An immersive "simulation week" enhances clinical performance of incoming surgical interns improved performance persists at 6 months follow-up

A Capstone Course for Senior Medical Students: from Innovative Elective to Required Core Curriculum

We describe our institution's development and implementation of our Capstone course from a small elective course to the only required fourth-year course. The course's structure evolved from mostly didactic to one including various workshops and simulation sessions. Course content has become increasingly specialty-specific. Implementation requires high faculty and resident involvement. Evaluations indicate a positive impact of the course on participants' self-reported confidence and residency preparedness. Assessment remains pass/fail with more specialty-specific questions. As steadily increasing numbers of medical schools are developing transition to residency courses, we share our Capstone course's evolution and lessons learned over the past nine years.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01880-2.

An Interprofessional Senior Medical Student Preparation Course: Improvement in Knowledge and Self-Confidence Before Entering Surgical Training

PURPOSE

Senior medical students are variably prepared to begin surgical training; and a national curriculum was established through the American College of Surgeons to better prepare senior medical students for surgical training. The purpose of our course is to prepare senior medical students to more effectively enter surgical training programs. We recently enhanced our independently developed surgical training preparation course by increasing exposure to surgical anatomy, medical physiology, surgical skills, and point-of-care ultrasound. We evaluated the impact of our interprofessional training course to increase confidence and readiness among senior medical students entering surgical training.

METHODS

The course focused on pre- and post-operative patient care, surgical anatomy, human physiology, and bedside ultrasound. Didactic lectures in anatomy, human physiology, and bedside ultrasound were provided prior to all hands-on simulated patient care sessions and mock surgical procedures. To evaluate our interprofessional curriculum, we administered pre- and post-course surveys, pre- and post-course knowledge tests, and a final surgical anatomy laboratory practical examination to 22 senior medical students who were enrolled in the course. All students created a final surgical anatomy presentation.

RESULTS

The students demonstrated a 100% pass rate in surgical anatomy. The knowledge test, which included assessment of knowledge on perioperative surgical decision making, human physiology, and bedside ultrasound, demonstrated an average improvement of 10%. Statistically significant improvements in median confidence values were identified in 10 of 32 surveyed categories, including surgical skills (p < 0.05); 84% of student goals for the course were achieved. The medical students' surveys confirmed increased confidence related to the use of point-of-care ultrasound, teamwork experience, and basic surgical skills through small group interactive seminars and surgical simulation exercises.

CONCLUSION

Our preparation for surgical training course resulted in high student satisfaction and demonstrated an increased sense of confidence to begin surgical training. The 10% improvement in medical student knowledge, as evaluated by a written examination, and the significant improvement in confidence level self-assessment scores confirms this surgery preparation course for senior medical students successfully achieved the desired goals of the course.

Otolaryngology Curriculum During Residency Preparation Course Improves Preparedness for Internship

OBJECTIVES/HYPOTHESIS

Residency preparation courses (RPCs) have become a widely adopted practice to ease the transition of medical students into residency, but these courses often lack training in skills expected of subspecialty interns. To fill this gap, a simulation-based curriculum in otolaryngology (ORL) was implemented at the University of Michigan Medical School. The curriculum aimed to improve confidence and perceived ability to perform common ORL skills for graduating students prior to internship.

STUDY DESIGN

Cross-sectional study.

METHODS

Six basic simulations (tracheostomy, flexible laryngoscopy, otomicroscopy, myringotomy and tube insertion, epistaxis and peritonsillar abscess management) were included in the first course in 2019. The course was expanded in 2020 with the addition of three advanced simulations (ear foreign body extraction, tracheostomy complications, and "cannot intubate, cannot ventilate" situations). Pre- and postsession surveys were collected to assess individual simulations and the course overall.

RESULTS

A total of 32 students participated in the ORL simulation curriculum in Spring 2019 and 2020. Paired t-tests showed significant improvement in self-perception of ability on every simulation. Qualitative feedback revealed that students particularly valued the opportunity for hands-on learning. Non-ORL students rated their baseline abilities significantly lower than ORL students on five stations, but they achieved statistically equivalent postsession ratings on all but the otomicroscopy station.

