The differing perceptions of plastic surgery between potential applicants and current trainees: The importance of clinical exposure and electives for medical students

BACKGROUND:

Exposure to plastic surgery during medical school is limited. Most interested applicants form their perceptions of careers in this surgical specialty during elective rotations.

OBJECTIVE:

To investigate the perceptions of Canadian medical students considering a career in plastic surgery. The results obtained were then compared with current Canadian plastic surgery residents’ perceptions.

METHODS:

The data were collected via two separate self-administered online surveys that were distributed to either Canadian plastic surgery residents or medical students. The questionnaires were similar and focused on three aspects: applicant details; driving force behind interest in the field; and essential character traits and competencies related to successful matching.

RESULTS:

Fifty-nine plastic surgery residents and 477 medical students participated in the online survey. The most commonly reported driving forces for interest in a plastic surgery career in both groups were variety of career choice, complexity of the field, future lifestyle and enjoyable rotations in plastic surgery. Despite these similarities, the proportion of medical students and residents who opted for future lifestyle and enjoyable rotations differed in a statistically significant manner (P=0.015 and P=0.029, respectively). In terms of the essential competencies to match into a plastic surgery training spot, the groups differed statistically in their opinions on the relevance of intellect (P<0.001), manual dexterity (P<0.001), spatial sense (P<0.001) and clerkship grades (P=0.004).

CONCLUSION:

Interested applicants should be encouraged to obtain as much elective experience as possible to assist both students in their career choice and selection committees in identifying capable applicants.     

Resident training and the dictated operative report: a national perspective

Background

Using a nationwide survey, we aimed to determine the current status of operative dictation training in Canada.

Methods

Residents and program directors in general surgery programs in Canada participated in this survey.

Results

In all, 274 residents and 11 program directors responded to the survey (70% and 79% response rates, respectively). Among residents, 73% reported that their dictations were in need of improvement, and 56% reported never receiving feedback about their dictations. Most residents (80%) stated that they learned to dictate by reading old operative dictations, 75% reported that their program did not use any formal methods to help improve dictations, and 70% requested further training in dictation. In all, 91% of program directors felt that residency programs should include formal training in dictation but half could not identify any formal methods currently used in their programs.

Conclusion

There appears to be a marked deficiency in resident training in operative dictation nationwide.     

The Advanced Trauma Operative Management course in a Canadian residency program

Background

The Advanced Trauma Operative Management (ATOM) course was first introduced into Canada in 2003 at the University of Toronto, with senior general surgery residents being the primary focus. We present an assessment of the course in this Canadian general surgery residency program.

Methods

We compared trainees'' pre-and postcourse self-efficacy scores and multiple choice question (MCQ) examination results, using paired t tests and resident (n = 24) and faculty (n = 7) course ratings made according to a 10-item, 5-point Likert scale. Faculty were previously trained as ATOM instructors.

Results

Mean pre-and postcourse self-efficacy scores were 68.9 (standard deviation [SD] 24.0) and 101.4 (SD 14.8), respectively (p < 0.001). Mean pre-and post-MCQ scores were 16.4 (SD 3.2) and 18.8 (SD 2.7), respectively (p = 0.006). On the Likert scale (1 = strongly disagree, 5 = strongly agree), all faculty and residents rated the following items as 4–5: objectives were met; knowledge, skills, clinical training, judgment and confidence improved; the live animal is a useful representation of clinical trauma; and the course should be continued but would be more appropriate for the fourth rather than the fifth year of residency. Residents rated as 1–2 the item that the human cadaver would be preferable for learning the surgical skills. Of 24 residents, 20 rated as 3 or less the item stating that the course prepares them for trauma management more adequately than their regular training program.

Conclusion

Self-efficacy, trauma knowledge and skills improved significantly with ATOM training. Preference was expressed for the live animal versus cadaver model, for ATOM training in the fourth rather than fifth year of residency and for the view that it complements general surgery trauma training. The data suggest that including ATOM training in Canadian general surgical residency should be considered.     

