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Wang TN, Woelfel IA, Huang E, Pieper H, Meara MP, Chen X(P. Behind the pattern: General surgery residsent autonomy in robotic surgery. Heliyon 2024; 10:e31691. [PMID: 38841510 PMCID: PMC11152925 DOI: 10.1016/j.heliyon.2024.e31691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 05/12/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024] Open
Abstract
Objective Robotic surgery is increasingly utilized and common in general surgery training programs. This study sought to better understand the factors that influence resident operative autonomy in robotic surgery. We hypothesized that resident seniority, surgeon work experience, surgeon robotic-assisted surgery (RAS) case volume, and procedure type influence general surgery residents' opportunities for autonomy in RAS as measured by percentage of resident individual console time (ICT). Methods General surgery resident ICT data for robotic cholecystectomy (RC), inguinal hernia (RIH), and ventral hernia (RVH) operations performed on the dual-console Da Vinci surgical robotic system between July 2019 and June 2021 were extracted. Cases with postgraduate year (PGY) 2-5 residents participating as a console surgeon were included. A sequential explanatory mixed-methods approach was undertaken to explore the ICT results and we conducted secondary qualitative interviews with surgeons. Descriptive statistics and thematic analysis were applied. Results Resident ICT data from 420 robotic cases (IH 200, RC 121, and VH 99) performed by 20 junior residents (PGY2-3), 18 senior residents (PGY4-5), and 9 attending surgeons were extracted. The average ICT per case was 26.8 % for junior residents and 42.4 % for senior residents. Compared to early-career surgeons, surgeons with over 10 years' work experience gave less ICT to junior (18.2 % vs. 32.0 %) and senior residents (33.9 % vs. 56.6 %) respectively. Surgeons' RAS case volume had no correlation with resident ICT (r = 0.003, p = 0.0003). On average, residents had the most ICT in RC (45.8 %), followed by RIH (36.7 %) and RVH (28.6 %). Interviews with surgeons revealed two potential reasons for these resident ICT patterns: 1) Surgeon assessment of resident training year/experience influenced decisions to grant ICT; 2) Surgeons' perceived operative time pressure inversely affected resident ICT. Conclusions This study suggests resident ICT/autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, but not related to surgeon RAS case volume. Design and implementation of an effective robotic training program must consider the external pressures at conflict with increased resident operative autonomy and seek to mitigate them.
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Affiliation(s)
- Theresa N. Wang
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Ingrid A. Woelfel
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Emily Huang
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Heidi Pieper
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Michael P. Meara
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
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Ahmad QA, Mahboob U, Khan RA, Waheed K, Fahim A. Factors necessary for entrustment decision-making in surgical operating rooms: A modified Delphi study. J Taibah Univ Med Sci 2024; 19:611-618. [PMID: 38800351 PMCID: PMC11126524 DOI: 10.1016/j.jtumed.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 03/18/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
Objective Resident autonomy in an operation theatre has been directly linked with patient safety in healthcare. The objective of this study was to identify the factors necessary for making resident-entrustment decisions from the perspective of a supervisor/consultant viewpoint. The second objective was to develop a checklist for assessing resident readiness for independent work. Materials and methods This study employed a mixed-method Delphi approach. In the first stage, a comprehensive literature review and a qualitative exploratory study produced a list of factors related to residents. The second phase involved content validation by a panel of experts, followed by a two-round Delphi study with 20 expert panelists. Results A total of 49 resident-related factors for entrustment were identified, which were reduced to 46 after content validation. During Delphi Round I, 17 factors were fully accepted, 7 were rejected and 22 items were partially accepted. Out of the 39 items sent to Delphi Round II, 23 items were accepted and 16 were rejected. A final 23-item checklist was formed based on the following factors; 6 Cognitive (knowledgeable, risk manager, safe doctor, general manager, field of interest, communicator), 5 Psychomotor (past performer, competent, ability to pick critical findings, ability to act situationally, decision maker) and 12 affective (responsible, leader, honest, empathetic, ethical, receptive, humble, emotionally intelligent, motivated, accountable, team player, disciplined) factors. Conclusion The study resulted in the formation of a checklist based on the factors necessary for entrustment decision-making in surgical operating rooms. Some of the novel contextual factors were 'general manager', 'field of interest', 'ability to pick critical findings', 'accountable', 'risk manager', and 'past performer'. This framework offers a guideline for supervisors and residents to evaluate progress throughout the residency program. The developed tool demonstrates good content validity and is suitable for entrustment assessment following construct validation.
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Affiliation(s)
- Qamar A. Ahmad
- Department of Medical Education, The University of Lahore, Lahore, Pakistan
- Department of Surgery, Post Graduate Medical Institute, Ameer-u-din Medical College Lahore, Pakistan
| | - Usman Mahboob
- Department of Medical Education, Institute of Health Professions Education & Research, Khyber Medical University, Peshawar, Pakistan
| | - Rehan A. Khan
- Department of Medical Education, Islamic International Medical College, Riphah International University, Islamabad, Pakistan
| | - Khadija Waheed
- Department of Obstetrics & Gynaecology, King Edward Medical University, Lahore, Pakistan
| | - Ayesha Fahim
- Department of Oral Biology, University College of Dentistry, The University of Lahore, Lahore, Pakistan
- Department of Health Sciences, The Equator University of Science and Technology, Uganda
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Millar JK, Matusko N, Evans J, Baker SJ, Lindeman B, Jung S, Minter RM, Weinstein E, Goodstein F, Cook MR, Brasel KJ, Sandhu G. Faculty Entrustment and Resident Entrustability. JAMA Surg 2024; 159:277-285. [PMID: 38198146 PMCID: PMC10782383 DOI: 10.1001/jamasurg.2023.6915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/17/2023] [Indexed: 01/11/2024]
Abstract
Importance As the surgical education paradigm transitions to entrustable professional activities, a better understanding of the factors associated with resident entrustability are needed. Previous work has demonstrated intraoperative faculty entrustment to be associated with resident entrustability. However, larger studies are needed to understand if this association is present across various surgical training programs. Objective To assess intraoperative faculty-resident behaviors and determine if faculty entrustment is associated with resident entrustability across 4 university-based surgical training programs. Design, Setting, and Participants This cross-sectional study was conducted at 4 university-based surgical training programs from October 2018 to May 2022. OpTrust, a validated tool designed to assess both intraoperative faculty entrustment and resident entrustability behaviors independently, was used to assess faculty-resident interactions. A total of 94 faculty and 129 residents were observed. Purposeful sampling was used to create variation in type of operation performed, case difficulty, faculty-resident pairings, faculty experience, and resident training level. Main Outcomes and Measures Observed resident entrustability scores (scale 1-4, with 4 indicating full entrustability) were compared with reported measures (faculty level, case difficulty, resident postgraduate year [PGY], resident gender, observation month) and observed faculty entrustment scores (scale 1-4, with 4 indicating full entrustment). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients. Results A total of 338 cases were observed. Cases observed were evenly distributed by faculty experience (1-5 years' experience: 67 [20.9%]; 6-14 years' experience: 186 [58%]; ≥15 years' experience: 67 [20.9%]), resident PGY (PGY 1: 28 [8%]; PGY 2: 74 [22%]; PGY 3: 64 [19%]; PGY 4: 40 [12%]; PGY 5: 97 [29%]; ≥PGY 6: 36 [11%]), and resident gender (female: 183 [54%]; male: 154 [46%]). At the univariate level, PGY (mean [SD] resident entrustability score range, 1.44 [0.46] for PGY 1 to 3.24 [0.65] for PGY 6; F = 38.92; P < .001) and faculty entrustment (2.55 [0.86]; R2 = 0.94; P < .001) were significantly associated with resident entrustablity. Path analysis demonstrated that faculty entrustment was associated with resident entrustability and that the association of PGY with resident entrustability was mediated by faculty entrustment at all 4 institutions. Conclusions and Relevance Faculty entrustment remained associated with resident entrustability across various surgical training programs. These findings suggest that efforts to develop faculty entrustment behaviors may enhance intraoperative teaching and resident progression by promoting resident entrustability.
