Hill KA, Dasari M, Littleton EB, Hamad GG. How can surgeons facilitate resident intraoperative decision-making? Am J Surg 2017; 214:583-588. [DOI: 10.1016/j.amjsurg.2017.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/26/2017] [Accepted: 06/18/2017] [Indexed: 10/19/2022]
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Entrustment Evidence Used by Expert Gynecologic Surgical Teachers to Determine Residents' Autonomy. Obstet Gynecol 2017; 130 Suppl 1:8S-16S. [DOI: 10.1097/aog.0000000000002201] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Williams RG, George BC, Meyerson SL, Bohnen JD, Dunnington GL, Schuller MC, Torbeck L, Mullen JT, Auyang E, Chipman JG, Choi J, Choti M, Endean E, Foley EF, Mandell S, Meier A, Smink DS, Terhune KP, Wise P, DaRosa D, Soper N, Zwischenberger JB, Lillemoe KD, Fryer JP. What factors influence attending surgeon decisions about resident autonomy in the operating room? Surgery 2017; 162:1314-1319. [PMID: 28950992 DOI: 10.1016/j.surg.2017.07.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 07/10/2017] [Accepted: 07/29/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. METHODS We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. RESULTS Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74). CONCLUSION Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors.
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Affiliation(s)
- Reed G Williams
- Department of Surgery, Indiana University, Indianapolis, IN.
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | | | - Jordan D Bohnen
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | - Laura Torbeck
- Department of Surgery, Indiana University, Indianapolis, IN
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Edward Auyang
- Department of Surgery, University of New Mexico, Albuquerque, NM
| | | | - Jennifer Choi
- Department of Surgery, Indiana University, Indianapolis, IN
| | - Michael Choti
- Department of Surgery, University of Texas Southwestern, Surgery, Dallas, TX
| | - Eric Endean
- Department of Surgery, University of Kentucky, Lexington, KY
| | - Eugene F Foley
- Department of Surgery, University Of Wisconsin, Madison, WI
| | - Samuel Mandell
- Department of Surgery, University of Washington, Surgery, Seattle, WA
| | - Andreas Meier
- Department of Surgery, State University of New York, Surgery, Syracuse, NY
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Surgery, Boston, MA
| | - Kyla P Terhune
- Department of Surgery, Vanderbilt University Medical Center, Surgery, Nashville, TN
| | - Paul Wise
- Department of Surgery, Washington University, Surgery, St. Louis, MO
| | - Debra DaRosa
- Department of Surgery, Northwestern University, Chicago, IL
| | | | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Timberlake MD, Mayo HG, Scott L, Weis J, Gardner AK. What Do We Know About Intraoperative Teaching? Ann Surg 2017; 266:251-259. [DOI: 10.1097/sla.0000000000002131] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Morgan R, Kauffman DF, Doherty G, Sachs T. Resident and attending assessments of operative involvement: Do we agree? Am J Surg 2017; 213:1178-1185.e1. [DOI: 10.1016/j.amjsurg.2016.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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McKendy KM, Watanabe Y, Lee L, Bilgic E, Enani G, Feldman LS, Fried GM, Vassiliou MC. Perioperative feedback in surgical training: A systematic review. Am J Surg 2016; 214:117-126. [PMID: 28082010 DOI: 10.1016/j.amjsurg.2016.12.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/09/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Changes in surgical training have raised concerns about residents' operative exposure and preparedness for independent practice. One way of addressing this concern is by optimizing teaching and feedback in the operating room (OR). The objective of this study was to perform a systematic review on perioperative teaching and feedback. METHODS A systematic literature search identified articles from 1994 to 2014 that addressed teaching, feedback, guidance, or debriefing in the perioperative period. Data was extracted according to ENTREQ guidelines, and a qualitative analysis was performed. RESULTS Thematic analysis of the 26 included studies identified four major topics. Observation of teaching behaviors in the OR described current teaching practices. Identification of effective teaching strategies analyzed teaching behaviors, differentiating positive and negative teaching strategies. Perceptions of teaching behaviors described resident and attending satisfaction with teaching in the OR. Finally models for delivering structured feedback cited examples of feedback strategies and measured their effectiveness. CONCLUSIONS This study provides an overview of perioperative teaching and feedback for surgical trainees and identifies a need for improved quality and quantity of structured feedback.