Pregnancy among residents enrolled in general surgery: a nationwide survey of attitudes and experiences

Background

Medical student interest in general surgery has declined, and the lack of adequate accommodation for pregnancy and parenting during residency training may be a deterrent. We explored resident and program director experiences with these issues in general surgery programs across Canada.

Methods

Using a web-based tool, residents and program directors from 16 Canadian general surgery programs were surveyed regarding their attitudes toward and experiences with pregnancy during residency.

Results

One hundred seventy-six of 600 residents and 8 of 16 program directors completed the survey (30% and 50% response rate, respectively). Multiple issues pertaining to pregnancy during surgical residency were reported including the lack of adequate policies for maternity/parenting, the major obstacles to breast-feeding, and the increased workload for fellow resident colleagues. All program directors reported the lack of a program-specific maternity/parenting policy.

Conclusions

General surgery programs lack program-specific maternity/parenting policies. Several issues have been highlighted in this study emphasizing the importance of creating and implementing such a policy.     

Does sex affect residency application to surgery?

Objective

To determine whether women are proportionately underselected at the level of the annual residency match.

Methods

Data were obtained from the Royal College of Physicians and Surgeons of Canada and the Canadian Residency Matching Service. The odds of men being rejected from their top choice of surgical discipline were compared with the corresponding odds for women for the surgical specialties of general surgery, orthopedic surgery, neurosurgery, otolaryngology, urology, cardiac surgery and plastic surgery.

Results

Women continue to be underrepresented among surgery residents and surgeons in practice; however, the number of women has increased. Neither sex was overselected among the surgical specialties examined.

Conclusions

There was no evidence of overselection of either sex at the level of the annual resident selection committee.     

Survey of senior resident training in urologic laparoscopy,robotics and endourology surgery in Canada

Introduction:

We determined the status of Canadian training during senior residency in laparoscopic, robotic and endourologic surgery.

Methods:

Fifty-six residents in their final year of urology residency training were surveyed in person in 2007 or 2008.

Results:

All residents completed the survey. Most residents (85.7%) train at centres performing more than 50 laparoscopic procedures yearly and almost all (96.4%) believe laparoscopic radical nephrectomy is the gold standard. About 82% of residents participated in a laparoscopic partial nephrectomy in 2008, compared to 64.7% in 2007. Of the respondents, 66% have participated in a laparoscopic prostatectomy and 54% believe the procedure has promising potential. Exposure and training in robotic-assisted laparoscopic procedures seem to be increasing as 35.7% of 2008 residents have access to a surgical robot and 7% consider themselves trained in robotic-assisted procedures. Most residents (71.4%) train at centres that perform percutaneous ablation. However, 65% state the procedure is performed solely by radiologists. Percutaneous nephrolithotomy is widely performed (98.2%), but only 37.5% of residents report training in obtaining primary percutaneous renal access. Despite only 12.5% of residents ranking their laparoscopic experience as below average or poor, an increasing proportion of graduating residents are pursuing fellowships in minimally-invasive urology.

Conclusion:

Laparoscopic nephrectomy is commonly performed and is considered the standard of care by Canadian urology residents. Robotic-assisted surgery is becoming more common but will require continued evaluation by educators who will ultimately define its role in the urological residency training curriculum. Minimally-invasive surgical fellowships remain popular, as Canadian residents do not feel adequately trained in certain advanced procedures. Urologists must strive to learn and adapt to new technologies or risk losing them to other specialties.     

Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey

Background

Communication errors are considered one of the major causes of sentinel events. Our aim was to assess the process of patient handoff among junior surgical residents and to determine ways in which to improve the handoff process.

Methods

We conducted nationwide surveys that included all accredited general surgery residency programs in the United States and Canada.