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Affiliation(s)
- Jessica K. Millar
- Department of Surgery, University of Michigan, Ann Arbor
- Department of Cardiac Surgery, University of Michigan, Ann Arbor
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor
| | - Julie Evans
- Department of Surgery, University of Michigan, Ann Arbor
| | | | - Brenessa Lindeman
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Sarah Jung
- Department of Surgery, University of Wisconsin-Madison
| | | | - Emily Weinstein
- Department of Surgery, Oregon Health and Science University, Portland
| | | | - Mackenzie R. Cook
- Department of Surgery, Oregon Health and Science University, Portland
| | - Karen J. Brasel
- Department of Surgery, Oregon Health and Science University, Portland
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor
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Shim S, Kim H, Lee YM. Scoping review: exploring residents' views of supervisor entrustment and its effect on learning and professional development. KOREAN JOURNAL OF MEDICAL EDUCATION 2024; 36:81-98. [PMID: 38462244 PMCID: PMC10925806 DOI: 10.3946/kjme.2024.286] [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: 10/10/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 03/12/2024]
Abstract
This scoping review aimed to systematically explore the complex and nuanced perceptions of residents entrusted with significant responsibilities by their supervisors in the clinical context. We conducted a comprehensive search strategy targeting six major electronic databases. Data were extracted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist and a scoping review protocol. Resident perceptions regarding entrustment and its impact on learning and professional development were categorized. This review elucidated the role of supervisor entrustment in shaping residents' clinical performance, notably influencing autonomy, self-confidence, responsibility for patients, learning needs and goals, uncertainty management, and professional identity formation. Residents identified factors that promote and hinder performance and entrustment development resulting from supervisor entrustment and distinguished between appropriate supervision and over- or under-supervision. Our review suggests that residents' perceptions of supervisor entrustment, as bestowed by supervisors, serves as a catalyst for enhancing autonomy, thereby exerting a significant influence on clinical performance, and fostering the development of a professional identity. However, residents' views on appropriate supervision differ in some ways from supervisors' perspectives. Further research is needed to bridge the gap between residents' expectations of autonomy and what they are given, and to explore the intricate relationship between autonomy and entrustment.
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Affiliation(s)
- Sunhee Shim
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
| | | | - Young-Mee Lee
- Department of Medical Education, Korea University College of Medicine, Seoul, Korea
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Keuning MC, Lambert B, Nieboer P, Huiskes M, Diemers AD. Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review. JOURNAL OF SURGICAL EDUCATION 2024; 81:93-105. [PMID: 37838573 DOI: 10.1016/j.jsurg.2023.09.008] [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: 09/17/2022] [Revised: 12/24/2022] [Accepted: 09/11/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed. BACKGROUND Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence. METHODS A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included. RESULTS Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role. CONCLUSIONS This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.
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Affiliation(s)
- Martine C Keuning
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands.
| | - Bart Lambert
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick Nieboer
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition Groningen, University of Groningen, Groningen, The Netherlands
| | - Agnes D Diemers
- Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, The Netherlands
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Goldstein L, Lau J, Ford H, Balmer D, Tenney-Soeiro R. A Qualitative Exploration of Pediatric Resident Perceptions of Autonomy in the Era of Pediatric Hospital Medicine Fellowship. Acad Pediatr 2024; 24:162-172. [PMID: 37567441 DOI: 10.1016/j.acap.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE Some pediatric residents report experiencing less autonomy when working clinically with pediatric hospital medicine (PHM) fellows than with attendings alone. We sought to explore pediatric senior resident (SR) experiences working clinically with PHM fellows, with a focus on characterizing fellow behaviors that could impact perceived resident autonomy. METHODS In this qualitative study, we conducted virtual semistructured interviews with pediatric SRs. We recorded, deidentified, and transcribed interviews for codebook thematic analysis, making iterative adjustments to our codebook and themes until reaching thematic sufficiency. RESULTS We conducted 17 interviews. A subanalysis identified key components of the resident mental model of autonomy, including independent clinical decision-making with 3 core qualifiers: 1) plan follow-through, 2) availability of a safety net, and 3) ownership. Our primary analysis identified 4 key themes (with a total of 7 contributory subthemes) describing resident experiences of autonomy, scaffolded based on an organizing framework adapted from Bronfenbrenner's ecological model including 1) microsystem factors (based on direct resident-fellow or resident-leadership team interactions), 2) mesosystem factors (based on fellow-attending interactions), 3) exosystem factors (based on fellow-intrinsic characteristics), and 4) macrosystem factors (cultural values, norms, and policies governing academic pediatrics). CONCLUSIONS Many factors impact perceived resident autonomy on PHM fellow-inclusive teams. Although some are related to direct resident-fellow interactions, many others are more complex and may reflect resident interactions with the leadership team, attending-fellow dynamics, and the influence of cultural context. Based on our analysis, we propose several best-practice recommendations directed at fellows, attendings, the fellow-attending dyad, and Graduate Medical Education programs overall.
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Affiliation(s)
- Laura Goldstein
- Department of Pediatrics, Children's Hospital of Philadelphia, Pa.
| | - Julianna Lau
- Department of Pediatrics, Children's Hospital of Philadelphia, Pa
| | - Hannah Ford
- Department of Pediatrics, Children's Hospital of Philadelphia, Pa
| | - Dorene Balmer
- Department of Pediatrics, Children's Hospital of Philadelphia, Pa
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Foroushani S, Gaetani RS, Lin B, Chugh P, Siegel A, Whang E, Kristo G. Role Reversal Between Trainees and Surgeons: Improving Autonomy and Confidence in Surgical Residents. J Surg Res 2023; 289:75-81. [PMID: 37086599 DOI: 10.1016/j.jss.2023.03.022] [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: 11/21/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION There are increasing concerns regarding resident autonomy in the context of efficiency, legal ramifications, patient expectations and patient safety. However, autonomy is necessary to develop competent, independent surgeons. Therefore, educational paradigms that maximize opportunities for entrustability without sacrificing patient safety are necessary to ensure adequate training for surgeons. METHODS This is a prospective, qualitative study of intraoperative role reversal between surgeons and residents. Using Likert scales and binary questions, preintervention and postintervention surveys were collected, evaluating variables including intraoperative learning, decision making, communication, confidence, autonomy and opportunity for safe struggle. The Mann-Whitney U test was used to analyze results and compare responses between training years. RESULTS Thirty-six general surgery residents comprising post-graduate year 1, 2, 4, and 5 acted as primary surgeon in a total of 36 cases. Preoperative knowledge scores were significantly higher in more senior residents (P < 0.001), but all residents had significant improvement in knowledge scores postoperatively (P < 0.001). The knowledge improvement was quantitatively larger for junior versus senior residents. Intraoperative decision making significantly improved after the intervention for all training levels (P < 0.001). 25 intraoperative "rescues" were performed by faculty for failure to progress or unsafe conditions (23 for junior residents, 2 for senior residents). Residents indicated that this intraoperative role reversal improved preparation, confidence, autonomy, and intraoperative communication. CONCLUSIONS Intraoperative role reversal between residents and surgeons provides a safe opportunity for maximizing learning and increasing entrustability under direct supervision.
