Application of the "see one, do one, teach one" concept in surgical training

Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy

BACKGROUND

To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications.

METHODS

A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2).

RESULTS

Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications.

CONCLUSION

Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

Can paediatric surgical registrars safely perform supervised hypospadias surgery?

INTRODUCTION

Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors.

METHODS

We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2).

RESULTS

270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair).

DISCUSSION

Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement.

CONCLUSION

Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.

Comparing teaching with tactile guidance with video modeling with self-evaluative video feedback to train medical skills

Modern medical training consists largely of lecture-based instruction and in vivo or video modeling of specific skills. Other instructional methods, such as teaching with acoustical guidance (TAGteach), have rarely been evaluated. In this study, we compared teaching with tactile guidance, or tactile TAGteach in which a vibratory stimulus is delivered to indicate a correct response, with video modeling and self-evaluative video feedback to teach four participants two medical skills: simple interrupted suture and endotracheal intubation. The results showed that both instructional methods improved performance. However, three participants met the mastery criterion in the tactile TAGteach condition first, although this instructional method required more time to train the skills. We discuss the implications of these findings for training skills to medical practitioners.

Utility of pig head model as an oculoplastic wet lab surgical training tool

PURPOSE

To assess the utility of pig head model as an oculoplastic surgical training tool.

METHODS

Fresh pig head was availed for surgical workshop for entropion correction, eyelid margin repair, and evisceration with implant for oculoplastic surgery-naïve participants. Skill improvement, surgical understanding, and performance of the participants were evaluated both subjectively and objectively by trained oculoplastic surgeons. Subjective assessment was done by a standardized questionnaire based on Likert scale shared with the participants post training. Objective evaluation was done by the faculty based on a three-point scale and a competency-based surgical assessment rubric.

RESULTS

There were 18 surgery-naïve participants in the workshop which comprised ophthalmology residents and comprehensive ophthalmologists. About 88.88% of the participants were able to perform the lid margin and sub-tarsal dissection in entropion surgery. While performing lid tear repair, 94.44% were correctly able to identify the grey line and anterior and posterior lamellae. About 83.33% of the participants were able to place an implant in the scleral shell or intraconal space. About 83.33% of the participants noted that texture and tissue maneuvering were similar to the human eye while performing surgical steps. About 94.44% of the participants reported better understanding, development of skill and additional confidence after training. The median score on objective assessment was 3. The performance on real patients resulted in a median score of 4 for entropion correction.

CONCLUSION

Porcine orbital dissection is an available, affordable, and useful tool for oculoplastic surgical training. Training on porcine model can improve anatomical understanding, clinical judgement, and surgical efficiency in trainees.

Enhancing the Central Venous Catheterization Competency of Medical Students through a Specialized Team and an Interactive Response System: A pre-post study

Background

Central venous catheterization (CVC) is a critical clinical procedure. To avoid complications, possessing good knowledge regarding the CVC care bundle and skills for the proper insertion and maintenance of CVC are important.

Objectives

To evaluate the effectiveness of an educational intervention and the use of an interactive response system in enhancing the CVC bundle care and insertion skills of medical students undergoing critical care medicine training.

Materials and Methods

Sixth-year medical students (equivalent to fourth-year students in the United States) engaged in didactic lessons, interactive demonstrations, and simulator training facilitated by a CVC team comprising three thoracic and two vascular surgeons (all with a minimum 5 years of experience in central venous access) during their intensive care unit (ICU) rotation. Self-reported knowledge and confidence levels were assessed using pre-and posttests administered through the Zuvio App, an interactive response system.

Results

A total of 60 students underwent the educational intervention, of which 54 completed the pretest and 40 completed the posttest. In the posttest, significant improvement was found in the CVC bundle care competency and understanding (P = 0.002), preprocedural preparation (P = 0.002), insertion procedures (P = 0.004), complications (P = 0.003), and insertion depth decisions (P = 0.001). Staff and students reported that assessment and interaction via the Zuvio App were valuable, practical, and feasible in a clinical setting, providing trainees with an individual competency portfolio of receiving precise medical education.

Conclusions

Integrating the training provided by a specialized team with an interactive response system enhanced the knowledge and competency level in CVC insertion among medical students in this study.

Comparing virtual reality and simulation to teach the assessment and management of acute surgical scenarios: A pilot study

Background and Aims

Traditional apprenticeship-based surgical training presents with challenges, especially in acute scenarios. Simulation provides the current standard of facilitating surgical training in a low-risk environment but is restricted by limited accessibility and high costs. Virtual reality (VR) offers immersive three-dimensional computer-generated training scenarios and can connect users from various locations. We aimed to compare the performance of junior doctors to manage an acute surgical scenario using VR and mannequin-based simulation. We hypothesised that VR would be as effective as mannequin-based simulation in performance outcomes.

Methods

This multicentre, randomised controlled pilot study was conducted with eighteen junior doctor volunteers (Foundation and Core Trainee Year 1). Ten were randomly allocated to VR and eight to mannequin-based simulation. Participants completed questionnaires and a 15-min pneumothorax scenario. Quantitative metrics included overall score, time-to-critical decisions, and academic buoyancy scores (ABS). Qualitative metrics included participants' likes and dislikes of their allocated simulation modality.

Results

VR participants scored significantly higher than mannequin-based simulation participants in overall scores (74.30% (SD ± 5.08%) vs. 59.75% (SD ± 10.14) (p = 0.04)), and technical skills aspects (77.20% (SD ± 8.01%) vs. 65.00% (SD ± 8.21%) (p = 0.01)). Mannequin-based simulation participants initiated critical decisions faster and demonstrated a trend towards a faster mean time-to-completion (p = 0.06). ABS scores increased for both study groups, though was only significant for VR participants (p ≤ 0.01). VR participants liked how VR fostered independent learning but disliked the formulaic content and impaired communication-learning compared to mannequin-based simulation.

Conclusion

Both VR and mannequin-based simulation training are effective in training junior doctors in acute surgical scenarios but present different educational benefits. Future research should recruit a larger sample size for a full comparative randomised controlled trial.

The 6 degrees of curriculum integration in medical education in the United States

Despite explicit expectations and accreditation requirements for integrated curriculum, there needs to be more clarity around an accepted common definition, best practices for implementation, and criteria for successful curriculum integration. To address the lack of consensus surrounding integration, we reviewed the literature and herein propose a definition for curriculum integration for the medical education audience. We further believe that medical education is ready to move beyond “horizontal” (1-dimensional) and “vertical” (2-dimensional) integration and propose a model of “6 degrees of curriculum integration” to expand the 2-dimensional concept for future designs of medical education programs and best prepare learners to meet the needs of patients. These 6 degrees include: interdisciplinary, timing and sequencing, instruction and assessment, incorporation of basic and clinical sciences, knowledge and skills-based competency progression, and graduated responsibilities in patient care. We encourage medical educators to look beyond 2-dimensional integration to this holistic and interconnected representation of curriculum integration.

Remote feedback in endovascular simulation training: a mixed-methods study

BACKGROUND

There is an increasing need to increase simulation-based learning opportunities for vascular surgery residents in endovascular skills training. This study aims to explore the effectiveness of remote expert instructional feedback of endovascular simulation-based education, as a means of increasing training opportunities in this area for vascular surgery residents.

METHODS

A mixed-methods study design was adopted. Twelve vascular surgery residents from Ireland were tasked with completing two endovascular renal artery procedures: one with in-person expert feedback and the other with remote instruction. Participants ranged in experience levels from second year to final year of residency. Following the training activities, interviews and a questionnaire were employed to gather information on the usefulness of remote feedback.