Results

Of the 244 American and 17 Canadian accredited surgical residency programs contacted, 65 (27%) and 12 (71%), respectively, participated in the survey. Of the American and Canadian respondents, 66% and 69%, respectively, were from postgraduate year (PGY) 1, and 32% and 29%, respectively, were from PGY 2; 85 (77%) and 50 (96%), respectively, had not received any training about patient handoff before their surgical residency, and 27% and 64%, respectively, reported that the existing handoff system at their institutions did not adequately protect patient safety. Moreover, 29% of American respondents and 37% of Canadian respondents thought that the existing handoffs did not support continuity of patient care. Of the American residents, 67% and 6% reported receiving an incomplete handoff that resulted in minor and major patient harm, respectively. These results mirrored those from Canadian residents (63% minor and 7% major harm). The most frequent factor reported to improve the patient handoff process was standardization of the verbal handoff.

Conclusion

Our survey results indicate that the current patient handoff system contributes to patient harm. More efforts are needed to establish standardized forms of verbal and written handoff to ensure patient safety and continuity of care.     

Reconstructive or cosmetic plastic surgery? Factors influencing the type of practice established by Canadian plastic surgeons

BACKGROUND:

Some argue that the specialty of plastic surgery is facing a changing identity. Challenged by factors such as increasing competition in the cosmetic marketplace and decreasing reimbursement for reconstructive procedures, many American plastic surgeons have increasingly adopted cosmetic-focused practices. The present study investigated the currently unknown practice profiles of Canadian plastic surgeons to determine the reconstructive-cosmetic mix, as well as factors that influence practice type to determine whether a similar pattern exists in Canada.

METHODS:

An anonymous online survey regarding practice profiles was distributed to all 352 Canadian plastic surgeons with e-mail accounts registered with the Canadian Society of Plastic Surgeons and/or the Canadian Society for Aesthetic Plastic Surgery.

RESULTS:

The survey response rate was 34% (120 responses), of which 75% of respondents currently had a reconstructive practice and 25% had a cosmetic practice. Reconstructive surgeons had more educational debt following their training, spent more time on emergency call, academics and teaching and, when deciding which type of practice to establish, were more influenced by academic opportunities and less influenced by financial and nonfinancial metrics. Similarities between the groups included hours worked per week and academic achievements.

CONCLUSIONS:

The field of reconstructive plastic surgery appears to be thriving in Canada. While a transition from reconstructive to cosmetic practice is common, compared with their American colleagues, a greater proportion of Canadian plastic surgeons maintain reconstructive practices. Differences between reconstructive and cosmetic plastic surgeons are discussed.     

Mentorship in anesthesia: a survey of perspectives among Canadian anesthesia residents

Purpose

Mentorship is important for professional and academic growth; however, the role of mentorship in anesthesia is still being defined. We surveyed Canadian anesthesia residents to explore their perceptions of mentorship relationships.

Methods

We administered a 20-item cross-sectional survey to program directors and anesthesia residents in all Canadian departments of anesthesia. Program directors were asked about their mentorship programs, and residents were asked about their perceptions of benefits and barriers to effective mentoring.

Results

Sixteen of 17 (94%) program directors and 189 of 585 (32%) anesthesia residents responded to our survey. While 143 of 180 (79%) residents agreed that mentorship was beneficial to overall success as an anesthesiologist, only 11 of 16 (69%) program directors reported formal mentorship as part of their residency program, and only 119 of 189 (63%) residents reported access to a mentor. Barriers reported by residents included insufficient time with mentors, lack of formalized meeting times and objectives, mentor-mentee incompatibility (personal or professional), and lack of resident choice in mentor selection.

Conclusion

Our study confirms that, despite positive perceptions among residents, mentorship remains underutilized in anesthesia programs. We identify barriers to effective mentorship, including the need to consider resident choice as a means to improve formal anesthesia mentorship programs.

     

A survey of Canadian general surgery residents' interest in international surgery

Objective

This survey of Canadian general surgery residents was designed to determine their interest level, past experiences and awareness of opportunities in the field of international surgery.