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Affiliation(s)
- Sophia Foroushani
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Racquel S Gaetani
- Department of Surgery, Lahey Hospital and Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Brenda Lin
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Priyanka Chugh
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston University Medical School, Boston, Massachusetts
| | - Ashley Siegel
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Whang
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gentian Kristo
- Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Cost analysis of training residents in robotic-assisted surgery. Surg Endosc 2022; 37:2765-2769. [PMID: 36471060 DOI: 10.1007/s00464-022-09794-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Use of robotic-assisted surgery is increasing, and resident involvement may lead to higher costs. We investigated whether senior resident involvement in noncomplex robotic cholecystectomy (RC) and inguinal hernia (RIH) would take more time and cost more when compared to non-robotic cholecystectomy (NRC) and inguinal hernia repair (NRIH). METHODS We extracted surgery duration and total cost of NRC, NRIH, RC, and RIH from 7/2016 to 6/2020 with senior resident (PGY4-5) involvement. We excluded complex cases as well as prisoner cases and those with new faculty and research residents. We assessed differences between robotic and non-robotic cases in surgery duration and total cost per minute, using one-way ANOVA. RESULTS We included 1608 cases (non-robotic 1145 vs. robotic 463). On average, RC cases with a senior resident took less time than NRC (179.4 < 185.8, p = 0.401); surgery duration of RIH cases was similar with NRIH cases. The total cost per minute of RC cases with a senior resident on average was $9.30 higher than NRC cases for each minute incurred in the operating room but did not lead to a significant change in overall cost. RIH cases, on the other hand, cost less per minute than NRIH cases (114.1 < 126.5, p = 0.399). CONCLUSION Training in robotic surgery is important. Noncomplex RC and RIH involving senior residents were not significantly longer nor did they incur significantly more cost than non-robotic procedures. Senior resident training in noncomplex robotic surgery can be efficient and can be included in the residency curriculum.
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Kejela S, Tiruneh AG. Determinants of satisfaction and self-perceived proficiency of trainees in surgical residency programs at a single institution. BMC MEDICAL EDUCATION 2022; 22:473. [PMID: 35717190 PMCID: PMC9206365 DOI: 10.1186/s12909-022-03521-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND We aimed to identify factors contributing to training program satisfaction and self-perceived proficiency of residents in 5 integrated surgical residency programs within the same referral institution. METHODS We conducted a cross-sectional survey including all senior surgical residents in all integrated sub-specialty and general surgery residency programs at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, Ethiopia. Training programs were assessed on 6 educational components including operative case volume and diversity, intra-operative hands-on training, morning teaching sessions, seminars, ward rounds, and research opportunities. RESULTS Of 82 eligible residents, 69 (84.1%) responded to the survey. Overall resident satisfaction (rated from 0-10) varied between the 5 training programs, from a mean of 6.03 to 7.89 (overall p = 0.03). The percentage of residents who agreed they would be proficient by the end of their training ranged from 44.2%-88.9%. General surgery residents had the lowest overall satisfaction score, and lowest scores in all educational components except seminar teaching. In multivariable analysis, operative case volume and diversity (AOR 3.67; 95% CI, 1.24-10.83; P = 0.019), and hands-on training (AOR 4.15; 95% CI, 1.27-13.5; P = 0.018) were significantly associated with overall resident satisfaction. In ordinal logistic regression, hands-on training (OR 3.94, 95% CI, 1.69-9.2; P = 0.001), and seminar sessions (OR 2.43, 95% CI, 1.11-5.33; P = 0.028) were significantly associated with self-perceived proficiency. CONCLUSION Different surgical residency training programs within the same institution had divergent resident satisfaction scores and proficiency scores. Operative case volume and diversity, and intraoperative hands-on training are the most important predictors of resident satisfaction while hands-on training and seminar sessions independently predicted self-perceived proficiency. Attention to these key components of resident education is likely to have a strong effect on training outcomes.
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Affiliation(s)
- Segni Kejela
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. Explicit teaching in the operating room: Adding the why to the what. MEDICAL EDUCATION 2022; 56:202-210. [PMID: 34612530 PMCID: PMC9297931 DOI: 10.1111/medu.14675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/14/2021] [Accepted: 09/29/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Residents need their supervisors in the operating room to inform them on how to use expertise in present and future occasions. A few studies hint at such explicit teaching behaviour, however without explaining its underlying mechanisms. Understanding and improving explicit teaching becomes more salient nowadays, as access of residents to relevant procedures is decreasing, while end-terms of training programs remain unchanged: high quality patient care. OBJECTIVES A structured analysis of (1) the practices supervisors use for explicit teaching and (2) how supervisors introduce explicit teaching in real time during surgical procedures. METHODS An observational qualitative collection study in which all actions of nine supervisor-resident dyads during a total hip replacement procedure were videotaped. Interactions in which supervisors explicitly or implicitly inform residents how to use their expertise now and in future occasions were included for further analysis, using the iterative inductive process of conversation analysis. RESULTS 1. Supervisors used a basic template of if/then rules for explicit teaching, which they regularly customised by adding metaphors, motivations, and information about preference, prevalence and consequence. 2. If/then rules are introduced by supervisors to solve a (potential) problem in outcome for the present patient in reaction to local circumstances, for example, what residents said, did or were about to do. CONCLUSIONS If/then rules add the why to the what. Supervisors upgrade residents' insights in surgical procedures (professional vision) and teach the degree of individual freedom and variation of their expert standards for future occasions. These insights can be beneficial in improving supervisors' teaching skills.
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Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Mike Huiskes
- Center for Language and CognitionUniversity of GroningenGroningenThe Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial IntelligenceUniversity of GroningenGroningenThe Netherlands
| | - Martin Stevens
- Department of Orthopedic SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Sjoerd K. Bulstra
- Department of Orthopedic SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Debbie A. D. C. Jaarsma
- Center for Research and Innovation in Medical EducationUniversity Medical Center GroningenGroningenThe Netherlands
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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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Geary AD, Sanfey H, Glynn L, Pernar LI. Teaching assistant cases in general surgery training - A literature review. Am J Surg 2021; 223:1088-1093. [PMID: 34819229 DOI: 10.1016/j.amjsurg.2021.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/10/2021] [Accepted: 11/14/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND There is a lack of understanding of the scope and purpose of teaching assistant cases, impact on patients and safety, as well as the facilitators or barriers to resident participation in these cases. METHODS Four databases (PubMed, Embase, Web of Science, and the Education Resources Information Center), were searched. The references of identified resources were additionally hand-searched. 10 articles were identified and considered in the literature review. RESULTS The TA case literature focuses on case numbers and safety. The discussions of papers allude to perceived benefits of TA cases. The literature review reveals that residents are more likely to be granted TA opportunities if they show themselves worthy of entrustment. CONCLUSIONS The work elucidates aspects of TA cases that have not previously been emphasized or highlighted. The literature review can serve to inform attending surgeons and trainees how to optimize the opportunities teaching assistant cases can afford.
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Affiliation(s)
- Alaina D Geary
- Boston University School of Medicine, United States; Department of Surgery, Boston Medical Center, United States
| | - Hilary Sanfey
- Department of Surgery, Southern Illinois University, United States
| | - Loretto Glynn
- Department of Surgery, NYU Long Island School of Medicine, United States
| | - Luise I Pernar
- Boston University School of Medicine, United States; Department of Surgery, Boston Medical Center, United States.