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Affiliation(s)
- Katherine M McKendy
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Yusuke Watanabe
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Elif Bilgic
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Ghada Enani
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Liane S Feldman
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Gerald M Fried
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
| | - Melina C Vassiliou
- Henry K.M. de Kuyper Education Center, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
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Williams RG, Kim MJ, Dunnington GL. Practice Guidelines for Operative Performance Assessments. Ann Surg 2016; 264:934-948. [DOI: 10.1097/sla.0000000000001685] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Apramian T, Cristancho S, Watling C, Ott M, Lingard L. "Staying in the Game": How Procedural Variation Shapes Competence Judgments in Surgical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:S37-S43. [PMID: 27779508 PMCID: PMC5578755 DOI: 10.1097/acm.0000000000001364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE Emerging research explores the educational implications of practice and procedural variation between faculty members. The potential effect of these variations on how surgeons make competence judgments about residents has not yet been thoroughly theorized. The authors explored how thresholds of principle and preference shaped surgeons' intraoperative judgments of resident competence. METHOD This grounded theory study included reanalysis of data on the educational role of procedural variations and additional sampling to attend to their impact on assessment. Reanalyzed data included 245 hours of observation across 101 surgical cases performed by 29 participants (17 surgeons, 12 residents), 39 semistructured interviews (33 with surgeons, 6 with residents), and 33 field interviews with residents. The new data collected to explore emerging findings related to assessment included two semistructured interviews and nine focused field interviews with residents. Data analysis used constant comparison to refine the framework and data collection process until theoretical saturation was reached. RESULTS The core category of the study, called staying in the game, describes how surgeons make moment-to-moment judgments to allow residents to retain their role as operators. Surgeons emphasized the role of principles in making these decisions, while residents suggested that working with surgeons' preferences also played an important role in such intraoperative assessment. CONCLUSIONS These findings suggest that surgeons' and residents' work with thresholds of principle and preference have significant implications for competence judgments. Making use of these judgments by turning to situated assessment may help account for the subjectivity in assessment fostered by faculty variations.
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Affiliation(s)
- Tavis Apramian
- T. Apramian is MD candidate and centre fellow, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. S. Cristancho is assistant professor, Department of Surgery, and scientist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. C. Watling is associate dean, Postgraduate Medical Education, and scientist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. M. Ott is associate professor, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada. L. Lingard is professor, Department of Medicine, and director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Chong ACM, Pate RC, Prohaska DJ, Bron TR, Wooley PH. Validation of Improvement of Basic Competency in Arthroscopic Knot Tying Using a Bench Top Simulator in Orthopaedic Residency Education. Arthroscopy 2016; 32:1389-99. [PMID: 27117823 DOI: 10.1016/j.arthro.2016.01.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/04/2016] [Accepted: 01/18/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To validate basic competency in arthroscopic knot tying using a unique simulator device to compare the level of training needed for learning and tying the arthroscopic knot by evaluating the tensile properties of the arthroscopic knots. METHODS Three groups of surgeons of various experience levels (postgraduate year [PGY] 1, PGY 3, and experienced surgeons) tied 2 different arthroscopic knots (Tennessee Slider, considered easier, and Weston, considered more difficult) over a 10-week period. Each group went through 3 separate stages of knot tying: stage 1, tying 8 knots without cannula or knot pusher; stage 2, tying 12 knots with knot pusher; and stage 3, tying 20 knots with knot pusher through a cannula that simulates knot tying during surgery. A single load-to-failure test was performed and ultimate clinical failure loads were recorded. Time needed to tie each knot was also recorded. RESULTS At stages 1 and 2, the PGY 1 group had a significantly weak knot tensile strength (Tennessee Slider stage 1: 60 v 129 N, P = .001; Tennessee Slider stage 2: 69 v 132 N, P = .0029; Weston stage 1: 73 v 184 N, P = .0000; Weston stage 2: 125 v 173 N, P = .0045) and were slower (Weston: 56 v 30 seconds, P = .0010) than the experienced surgeon group for both knots. At stage 3, only the initial 2 weeks of Tennessee Slider showed a significant difference between groups 1 and 3 (week 6: 87 v 118 N, P = .0492; week 7: 89 v 126, P = .01485). Even though the Tennessee Slider knot is one of the easier arthroscopic knots to learn to tie, the results showed a slow trend of improvement in this knot-tying skill for group 1 after each stage. CONCLUSIONS The data validated an important learning effect in all trainees in arthroscopic knot tying over a 10-week period and showed that inexperienced trainees will be able to improve their knot-tying skill with training in 3 stages with a simulator environment. CLINICAL RELEVANCE The findings of this study indicated the importance of hands-on experience in performing arthroscopic knot tying, as determined by both knot performance and ultimate suture loop strength. In addition, each orthopaedic resident learned and developed his or her arthroscopic knot-tying skills and provided a foundation for his or her future practice in orthopaedic medicine.