Methods

A web-based national survey in both French and English was sent to all Canadian general surgery residents. This survey comprised 24 questions regarding demographics, education, previous international experience, interest level and perceived opportunities in international surgery.

Results

A 27% response rate revealed a high level of interest in international surgery among Canadian general surgery residents but a low level of awareness of the opportunities and relevant organizations.

Conclusion

Further initiatives are needed to increase international surgery awareness and opportunities among general surgery residents.     

Competence in pediatric urology upon graduation from residency: perceptions of residents,program directors and pediatric urologists

Objective

We aimed to clarify the scope of pediatric urological procedures that Canadian urology residents are perceived to be competent to perform upon graduation.

Methods

We conducted a survey from April 2005 to June 2006 of urology residency program directors (UPDs), senior urology residents (SURs) and Pediatric Urologists of Canada (PUC) members from all 12 Canadian training programs. Questions focused on which of 23 pediatric urological procedures the 3 study groups perceived urology residents would be competent to perform upon completion of residency without further fellowship training. Procedures were based on the “A,” “B” and “C” lists of procedures (least complex to most complex) as outlined in the Royal College of Physicians and Surgeons of Canada Objectives of Training in Urology.

Results

Response rates were 12/12 (100%), 41/53 (77%) and 17/23 (74%) for UPDs, SURs and PUC members, respectively. Average exposure to pediatric urology during residency was 5.4 (range 3–9) months and considered sufficient by 75% of UPDs and 69% of SURs, but only 41% of PUC members (p = 0.05). Overall, the 3 groups disagreed on the level of competence for performing level “A” and “B” procedures, with significant disagreement between PUC members and UPDs as well as SURs (p < 0.005).

Conclusion

PUC members perceive Canadian urology residents'' exposure to pediatric urology as insufficient and their competence for procedures of low to moderate complexity as inadequate. Further investigation regarding exposure to and competence in other emerging subspecialty spheres of urology may be warranted. Ongoing assessment of the objectives for training in pediatric urology is required.     

Simulation for Teaching Orthopaedic Residents in a Competency-based Curriculum: Do the Benefits Justify the Increased Costs?

Background

Although simulation-based training is becoming widespread in surgical education and research supports its use, one major limitation is cost. Until now, little has been published on the costs of simulation in residency training. At the University of Toronto, a novel competency-based curriculum in orthopaedic surgery has been implemented for training selected residents, which makes extensive use of simulation. Despite the benefits of this intensive approach to simulation, there is a need to consider its financial implications and demands on faculty time.

Questions/purposes

This study presents a cost and faculty work-hours analysis of implementing simulation as a teaching and evaluation tool in the University of Toronto’s novel competency-based curriculum program compared with the historic costs of using simulation in the residency training program.

Methods

All invoices for simulation training were reviewed to determine the financial costs before and after implementation of the competency-based curriculum. Invoice items included costs for cadavers, artificial models, skills laboratory labor, associated materials, and standardized patients. Costs related to the surgical skills laboratory rental fees and orthopaedic implants were waived as a result of special arrangements with the skills laboratory and implant vendors. Although faculty time was not reimbursed, faculty hours dedicated to simulation were also evaluated. The academic year of 2008 to 2009 was chosen to represent an academic year that preceded the introduction of the competency-based curriculum. During this year, 12 residents used simulation for teaching. The academic year of 2010 to 2011 was chosen to represent an academic year when the competency-based curriculum training program was functioning parallel but separate from the regular stream of training. In this year, six residents used simulation for teaching and assessment. The academic year of 2012 to 2013 was chosen to represent an academic year when simulation was used equally among the competency-based curriculum and regular stream residents for teaching (60 residents) and among 14 competency-based curriculum residents and 21 regular stream residents for assessment.

Results

The total costs of using simulation to teach and assess all residents in the competency-based curriculum and regular stream programs (academic year 2012–2013) (CDN 155,750, USD 158,050) were approximately 15 times higher than the cost of using simulation to teach residents before the implementation of the competency-based curriculum (academic year 2008–2009) (CDN 10,090, USD 11,140). The number of hours spent teaching and assessing trainees increased from 96 to 317 hours during this period, representing a threefold increase.