RESULTS

There was no significant difference reported by participants using a post-event validated questionnaire between remote and in-person feedback. During the interviews, participants expressed mixed feelings about the presence of the educator while practicing, but they eventually saw no limiting factors to their practice when the trainer provided remote feedback. When receiving performance feedback remotely, clear communication and a shared knowledge of the task development are critical to success.

CONCLUSIONS

We believe these findings can inform the design and development of remote learning and assessment of endovascular skills training and ultimately provide increased opportunities for more skills practice for vascular surgical residents.

3D MODEL of an anatomically inert human hand: feasibility study

OBJECTIVES

Surgery for congenital malformation of the hand is complex and protocols are not available. Simulation could help optimize results. The objective of the present study was to design, produce and assess a 3D-printed anatomical support, to improve success in rare and complex surgeries of the hand.

MATERIAL AND METHODS

We acquired MRI imaging of the right hand of a 30 year-old subject, then analyzed and split the various skin layers for segmentation. Thus we created the prototype of a healthy hand, using 3D multi-material and silicone printing devices, and drew up a printing protocol suitable for all patients. We printed a base comprising bones, muscles and tendons, with a multi-material 3D printer, then used a 3D silicone printer for skin and subcutaneous fatty cell tissues in a glove-like shape. To evaluate the characteristics of the prototype, we performed a series of dissections on the synthetic hand and on a cadaveric hand in the anatomy lab, comparing realism, ease of handling and the final result of the two supports, and evaluated their respective advantages in surgical and training contexts. A grading form was given to each surgeon to establish a global score.

RESULTS

This evaluation highlighted the positive and negative features of the model. The model avoided intrinsic problems of cadavers, such as muscle rigidity or tissue fragility and atrophy, and enables the anatomy of a specific patient to be rigorously respected. On the other hand, vascular and nervous networks, with their potential anatomical variants, are lacking. This preliminary phase highlighted the advantages and inconveniences of the prototype, to optimize the design and printing of future models. It is an indispensable prerequisite before performing studies in eligible pediatric patients with congenital hand malformation.

CONCLUSION

The validation of 3D-printed anatomical model of a human hand opens a large field of applications in the area of preoperative surgical planning. The postoperative esthetic and functional benefit of such pre-intervention supports in complex surgery needs assessing.

[Satisfaction with continuing education at a level 1 trauma center-Results of a survey and development of a competency-based continuing education concept]

BACKGROUND

Structured competency-based training is one of the most frequently articulated wishes of residents.

METHODS

A survey of 19 residents was conducted regarding their satisfaction with the resident education at a level 1 trauma center. In this article the development of a revised competency-based education concept was carried out.

RESULTS

The survey reflected uncertainty as to whether the current structures could meet the requirements of the residency regulations. The improved competency-based education concept consists of clinical mentoring, competency-based catalogs of learning objectives, regular theoretical and practical workshops as well as regular and structured staff evaluations.

CONCLUSION

The education concept presented reflects the attempt to establish a contemporary surgical training program which will be evaluated as it progresses.

Certification Training and Liver Transplant Experience Improves Liver Procurement Outcomes: The Dutch Approach

BACKGROUND

This study investigates the impact of certification training and liver transplant experience on procurement outcomes of deceased donor liver procurement in the Netherlands.

METHODS

Three groups (trainee, certified, and master) were formed, with further subdivision based on liver transplant experience. Three key outcomes-surgical injury, graft discard after injury, and donor hepatectomy duration-were analyzed.

RESULTS

There were no significant differences in surgical graft injury in the three groups (trainee, 16.9%; certified, 14.8%; master, 18.2%; P = 0.357; 2011 to 2018). The only predictor for surgical graft injury was donation after cardiac death (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.10-2.02). Of the three groups, the master group had the highest discard rate after surgical injury (trainee, 0%; certified, 1.3%; master, 2.8%; P = 0.013). Master group without liver transplant experience (OR, 3.16; 95% CI, 1.21-8.27) and male donor sex (OR, 3.58; 95% CI, 1.32-9.73) were independent risk factors for discarding livers after surgical injury. Independent predictors for shorter hepatectomy durations included donors older than 50 years (coefficient [Coeff], -7.04; 95% CI, -8.03 to -3.29; P < 0.001), and master group (Coeff, -9.84; 95% CI, -14.37 to -5.31; P < 0.001) and certified group with liver transplant experience (Coeff, -6.54; 95% CI, -10.83 to -2.26; P = 0.003). On the other hand, master group without liver transplant experience (Coeff, 5.00; 95% CI, 1.03-8.96; P = 0.014) and donation after cardiac death (Coeff, 10.81; 95% CI, 8.32-13.3; P < 0.001) were associated with longer hepatectomy durations.

CONCLUSIONS

Training and certification in abdominal organ procurement surgery were associated with a reduced discard rate for surgical injured livers and shorter hepatectomy times. The contrast between master group with and without liver transplant experience underscores the need for specialized training in this field.

Evaluation of a novel home-based laparoscopic and core surgical skills programme (Monash Online Surgical Training)

INTRODUCTION

Limitations to surgical education access were exacerbated during the COVID-19 Pandemic. In response, we created a national home-based comprehensive surgical skills course: Monash Online Surgical Training (MOST). Our aim was to evaluate the educational impact of this approach.

METHODS

A remote, 6-week course was designed with learning objectives aligned to the national surgical training. Participants received a personal laparoscopic bench trainer, instrument tracking software, live webinars, access to an online theoretical learning platform, and individualised feedback by system-generated or expert surgeons' assessments. Mixed method analysis of instrument tracking metrics, pre- and post-course questionnaires (11 core surgical domains) and participant comments was utilised. Data were analysed using the Mann-Whitney U test, and a p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 54 participants with varied levels of experience (1 to > 6 years post-graduate level) completed MOST. All 11 learning-outcome domains demonstrated statistically significant improvement including core laparoscopic skills (1.4/5 vs 2.8/5, p < 0.0001) and handling laparoscopic instruments (1.5/5 vs 2.8/5, p < 0.0001). A total of 3460 tasks were completed reflecting 158.2 h (9492 min) of practice, 394 were submitted for formal feedback. Participants rated the course (mean 8.5/10, SD 1.6), live webinars (mean 8.9/10, SD 1.6) and instrument tracking software (mean 8.6, SD 1.7) highly. Qualitative analysis revealed a paradigm shift including the benefits of a safe learning environment and self-paced, self-directed learning.

CONCLUSION

The MOST course demonstrates the successful implementation of a fully remote laparoscopic simulation course which participants found to be an effective tool to acquire core surgical skills.

Application of a user experience design approach for an EHR-based clinical decision support system

Objective

We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool.

Materials and methods

We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management.

Results

The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake.

Discussion

Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference.

Conclusion

A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

The Use of E-Learning in Peyton's 4-Step Approach: Evaluation of Facial Computed Tomography Scans

Imparting procedural skills is challenging. Peyton's approach is an effective face-to-face teaching technique increasingly used in complex skills training. Institutions are beginning to incorporate online training as part of their procedural curriculum. We developed E-Peyton's to employ Peyton's approach through an electronic learning platform. The efficacy of E-Peyton's approach in teaching the interpretation of facial computed tomography (CT) scans is evaluated in this study. Naïve learners (n=41) were randomized into 2 groups based on teaching techniques employed: E-Peyton's (n=20) and Peyton's (n=21) approaches. The distance between the infraorbital margin and the posterior ledge was measured using a 3-part standardized measuring protocol on OsiriX. Twenty measurements were assessed for accuracy against the benchmark (±2 mm) at week 0 and week 1. Training durations were compared. Questionnaires were administered before and after the study to identify learners' acceptance of teaching techniques and their confidence in interpreting facial CT scans. Learners in both teaching techniques had comparable skills retention. Gap scores indicate significant improvement in learner's confidence levels regardless of teaching technique (P<0.05). Both teaching techniques were well-accepted by learners. E-Peyton's and Peyton's approaches required a similar training duration. The COVID-19 pandemic highlights the importance of effective remote learning platforms. E-Peyton's approach is comparable to that of Peyton's in all areas of assessment. E-Peyton's approach effectively automates Peyton's approach, allowing for standardized, high-quality procedural skills training while reducing manpower burden.