CONCLUSIONS

An ORL-specific curriculum is a valuable addition to procedural RPCs. The curriculum resulted in increased confidence and perceived ability in skill performance for both students pursuing ORL residencies, as well as those pursuing other procedural specialties.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2143-E2148, 2021.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training

Objective

To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency.

Design

Prospective evaluation.

Setting

Simulation Center.

Patients

Forty REI fellows.

Interventions

Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice.

Main Outcome Measures

Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency.

Results

Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03).

Conclusions

An intensive surgical boot camp enhances surgical skill among REI fellows.

The Impact of a Surgical Unit's Structure and Operative Technique on Quality in Two Swedish Rural Hospitals

Introduction: Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure with a low complication rate. It is performed either as an acute or as an elective procedure. Most elective LCs are performed on nonlethal diseases and this is why good quality is important. Our study compared the quality of LC in two surgical units in northern Sweden (Sundsvall and Östersund) which use different clinical structures (subspecialised vs. general surgery) and surgical techniques (ultrasound fundus first vs. conventional diathermy). The study aimed to investigate whether these differences affected the quality of outcomes after LC. Materials and methods: This is a registry-based study which included 607 elective LCs from January 2014 to May 2016. There were 286 from Sundsvall and 321 from Östersund. Primary outcomes were operative time and the percentage of day surgeries. The secondary outcome was the presence of postoperative complications within the first 30 days in terms of bile duct injury, bleeding that necessitated reoperation, bile leakage and abscesses treated with drainage and mortality. Results: The time length of surgery was shorter in Sundsvall (mean 48.3 min) compared to Östersund (mean 108.6 min, p < 0.001. The percentage of day care surgeries was 94% in Sundsvall and 23% in Östersund, p < 0.001. Six patients (2.1%) had a complication in Sundsvall compared to seven patients (2.2%) in Östersund, p = 1.00. Conclusion: There is a significant difference between the two hospitals regarding operative time and the percentage of day surgeries. Complication rates in both units were equal and low.

Evaluation of a First-Year Veterinary Surgical Skills Laboratory: A Retrospective Review

A retrospective review of the first-year surgical skills competency-based assessment was performed at the Western College of Veterinary Medicine (WCVM) using 6 years of data from 475 students. The cumulative pass rate was 88.2% on first attempt and 99.2% upon remediation. Student gender did not influence overall pass/fail rates, with a failure rate of 11.1% for female students and 10.5% for male students (p = 0.88). Significantly decreased pass rates were associated with identification of the Mayo scissors (p = 0.03), explanation of using Allis tissue forceps (p = 0.002), and performance of a Lembert suture pattern (p < 0.01). An increased pass rate was observed for the cruciate pattern (p < 0.01). No differences were found in pass/fail rates for hand ties (p = 0.80) or instrument ties (p = 0.60). The most common errors occurred with half hitch ties: hand ties (53%) and instrument ties (38%). The most common errors were also recognized for instrument handling (31%) and needle management (20%) during the suture pattern section. The veterinary medical education community may benefit from the evidence-based findings of this research, in terms of understanding student performance across competencies, identifying areas requiring additional mentoring, and determining appropriate competencies for first-year veterinary students.

An Interdisciplinary Approach to Surgical Skills Training Decreases Programmatic Costs

BACKGROUND

Surgical resident duty hour limitations have necessitated operative skill training outside of the operating room. Although wet-lab skills training is ideal, materials and human resource requirements make wet labs-utilizing biologic samples cost prohibitive for many residency programs. To resolve this problem, our general surgery residency program collaborated with the Institution's School of Veterinary Medicine Surgery Residency program to pilot a cost-effective interdisciplinary surgical skills curriculum.

MATERIALS AND METHODS

The general surgery residency program manager and program director initiated a collaboration with the Veterinary Surgery Residency. Postgraduate year (PGY) 2 general surgery residents and PGY 1-3 veterinary surgery residents participated in monthly joint surgical skills practice sessions. A novel interdisciplinary surgical skills curriculum was implemented that incorporated skills beneficial to both sets of trainees utilizing donated canine cadavers.

