Personalized video feedback improves suturing skills of incoming general surgery trainees

What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework

OBJECTIVE

To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes.

BACKGROUND

Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies.

METHODS

A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents.

RESULTS

Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored.

CONCLUSION

The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.

Association of Gender and Operative Feedback Quality in Surgical Residents

OBJECTIVE

Feedback is critical for learning, however, gender differences exist in the quality of feedback that trainees receive. For example, narrative feedback on surgical trainees' end-of-block rotations differs based on trainee-faculty gender dyads, with female faculty giving higher quality feedback and male trainees receiving higher quality feedback. Though this represents evidence of gender bias in global evaluations, there is limited understanding of how much bias might be present in operative workplace-based assessments (WBAs). In this study, we explore the quality of narrative feedback among trainee-faculty gender dyads in an operative WBA.

DESIGN

A previously validated natural language processing model was used to examine instances of narrative feedback and assign a probability of being characterized as high quality feedback (defined as feedback which was relevant as well as corrective and/or specific). A linear mixed model was performed, with probability of high quality feedback as the outcome, and resident gender, faculty gender, PGY, case complexity, autonomy rating, and operative performance rating as explanatory variables.

PARTICIPANTS

Analyses included 67,434 SIMPL operative performance evaluations (2,319 general surgery residents, 70 institutions) collected from September 2015 through September 2021.

RESULTS

Of 36.3% evaluations included narrative feedback. Male faculty were more likely to provide narrative feedback compared to female faculty. Mean probabilities of receiving high quality feedback ranged from 81.6 (female faculty-male resident) to 84.7 (male faculty-female resident). Model-based results demonstrated that female residents were more likely to receive high quality feedback (p < 0.01), however, there was no significant difference in probability of high quality narrative feedback based on faculty-resident gender dyad (p = 0.77).

CONCLUSIONS

Our study revealed resident gender differences in the probability of receiving high-quality narrative feedback following a general surgery operation. However, we found no significant differences based on faculty-resident gender dyad. Male faculty were more likely to provide narrative feedback compared to their female colleagues. Further research using general surgery resident-specific feedback quality models may be warranted.

Video-based assessment (VBA) of an open, simulated orthopedic surgical procedure: a pilot study using a single-angle camera to assess surgical skill and decision making

BACKGROUND

Videos have been used in many settings including medical simulation. Limited information currently exists on video-based assessment in surgical training. Effective assessment tools have substantial impact on the future of training. The objectives of this study were as follows: to evaluate the inter-rater reliability of video-based assessment of orthopedic surgery residents performing open cadaveric simulation procedures and to explore the benefits and limitations of video-based assessment.

METHODS

A multi-method technique was used. In the quantitative portion, four residents participated in a Surgical Objective Structured Clinical Examination in 2017 at a quaternary care training center. A single camera bird's-eye view was used to videotape the procedures. Five orthopedic surgeons evaluated the surgical videos using the Ottawa Surgical Competency Operating Room Evaluation. Interclass correlation coefficient was used to calculate inter-rater reliability. In the qualitative section, semi-structured interviews were used to explore the perceived strengths and limitations of video-based assessment.

RESULTS AND DISCUSSION

The scores using video-based assessment demonstrated good inter-rater reliability (ICC = 0.832, p = 0.014) in assessing open orthopedic procedures on cadavers. Qualitatively, the strengths of video-based assessment in this study are its ability to assess global performance and/or specific skills, ability to reassess missed points during live assessment, and potential use for less common procedures. It also allows for detailed constructive feedback, flexible assessment time, anonymous assessment, multiple assessors and serves as a good coaching tool. The main limitations of video-based assessment are poor audio-video quality, and questionable feasibility for assessing readiness for practice.

CONCLUSION

Video-based assessment is a potential adjunct to live assessment in orthopedic open procedures with good inter-rater reliability. Improving audio-video quality will enhance the quality of the assessment and improve the effectiveness of using this tool in surgical training.

Taking advantage of asynchronous digital feedback: development of an at-home basic suture skills training program for undergraduate medical students that facilitates skills retention

Purpose

To date, there are no training programs for basic suturing that allow remote deliberate practice. This study seeks to evaluate the effectiveness of a basic suture skills training program and its 6-month skill retention applying unsupervised practice and remote digital feedback.

Methods

Fourth-year medical-student trainees reviewed instructional videos from a digital platform and performed unsupervised practice as needed at their homes. When they felt competent, trainees uploaded a video of themselves practicing the skill. In < 72 h, they received expert asynchronous digital feedback. The course had two theoretical stages and five video-based assessments, where trainees performed different suturing exercises. For the assessment, a global (GRS) and specific rating scale (SRS) were used, with a passing score of 20 points (max:25) and 15 (max:20), respectively. Results were compared to previously published work with in-person expert feedback (EF) and video-guided learning without feedback (VGL). A subgroup of trainees underwent a 6-month skills retention assessment.