Realistic simulation and medical students' performance in the Advanced Cardiac Life Support course: a comparative study

Clinical practice has benefited from new methodologies such as realistic simulation (RS). RS involves recreating lifelike scenarios to more accurately reflect real clinical practice, enhancing learners' skills and decision-making within controlled environments, and experiencing remarkable growth in medical education. However, RS requires substantial financial investments and infrastructure. Hence, it is essential to determine the effectiveness of RS in the development of skills among medical students, which will improve the allocation of resources while optimizing learning. This cross-sectional study was carried out in the simulation laboratory of a medical school, and the performance of students who underwent two different curriculum matrices (without RS and with RS, from 2021 to 2022) in the Advanced Cardiac Life Support (ACLS) course was compared. This test was chosen considering that the competencies involved in cardiac life support are essential, regardless of the medical specialty, and that ACLS is a set of life-saving protocols used worldwide. We observed that the impact of RS can be different for practical abilities when compared with the theoretical ones. There was no correlation between the general academic performance and students' grades reflecting the RS impact. We conclude that RS leads to less remediation and increased competence in practical skills. RS is an important learning strategy that allows repeating, reviewing, and discussing clinical practices without exposing the patient to risks.NEW & NOTEWORTHY Realistic simulation (RS) positively affected the performance of the students differently; it had more influence on practical abilities than theoretical knowledge. No correlation between the general academic performance and grades of the students without RS or with RS was found, providing evidence that RS is an important tool in Advanced Cardiac Life Support education.

Clinical Outcomes of Standardized Central Venous Catheterization Simulation Training: A Comparative Analysis

OBJECTIVE

A standardized ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) using online- and simulation-based training was first designed and then large-scale deployed at a teaching hospital institution to improve CVC surgical education. To understand the impact that the standardized training might have on patient complications, this study focuses on identifying the impact of the integration of an iteratively designed US-IJCVC training on clinical complications at a teaching hospital.

DESIGN AND PARTICIPANTS

A comparative study was conducted using TriNetX, a global health research network. Using Current Procedural Terminology (CPT) codes and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, we identified the total number of patients with a CVC and mechanical, infectious, and thrombosis complications with and without billable ultrasound between July 1 to June 30 in 2016, 2017, and 2022.

SETTING

A teaching hospital institution in Pennsylvania.

RESULTS

Results showed a correlation between years and complications indicating, (1) mechanical complications billable ultrasound, (2) infectious complications billable ultrasound, and (3) thrombosis complications billable ultrasound were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported.

CONCLUSION

These results indicate that there has been a decrease in mechanical, infectious, and thrombosis complications, which correlates with the US-IJCVC training large-scale deployment.

Evaluating a Single Surgeon's Learning Curve for Laparoscopic Totally Extraperitoneal Repair of Inguinal Hernia with Telescopic Dissection: A Cumulative Sum Control Chart Analysis

Background: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair (IHR) reduces risk of injury to intraperitoneal structures. Balloon dissection is more costly and has theoretical risk of injury to the surrounding structures compared with telescopic dissection (TD). This study aims to evaluate the learning curve (LC) for TEP IHR with TD of a single surgeon. Methods: This is a 3-year retrospective cohort study from January 2020 to December 2022 on patients who underwent elective laparoscopic TEP unilateral IHR with TD. Exclusion criteria were recurrent inguinal hernia. Cumulative sum (CUSUM) analysis was performed to evaluate the number of cases required to surmount the LC, that is, NLC for operating time (OT) and open conversion. One way analysis of variance was used to perform groupwise comparison. Results: There were 69 patients who underwent laparoscopic TEP unilateral IHR with TD. The median age was 58.0 years (range 24.0-80.0) and body mass index was 23.0 (range 18.6-30.0). Majority of the hernia was indirect (n = 48, 69.6%). The median OT was 70 minutes (range 35-210). Three cases (4.3%) had open conversion. One-year recurrence was 4.2% (n = 1/24). CUSUM analysis showed improvement in OT after the eighth case. However, this was followed by multiple inflection points with no apparent stabilization in OT. Pairwise comparison showed a decrease in OT between cases 18-36 and cases 37-54. There was no incidence of open conversion until the 56th case. Conclusion: Laparoscopic TEP IHR using TD is safe in the absence of a practor. A minimum of 36 cases is required to surmount the initial LC.

Online versus in-person surgical near-peer teaching in undergraduate medical education during the COVID-19 pandemic: A mixed-methods study

Background and Aims

The coronavirus disease 2019 (COVID-19) pandemic stimulated a paradigm shift in medical and surgical education from in-person teaching to online teaching. It is unclear whether an in-person or online approach to surgical teaching for medical students is superior. We aim to compare the outcomes of in-person versus online surgical teaching in generating interest in and improving knowledge of surgery in medical students. We also aim the quantify the impact of a peer-run surgical teaching course.

Methods

A six-session course was developed by medical students and covered various introductory surgical topics. The first iteration was offered online to 70 UK medical students in March 2021, and the second iteration was in-person for 20 students in November 2021. Objective and subjective knowledge was assessed through questionnaires before and after each session, and also for the entire course. Data were analyzed from this mixed-methods study to compare the impact of online versus in-person teaching on surgical knowledge and engagement.

Results

Students in both iterations showed significant improvement of 33%-282% across the six sessions in knowledge and confidence after completing the course (p < 0.001). There was no significant difference in the level of objective knowledge, enjoyment, or organization of the course between online and in-person groups, although the in-person course was rated as more engaging (mean Likert score 9.1 vs. 9.7, p = 0.033).

Discussion

Similar objective and subjective surgical teaching outcomes were achieved in both iterations, including in "hands-on" topics such as suturing, gowning, and gloving. Students who completed the online course did not have any lower knowledge or confidence in their surgical skills; however, the in-person course was reported to be more engaging. Surgical teaching online and in-person may be similarly effective and can be delivered according to what is most convenient for the circumstances, such as in COVID-19.

Implementation of the REFLECT Communication Curriculum for Clinical Oncology Graduate Medical Education

Background: Communication and interpersonal skills are essential medical components of oncology patient care. Patients and families rely on physicians for treatment, expertise, guidance, hope, meaning, and compassion throughout a life-threatening illness. A provider's inability to empathize with patients is linked to physician-related fatigue and burnout. Because oncology training programs focus on teaching evidence-based medicine and clinical acumen, little time may be dedicated to professional development and acquisition of interactive skills. Traditional communication courses typically include two components: formal, knowledge-based learning skills, which are gained from didactic lectures, and role-playing, which usually occurs in small groups. We report the implementation of a novel longitudinal communication curriculum for trainees in Oncology. Materials and Methods: At a single-center institution, an innovative communication curriculum titled "REFLECT" (Respect, Empathy, Facilitate Effective Communication, Listen, Elicit Information, Compassion, and Teach Others) was implemented for radiation oncology residents and medical oncology fellows to improve and refine physician/patient interactions. All oncology specialty residents and fellows were eligible to participate in this communication curriculum. The curriculum emphasized a reflective process to guide trainees through challenging scenarios. Results: Since October 2018, this comprehensive course consisted of quarterly (four hour) workshops comprising assigned reading, knowledge assessments, didactic lectures, expert guest lecturers, standardized patient simulations, role-playing, patient/expert panels, coaching, reflective writing, and debriefing/feedback sessions. The curriculum provided longitudinal communication training integrated with the learners' daily physician/patient encounters rather than occasional isolated experiences. Fifteen workshops have been completed. Each focused on navigating challenging situations with patients, loved ones, or colleagues. Conclusions: Future directions of the curriculum will entail improving the communication skills of oncology trainees and gathering communication improvement data to assess the program's success formally.

Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network

BACKGROUND

Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research.

METHODS

In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations.

RESULTS

Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic.

CONCLUSIONS

Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Clinical Supervision of Medical Students in Primary Health Care Services: General Practitioners' Perspectives in Morocco

Introduction

Clinical supervision is crucial to establish a learning climate in which the supervisor guides the supervised. Clinical supervisors might have numerous barriers and motivations. Our study aimed to explore the clinical supervision practices among general practitioners and to describe their motivations, barriers, and needs.

Methods

A qualitative study was conducted using purposive sampling which is a non-probabilistic sampling method. The population was the general practitioners who were working at the primary health care centers either in the public or the private sectors (N=16). Individual semi-structured interviews were conducted by two authors, using an interview guide. All interviews were recorded, transcribed, and coded. A thematic content analysis was done manually based on an inductive approach.

Results

Sixteen general practitioners participated. Three main themes emerged from the study: 1) General practitioners' practices in clinical supervision, 2) the enablers to adequate clinical supervision in general practice, and 3) the general practitioners' fundamental barriers and needs in clinical supervision. Despite their lack of clinical supervision training, they could describe the different clinical supervision steps without giving their exact names. We found that their teaching skills must be reinforced. General practitioners were mainly motivated by personal and professional interests as well as moral obligations. Numerous barriers and needs were identified at the organizational, relational, and financial levels. The principles barriers and needs were the lack of clinical supervision training, lack of equipment, and remuneration.

Conclusion

The current study highlighted the motivations and challenges of general practitioners concerning clinical supervision. These results are helpful for all responsible institutions involved in clinical supervision and upcoming programs in Morocco.

Integration of simulation-based teaching in anaesthesiology curriculum

Simulation refers to the replication of various elements of a real-world situation to achieve pre-specified objectives by enabling experiential learning. As the global burden of preventable medical errors remains high, simulation-based teaching may be used to standardise medical training and improve patient safety. With the same intent, the National Medical Commission has adopted simulation as part of the Competency Based Medical Education approach. Simulation-based training creates immersive and experiential learning, which keeps the new generation of learners actively involved in the learning process. Simulation is widely used to impart technical and non-technical skills for postgraduate trainees in anaesthesiology, but it is still not integrated as a structured part of the curriculum. This article aims to identify technical and non-technical skills that can be taught using simulation and suggests opportunities for using the existing infrastructure and resources to integrate simulation as part of the anaesthesiology training curriculum.

Does Extended Reality Simulation Improve Surgical/Procedural Learning and Patient Outcomes When Compared With Standard Training Methods?: A Systematic Review

INTRODUCTION

The use of extended reality (XR) technologies, including virtual, augmented, and mixed reality, has increased within surgical and procedural training programs. Few studies have assessed experiential learning- and patient-based outcomes using XR compared with standard training methods.

METHODS

As a working group for the Society for Simulation in Healthcare, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a PICO strategy to perform a systematic review of 4238 articles to assess the effectiveness of XR technologies compared with standard training methods. Outcomes were grouped into knowledge, time-to-completion, technical proficiency, reactions, and patient outcomes. Because of study heterogeneity, a meta-analysis was not feasible.

RESULTS

Thirty-two studies met eligibility criteria: 18 randomized controlled trials, 7 comparative studies, and 7 systematic reviews. Outcomes of most studies included Kirkpatrick levels of evidence I-III (reactions, knowledge, and behavior), while few reported level IV outcomes (patient). The overall risk of bias was low. With few exceptions, included studies showed XR technology to be more effective than standard training methods in improving objective skills and performance, shortening procedure time, and receiving more positive learner ratings. However, XR use did not show significant differences in gained knowledge.

CONCLUSIONS

Surgical or procedural XR training may improve technical skill development among trainees and is generally favored over standard training methods. However, there should be an additional focus on how skill development translates to clinically relevant outcomes. We recommend longitudinal studies to examine retention and transfer of training to clinical settings, methods to improve timely, adaptive feedback for deliberate practice, and cost analyses.

Training in Endoscopic Ear Surgery: A Scoping Review

OBJECTIVE

Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification.

DATA SOURCES

A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included.

REVIEW METHODS

A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed.

RESULTS

Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present.

CONCLUSIONS

Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.

Case report: Acute appendicitis in appendix duplication

INTRODUCTION

Duplication of the appendix is a very rare presentation. According to the Cave-Wallbridge classification, there are three types of duplicate appendix.

PRESENTATION OF CASE

A 43 year old female presented with classical symptoms of acute appendicitis, with unremarkable inflammatory markers. The diagnosis was confirmed on pre-operative computer tomography (CT). During laparoscopy two tubular structures were identified: one arising from the tenia libera of the caecum adjacent to the terminal ileum and one retrocaecally at the confluence of the teniae. Both structures were excised using a laparoscopic linear stapler. Histopathological analysis demonstrated the accessory structure to be a microscopically unremarkable blind-ended tubular structure. The other specimen demonstrated acute gangrenous inflammation of the appendix. The patient had an uneventful recovery and was discharged home the following day.

DISCUSSION

Appendix duplication is rare; however, failure to recognise it in a patient with acute appendicitis could result in a retained source of sepsis, requiring subsequent re-exploration of the abdomen. The case presented here represents a Type B2 according to the Cave-Wallbridge classification and is the most susceptible to inadvertent error due to having appendixes in both typical and atypical anatomical locations. This case also highlights the probability of this diagnosis being missed on pre-operative CT.

CONCLUSION

This case report presents a unique opportunity for surgical trainees to review intra-operative laparoscopic images of a duplicate appendix, both to allow them to recognise this pathology if encountered in the future, and to embed the importance of ruling it out with thorough intra-operative examination.

[Goal-setting in Plastic Surgery using the SMART principle]

INTRODUCTION

The process of continuous acquisition of surgical expertise is a key element in registrar training. The principle of active, self-directed learning, which is regularly applied in medical school, can also be used to gain surgical expertise in registrar training.

METHODS

Surgical training can be compared to acquiring expertise in music or sport, where both intellectual and manual capabilities are required. Specific training principles, including analysis, goal setting, practice and reflection on the process, are commonly encountered in these fields. Smart goal setting is preferred in order to ensure compliance and a successful strategy. This can also be used in plastic surgery training.

APPLICATION

Surgical principles as well as partial or complete surgical procedures can be practiced using the smart principle. The fragmentation of a larger task into smaller units allows rapid acquisition of surgical expertise without impeding patient safety.

DISCUSSION

Surgical training today happens in a setting caught between economic and medicolegal challenges. The reduction of case load requires simulation practice as well as self-directed learning - which has been shown to improve outcomes. The smart principle allows distinct goal setting which can improve compliance of the student and increase success. As this form of learning is not intuitive to all individuals, supervisors and mentor can support trainees in the acquisition of surgical expertise using this principle.

Totally endoscopic cartilage tympanoplasty: a hierarchical task analysis

BACKGROUND

Totally endoscopic ear surgery is a novel method of conducting otological surgery. Hierarchical task analysis and the systematic human error reduction and prediction approach ('SHERPA') are valuable tools that can effectively deconstruct the technical and non-technical skills required to successfully complete a surgical procedure.

METHODS

Twenty-five endoscopic tragal cartilage tympanoplasties were observed, to identify the tasks and subtasks required for completion of totally endoscopic tragal cartilage tympanoplasty. The systematic human error reduction and prediction approach was used to identify the potential risks and methods, to reduce or remediate these risks.