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Affiliation(s)
- Alexander C M Chong
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Via Christi Health-Orthopedic Research Institute, Wichita, Kansas, U.S.A..
| | - Ryan C Pate
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Robert J Dole VA Medical Center, Wichita, Kansas, U.S.A
| | - Daniel J Prohaska
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Advanced Orthopaedics Associates, Wichita, Kansas, U.S.A
| | - Tyler R Bron
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A
| | - Paul H Wooley
- Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kansas, U.S.A.; Via Christi Health-Orthopedic Research Institute, Wichita, Kansas, U.S.A
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D'Souza N, Aggarwal R. Does Resident Involvement Equate with Development of Independent Surgical Practitioners? J Am Coll Surg 2016; 222:1265-6. [DOI: 10.1016/j.jamcollsurg.2016.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 03/14/2016] [Indexed: 11/29/2022]
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Jeyarajah DR, Berman RS, Doyle MB, Geevarghese SK, Posner MC, Farmer D, Minter RM. Consensus Conference on North American Training in Hepatopancreaticobiliary Surgery: A Review of the Conference and Presentation of Consensus Statements. Am J Transplant 2016; 16:1086-93. [PMID: 26928942 DOI: 10.1111/ajt.13675] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/29/2015] [Accepted: 11/29/2015] [Indexed: 01/25/2023]
Abstract
The findings and recommendations of the North American consensus conference on training in hepatopancreaticobiliary (HPB) surgery held in October 2014 are presented. The conference was hosted by the Society for Surgical Oncology (SSO), the Americas Hepato-Pancreatico-Biliary Association (AHPBA), and the American Society of Transplant Surgeons (ASTS). The current state of training in HPB surgery in North America was defined through three pathways-HPB, surgical oncology, and solid organ transplant fellowships. Consensus regarding programmatic requirements included establishment of minimum case volumes and inclusion of quality metrics. Formative assessment, using milestones as a framework and inclusive of both operative and nonoperative skills, must be present. Specific core HPB cases should be defined and used for evaluation of operative skills. The conference concluded with a focus on the optimal means to perform summative assessment to evaluate the individual fellow completing a fellowship in HPB surgery. Presentations from the hospital perspective and the American Board of Surgery led to consensus that summative assessment was desired by the public and the hospital systems and should occur in a uniform but possibly modular manner for all HPB fellowship pathways. A task force composed of representatives of the SSO, AHPBA, and ASTS are charged with implementation of the consensus statements emanating from this consensus conference.
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Affiliation(s)
- D R Jeyarajah
- Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | - R S Berman
- Department of Surgery, Division of Surgical Oncology, New York University, New York, NY
| | - M B Doyle
- Department of Abdominal Transplantation, Washington University School of Medicine, St Louis, MO
| | - S K Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - M C Posner
- Section of General Surgery and Surgical Oncology, University of Chicago Medicine, Chicago, IL
| | - D Farmer
- Department of Transplantation, UCLA Medical Center, Los Angeles, CA
| | - R M Minter
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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Jeyarajah DR, Berman RS, Doyle M, Geevarghese SK, Posner MC, Farmer D, Minter RM. Consensus Conference on North American Training in Hepatopancreaticobiliary Surgery: A Review of the Conference and Presentation of Consensus Statements. Ann Surg Oncol 2016; 23:2153-60. [DOI: 10.1245/s10434-016-5111-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Indexed: 11/18/2022]
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Torbeck L, Wilson A, Choi J, Dunnington GL. Identification of behaviors and techniques for promoting autonomy in the operating room. Surgery 2015. [DOI: 10.1016/j.surg.2015.05.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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