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13
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S Schmiederer I, Torices-Dardon A, M Ferrari-Light D, Charbel Abboud E, Villani V, N Lau J, M Foglia C. Developing a Robotic General Surgery Training Curriculum: Identifying Key Elements Through a Delphi Process. JOURNAL OF SURGICAL EDUCATION 2021; 78:e129-e136. [PMID: 34456170 DOI: 10.1016/j.jsurg.2021.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/23/2021] [Accepted: 08/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE A national robotic surgery curriculum is still developing for general surgery residents as robotic surgery becomes increasingly accessible. One general surgery residency program utilized a Delphi process to optimize a robotic surgery curriculum and to determine key factors that might affect robotic proficiency and intraoperative independence. DESIGN Delphi methodology was used to gain consensus amongst robotic surgery faculty and trainees. Consensus was defined as agreement of 66.7% or above in factors that would allow a resident to independently operate in a robotic case. A panel of diverse representatives proposed factors that might affect resident robotic learning and operative experience. In a subsequent round, questions were sent through an anonymous online survey for respondents to identify factors that affect resident robotic independence. Respondents were also given the ability to write in pertinent factors. SETTING This study was conducted from July 2020 to September 2020 via anonymous web-based questionnaires for education researchers, faculty members, and residents of a university-affiliated independent general surgery residency program. PARTICIPANTS The initial panel consisted of a robotic surgeon, a 2020 graduate, a 2019 graduate and/or robotic fellow, a research resident, and a current resident. The subsequent survey was completed by 8 faculty members, 6 recent graduates, and 15 current residents within the general surgery residency program. RESULTS Proposed items fell into 3 categories: institutional resources, individual qualities, and curricular elements. Consensus within groups was achieved in the following items: dual robotic console models, robotic-focused faculty, resident interest, PGY level, and resident time spent on a simulator. CONCLUSIONS This Delphi exercise has informed this general surgery residency program in the development of a robotic surgery curriculum, through contribution from multiple stakeholders. While curricular elements for baseline robotic knowledge are necessary, institutional resources, deliberate practice, resident entrustment and faculty teaching proficiency warrant further study.
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Affiliation(s)
- Ingrid S Schmiederer
- Department of Surgery, Stanford University Medical Center, Stanford, California.
| | | | | | - Elia Charbel Abboud
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Vincenzo Villani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - James N Lau
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
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14
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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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15
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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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Chen XP, Cochran A, Harzman AE, Ellison EC. A Novel Operative Coaching Program for General Surgery Chief Residents Improves Operative Efficiency. JOURNAL OF SURGICAL EDUCATION 2021; 78:1097-1102. [PMID: 33358340 PMCID: PMC8217072 DOI: 10.1016/j.jsurg.2020.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/29/2020] [Accepted: 12/05/2020] [Indexed: 06/01/2023]
Abstract
INTRODUCTION We evaluated the effect of an operative coaching (OC) model on general surgery chief residents' operative efficiency (OE) measured by operative times. We hypothesized that higher levels of entrustment surgeons intend to offer resident in future similar cases are associated with improved OE. MATERIALS AND METHODS From July 2018 to June 2019, we used a validated instrument to score prospective resident entrustment in 228 evaluations of 6 chief residents during 12 OC sessions each (3 lap colectomy, 3 lap cholecystectomy, 3 ventral hernia, 3 inguinal hernia). Operative times of matched case CPT codes performed by coached chiefs (N = 500) were matched via CPT code to the cases of uncoached chiefs in the academic year 2016-2017 (N = 478). Statistical analysis was performed using Pearson correlation and one-way ANOVA. RESULTS Prospective entrustment scores from coached chief residents were associated with significantly shorter operative times in matched complex cases (CC) (r = -0.58, p = 0.0047). A similar trend was observed in noncomplex cases (NCC) (r = -0.29, p = 0.18). Compared to the historical cohort, coached chief residents showed a decrease in mean operative time during complex cases (p = 0.0008, d = 0.44), but an increase in mean operative times for noncomplex cases (p < 0.0001, d = 0.33). CONCLUSIONS An OC model improves chief residents' prospective entrustment leading to increased OE in cases with greater levels of operative complexity, showing a decrease in mean operative time compared to uncoached residents in certain procedures. This is the first report showing formal coaching may be a method to enhance chief resident OE.
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Affiliation(s)
| | - Amalia Cochran
- Department of Surgery, The Ohio State University, Columbus Ohio
| | - Alan E Harzman
- Department of Surgery, The Ohio State University, Columbus Ohio
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17
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Eskander MF, Woelfel I, Harzman A, Cochran AL, Ellison EC, Phoenix Chen X. Education Morbidity and Mortality: Reviving Intraoperative Teaching and Learning. J Surg Res 2021; 264:462-468. [PMID: 33848846 DOI: 10.1016/j.jss.2021.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/08/2021] [Accepted: 02/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Using the platform of morbidity and mortality conference, we developed and executed a combined faculty-resident intervention called "Education M&M" to discuss challenges faced by both parties in the operating room (OR), identify realistic solutions, and implement action plans. This study aimed to investigate the impact of this intervention on resident OR training. MATERIALS AND METHODS Two resident case presentations were followed by audience discussion and recommendations regarding actionable solutions aimed at improving resident OR training from an expert faculty panel. Postintervention surveys were completed by participants immediately and 2 mo later to assess perceived short and long-term impact on OR teaching and/or learning and the execution of two recommended solutions. Descriptive statistical analysis was applied. RESULTS Immediate post-intervention surveys (n = 44) indicated that 81.8% of participants enjoyed the M&M "a lot"; 90.1% said they would use some or a lot of the ideas presented. Awareness of OR teaching/learning challenges before and after the M&M improved from 3.0 to 3.7 (P = 0.00001) for faculty and 3.0 to 3.9 for trainees (P = 0.00004). Understanding of OR teaching and/or learning approaches improved from 3.1 to 3.7 for faculty (P = 0.00004) and 2.7 to 3.9 for trainees (P = 0.00001). In 2-mo post-intervention surveys, most residents had experienced two recommended solutions (71% and 88%) in the OR, but self-reported changes to faculty behavior did not reach statistical significance. CONCLUSIONS A department-wide education M&M could be an effective approach to enhance mutual communication between faculty members and residents around OR teaching/learning by identifying program-specific challenges and potential actionable solutions.
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Affiliation(s)
| | - Ingrid Woelfel
- Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Alan Harzman
- Ohio State University Wexner Medical Center, Columbus, Ohio
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18
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Huynh C, Da Cunha Godoy L, Kuo CL, Smeds M, Amankwah KS. Examining the Development of Operative Autonomy in Vascular Surgery Training and When Trainees and Program Directors Agree and Disagree. Ann Vasc Surg 2021; 74:1-10. [PMID: 33826957 DOI: 10.1016/j.avsg.2021.01.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lack of autonomy in the operating room (OR) during general surgery residency is a major contributing factor to low confidence operating independently after graduation. Although attempts to address decreased autonomy and development of entrustment in the OR are being made in general surgery programs, this issue has not been examined thoroughly in vascular surgery. We sought to determine barriers and opportunities for developing operative autonomy during vascular surgery training by surveying program directors (PDs) and trainees (integrated residents and fellows) in U.S. vascular surgery training programs. METHODS An anonymous electronic survey was sent via email to all PDs (n = 155) and trainees (n = 516) in United States vascular surgery training programs. Demographics, academic characteristics, and responses regarding factors impacting the development of entrustment were collected. RESULTS Thirty-five PDs and 100 trainees completed the survey (22.5% and 19.4% response rate, respectively). Sixty percent of trainees were integrated residents and 40% were fellows. Twenty percent of PDs and 33% of trainees were female, and 5% of all PDs and trainees were from underrepresented minorities. The single most positive factor affecting the development of autonomy according to trainees and PDs is familiarity of the faculty with the trainee. Both PDs and trainees thought the trainee's preparation for the case positively affected development of autonomy; however, more PDs believed that involvement with preoperative preparation in particular (marking the patient, consenting the patient, filling out a history and physical, prepping and draping the patient) was important (P < 0.05). PDs believed that duty-hour limitations negatively affected the trainee's ability to develop autonomy in the OR, whereas more trainees believed that hospital or OR efficiency policies played a negative role (P < 0.05). Finally, compared with trainees, PDs believed that the appropriate amount of time for safe struggle before the attending should take over the case was when OR efficiency was compromised or at any moment the trainee is unsure of themselves (P < 0.05); trainees believed that the attending should take over the case after the limit of their skill set or troubleshooting ability was reached (P < 0.05). CONCLUSIONS Familiarity of the attending physician with the trainee is an important positive factor for development of entrustment and autonomy in vascular surgery trainees. Duty-hour limitations and belief of the need for hospital efficiency may negatively impact operative independence of trainees. An open discussion about balancing OR efficiency and trainees' safe struggle is essential to address the growth of independent operative skills in vascular surgery trainees.