RESULTS

A hierarchical task analysis was performed, identifying 8 tasks and 50 subtasks for a safe approach to completing totally endoscopic tragal cartilage tympanoplasty. A risk score for each subtask was calculated to produce a systematic human error reduction and prediction approach and to highlight potential errors.

CONCLUSION

This hierarchical task analysis allowed for quick reference to a correct method of endoscopic tympanoplasty. The systematic human error reduction and prediction approach was employed to reduce the risks associated with undergoing endoscopic tympanoplasty, to improve patient safety.

Applied use of biomechanical measurements from human tissues for the development of medical skills trainers: a scoping review

OBJECTIVE

The objective of this review was to identify quantitative biomechanical measurements of human tissues, the methods for obtaining these measurements, and the primary motivations for conducting biomechanical research.

INTRODUCTION

Medical skills trainers are a safe and useful tool for clinicians to use when learning or practicing medical procedures. The haptic fidelity of these devices is often poor, which may be because the synthetic materials chosen for these devices do not have the same mechanical properties as human tissues. This review investigates a heterogeneous body of literature to identify which biomechanical properties are available for human tissues, the methods for obtaining these values, and the primary motivations behind conducting biomechanical tests.

INCLUSION CRITERIA

Studies containing quantitative measurements of the biomechanical properties of human tissues were included. Studies that primarily focused on dynamic and fluid mechanical properties were excluded. Additionally, studies only containing animal, in silico , or synthetic materials were excluded from this review.

METHODS

This scoping review followed the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sources of evidence were extracted from CINAHL (EBSCO), IEEE Xplore, MEDLINE (PubMed), Scopus, and engineering conference proceedings. The search was limited to the English language. Two independent reviewers screened titles and abstracts as well as full-text reviews. Any conflicts that arose during screening and full-text review were mediated by a third reviewer. Data extraction was conducted by 2 independent reviewers and discrepancies were mediated through discussion. The results are presented in tabular, figure, and narrative formats.

RESULTS

Data were extracted from a total of 186 full-text publications. All of the studies, except for 1, were experimental. Included studies came from 33 countries, with the majority coming from the United States. Ex vivo methods were the predominant approach for extracting human tissue samples, and the most commonly studied tissue type was musculoskeletal. In this study, nearly 200 unique biomechanical values were reported, and the most commonly reported value was Young's (elastic) modulus. The most common type of mechanical test performed was tensile testing, and the most common reason for testing human tissues was to characterize biomechanical properties. Although the number of published studies on biomechanical properties of human tissues has increased over the past 20 years, there are many gaps in the literature. Of the 186 included studies, only 7 used human tissues for the design or validation of medical skills training devices. Furthermore, in studies where biomechanical values for human tissues have been obtained, a lack of standardization in engineering assumptions, methodologies, and tissue preparation may implicate the usefulness of these values.

CONCLUSIONS

This review is the first of its kind to give a broad overview of the biomechanics of human tissues in the published literature. With respect to high-fidelity haptics, there is a large gap in the published literature. Even in instances where biomechanical values are available, comparing or using these values is difficult. This is likely due to the lack of standardization in engineering assumptions, testing methodology, and reporting of the results. It is recommended that journals and experts in engineering fields conduct further research to investigate the feasibility of implementing reporting standards.

REVIEW REGISTRATION

Open Science Framework https://osf.io/fgb34.

Mechanical Characterization of the Human Abdominal Wall Using Uniaxial Tensile Testing

It is generally accepted that the human abdominal wall comprises skin, subcutaneous tissues, muscles and their aponeuroses, and the parietal peritoneum. Understanding these layers and their mechanical properties provides valuable information to those designing procedural skills trainers, supporting surgical procedures (hernia repair), and engineering-based work (in silico simulation). However, there is little literature available on the mechanical properties of the abdominal wall in layers or as a composite in the context of designing a procedural skills trainer. This work characterizes the tensile properties of the human abdominal wall by layer and as a partial composite. Tissues were collected from fresh-never-frozen and fresh-frozen cadavers and tested in uniaxial tension at a rate of 5 mm/min until failure. Stress-strain curves were created for each sample, and the values for elastic moduli, ultimate tensile strength, and strain at failure were obtained. The experimental outcomes from this study demonstrated variations in tensile properties within and between tissues. The data also suggest that the tensile properties of composite abdominal walls are not additive. Ultimately, this body of work contributes to a deeper comprehension of these mechanical properties and will serve to enhance patient care, refine surgical interventions, and assist with more sophisticated engineering solutions.

Residency graduates should not be expected to perform hypospadias repair without fellowship training: Results from a survey of SPU membership

BACKGROUND

Trainee autonomy has eroded over time as surgery has become more subspecialized and as attending oversight has increased, causing many trainees to seek additional fellowship training beyond residency. Less clear is whether there are cases that attendings view as "fellowship-level" or "privileged" cases in which resident-level trainees should not have high levels of autonomy due to complexity or high-stakes outcomes.

OBJECTIVE

We sought to better understand current attitudes and practices with regards to trainee autonomy in hypospadias repair as it represents a high complexity procedure within pediatric urology.

STUDY DESIGN

We administered a RedCap survey to the SPU membership, asking respondents to describe the level of autonomy afforded to trainees in various types of hypospadias repair (distal, midshaft, proximal, perineal) as measured by the Zwisch scale. The Zwisch scale describes the role of the attending in the attending-trainee relationship in a low-to-high trainee autonomy fashion: show and tell; active help; passive help; supervision only.

RESULTS

177 of 761 (23%) unique recipients completed our survey and 174 of 177 (98%) of respondents felt that trainees should not perform hypospadias repair independently in practice without additional fellowship training. Among pediatric urologists who train residents, trainee autonomy as measured by the Zwisch scale decreased as the type of hypospadias repair moved from distal to proximal.

DISCUSSION

There was near unanimous agreement among respondents that urology trainees should not perform hypospadias repair in practice without additional pediatric urology fellowship training, and that current practice affords little trainee autonomy in hypospadias repair at the resident level. These findings introduce a new wrinkle into the issue of trainee autonomy: cases in which trainees perhaps should not have autonomy. Concurrently, the concern with such findings is that this intentional lack of autonomy may extend to other urologic procedures that one would expect trainees to be able to perform independently.

CONCLUSION

Urology trainees are not expected to be able to perform hypospadias in practice without additional training. This raises the question that there may be other such procedures in urology, and if so, should we as instructors, be forthcoming about the limitations of urology residency training to set appropriate trainee expectations?

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

Introduction

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

Research question

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

Material and methods

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

Results

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

Discussion and conclusion

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

Implementing an Interdisciplinary Procedure Curriculum

INTRODUCTION

This curriculum was designed to improve access to procedures for our internal medicine residents.

METHODS

We created an interdisciplinary procedure course (IDPC) composed of two simulation sessions and a one-week procedural rotation supervised by multiple specialties including nephrology, cardiology, cardiothoracic anesthesiology, general anesthesiology, and interventional radiology. After the course, residents completed two surveys documenting the number of procedures and their level of confidence on a Likert scale (1 = very unconfident to 5 = very confident) prior to and after completing the curriculum.

RESULTS

Sixteen residents participated in the course from September 2021 to June 2022. The collective number of procedures performed by these 16 residents increased from 176 to 343 after a one-week rotation. For arterial lines, the proportion of residents that reported an improvement in confidence scores was 0.44 (95% confidence interval 0.23 to 1, p-value of 0.60). The proportion of residents that had an increase in their confidence performing central lines was 0.63 (95% confidence interval 0.39 to 1, p-value of 0.23). For intubations, the proportion of residents that reported an improvement in confidence was 0.94 (95% confidence interval 0.72 to 1, p-value of 0.0006).