Results

Two-hundred and forty-three trainees underwent the course between March and December 2021. A median GRS of 24 points was achieved in the final assessment, showing significantly higher scores (p < 0.001) than EF and VGL (20.5 and 15.5, respectively). Thirty-seven trainees underwent a 6-month skills retention assessment, improving in GRS (23.38 vs 24.03, p value = 0.06) and SRS (18.59 vs 19, p value = 0.07).

Conclusion

It is feasible to teach basic suture skills to undergraduate medical students using an unsupervised training course with remote and asynchronous feedback through a digital platform. This methodology allows continuous training with the repetition of quality practice, personalized feedback, and skills retention at 6 months.

Video feedback with error-focused or correct-focused examples in surgical skills distance learning: A randomized trial

BACKGROUND

Although it seems natural that surgical trainees would learn from demonstrations of a correct performance, evidence outside of surgical education has suggested that error-focused examples may promote error detection and improved procedural task performance. We hypothesized that feedback through error-focused videos would improve procedural learning more than correct-focused videos.

METHODS

We conducted a randomized controlled trial of video feedback comparing error-focused versus correct-focused examples. The participants were interviewees at our general surgery residency program in December 2020. All of the interviewees performed suturing and knot tying tasks on their interview day (baseline), with 70 common errors identified. For each error, we created an instructional feedback video in two formats: one video demonstrating the error and another demonstrating correct performance. The study participants received feedback videos based on baseline performance errors, with the format randomly assigned. Two blinded raters assessed the baseline and postintervention performances.

RESULTS

Thirty-seven interviewees enrolled and 17 submitted postintervention videos. The postintervention mean performance scores were significantly higher (P = .02) in the error-focused than the correct-focused example group (suturing [maximum score 18]: 16.9 vs 13.9 [difference 2.9; 95% CI 0.7, 5.1]; knot-tying [maximum score 24]: 21.6 vs 17.8 [difference 3.8; 95% CI 0.5, 7.0]). We found no between-group differences in performance time ([error-focused versus correct-focused] suturing: 246 vs 256 s; knot-tying: 170 vs 138 s; P = .08). Mean satisfaction with feedback was similar between groups (error-focused: mean = 5.3 versus correct-focused: mean = 5.2, out of 7; P = .95).

CONCLUSION

Feedback that highlights errors is associated with better learning of surgical skills than feedback demonstrating correct performance, confirming our hypothesis.

Video Coaching: A National Survey of Surgical Residency Program Directors

OBJECTIVE

Video coaching has been demonstrated to improve resident and attending skills and is overwhelmingly well received by the participants. However, misperceptions about its utility among those who do not use video coaching may be a barrier to widespread implementation.

DESIGN

Cross-sectional web-based survey SETTING: National survey PARTICIPANTS: Surgical program director members of the Association of Program Directors of Surgery STUDY DESIGN: The survey was developed via a deductive approach after a literature review and was piloted with surgical attendings and residents. All Likert scale were averaged and comparisons between groups was performed via independent t-tests.

RESULTS

There were 52 responses from PDs. 27/52(51.9%) PDs reported their program supported video coaching of residents. PDs from residences with video coaching programs were more likely to believe that video coaching was useful in identifying their own strengths and weakness (p = 0.005), was a useful adjunct for resident feedback (p = 0.024), and a personal library of video recordings would be helpful (p = 0.015) when compared to PDs from residencies without video coaching. Programs without video coaching were more likely to believe barriers to implementation included it being ineffective (p = 0.024) and that the technology was unavailable (p = 0.006). Over 50% of respondents from both groups believed expense, difficulty with set up, time required, and patient privacy were "Very" or "Extremely" likely to be barriers to implementation.

CONCLUSIONS

This is the first national survey of PDs regarding the use of video coaching. Residency programs without video coaching may underestimate the utility of video coaching in training surgical residents.

Video Coaching in Surgical Education: Utility, Opportunities, and Barriers to Implementation

OBJECTIVE

This review discusses the literature on Video-Based Coaching (VBC) and explores the barriers to widespread implementation.

DESIGN

A search was performed on Scopus and PubMed for the terms "operation," "operating room," "surgery," "resident," "house staff," "graduate medical education," "teaching," "coaching," "assessment," "reflection," "camera," and "video" on July 27, 2021, in English. This yielded 828 results. A single author reviewed the titles and abstracts and eliminated any results that did not pertain to operative VBC or assessment. All bibliographies were reviewed, and appropriate manuscripts were included in this study. This resulted in a total of 52 manuscripts included in this review.