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Affiliation(s)
- Cindy Huynh
- Department of Surgery, Division of Vascular and Endovascular Services, State University of New York Upstate Medical University, Syracuse, NY; Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Lucas Da Cunha Godoy
- Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut (UConn Health), Farmington, CT
| | - Chia-Ling Kuo
- Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut (UConn Health), Farmington, CT
| | - Matthew Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University, St. Louis, MO
| | - Kwame S Amankwah
- Department of Surgery, Division of Vascular and Endovascular Services, State University of New York Upstate Medical University, Syracuse, NY; Division of Vascular and Endovascular Surgery, University of Connecticut (UConn Health), Farmington, CT.
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19
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Smith BK, Rectenwald J, Yudkowsky R, Hirshfield LE. A Framework for Understanding the Association Between Training Paradigm and Trainee Preparedness for Independent Surgical Practice. JAMA Surg 2021; 156:535-540. [PMID: 33759997 DOI: 10.1001/jamasurg.2021.0031] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The sociopolitical and cultural context of graduate surgical education has changed considerably over the past 2 decades. Although new structures of graduate surgical training programs have been developed in response and the comparative value of formats are continually debated, it remains unclear how different time-based structural paradigms are preparing trainees for independent practice after program completion. Objective To investigate the factors associated with trainees' and program directors' perception of trainee preparedness for independent surgical practice. Design, Setting, and Participants This qualitative study used an instrumental case study approach and obtained information through semistructured interviews, which were analyzed using open-and-focused coding. Participants were recent graduates and program directors of vascular surgery training programs in the United States. The 2 training paradigms analyzed were the integrated vascular surgery residency program (0 + 5, with 0 indicating that the general surgery training experiences are fully integrated into the 5 years of overall training and 5 indicating the total number of years of training) and the traditional vascular surgery fellowship program (5 + 2, with 5 indicating the number of years of general surgery training and 2 indicating the number of years of vascular surgery training). All graduates completed their training in 2018. All interviews were conducted between July 1, 2018, and September 30, 2018. Main Outcomes and Measures A conceptual framework to inform current and ongoing efforts to optimize graduate surgical training programs across specialties. Results A total of 22 semistructured interviews were completed, involving 7 graduates of 5 + 2 programs, 9 graduates of 0 + 5 programs, and 6 vascular surgery program directors. Of the 22 participants, 15 were men (68%). Participants described 4 interconnected domains that were associated with trainees' perceived preparedness for practice: structural, individual, relational, and organizational. Structural factors included the overall and vascular surgery-specific time spent in training, whereas individual factors included innate technical skills, confidence, maturity, and motivation. Faculty-trainee relationships (or relational factors) were deemed important for building trust and granting of autonomy. Organizational factors included features of the local organization, including patient population, case volume, and case mix. Conclusions and Relevance Findings suggest that restructuring training paradigms alone is insufficient to address the issue of trainees' perceived preparedness for practice. A framework was created from the results for evaluating and improving residency and fellowship programs as well as for developing graduate surgical training paradigms that incorporate all 4 domains associated with preparedness.
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Affiliation(s)
- Brigitte K Smith
- Division of Vascular Surgery, Department of Surgery, University of Utah, Salt Lake City
| | - John Rectenwald
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison
| | - Rachel Yudkowsky
- Department of Medical Education, University of Illinois at Chicago, Chicago
| | - Laura E Hirshfield
- Department of Medical Education, University of Illinois at Chicago, Chicago
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20
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Listijono DR, Rosen DMB, Choi S, Bukhari M, Cario GM, Chou D. Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee. Case Rep Obstet Gynecol 2021; 2021:5560309. [PMID: 33747585 PMCID: PMC7960069 DOI: 10.1155/2021/5560309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/13/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022] Open
Abstract
Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.
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Affiliation(s)
- Dave R. Listijono
- Sydney Women's Endosurgery Centre (SWEC), Sydney, Australia
- IVF Australia, Sydney, Australia
| | | | - Sarah Choi
- Sydney Women's Endosurgery Centre (SWEC), Sydney, Australia
| | | | | | - Danny Chou
- Sydney Women's Endosurgery Centre (SWEC), Sydney, Australia
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21
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Foster MJ, O'Hara NN, Weir TB, Aneizi A, Henn RF, Packer JD, Hasan SA, Slobogean GP, Gilotra MN. Difference in Resident Versus Attending Perspective of Competency and Autonomy During Arthroscopic Rotator Cuff Repairs. JB JS Open Access 2021; 6:JBJSOA-D-20-00014. [PMID: 33748637 PMCID: PMC7963494 DOI: 10.2106/jbjs.oa.20.00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A noted deficiency in orthopaedic resident education is a lack of intraoperative autonomy; however, no studies exist evaluating this issue. The purpose of this study was to determine whether there is a difference between resident and attending perception of resident competency and autonomy during arthroscopic rotator cuff repairs and whether increased perceived competency leads to more autonomy.
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Affiliation(s)
- Michael J Foster
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tristan B Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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Cassidy DJ, McKinley SK, Ogunmuyiwa J, Mullen JT, Phitayakorn R, Petrusa E, Kim MJ. Surgical autonomy: A resident perspective and the balance of teacher development with operative independence. Am J Surg 2021; 221:336-344. [DOI: 10.1016/j.amjsurg.2020.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/05/2020] [Accepted: 10/18/2020] [Indexed: 10/23/2022]
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Perceptions of Preparedness in Plastic Surgery Residency Training. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3163. [PMID: 33173679 PMCID: PMC7647638 DOI: 10.1097/gox.0000000000003163] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/10/2020] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Graduating competent surgical residents requires progressive independence during training. Recent studies in other surgical subspecialties have demonstrated overall fewer opportunities for resident independence due to changes in residency regulations, medical–legal concerns, and financial incentives. A survey study was conducted to assess perceived autonomy and preparedness during plastic surgery residency training and to assess factors affecting autonomy.
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24
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Nishii A, Burdine J, Matusko N, Wang T, De Roo A, Lussiez A, Sutzko DC, Minter R, Sandhu G. Identification of promotion and prevention associated surgeon behaviors in the operating room to facilitate resident self-regulated learning. Am J Surg 2020; 221:331-335. [PMID: 33729917 DOI: 10.1016/j.amjsurg.2020.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/24/2020] [Accepted: 10/18/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The regulatory focus theory (RFT) posits that people can pursue goals with a promotion or prevention focus. Greater alignment of RFT motivational styles between faculty and residents may enhance resident operative autonomy. This study establishes a set of faculty behaviors residents can identify to infer faculty motivational styles. METHODS 10 behaviors associated with promotion and prevention motivational styles were identified. General surgery residents rated faculty on how strongly they exhibit these behaviors. Faculty conducted a self-assessment of how strongly they exhibit these behaviors. RESULTS There is a positive correlation between resident and faculty ratings for the promotion-associated behaviors of "works quickly," "high energy," and "mostly provides broad oversight," and for the prevention-associated behaviors of "works slowly and deliberately," "quiet and calm," and "preference for vigilant strategies." CONCLUSION Residents can observe faculty operative behaviors to infer faculty motivational styles. Residents may use this knowledge to adjust to faculty motivational styles and enhance operative interactions.