CONCLUSION

By collaborating with multiple specialties, residents almost doubled the number of procedures performed during training and reported an increased level of confidence in procedural performance for airway intubation. We learned residents want to improve their access to procedures and described a curriculum that was easily implemented.

The Academic Learning Health System: A Framework for Integrating the Multiple Missions of Academic Medical Centers

The learning health system (LHS) has emerged over the past 15 years as a concept for improving health care delivery. Core aspects of the LHS concept include: promoting improved patient care through organizational learning, innovation, and continuous quality improvement; identifying, critically assessing, and translating knowledge and evidence into improved practices; building new knowledge and evidence around how to improve health care and health outcomes; analyzing clinical data to support learning, knowledge generation, and improved patient care; and engaging clinicians, patients, and other stakeholders in processes of learning, knowledge generation, and translation. However, the literature has paid less attention to how these LHS aspects may integrate with the multiple missions of academic medical centers (AMCs). The authors define an academic learning health system (aLHS) as an LHS built around a robust academic community and central academic mission, and they propose 6 features that emphasize how an aLHS differs from an LHS. An aLHS capitalizes on embedded academic expertise in health system sciences; engages the full spectrum of translational investigation from mechanistic basic sciences to population health; builds pipelines of experts in LHS sciences and clinicians with fluency in practicing in an LHS; applies core LHS principles to the development of curricula and clinical rotations for medical students, housestaff, and other learners; disseminates knowledge more broadly to advance the evidence for clinical practice and health systems science methods; and addresses social determinants of health, creating community partnerships to mitigate disparities and improve health equity. As AMCs evolve, the authors expect that additional differentiating features and ways to operationalize the aLHS will be identified and hope this article stimulates further discussion around the intersection of the LHS concept and AMCs.

System identification and simulation of soft tissue force feedback in a spine surgical simulator

Surgical simulators are being introduced as training modalities for surgeons. This paper aims to evaluate dynamic models used to convey force feedback from puncturing the soft tissue during a spine surgical simulation. The force feedback of the tissue is treated as a dynamic system. This is done by performing classical system identification across a bandwidth of frequencies on a tissue analogue and fitting that behaviour to dynamic viscoelastic models. The models that are tested are an inverted linear model, the Maxwell model, the Kelvin-Boltzmann (KB) model, and a higher-order blackbox (HO) model. Several error metrics such as percent variance accounted for (%VAF) are determined to measure solution accuracy. The force feedback models are programmed into a surgical simulator and tested with study participants who rated them based on how well the identified models match the behaviour of the rubber tissue analogue. The highest %VAF is 82.64% when the tissue is modelled as the HO model. Statistically significant differences (p < 0.05) are found between all model ratings from participants except between the HO model and the KB model. However, the HO model has the highest percentage (37.8%) of participants who rank its performance as the closest to the tissue analogue compared to the other force feedback models. The more accurately the dynamic behaviour resembles the tissue analogue, the higher the model was rated by study participants. This study highlights the importance of utilizing dynamic signals to generate dynamic models of soft tissue for spine surgical simulators.

Three-dimensional printing in modelling mitral valve interventions

Mitral interventions remain technically challenging owing to the anatomical complexity and heterogeneity of mitral pathologies. As such, multi-disciplinary pre-procedural planning assisted by advanced cardiac imaging is pivotal to successful outcomes. Modern imaging techniques offer accurate 3D renderings of cardiac anatomy; however, users are required to derive a spatial understanding of complex mitral pathologies from a 2D projection thus generating an 'imaging gap' which limits procedural planning. Physical mitral modelling using 3D printing has the potential to bridge this gap and is increasingly being employed in conjunction with other transformative technologies to assess feasibility of intervention, direct prosthesis choice and avoid complications. Such platforms have also shown value in training and patient education. Despite important limitations, the pace of innovation and synergistic integration with other technologies is likely to ensure that 3D printing assumes a central role in the journey towards delivering personalised care for patients undergoing mitral valve interventions.

Preprint Peer Review Enhances Undergraduate Biology Students' Disciplinary Literacy and Sense of Belonging in STEM

Education about scientific publishing and manuscript peer review is not universally provided in undergraduate science courses. Since peer review is integral to the scientific process and central to the identity of a scientist, we envision a paradigm shift where teaching peer review becomes integral to undergraduate science education. We hypothesize that teaching undergraduates how to peer review scientific manuscripts may facilitate their development of scientific literacy and identity formation. To this end, we developed a constructivist, service-learning curriculum for biology undergraduates to learn about the mechanisms of peer review using preprints and then to write and publish their own peer reviews of preprints as a way to authentically join the scientific community of practice. The curriculum was implemented as a semester-long intervention in one class and, in another class, as an embedded module intervention. Students' scientific literacy and peer review ability were assessed using quantitative methods. Student's perceptions of their scientific literacy and identity were assessed using thematic analysis of students' reflective writing. Here, we present data on the improvement in the peer review ability of undergraduates in both classes and data on the curriculum's interrelated impact on students' development of scientific literacy, identity, and belonging in peer and professional discourse spaces. These data suggest that undergraduates can and should be trained in peer review to foster the interrelated development of their scientific literacy, scientific identity, and sense of belonging in science.

Mentorship in a Surgical Residency: A Comprehensive Review of the Literature

Mentorship in surgical training is an experience that extends beyond the teacher-student interaction. Effective mentorship is crucial in surgical training and requires ongoing support at all stages of graduate surgical education, particularly in the context of busy surgical residency programs. It is important to recognize that mentors and mentees may have different styles of learning and teaching, making it essential to discuss and review these approaches to ensure effective mentorship. By acknowledging these differences and developing a supportive mentorship program that addresses them, surgical residents can receive the guidance they need to progress successfully through their training and prepare for independent practice. This review provides a comprehensive analysis of mentorship styles in various surgical training residencies. By including 30 publications, this study highlights different mentorship approaches and their contributions to education in surgical residency programs. Moreover, this study summarizes the 10 stages of mentorship, offering a clearer understanding of the mentorship model in the context of graduate surgical education. Finally, the review provides insight into the common challenges and pitfalls among mentorship programs. The findings of this study aim to provide valuable guidance for developing effective mentorship programs in surgical residency programs, contributing to better support and outcomes for surgical trainees.

Perception and knowledge of learners about the use of 3D technologies in manual therapy education - a qualitative study

OBJECTIVES

Manual therapy is a specific hands-on approach used and taught by various professions such as physiotherapy and osteopathy. The current paradigm of teaching manual therapy incorporates the traditional 'See one, do one, teach one' approach. However, this 'teacher centred' approach may not enable learners to develop the complex clinical skills of manual therapy. In this context, 3D technologies such as virtual reality may facilitate the teaching and learning of manual therapy. Hence the aim of the current study was to investigate the perception, knowledge and attitude of manual therapy learners about the use of 3D technologies in manual therapy education.

METHODS

An exploratory qualitative research design using semi-structured interviews was used in this study. A total of ten manual therapy (5 physiotherapy and 5 osteopathic) students (mean age = 32; 80% female) enrolled in an appropriate physiotherapy or osteopathic degree provided by a New Zealand recognized institution (e.g., university or polytechnic) participated in this study. Data saturation was achieved after 10 interviews (average duration: 35 min) that provided thick data. A thematic analysis was used for data analysis.

RESULTS

Six factors were identified which appeared to influence participants' perception of role of technology in manual therapy education. These were (1) the sufficiency of current teaching method; (2) evolution as a learner (a novice to an expert); (3) need for objectivity; (4) tutor feedback; (5) knowledge and (6) barriers and enablers. These six factors influenced the participants' perception about the role of 3D technologies in manual therapy education with participants evidently taking two distinct/polarized positions ('no role' (techstatic) versus a 'complete role' (techsavvy)).