SETTING/PARTICIPANTS

Original, peer-reviewed studies focused on VBC or assessment.

RESULTS

VBC has been both subjectively and objectively found to be a valuable educational tool. Nearly every study of video recording in the operating room found that subjects, including surgical residents and seasoned surgeons alike, overwhelmingly considered it a useful, non-redundant adjunct to their training. Most studies that evaluated skill acquisition via standardized assessment tools found that surgical residents who underwent a VBC program had significant improvements compared to their counterparts who did not undergo video review. Despite this evidence of effectiveness, fewer than 5% of residency programs employ video recording in the operating room. Barriers to implementation include significant time commitments for proposed coaching curricula and difficulty with integration of video cameras into the operating room.

CONCLUSIONS

VBC has significant educational benefits, but a scalable curriculum has not been developed. An optimal solution would ensure technical ease and expediency, simple, high-quality cameras, immediate review, and overcoming entrenched surgical norms and culture.

Impact of the COVID-19 pandemic on the clinical training of last year medical students in Mexico: a cross-sectional nationwide study

BACKGROUND

The COVID-19 pandemic has brought unprecedented changes to medical education. However, no data are available regarding the impact the pandemic may have on medical training in Mexico. The aim of our study was to evaluate and identify the medical school students' perceptions of the changes in their clinical training due to the pandemic in Mexico.

METHODS

This was a cross-sectional study where a previous validated online survey was translated and adapted by medical education experts and applied to senior medical students from March to April of 2021. The 16-item questionnaire was distributed online combining dichotomous, multiple-choice, and 5-point Likert response scale questions. Descriptive and multivariate analyses were performed to compare the student's perceptions between public and private schools.

RESULTS

A total of 671 responses were included in the study period. Most participants were from public schools (81%) and female (61%). Almost every respondent (94%) indicated it was necessary to obtain COVID-19 education, yet only half (54%) received such training. Students in private schools were less likely to have their clinical instruction canceled (53% vs. 77%, p = 0.001) and more likely to have access to virtual instruction (46% vs. 22%, p = 0.001) when compared to students from public schools. Four out of every five students considered their training inferior to that of previous generations, and most students (82%) would consider repeating their final year of clinical training.

CONCLUSIONS

The impact of the COVID-19 on medical education in Mexico has been significant. Most final-year medical students have been affected by the cancellation of their in-person clinical instruction, for which the majority would consider repeating their final year of training. Efforts to counterbalance this lack of clinical experience with virtual or simulation instruction are needed.

Better in 2021

While effective teaching is critical to passing on knowledge and skill to surgical trainees, the actual learning must be done by the trainees. Neural pathways are created as memories which are consolidated, refined, forgotten, and subsequently retrieved. Knowledge and skill build on previous memories as learners gain additional experience. Learning will be greatly enhanced when teachers: 1) praise student efforts, 2) offer individualized feedback, and 3) consistently challenge (assess) trainees. Coaxing learners to put forth more effort creates stronger memories that are easier to retrieve. Detailed feedback leads to refining neural pathways and enhance learning efficiency. Challenging learners with quizzes, assessments, and questions makes it clear to both learner and teacher what the trainee knows and does not know - and additional efforts, feedback, and assessments offer opportunities for learners to master surgical knowledge and skill.

Implementation of written structured feedback into a surgical OSCE

BACKGROUND

Feedback is an essential element of learning. Despite this, students complain about receiving too little feedback in medical examinations, e.g., in an objective structured clinical examination (OSCE). This study aims to implement a written structured feedback tool for use in OSCEs and to analyse the attitudes of students and examiners towards this kind of feedback.

METHODS

The participants were OSCE examiners and third-year medical students. This prospective study was conducted using a multistage design. In the first step, an unstructured interrogation of the examiners formed the basis for developing a feedback tool, which was evaluated and then adopted in the next steps.

RESULTS

In total, 351 students and 51 examiners participated in this study. A baseline was created for each category of OSCE station and was supplemented with station-specific items. Each of these items was rated on a three-point scale. In addition to the preformulated answer options, each domain had space for individual comments. A total of 87.5% of the students and 91.6% of the examiners agreed or rather agreed that written feedback should continue to be used in upcoming OSCEs.

CONCLUSION

The implementation of structured, written feedback in a curricular, summative examination is possible, and examiners and students would like the feedback to be constant.