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Affiliation(s)
- Akira Nishii
- University of Michigan, 500 S State St, Ann Arbor, MI, 48109, United States.
| | - Julie Burdine
- Department of Surgery, Michigan Medicine, 1500, E. Medical Center Dr, Ann Arbor, MI, United States.
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, 1500, E. Medical Center Dr, Ann Arbor, MI, United States.
| | - Ton Wang
- Department of Surgery, Michigan Medicine, 1500, E. Medical Center Dr, Ann Arbor, MI, United States.
| | - Ana De Roo
- Department of Surgery, Michigan Medicine, 1500, E. Medical Center Dr, Ann Arbor, MI, United States.
| | - Alisha Lussiez
- Department of Surgery, Michigan Medicine, 1500, E. Medical Center Dr, Ann Arbor, MI, United States.
| | - Danielle C Sutzko
- Department of Surgery, University of Alabama at Birmingham School of Medicine, 1808 7th Avenue South, BDB 652, Birmingham, AL, 35294, United States.
| | - Rebecca Minter
- Department of Surgery, University of Wisconsin School of Medicine & Public Health, H4/710D Clinical Science Center, 600 Highland Avenue, Madison, WI, United States.
| | - Gurjit Sandhu
- Department of Surgery, Michigan Medicine, 1500, E. Medical Center Dr, Ann Arbor, MI, United States.
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Senociain Gonzalez JE, Dominguez Torres LC. Transferencia de autonomía operatoria en apendicectomía abierta y laparoscópica: Un estudio de métodos mixtos desde la perspectiva de residentes y supervisores. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. Existe información limitada sobre el desarrollo apropiado de curvas quirúrgicas de aprendizaje, con altos niveles de autonomía, en residentes de cirugía general en Colombia. El objetivo de este estudio fue caracterizar los niveles de autonomía, para la realización de apendicectomía laparoscópica o abierta en un programa de especialización, desde la perspectiva de médicos residentes y supervisores.
Métodos. Estudio de métodos mixtos que se realizó en dos fases. La primera fase incluyó la recolección prospectiva de la información de cada procedimiento (apendicectomía abierta o laparoscópica), realizado entre agosto de 2015 y diciembre de 2018, en la que participaron 29 médicos residentes. Cada residente evaluó su función (cirujano, ayudante), el nivel de supervisión y el nivel de autonomía intraoperatoria mediante la Escala de Zwisch (EZ). En la segunda fase (cualitativa), se realizaron entrevistas a un total de 15 cirujanos generales que supervisaron la práctica de los residentes con preguntas que buscaban explicar los hallazgos cuantitativos.
Resultados. Se analizaron 1732 intervenciones: 629 (36 %) se realizaron por vía abierta y 1103 (63 %) por vía laparoscópica. El 81,4 % (n=1411) de los procedimientos fueron realizados en hospitales privados. La percepción global de autonomía reportada por los residentes de acuerdo con la Escala de Zwisch tuvo nivel A 28,9 % (n=500), nivel B 18,1 % (n=313), nivel C 30,4 % (n=526) y nivel D 22,7 % (n=393). El 35,2 % (n=388) de apendicectomías laparoscópicas y el 17,8% (n=112) por vía abierta fueron realizadas con un nivel A, mientras el 19,5 % (n=215) de apendicectomías laparoscópicas y el 28,2 % (n=178) por vía abierta fueron realizadas con un nivel D. La explicación dada de los hallazgos cuantitativos fue la frecuencia de apendicectomías abiertas en hospitales públicos, aspectos relacionados con la transferencia de autonomía hacia el residente y el aumento progresivo en el nivel de autonomía avanzada entre 2015-2018.
Discusión. Se encontró un mayor nivel de autonomía en la realización de apendicectomía por vía abierta comparada con la vía laparoscópica, y los niveles de autonomía fueron mayores en hospitales públicos. La explicación a estos hallazgos estuvo relacionada con el contexto clínico y profesional de los residentes.
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Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya. J Surg Res 2020; 258:137-144. [PMID: 33010559 DOI: 10.1016/j.jss.2020.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/07/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The education of surgical trainees is ideally designed to produce surgeons with both confidence and competence. This involves the development of autonomy in the operating room. Factors associated with autonomy and entrustment have been studied in high-resource settings. In a resource-limited context, where autonomy is solely at the discretion of faculty, and there are fewer external constraints to restrict it, we hypothesized that assessment of a trainee's performance would be dependent upon reported confidence levels of both faculty and trainees in those trainees' abilities. MATERIALS AND METHODS At a teaching hospital in rural Kenya, operative experience surveys were administered to eleven general surgery trainees (PGY1-5) and six faculty paired dyads immediately following operative procedures in May 2016 to elicit self-reported assessments of confidence, hesitation, and ability as measured by the Zwisch Scale. We examined factors related to learning and used dyadic structural equation models to understand factors related to the assessment of ability. RESULTS There were 107 paired surveys among 136 trainees and 130 faculty evaluations. Faculty scrubbed into 76 (72%) cases. In comparison to trainees, faculty were more likely to give a higher average score for confidence (4.08 versus 3.90; P value: 0.005), a lower score for hesitation (2.67 versus 2.84; P value: 0.001), and a lower score for the ability to perform the operation independently (2.73 versus 3.02; P value: 0.01). Faculty and trainee perceptions of hesitation influenced their ability scores. Trainee hesitation (OR 12.1; 1.2-127.6, P = 0.04) predicted whether trainees reported experiencing learning. CONCLUSIONS Between trainees and faculty at a teaching program in rural Kenya, assessment scores of confidence, hesitation, and ability differ in value but remain fairly correlated. Hesitation is predictive of ability assessment, as well as self-reported learning opportunities. Focus upon identifying when trainees hesitate to proceed with a case may yield important educational opportunities.
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Woelfel I, Smith BQ, Strosberg D, Villarreal M, Harzman A, Salani R, Cochran A, Chen X(P. Residents’ method for gaining operative autonomy. Am J Surg 2020; 220:893-898. [DOI: 10.1016/j.amjsurg.2020.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/10/2020] [Accepted: 03/19/2020] [Indexed: 11/24/2022]
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Torbeck L, Dunnington G. Development of a peer review of operative teaching process and assessment tool. Am J Surg 2020; 221:263-269. [PMID: 32958155 DOI: 10.1016/j.amjsurg.2020.08.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/24/2020] [Accepted: 08/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND While teaching evaluation systems are common in academia, very little information is available regarding formal coaching and peer review of teaching performance in surgery. This article is a report on the development and implementation of a peer review of operative teaching program. METHODS Our process was designed using a multistep sequential model which included developing a peer review of teaching instrument that was piloted to study the efficacy and utility of the tool. RESULTS Thirty-nine peer reviews of teaching were conducted. Among the most frequent challenges that faculty identified were allowing residents to struggle/give autonomy, judging when to take over the case, communicating effectively, being patient, balancing education and patient safety, and giving feedback. CONCLUSIONS Our peer review of teaching program is systematic, feasible, and can be adopted by other surgery departments. Faculty's identified strengths and challenges have been incorporated into our faculty development curricula.