CONCLUSION

Although 3D technology may not replace face-to-face teaching, it may be used to complement the traditional approach of learning/teaching to facilitate the learning of complex skills according to the perceptions of manual therapy learners in our study. The advantage of such an approach is an area of future research.

Video-based digital platforms as an educational resource for the surgical preparation of orthopedic surgeons

OBJECTIVE

The aim of the study was to research the video-based digital platforms that orthopedic specialists in Turkey use as an educational resource in their surgical preparations that they have not seen or done before, the frequency of their use of these platforms, and their trust in these platforms, with a survey study.

METHODS

The importance of video-based digital platforms in surgical preparations that surgeons have not seen or done before was measured using the data obtained from 181 orthopedic specialists using a survey prepared on an Internet-based server (docs.google.com).

RESULTS

Orthopedists used video-based digital platforms with a ratio of 38.7% among the educational resources in their surgical preparations that they have not seen or done before. There was no significant difference between the specialists with a surgical experience of 1-10 years and more than 10 years of experience in terms of using video-based digital platforms in surgical preparation (p>0.05). A total of 81.2% of the participants used only video-based digital platforms in the preparation of a surgical procedure they have never seen before. The most frequently used digital platform was YouTube, and 62% of the participants considered these platforms reliable.

CONCLUSION

Orthopedic specialists in Turkey primarily and frequently use video-based digital platforms as a training resource in their preparations for surgery that they have not seen or done before. The establishment or support of platforms with evidence-based content with references from official orthopedic institutions and organizations can increase the trust of orthopedic specialists in these platforms.

The Whiteboard Time Out: A Novel Tool to Improve Resident Learning in the Operating Room

OBJECTIVE

"Flipping the classroom" is a strategy that has been implemented in various educational environments to create a student-centered learning environment. Within this model of teaching, "first exposure" occurs prior to the classroom in a lower form of cognitive demand, allowing students to employ higher forms of cognition within the classroom. Surgical education has evolved over recent years to incorporate different modalities of learning; however, optimal educational approaches within the operating room (OR) have not been clearly defined. The Whiteboard Time Out (WBTO) utilizes the idea of "flipping the classroom" to make learning within the OR more resident centered. Residents complete most of the preoperative work prior to the case with a focus on the indications, steps of the procedure, and potential complications associated with the procedure. Residents then utilize a whiteboard located in the OR to outline, diagram, and discuss this information with the attending. Aims of the study are to enhance higher level intraoperative resident learning and attending teaching and improve resident knowledge and the ability to communicate surgical steps.

DESIGN

Faculty and residents completed a preimplementation questionnaire aligned to the Student Evaluation of Educational Quality (SEEQ) in July 2021. Participants were assigned 3 digit codes to ensure anonymity. The questionnaire was composed of 6 questions with a 5-point Likert scale. Whiteboards were mounted in every operating room, 19 total, in both the general OR and an ambulatory surgical center. The residents were expected to go to the OR, prior to scrubbing the case, and use the whiteboard to outline the indications, key steps and potential complications. After the resident completed the white board, the resident and attending reviewed the white board together prior to the start of the case. After the procedure, residents uploaded a picture of the whiteboard with a self-evaluation and faculty provided resident feedback via an online Wufoo Survey link. The start of the utilization of the whiteboards occurred after the initial survey in July 2021. The SEEQ questionnaire was again administered in October 2021, 3 months post-WBTO implementation, to assess resident and attending satisfaction. SEEQ questionnaire results were compared using a t-test.

PARTICIPANTS

Participants included surgical residents and attendings at Maimonides Medical Center (MMC). MMC is a 700-bed university-affiliated, academic, tertiary medical center in Brooklyn, New York. The General Surgery Residency is approved for up to 5 graduates annually.

RESULTS

A total of 17 attendings and 17 residents filled out the questionnaire. The average number of whiteboards completed was highest amongst the PGY1 class with an average of 18 whiteboards per resident. However, the average number of whiteboards completed declined amongst more senior residents. There was a statistically significant increase in overall SEEQ survey score amongst residents and attendings after implementation of the WBTO suggesting that whiteboards were useful (p < 0.03 and p < 0.02, respectively). Residents found that the whiteboard was an effective means of teaching surgical education compared to the current curriculum (p < 0.04).

CONCLUSIONS

The whiteboard timeout is a tool created to enhance resident education in the OR. This idea is centered on a "flipped classroom," an educational strategy to increase student engagement. Our data demonstrates that the whiteboard timeout is an effective method of intraoperative teaching.

Five-Year results of a multi-specialty induction course for surgical training

Background

The Essential Surgical Skills Course (ESSC) is a multi-specialty induction "boot camp" style course that has been run successfully for five years. The aim of the current paper is to create an accurate guide for the replication of the course by other teams and assess the course's fitness for purpose, through the survey feedback provided by trainees.

Methods

The course's fitness for purpose was assessed through cumulative five-year survey feedback from trainees. This observational study describes the design and process of content adjustment according to feedback.

Results

The course its five-year span offered twelve different procedural skills in four different specialties. Feedback for each session was persistently >8/10. Key themes identified as beneficial include teacher-to-trainee ratio (often 1:1), teaching style, course structure and responsiveness.

Conclusions

The ESSC was found to be fit for purpose for the induction of trainees into surgical training. The key factors contributing to the success of the course include the structured method of curriculum design, outstanding teaching delivery methods, teacher-to-trainee ratio, the availability of appropriate faculty and infrastructure and the willingness to learn from trainee feedback and adjust the content of the course accordingly. It acts as a paradigm for courses aimed to prepare surgical trainees for a "step-up" in their careers.

Using hand pose estimation to automate open surgery training feedback

PURPOSE

This research aims to facilitate the use of state-of-the-art computer vision algorithms for the automated training of surgeons and the analysis of surgical footage. By estimating 2D hand poses, we model the movement of the practitioner's hands, and their interaction with surgical instruments, to study their potential benefit for surgical training.

METHODS

We leverage pre-trained models on a publicly available hands dataset to create our own in-house dataset of 100 open surgery simulation videos with 2D hand poses. We also assess the ability of pose estimations to segment surgical videos into gestures and tool-usage segments and compare them to kinematic sensors and I3D features. Furthermore, we introduce 6 novel surgical dexterity proxies stemming from domain experts' training advice, all of which our framework can automatically detect given raw video footage.

RESULTS

State-of-the-art gesture segmentation accuracy of 88.35% on the open surgery simulation dataset is achieved with the fusion of 2D poses and I3D features from multiple angles. The introduced surgical skill proxies presented significant differences for novices compared to experts and produced actionable feedback for improvement.

CONCLUSION

This research demonstrates the benefit of pose estimations for open surgery by analyzing their effectiveness in gesture segmentation and skill assessment. Gesture segmentation using pose estimations achieved comparable results to physical sensors while being remote and markerless. Surgical dexterity proxies that rely on pose estimation proved they can be used to work toward automated training feedback. We hope our findings encourage additional collaboration on novel skill proxies to make surgical training more efficient.

The role of high-fidelity simulation in the acquisition of endovascular surgical skills: a systematic review

INTRODUCTION

The widespread introduction of minimally invasive endovascular techniques in cardiovascular surgery has necessitated a transition in the psychomotor skillset of trainees and surgeons. Simulation has previously been used in surgical training; however, there is limited high quality evidence regarding the role of simulation-based training on the acquisition of endovascular skills. This systematic review aimed to systematically appraise the currently available evidence regarding endovascular high-fidelity simulation interventions, to describe the overarching strategies used, the learning outcomes addressed, the choice of assessment methodology, and the impact of education on learner performance.

METHODS

A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using relevant keywords to identify studies evaluating simulation in the acquisition of endovascular surgical skills. References of review articles were screened for additional studies.