RESULTS

A total of nine joint skills sessions were conducted for nine general surgery residents and five veterinary surgery residents. A cost analysis was conducted for a surgical skills curriculum servicing both programs independently and compared to the actual costs of the collaborative curriculum. The cost analysis estimated total savings generated by the collaborative to be $27,323.79. Review of initial feedback from trainees suggest that skill sessions reinforce knowledge, and that the collaborative skills sessions were an enjoyable and valuable learning activity.

CONCLUSIONS

The skills curriculum collaborative has proven to be a cost-effective and high quality interdisciplinary pedagogic tool. The partnership allowed for mutually beneficial resource sharing and allowed for the initiation of a surgical skills wet lab that had previously been unavailable to both groups.

Simulation-based Education and Human Factors Training in Postgraduate Medical Education: A Northern Ireland Perspective

With their potential to improve patient safety, simulation based education (SBE) and human factors training are gaining momentum across the spectrum of medical education. There are ever increasing drivers for their integration, in particular within the postgraduate arena. This article aims to provide an overview of both simulation based education and human factors training. The breadth of terminology can be bewildering and our target audience is novice or developing practitioners and policymakers. We focus particularly on a regional setting where the Northern Ireland Simulation and Human Factors Network (NISHFN) is working to advance the field.

High-Fidelity Emergency Department Thoracotomy Simulator With Beating-Heart Technology and OSATS Tool Improves Trainee Confidence and Distinguishes Level of Skill

OBJECTIVE

Resuscitative Thoracotomy or Emergency Department Thoracotomy (EDT) is a time-sensitive and potentially life-saving procedure. Yet, trainee experience with this procedure is often limited in both clinical and simulation settings. We sought to develop a high-fidelity EDT simulation module and assessment tool to facilitate trainee education.

DESIGN

Using the Kern model for curricular development, a group of expert trauma surgeons identified EDT as a high-stakes, low-frequency procedure. Task analysis identified 5 key steps of EDT: (1) opening chest/rib spreader utilization; (2) pericardiotomy/cardiac repair; (3) open cardiac massage; (4) clamping aorta; and (5) control of pulmonary hilum. A high-fidelity simulator with beating-heart technology was built. The previously validated Objective Structured Assessment of Technical Skills (OSATS) was adapted to create the "EDT-OSATS" which assessed performance along several domains: (1) Surgical technique (key steps); (2) general skills; and (3) global rating. A pilot test was performed to compare board-certified trauma surgeons (i.e., Experts) with categorical general surgery interns (i.e., Novices). Each subject received preparatory materials, completed a presimulation quiz, performed a videotaped procedure on the EDT simulator, and completed a postmodule survey. Two independent raters scored performances using the EDT-OSATS. Groups were compared in descriptive and unadjusted analyses. We hypothesized that our EDT simulation module would distinguish between expert vs novice performance and improve trainee confidence.

SETTING

Simulation laboratory at Massachusetts General Hospital in Boston, MA.

PARTICIPANTS

Trauma surgeons (Experts, n = 6) and categorical general surgery interns (Novices, n = 8).

RESULTS

Experts scored significantly higher than Novices on nearly all components of the EDT-OSATS, including: (1) surgical technique: pericardiotomy (4.2 vs 3.4, p = 0.040), cardiac massage (3.6 vs 2.4, p = 0.028), clamping aorta (4.1 vs 3.3, p = 0.035), control of pulmonary hilum (4.8 vs 3.4, p < 0.001); (2) general skills: time/motion (4.1 vs 2.9, p = 0.011), knowledge and handling of instruments (4.3 vs 3.1, p = 0.004), and (3) global rating (3.9 vs 2.9, p = 0.026). There was no statistical difference between groups on opening chest/rib spreader utilization (3.8 vs 3.3, p = 0.352) or procedure time (204sec vs 227sec, p = 0.401), though Experts scored numerically higher than Novices on every measure. Novices reported significantly increased confidence after the simulation (3.1 vs 1.4, p = 0.001). Ninety-three percent (13/14) of participants found the simulator realistic.

CONCLUSIONS

Our novel high-fidelity beating-heart EDT simulator is realistic and improves trainee confidence in this low-frequency, high-stakes emergency procedure. The EDT-OSATS tool differentiates between performances of experienced surgeons vs novice trainees on the beating-heart simulator. This training module and accompanying assessment instrument hold promise as a learning tool for clinicians who may perform emergency department thoracotomy.