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Affiliation(s)
- Laura Torbeck
- Indiana University, 545 Barnhill Dr., 543 Emerson Hall, Indianapolis, IN, 46202, USA.
| | - Gary Dunnington
- Indiana University, 545 Barnhill Dr., 543 Emerson Hall, Indianapolis, IN, 46202, USA
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Woelfel I, Strosberg D, Smith B, Harzman A, Salani R, Cochran A, Chen X. The Construction of Case-Specific Resident Learning Goals. JOURNAL OF SURGICAL EDUCATION 2020; 77:859-865. [PMID: 32201144 DOI: 10.1016/j.jsurg.2020.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Developing resident autonomy in the operating room is a complex process and resident established case specific learning goals may increase resident operating room training efficiency. However, little is understood about residents' experience identifying learning goals for a given case. The aim of this study was to explore the essential components contributing to surgery residents' identification of specific learning goals for surgical cases. DESIGN We conducted focus group interviews with general surgery residents across all post-graduate years (PGY) through convenience sampling. Audio recordings of each interview were transcribed and iteratively analyzed. Emerging themes were identified using a framework method. SETTING The study was conducted within the Department of General Surgery at the Ohio State University Medical Center, a tertiary academic medical center. PARTICIPANTS Eight junior (PGY 1-2) and 10 senior (PGY 3-5) residents participated, of whom 10 were female and 8 were male. RESULTS On average, each focus group interview lasted 57.00 (SD ± 12.99) minutes. Three essential components of residents' creation of case-specific learning goals emerged from the focus group interviews: medical knowledge, surgical experience and entrustment. Residents require baseline knowledge and surgical experience with an operation to identify the learning goal they would aim to execute. They also require entrustment of themselves and support of the attending to accomplish the case specific learning goal. Differences in the possession of these three components would likely influence differences in the ability to create learning goals between junior and senior residents. CONCLUSIONS Medical knowledge, surgical experience and entrustment are 3 factors that are imperative to the creation of a resident's case specific learning goal. The complex combination of these three components contributes to the building of the learning goal prior to the start of the operation. Elucidating these aspects provides additional information for targeted interventions in the future.
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Affiliation(s)
- Ingrid Woelfel
- Department of Surgery, The Ohio State University, Columbus, Ohio.
| | - David Strosberg
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Brentley Smith
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, The Ohio State University, Columbus, Ohio
| | - Alan Harzman
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Ritu Salani
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, The Ohio State University, Columbus, Ohio
| | - Amalia Cochran
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Xiaodong Chen
- Department of Surgery, The Ohio State University, Columbus, Ohio
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Johnston WF, Zelhart MD. Challenges of new surgeon educators: Learning how to lead residents through a case and how much autonomy to give. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2019.100720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Appropriate, progressive trainee autonomy is critical for training competent plastic surgeons who are adequately prepared to enter independent practice. Evaluation and reporting of meaningful operative autonomy among trainees in plastic surgery are understudied. METHODS Parallel survey instruments were developed using the Zwisch metric for progressive operative autonomy and distributed electronically to trainees and faculties in all accredited training programs. Trainees were queried about their operative autonomy in 17 core plastic surgery procedures, associated approach to logging cases, and perceived readiness to enter practice. Faculties provided assessment of their final-year trainees using the same metrics. RESULTS Trainees in 28 programs and faculties in 35 programs participated. Final-year trainees reported the most operative independence with breast tissue expander reconstruction and carpal tunnel release and the least with facelift and rhinoplasty. A mean of 40% of final-year trainees reached supervision only autonomy in the procedures queried; none achieved this with rhinoplasty. Faculties identified the highest final-year trainee operative autonomy with botulinum toxin injection and burn excision and grafting; the least trainee independence was reported with rhinoplasty, cleft lip repair, and facelift. Faculty perception of final-year trainee autonomy was higher than that of trainees for 82% of procedures queried. CONCLUSIONS Although plastic surgery trainees endorse gradual operative autonomy overall, a majority of final-year trainees do not perceive supervision only independence in the majority of core procedures queried. Faculties perceive higher trainee operative autonomy than trainees for most procedures. Discordant approaches to case logging were identified both among trainees and between trainees and faculties. Standardization may improve both progression and assessment of operative autonomy in plastic surgery training.
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Sandhu G, Thompson-Burdine J, Nikolian VC, Sutzko DC, Prabhu KA, Matusko N, Minter RM. Association of Faculty Entrustment With Resident Autonomy in the Operating Room. JAMA Surg 2019; 153:518-524. [PMID: 29466559 DOI: 10.1001/jamasurg.2017.6117] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A critical balance is sought between faculty supervision, appropriate resident autonomy, and patient safety in the operating room. Variability in the release of supervision during surgery represents a potential safety hazard to patients. A better understanding of intraoperative faculty-resident interactions is needed to determine what factors influence entrustment. Objective To assess faculty and resident intraoperative entrustment behaviors and to determine whether faculty behaviors drive resident entrustability in the operating room. Design, Setting, and Participants This observational study was conducted from September 1, 2015, to August 31, 2016, at Michigan Medicine, the University of Michigan's health care system. Two surgical residents, 1 medical student, 2 behavioral research scientists, and 1 surgical faculty member observed surgical intraoperative interactions between faculty and residents in 117 cases involving 28 faculty and 35 residents and rated entrustment behaviors. Without intervening in the interaction, 1 or 2 researchers observed each case and noted behaviors, verbal and nonverbal communication, and interaction processes. Immediately after the case, observers completed an assessment using OpTrust, a validated tool designed to assess progressive entrustment in the operating room. Purposeful sampling was used to generate variation in type of operation, case difficulty, faculty-resident pairings, faculty experience, and resident training level. Main Outcomes and Measures Observer results in the form of entrustability scores (range, 1-4, with 4 indicating full entrustability) were compared with resident- and faculty-reported measures. Difficulty of operation was rated on a scale of 1 to 3 (higher scores indicate greater difficulty). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and observation duration, observation month, and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients. Results Twenty-eight faculty and 35 residents were observed across 117 surgical cases from 4 surgical specialties. Cases observed by postgraduate year (PGY) of residents were distributed as follows: PGY-1, 21 (18%); 2, 15 (13%); 3, 17 (15%); 4, 27 (23%); 5, 28 (24%); and 6, 9 (8%). Case difficulty was evenly distributed: 36 (33%) were rated easy/straightforward; 43 (40%), moderately difficult; and 29 (27%), very difficult by attending physicians. Path analysis showed that the association of PGY with resident entrustability was mediated by faculty entrustment (0.23 [.03]; P < .001). At the univariate level, case difficulty (mean [SD] resident entrustability score range, 1.97 [0.75] for easy/straightforward cases to 2.59 [0.82] for very difficult cases; F = 6.69; P = .01), PGY (range, 1.31 [0.28] for PGY-1 to 3.16 [0.54] for PGY-6; F = 22.85; P < .001), and faculty entrustment (2.27 [0.79]; R2 = 0.91; P < .001) were significantly associated with resident entrustability. Mean (SD) resident entrustability scores were highest for very difficult cases (2.59 [0.82]) and PGY-6 (3.16 [0.54]). Conclusions and Relevance Faculty entrustment behaviors may be the primary drivers of resident entrustability. Faculty entrustment is a feature of faculty surgeons' teaching style and could be amenable to faculty development efforts.