Synchronized Video-Review as a Tool to Enhance Reflection and Feedback: A Design-Based Feasibility Study

INTRODUCTION

UK surgical training currently faces the challenge of expanding surgical skills in a context of reduced training opportunities. Video-review in theatre offers the potential to gain more from each learning opportunity and to enhance feedback.

AIM

This was a designed-based study to test the feasibility of using synchronized video-review as a reflective tool to enhance surgical training and to gain a deeper understanding of intraoperative feedback.

METHOD

Ten supervised laparoscopic cholecystectomy operations were video-recorded using a synchronized split screen, to show trainees' actions, instrument manipulation, and interactions with other theatre staff. This was followed up by joint review of the operation-recording by both the trainee and supervisor. Video-review sessions were audio-recorded along with the consultant and Specialist Registrar interviews after the review session. Audio recordings were thematically analyzed. Supervisors completed the Procedure-Based Assessment forms, twice: post operation and post video-review to check potential trainers' enhanced insight. Forms were analyzed to note any changes and to triangulate the findings.

RESULTS

Overall trainee and supervisor feedback was positive. Trainees and supervisors reported the video-review added value in terms of reflection-on-action. It removed the stress of conducting/supervising the operation in real time and focused the attention on feedback. Satisfaction was reported across trainee levels with both scrubbed and unscrubbed supervisors. Audio-visual review allowed trainees to understand the feedback better and to identify new targets beyond those gained from the verbal feedback during the procedure. It also facilitated appraisal of the trainer's teaching.

DISCUSSION

This study established the feasibility of using synchronized video-review as a reflection-on-action tool to potentially enhance surgical training by improving feedback. It identified trainees' difficulty in processing intraoperative feedback due to mental overload from the operation. It showed the limitations of current verbal feedback practice, using Procedure-Based Assessment forms, with regard to enhancing technical and nontechnical skills due to denial and memory fading.

Quantifying surgeon maneuevers across experience levels through marker-less hand motion kinematics of simulated surgical tasks

This paper compares clinician hand motion for common suturing tasks across a range of experience levels and tissue types. Medical students (32), residents (41), attending surgeons (10), and retirees (2) were recorded on digital video while suturing on one of: foam, pig feet, or porcine bowel. Depending on time in position, each medical student, resident, and attending participant was classified as junior or senior, yielding six experience categories. This work focuses on trends associated with increasing tenure observed from those medical students (10), residents (15), and attendings (10) who sutured on foam, and draws comparison across tissue types where pertinent. Utilizing custom software, the two-dimensional location of each of the participant's hands were automatically recorded in every video frame, producing a rich spatiotemporal feature set. While suturing on foam, increasing clinician experience was associated with conserved path length per cycle of the non-dominant hand, significantly reducing from junior medical students (mean = 73.63 cm, sd = 33.21 cm) to senior residents (mean = 46.16 cm, sd = 14.03 cm, p = 0.015), and again between senior residents and senior attendings (mean = 30.84 cm, sd = 14.51 cm, p = 0.045). Despite similar maneuver rates, attendings also accelerated less with their non-dominant hand (mean = 16.27 cm/s², sd = 81.12 cm/s², p = 0.002) than senior residents (mean = 24.84 cm/s², sd = 68.29 cm/s², p = 0.002). While tying, medical students moved their dominant hands slower (mean = 4.39 cm/s, sd = 1.73 cm/s, p = 0.033) than senior residents (mean = 6.53 cm/s, sd = 2.52 cm/s). These results suggest that increased psychomotor performance during early training manifest through faster dominant hand function, while later increases are characterized by conserving energy and efficiently distributing work between hands. Incorporating this scalable video-based motion analysis into regular formative assessment routines may enable greater quality and consistency of feedback throughout a surgical career.

Using a self-regulated learning-enhanced video feedback educational intervention to improve junior doctor prescribing

Introduction: Medical school graduates in the UK consistently report feeling underprepared for the task of prescribing when embarking on practice. The effective application of self-regulated learning (SRL) approaches and feedback on complex tasks are associated with improved outcomes in practice-based clinical skills.Aims: This study aimed to investigate the effectiveness of an educational intervention using SRL-enhanced video feedback for improving the prescribing competency of junior doctors.Methods: A prospective cohort study was designed to compare intervention and control cohorts of junior doctors undertaking simulated clinical encounters at the beginning and end of their 4-month rotation through renal medicine.Results: The improvement in prescribing competency for the intervention cohort was significant (p < 0.001) with large effect size (d = 1.42). Self-efficacy improved in both cohorts with large (control cohort p = 0.026, r= 0.64) and medium (intervention cohort p = 0.083, d = 0.55) effect sizes. Goal setting and self-monitoring skills improved in the intervention cohort only with medium effect size (p = 0.096, d = 0.53).Conclusions: SRL-enhanced video feedback is effective for improving prescribing competency and developing SRL processes such as goal setting and self-monitoring skills in simulated clinical encounters. Further research is required to evaluate transferability to other clinical sub-speciality contexts and investigate the effectiveness of the intervention for improving prescribing in non-simulated settings.