The laparoscopic inguinal and diaphragmatic defect (LIDD) model: a validation study of a novel box trainer model

BACKGROUND

Paediatric laparoscopic procedures are now becoming routine practice. Therefore, there is a need for simulated laparoscopic models to acquire part-procedural competency prior to direct patient contact in a safe learning environment. For this reason, we chose two paediatric conditions; inguinal hernia (IH) and congenital diaphragmatic hernia (CDH), which were combined to create the laparoscopic inguinal and diaphragmatic defect (LIDD) model. Our aim was to assess this novel surgical simulation model by determining its construct and content validity.

METHODS

A total of 107 participants completed the validation study: volunteer medical students (novices), surgical trainees (intermediate) and consultant surgeons (experts). Basic demographic data were collected. Subjects were shown a pre-recorded video of both exercises. The assessment exercise involved closing both the simulated inguinal or diaphragmatic hernial orifice. The task was assessed using a novel scoring system with a maximum score of 21 for IH model and 15 for the CDH. The content validity was assessed by a 6-point Likert scale of the expert group.

RESULTS

105/107 participants successfully completed the two exercises. Both aspects of the LIDD model revealed a statistical significance between the scores obtained by the three groups of subjects. Experts scored 20.3/21 for the IH and 14.8/15 for the CDH models which significantly higher than medical students (6.3/21 and 5.3/15; p < 0.05 for both) and trainees (11.2/21 and 9.3/15; p < 0.05 for both). Similarly, trainees performed significantly better than medical students in both models (p < 0.05). Therefore, the LIDD model was found to have a good construct validity. It was, however, unable to differentiate between the various levels of trainees in the intermediate group. Content validity from the experts revealed that there was a high score for the potential of both aspects of LIDD (4.8 and 4.8). There was also a high level of functional fidelity for task completion (4.0 and 4.0).

CONCLUSIONS

We have demonstrated both the construct and content validity of the LIDD model for both laparoscopic IH and CDH repair. It was able to successfully differentiate between the expert, trainees and inexperienced laparoscopic surgeons.

Learning outcomes evaluation of a simulation-based introductory course to anaesthesia

OBJECTIVE

An increased number of errors and reduced patient safety have been reported during the incorporation of residents, as this period involves learning new skills. The objectives were to evaluate the learning outcomes of an immersive simulation boot-camp for incoming residents before starting the clinical rotations. Airway assessment, airway control with direct laryngoscopy, and epidural catheterization competencies were evaluated.

MATERIAL AND METHOD

Twelve first-year anaesthesiology residents participated. A prospective study to evaluate transfer of endotracheal intubation skills learned at the simulation centre to clinical practice (primary outcome) was conducted. A checklist of 28 skills and behaviours was used to assess the first supervised intubation performed during anaesthesia induction in ASA I/II patients. Secondary outcome was self-efficacy to perform epidural catheterization. A satisfaction survey was also performed.

RESULTS

Seventy-five percent of residents completed more than 21 out of 28 skills and behaviours to assess and control the airway during their first intubation in patients. Twelve items were performed by all residents and 5 by half of them. More than 83% of participants reported a high level of self-efficacy in placing an epidural catheter. All participants would recommend the course to their colleagues.

CONCLUSIONS

A focused intensive simulation-based boot-camp addressing key competencies required to begin anaesthesia residency was well received, and led to transfer of airway management skills learned to clinical settings when performing for first time on patients, and to increased self-reported efficacy in performing epidural catheterization.

Standardizing hysteroscopy teaching: development of a curriculum using the Delphi method

BACKGROUND

Hysteroscopy is performed often and in many indications but is challenging to learn. Hands-on training in live patients faces ethical, legal, and economic obstacles. Virtual reality simulation may hold promise as a hysteroscopy training tool. No validated curriculum specific in hysteroscopy exists. The aim of this study was to develop a hysteroscopy curriculum, using the Delphi method to identify skill requirements.

METHODS

Based on a literature review using the key words "curriculum," "simulation," and "hysteroscopy," we identified five technical and non-technical areas in which skills were required. Twenty hysteroscopy experts from different French hospital departments participated in Delphi rounds to select items in these five areas. The rounds were to be continued until 80-100% agreement was obtained for at least 60% of items. A curriculum was built based on the selected items and was evaluated in residents.