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Affiliation(s)
- Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor
| | | | | | | | | | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor
| | - Rebecca M Minter
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas.,Currently with Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
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Factors and Behaviors Related to the Promotion of Pediatric Hospital Medicine Fellow Autonomy: A Qualitative Study of Faculty. Acad Pediatr 2019; 19:703-711. [PMID: 31077880 DOI: 10.1016/j.acap.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/24/2019] [Accepted: 05/04/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify factors that influence faculty to promote or reduce the expression of autonomy for pediatric hospital medicine (PHM) fellows and describe behaviors faculty employ to support fellow autonomy in the clinical setting. METHODS This was a multicenter, qualitative study using semistructured interviews with core faculty in PHM fellowships. Data were transcribed verbatim and analyzed using a phenomenological approach. Each transcript was coded independently by 2 trained reviewers who then met to reconcile differences. Codes were identified using an iterative approach and organized into themes. Investigators engaged in peer debriefing during data collection, and member checking confirmed the results. RESULTS Interviews were conducted December 2016 to January 2017 with 20 faculty from 5 PHM fellowships. Most participants were female (12, 60%) and assistant (13, 65%) or associate (6, 30%) professors. Data analysis yielded 6 themes. Themes reflect the importance of faculty experience, style, and approach to balancing patient care with education in the provision of autonomy for PHM fellows. Faculty appreciation for the role of autonomy in medical education, investment in their roles as educators, and investment in PHM fellowship training are also influential factors. Finally, fellow clinical, educational, leadership, and communication skills influence the provision of autonomy. Faculty employ various levels of supervision, scaffolding techniques, and direct observation with feedback to support fellow autonomy. Professional development was considered essential for developing these skills. CONCLUSIONS We identified 6 themes related to faculty provision of autonomy to PHM fellows, as well as strategies employed by faculty to support fellow autonomy.
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Allen M, Gawad N, Park L, Raîche I. The Educational Role of Autonomy in Medical Training: A Scoping Review. J Surg Res 2019; 240:1-16. [DOI: 10.1016/j.jss.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
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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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Hoops HE, Haley C, Cook MR, Lopez O, Dewey E, Brasel KJ, Spight D, Kiraly LN. Factors influencing amount of guidance in the operating room during laparoscopic cases. Am J Surg 2019; 217:979-985. [PMID: 30929750 DOI: 10.1016/j.amjsurg.2019.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/13/2019] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Identifying factors associated with resident autonomy may help improve training efficiency. This study evaluates resident and procedural factors associated with level of guidance needed in the operating room. METHODS Intraoperative performance and yearly performance on Fundamentals of Laparoscopic Surgery (FLS) tasks from 74 general surgery residents were retrospectively reviewed. The effect of post-graduate year (PGY), procedure complexity, case difficulty, intraoperative performance, and FLS task performance were analyzed using a mixed-effects model. RESULTS PGY level, procedure complexity, case difficulty, operative technique, and operative knowledge were significantly associated with level of intraoperative guidance. In PGY2-4 residents, ratings of medical knowledge and communication were also significantly associated with guidance. There was no significant association between FLS performance and level of guidance for any PGY level. CONCLUSIONS The amount of intraoperative guidance is influenced by many factors, including resident performance and case characteristics. FLS tasks performance was not significantly associated with intraoperative guidance.
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Affiliation(s)
- Heather E Hoops
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA.
| | - Caleb Haley
- Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Mackenzie R Cook
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Olga Lopez
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Elizabeth Dewey
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Donn Spight
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health and Sciences University, Portland, OR, USA
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Resident autonomy in the operating room: Does gender matter? Am J Surg 2019; 217:301-305. [DOI: 10.1016/j.amjsurg.2018.12.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/24/2018] [Accepted: 12/14/2018] [Indexed: 11/19/2022]
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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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PGY-specific benchmarks improve resident performance on Fundamentals of Laparoscopic Surgery tasks. Am J Surg 2018; 215:880-885. [DOI: 10.1016/j.amjsurg.2018.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 11/17/2022]
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Training Surgeons in the Current US Healthcare System: A Review of Recent Changes in Resident Education. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0195-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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Sutkin G, Littleton EB, Kanter SL, Cianciolo AT, Chen XP, Cope A, Koschmann T. Teaching, Learning, and Performance in the Surgical Workplace: Insights From the Examination of Intraoperative Interactions. TEACHING AND LEARNING IN MEDICINE 2017; 29:378-382. [PMID: 29020522 DOI: 10.1080/10401334.2017.1384732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.
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Affiliation(s)
- Gary Sutkin
- a Departments of Biomedical and Health Informatics and Obstetrics and Gynecology , University of Missouri-Kansas City School of Medicine , Kansas City , Missouri , USA
| | - Eliza Beth Littleton
- b Department of Medicine , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | - Steven L Kanter
- c Office of the Dean , University of Missouri-Kansas City School of Medicine , Kansas City , Missouri , USA
| | - Anna T Cianciolo
- d Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Xiaodong Phoenix Chen
- e Obstetrics Gynecology and Reproductive Biology , Brigham and Women's Hospital , Boston , Massachusetts , USA
| | - Alexandra Cope
- f Leeds Institution of Medical Education , University of Leeds , Leeds , England
| | - Timothy Koschmann
- d Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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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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Phitayakorn R, Kelz RR, Petrusa E, Sippel RS, Sturgeon C, Patel KN, Perrier ND. Expert consensus of general surgery residents’ proficiency with common endocrine operations. Surgery 2017; 161:280-288. [DOI: 10.1016/j.surg.2016.06.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/05/2016] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
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Dubov A, Fraenkel L, Seng E. The Importance of Fostering Ownership During Medical Training. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:3-12. [PMID: 27471927 PMCID: PMC4968578 DOI: 10.1080/15265161.2016.1197338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of "diffusion of responsibility." We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care.
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Klingensmith ME, Potts JR, Merrill WH, Eberlein TJ, Rhodes RS, Ashley SW, Valentine RJ, Hunter JG, Stain SC. Surgical Training and the Early Specialization Program: Analysis of a National Program. J Am Coll Surg 2016; 222:410-6. [PMID: 27016968 DOI: 10.1016/j.jamcollsurg.2015.12.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Early Specialization Program (ESP) in surgery was designed by the American Board of Surgery, the American Board of Thoracic Surgery, and the Residency Review Committees for Surgery and Thoracic Surgery to allow surgical trainees dual certification in general surgery (GS) and either vascular surgery (VS) or cardiothoracic surgery (CTS) after 6 to 7 years of training. After more than 10 years' experience, this analysis was undertaken to evaluate efficacy. STUDY DESIGN American Board of Surgery and American Board of Thoracic Surgery records of VS and CTS ESP trainees were queried to evaluate qualifying exam and certifying exam performance. Case logs were examined and compared with contemporaneous non-ESP trainees. Opinions of programs directors of GS, VS, and CTS and ESP participants were solicited via survey. RESULTS Twenty-six CTS ESP residents have completed training at 10 programs and 16 VS ESP at 6 programs. First-time pass rates on American Board of Surgery qualifying and certifying exams were superior to time-matched peers; greater success in specialty specific examinations was also found. Trainees met required case minimums for GS despite shortened time in GS. By survey, 85% of programs directors endorsed satisfaction with ESP, and 90% endorsed graduate readiness for independent practice. Early Specialization Program participants report increased mentorship and independence, greater competence for practice, and overall satisfaction with ESP. CONCLUSIONS Individuals in ESP programs in VS and CTS were successful in passing GS and specialty exams and achieving required operative cases, despite an accelerated training track. Programs directors and participants report satisfaction with the training and confidence that ESP graduates are prepared for independent practice. This documented success supports ESP training in any surgical subspecialty, including comprehensive GS.
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Affiliation(s)
| | - John R Potts
- Accreditation Council for Graduate Medical Education, Chicago, IL
| | - Walter H Merrill
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | - R James Valentine
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - John G Hunter
- Department of Surgery, Oregon Health and Sciences University, Portland, OR
| | - Steven C Stain
- Department of Surgery, Albany Medical College, Albany, NY
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Aggarwal R. Entrustment, autonomy, and performance in the operating room. Surgery 2015; 158:1113-5. [DOI: 10.1016/j.surg.2015.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
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