RESULTS

A total of 1081 studies were identified (474 after removal of duplicates). There was marked heterogeneity in methodologies and reporting of outcomes. Quantitative analysis was deemed inappropriate due to the risk of serious confounding and bias. Instead, a descriptive synthesis was performed, summarising key findings and quality components. Eighteen studies were included in the synthesis (15 observational, 2 case-control and 1 randomised control studies). Most studies measured procedure time, contrast usage, and fluoroscopy time. Other metrics were recorded to a lesser extent. Significant reductions were noted in both procedure and fluoroscopy times with the introduction of simulation-based endovascular training.

CONCLUSION

The evidence regarding the use of high-fidelity simulation in endovascular training is very heterogeneous. The current literature suggests simulation-based training leads to improvements in performance, mostly in terms of procedure and fluoroscopy time. High-quality randomised control trials are needed to establish the clinical benefits of simulation training, sustainability of improvements, transferability of skills and its cost-effectiveness.

Cognitive Load Management: An Invaluable Tool for Safe and Effective Surgical Training

This article highlights the importance of considering Cognitive Load (CL) and Cognitive Load Theory (CLT) during surgical training, focusing on the acquisition of intra-operative skills. It describes the basis of CLT with the overarching aim of describing CLT-based techniques to enhance current training strategies and surgical performance, many of which are instinctively already employed in surgical practice. Currently, methods of feedback and assessment are imperfect - typically subjective, unsystematic, opportunistic, or retrospective, and at risk of human bias. Surgical Sabermetrics, the advanced analytics of surgical and audio-visual data, aims to enhance this feedback by providing objective, real-time, digital-based feedback. This article introduces the benefit of real-time measurement of CL to enhance feedback and its applications to surgical performance that follow the ethos of Surgical Sabermetrics.¹ The 2022 theme for ICOSET was "Making it Better." Cognitive Load and Surgical Sabermetrics principles provide tools to make Surgical training better, with the goal of higher quality care for patients.

Faculty Professional Development Strategies Supporting Increased Scholarship

In this article, we describe the implementation of two nursing continuing professional development activities and a 15-week online Writing for Publication course for faculty using American Nurses Credentialing Center accreditation program criteria. The application of the criteria ensured quality continuing nursing education and assisted the provider unit in meeting its goals and outcomes. Evaluation data for the activities were collected and analyzed to determine whether the learning outcomes were met and to prepare course adjustments. [J Contin Educ Nurs. 2023;54(3):121-129.].

The role of virtual reality in knee arthroscopic simulation: a systematic review

PURPOSE

Surgical training is crucial for orthopedics residents during their educational careers. Residents who follow classic training courses are less skilled than those trained with simulators. Virtual simulators are reported to be global learning tools for knee arthroscopy. The primary purpose of our study is to evaluate the current state of use of arthroscopic knee simulators and their actual effectiveness in transfer the skills learned in training to the operating theatre. The secondary purpose is to evaluate if the virtual simulators are better than the others in improve arthroscopic skills.

METHODS

Studies involving knee arthroscopy training with virtual reality simulators were included: a search of the literature from 2009 to September 2019 was performed on MEDLINE(PubMed) using PRISMA guidelines. Exclusion criteria were systematic review articles, aims and topics not related to the purpose of the study, single case and technical reports, biomechanical analysis, articles not in the English language, and editorial commentaries.

RESULTS

The literature review selected, nine studies and they included results on 93 residents, three expert surgeons and 189 medical students. All studies report improved arthroscopic skills after training with a simulator. Only four studies evaluated the transfer of arthroscopic skills of knee simulators to the operating theatre.

CONCLUSIONS

Benchtop and Virtual Reality simulators are excellent tools for accelerating and improving arthroscopic training and skills acquisition. The second ones, high-cost, and fidelity simulators, seem to be the best of the two. A greater diffusion of Virtual Reality in universities is to be considered to improve residents' training and patients' clinical outcomes.

Deconstructing forearm casting task by videos with step-by-step simulation teaching improved performance of medical students: is making working student's memory work better similar to a process of artificial intelligence or just an improvement of the prefrontal cortex homunculus?

PURPOSE

To compare two teaching methods of a forearm cast in medical students through simulation, the traditional method (Trad) based on a continuous demonstration of the procedure and the task deconstruction method (Decon) with the procedure fragmenting into its constituent parts using videos.

METHODS

During simulation training of the below elbow casting technique, 64 medical students were randomized in two groups. Trad group demonstrated the entire procedure without pausing. Decon group received step-wise teaching with educational videos emphasizing key components of the procedure. Direct and video evaluations were performed immediately after training (day 0) and at six months. Performance in casting was assessed using a 25-item checklist, a seven item global rating scale (GRS Performance), and a one item GRS (GRS Final Product).

RESULTS

Fifty-two students (Trad n = 24; Decon n = 28) underwent both day zero and six month assessments. At day zero, the Decon group showed higher performance via video evaluation for OSATS (p = 0.035); GRS performance (p < 0.001); GRS final product (p < 0.001), and for GRS performance (p < 0.001) and GRS final product (p = 0.011) via direct evaluation. After six months, performance was decreased in both groups with ultimately no difference in performance between groups via both direct and video evaluation. Having done a rotation in orthopaedic surgery was the only independent factor associated to higher performance.

CONCLUSIONS

The modified video-based version simulation led to a higher performance than the traditional method immediately after the course and could be the preferred method for teaching complex skills.

Expanding Educational Frontiers in Neurosurgery: Current and Future Uses of Augmented Reality

BACKGROUND

Augmented reality (AR) technology is a new and promising option to advance and expand neurosurgical training because of recent advances in computer vision technology, improved AR software and hardware, and growing acceptance of this technology in clinical practice.

OBJECTIVE

To analyze the current status of AR use cases with the goal of envisioning future uses of AR in neurosurgical education.

METHODS

Articles applying to AR technology use in neurosurgical education were identified using PubMed, Google Scholar, and Web of Science databases following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines. Articles were included for review based on applicable content related to neurosurgical or neuroanatomy training. Assessment of literature quality was completed using standardized MERSQI scoring.

RESULTS

The systematic search identified 2648 unique articles. Of these, 12 studies met inclusion criteria after extensive review. The average MERSQI score was 10.2 (SD: 1.7). The most common AR platform identified in this study was the Microsoft Hololens. The primary goals of the studies were to improve technical skills and approaches to surgical planning or improve understanding of neuroanatomy.

CONCLUSION

Augmented reality has emerged as a promising training tool in neurosurgery. This is demonstrated in the wide range of cases in technical training and anatomic education. It remains unclear how AR-based training compares directly with traditional training methods; however, AR shows great promise in the ability to further enhance and innovate neurosurgical education and training.

The Smart Use of Smart Technologies in Teaching and Learning: Where we are and Where we Need to be

OBJECTIVE

The advantages and popularity of technology among learners have vaulted it to the forefront of medical education. The current state of learning and teaching intertwined with technology in medical education and residency is described. Following these characterizations, consideration is given to changes worth exploring in the habits of mind and habits of action that medical students and residents exhibit to deepen their learning and improve their performance.

METHODS

Review of literature was conducted to summarize relevant transformations in instructional practices in medical school and residency that can contribute to more effective learning environments.

RESULTS

Learners have different approaches that will include differing uses of technology. Technology encourages multitasking, information overload, and the increasing prevalence of invalid information. Implementing bite-sized learning approaches, problem-based or case-based formats, questions, and alternative hypotheses encourages learners to channel technological innovations into their own styles of learning.

CONCLUSION

To build knowledge in the technological era of learning, do not take learners' digital readiness for granted. Approach technology as a tool to be wielded when required and not as a crutch.