RESULTS

From November 2014 to April 2015, 18 of 20 invited experts participated in three Delphi rounds. Of the 51 items selected during the first round, only 25 (49%) had 80-100% agreement during the second round, and a third round was therefore conducted. During this last round, 80-100% agreement was achieved for 31 (61%) items, which were used to create the curriculum. All 14 residents tested felt that a simulator training session was acceptable and helped them to improve their skills.

CONCLUSIONS

We describe a simulation-based hysteroscopy curriculum focusing on skill requirements identified by a Delphi procedure. Its development allows standardization of training programs offered to residents.

A pilot study examining experiential learning vs didactic education of abdominal compartment syndrome

BACKGROUND

Current surgical education relies on simulated educational experiences or didactic sessions to teach low-frequency clinical events such as abdominal compartment syndrome (ACS). The purpose of this pilot study was to evaluate if simulation would improve performance and knowledge retention of ACS better than a didactic lecture.

METHODS

Nineteen general surgery residents were block randomized by postgraduate year level to a didactic or a simulation session. After 3 months, all residents completed a knowledge assessment before participating in an additional simulation. Two independent reviewers assessed resident performance via audio-video recordings.

RESULTS

No baseline differences in ACS experience were noted between groups. The observational evaluation demonstrated a significant difference in performance between the didactic and simulation groups: 9.9 vs 12.5, P = .037 (effect size = 1.15). Knowledge retention was equivalent between groups.

CONCLUSIONS

This pilot study suggests that simulation-based education may be more effective for teaching the basic concepts of ACS.

Successful intravenous catheterization by medical students

BACKGROUND

Intravenous (IV) catheter placement is one of the most basic and essential medical procedures. However, IV placement can be a source of anxiety for medical students as it is often their first procedural patient care. We sought to investigate the factors that impact the success rate of this skill and to determine at what rate students improve.

MATERIALS AND METHODS

A confidential web-based survey was distributed to a total of 367 third and fourth year students at Virginia Commonwealth University School of Medicine. The responses were collected over a 2-wk period in July 2015.

RESULTS

The response rate was 49.0% (180/367); 65.5% of the M3s and 21.8% of the M4s have never had an opportunity to place an IV. The success rate was higher in students with prior experience as laboratory researchers (86.6%, P = 0.014) as well as emergency medical technicians (81.4%, P = 0.038) when compared to students with no experience. Prior preparation such as reading, watching videos, or even lectures did not increase the success rate. Success rates rapidly improved from 47% for the first attempt to 86% for the fifth attempt.

CONCLUSIONS

A significant percentage of students did not have opportunities to attempt IV catheter placement. We found prior experience, not only as an emergency medical technician but also as a laboratory researcher, significantly increased the success rate. Prior preparations did not improve success rate, and most of the students were successful after only five attempts.

Active Learning in Medical Education: Application to the Training of Surgeons

Our article defines active learning in the context of surgical education and reviews the growing body of research on new approaches to teaching. We then discuss future perspectives and the challenges faced by the trainee and surgeon in applying active learning to surgical training. As modern surgical education faces numerous challenges, we hope our article will help surgical educators in the evaluation of curriculum development, methods of instruction, and assessment.

An evidence-based laparoscopic simulation curriculum shortens the clinical learning curve and reduces surgical adverse events

BACKGROUND

Surgical simulation is becoming increasingly important in surgical education. However, the method of simulation to be incorporated into a surgical curriculum is unclear. We compared the effectiveness of a proficiency-based preclinical simulation training in laparoscopy with conventional surgical training and conventional surgical training interspersed with standard simulation sessions.

MATERIALS AND METHODS

In this prospective single-blinded trial, 30 final-year medical students were randomized into three groups, which differed in the way they were exposed to laparoscopic simulation training. The control group received only clinical training during residency, whereas the interval group received clinical training in combination with simulation training. The Center for Surgical Technologies Preclinical Training Program (CST PTP) group received a proficiency-based preclinical simulation course during the final year of medical school but was not exposed to any extra simulation training during surgical residency. After 6 months of surgical residency, the influence on the learning curve while performing five consecutive human laparoscopic cholecystectomies was evaluated with motion tracking, time, Global Operative Assessment of Laparoscopic Skills, and number of adverse events (perforation of gall bladder, bleeding, and damage to liver tissue).