Improving junior doctor medicine prescribing and patient safety: An intervention using personalised, structured, video-enhanced feedback and deliberate practice

AIMS

This research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video-enhanced feedback and deliberate practice, undertaken at the start of four-month sub-specialty rotations.

METHODS

Three prospective, non-randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break-even analysis evaluated cost-effectiveness.

RESULTS

There was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI -0.068 to -0.001). The break-even analysis demonstrates cost-effectiveness for the intervention.

CONCLUSION

Simulated clinical encounters using personalised, structured, video-enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost-effective with potential to reduce avoidable harm.

Group Video Feedback is an Effective and Efficient Tool for Enhancing Skills of Surgical Interns

BACKGROUND

Our group has shown that personalized video feedback (PVF) is better than a task demonstration video at increasing wound closure skills among incoming surgical interns. However, offering PVF can be time-consuming. We sought to compare the educational effects and time required for group video feedback (GVF) and PVF.

METHODS

We have mailed our matched incoming "surgical" interns a "welcome package" in mid-March for the past 3 y. The package includes similar resources each year. Incoming interns were asked to video record themselves performing six tasks three separate times between April 1 and June 15. After each submission in 2016 and 2017, incoming interns received 2 min of personalized feedback on their three separate wound closure videos (PVF). In 2018, incoming interns received 5 min of group-based feedback three separate times covering all six tasks (GVF). We compared performance (July Surgical Olympics) of these six skills against the interns from the previous 2 y who received PVF on only one skill (suturing).

RESULTS

Twenty-three incoming interns received the pre-residency package and participated in the 2018 Surgical Olympics. This 2018 GVF class had a higher overall mean score for six stations (31.5 [standard deviation = ±7.7]) than the 2016 and 2017 PVF classes (25.6 [standard deviation = ±8]; P < 0.0001). Knot tying ability and suturing skill were similar between the classes. The GVF group performed better on the remaining four skills . The total time of surgical staff and educators spent per class in 2018 (GVF class) was 30 min and includes six tasks compared with 276 min of effort in each of the 2016 and 2017 classes (PVF included one task).

CONCLUSIONS

GVF and PVF as a component of preemptive training had the same effect on improving suturing skills among the interns. GVF required less educator editing and voice over time. GVF is effective and efficient in enhancing incoming interns' performance in multiple skills.

Boot Camp in a Box: Initial Experience with Pretraining Skills Preparation for New Interns

PURPOSE

In order to increase selected skills at onset of training, we provided newly matched PGY-1 trainees with materials and instructions to practice these skills, as well as the opportunity to share video-recorded performance and receive feedback based on these videos.

METHODS

Knot tying and suturing kits, instruments and supplies, and video instructions for task performance were sent to newly matched trainees to our program (n = 10), with instructions to practice 4 tasks (1- and 2-handed knot tying, interrupted and running suturing) until self-assessed comfort with each task was achieved or the 8-week time point before start of training was reached. Each trainee returned a video of each task, which was graded by blinded reviewers for time and errors using an itemized evaluation instrument (12 items for suturing and five items for knot-tying). Feedback (annotations of submitted videos) was provided after grading was completed. Task performance was repeated and reassessed at the time of new intern "Boot Camp" and again 8 weeks after start of training. Performance scores were compared for the 3 time points and with scores of PGY 2-4 residents using ANOVA with posthoc tests.

RESULTS

Compliance with instruction for practice and return of video recorded tasks in the months before start of PGY-1 training was high, with only 1 of 10 failing to return knot-tying videos. A significant pattern of performance change (p < 0.05) was observed for all tasks with an initial decrease between the pre-employment practice period and the Boot Camp test followed by an increase to the highest level of performance 2 months after start of training. At that point, scores were not significantly different than those of more senior residents.

CONCLUSIONS

A high level of compliance was achieved with requested skills practice and video documentation of performance. We attribute the consistently lower scores on the tasks during Boot Camp tests to higher stress test environment which was apt to be less favorable than having the trainee choose to submit their best possible preresidency video recording of performance in a low-stress situation. Subsequent achievement of significantly higher performance even compared to more senior residents may have been helped by incentivized pretraining practice.