RESULTS

The odds of adverse events were 4.5 (95% confidence interval 1.3-15.3) and 3.9 (95% confidence interval 1.5-9.7) times lower for the CST PTP group compared with the control and interval groups. For raw time, corrected time, movements, path length, and Global Operative Assessment of Laparoscopic Skills, the CST PTP trainees nearly always started at a better level and were never outperformed by the other trainees.

CONCLUSION

Proficiency-based preclinical training has a positive impact on the learning curve of a laparoscopic cholecystectomy and diminishes adverse events.

Effect of Table Trainer-to-Student Ratios on Outcome in Student Assessments of Cervical Muscle Energy Techniques

CONTEXT

Improving the acquisition of osteopathic manipulative treatment (OMT) skills may increase student confidence and later use of OMT. A first step in this process is determining the optimal table trainer-to-student ratio (TTR).

OBJECTIVE

To determine the effect of TTR on knowledge and skill acquisition of cervical muscle energy OMT techniques in first-year osteopathic medical students.

METHODS

First-year students at 3 colleges of osteopathic medicine received instruction on cervical diagnosis and muscle energy techniques at 1 of 3 workshops, each having a different TTR (1:4, 1:8, or 1:16). Written assessments were conducted immediately before and after the workshop and again 2 weeks later to test retention of the knowledge acquired. Practical assessments were conducted immediately after the workshop and 2 weeks later to test retention of the skills acquired and were graded for technical and proficiency elements.

RESULTS

Ninety-two students completed pre- and postworkshop assessments, and 86 completed the retention assessment. No difference was found between TTRs on the preworkshop, postworkshop, and retention written scores (P≥.15). Postworkshop written assessment scores were highest, followed by retention scores; preworkshop scores were lowest (P&lt;.001). Although the mean (SD) postworkshop practical scores for the 1:4 and 1:8 TTR workshop groups (266.3 [43.1] and 250.6 [47.5], respectively) were higher than those for the 1:16 TTR groups (230.3 [62.2]), the difference was not significant (P=.06). For the retention practical assessment scores, no significant difference was found between TTRs (P=.19). A significant interaction was noted between TTR and the timing of practical assessments; scores declined from postworkshop to retention assessments for the 1:4 (P=.04) and 1:8 (P=.02) TTR workshop groups but not the 1:16 TTR workshop groups (P=.21). Student order in paired student demonstrations also had a significant effect on technical scores (P≤.03); students who demonstrated techniques second had higher scores than those who demonstrated techniques first.

CONCLUSION

The TRR had no significant effect on written or practical assessment scores. Practical assessment scores for the 1:4 and 1:8 TTRs declined significantly between postworkshop and retention assessments. Future studies with more statistical power will be necessary to determine the effect of TTRs on student learning. The current study also found that student order in paired demonstrations may affect practical assessment scores, because the second-demonstrating student scored higher than the first; colleges of osteopathic medicine should therefore consider randomizing student order during practical assessments.

Chasing Perfection and Catching Excellence in Graduate Medical Education

The author reflects on the chapter titled "Preserving Excellence in Residency Training and Medical Care" in Dr. Kenneth Ludmerer's book Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. Rather than assuming that the status quo represents excellence, however, the author asserts that we must make an informed judgment regarding the quality of graduate medical education (GME) by applying an evidence-based approach, carefully measuring performance against specific criteria. But what are the right criteria to judge excellence in GME? The author posits that the first criterion for excellence is the foundational concept identified by the Josiah Macy Jr. Foundation, that of accountability to the public. The author argues that for GME to be truly excellent it must produce a workforce "of sufficient size, specialty mix, and skill" needed to serve the public good. For GME to be truly excellent it must produce the right composition (reflecting the population it serves), use the right pedagogy, and be embedded within the right clinical learning environment. Implementation of competency-based education must be bolder and accelerated. The process of culling out service from education in GME must be more honest, not because all service cannot in some ways be educational but because it is simply too expensive to squander a single minute of time in training. Finally, the epidemic of burnout must be addressed urgently and innovatively.