Conclusions

Although the financial costs and time demands on faculty in running the simulation program in the new competency-based curriculum at the University of Toronto have been substantial, augmented learner and trainer satisfaction has been accompanied by direct evidence of improved and more efficient learning outcomes.

Clinical Relevance

The higher costs and demands on faculty time associated with implementing simulation for teaching and assessment must be considered when it is used to enhance surgical training.     

Point-of-care ultrasonography in Canadian anesthesiology residency programs: a national survey of program directors

Purpose

Point-of-care ultrasonography (POCUS) is a useful tool with multiple perioperative applications relevant to the anesthesiologist. Nevertheless, the full scope of POCUS applications has yet to be formally incorporated into Canadian anesthesiology training. The purpose of this study was to determine the current state of POCUS training in Canadian anesthesiology residency programs.

Methods

We conducted a web-based survey of program directors from Royal College-accredited anesthesiology residency programs across Canada. Respondents were asked about POCUS training and assessment strategies at their institution as well as perceived barriers to POCUS education. We also elicited program directors’ views on the importance of various POCUS applications as well as future direction of POCUS education within Canadian anesthesiology residency programs.

Results

Thirteen of 17 (76%) program directors responded to our survey. All respondents’ residency programs provide some training in POCUS-facilitated vascular access, peripheral nerve blocks, neuraxial techniques, and transthoracic echocardiography. Nevertheless, training varies significantly for the other POCUS applications in our survey. The most frequently quoted teaching method employed is informal bedside teaching, followed by structured expert demonstration, hands-on scanning, and didactic lectures. The most frequently quoted barrier to teaching POCUS is the lack of trained staff. The majority of respondents agreed that competence in POCUS is important for graduating anesthesiology residents, and that POCUS should be incorporated into the National Curriculum for Canadian Anesthesiology Residency.

Conclusion

Point-of-care ultrasonography training within Canadian anesthesiology residency programs is highly variable. Given the importance of POCUS abilities and their relevance to modern anesthesia practice, POCUS training and assessment within Canadian anesthesiology residency programs should be formalized.

     

The historic predictive value of Canadian orthopedic surgery residents’ orthopedic in-training examination scores on their success on the RCPSC certification examination

Background

Positive correlation between the orthopedic in-training examination (OITE) and success in the American Board of Orthopaedic Surgery examination has been reported. Canadian training programs in internal medicine, anesthesiology and urology have found a positive correlation between in-training examination scores and performance on the Royal College of Physicians and Surgeons of Canada (RCPSC) certification examination. We sought to determine the potential predictive value of the OITE scores of Canadian orthopedic surgery residents on their success on their RCPSC examinations.

Methods

A total of 118 Canadian orthopedic surgery residents had their annual OITE scores during their 5 years of training matched to the RCPSC examination oral and multiple-choice questions and to overall examination pass/fail scores. We calculated Pearson correlations between the in-training examination for each postgraduate year and the certification oral and multiple-choice questions and pass/fail marks.

Results

There was a predictive association between the OITE and success on the RCPSC examination. The association was strongest between the OITE and the written multiple-choice examination and weakest between the OITE and the overall examination pass/fail marks.

Conclusion

Overall, the OITE was able to provide useful feedback to Canadian orthopedic surgery residents and their training programs in preparing them for their RCPSC examinations. However, when these data were collected, truly normative data based on a Canadian sample were not available. Further study is warranted based on a more refined analysis of the OITE, which is now being produced and includes normative percentile data based on Canadian residents.     

Using CanMEDS to guide international health electives: an enriching experience in Uganda defined for a Canadian surgery resident

Background

Surgery residents who wish to travel during their residency will often seek an elective experience in a low-or middle-income country. Objectives for international health electives (IHEs) are often vague and poorly defined. Further, feedback to, and evaluation of, the resident after the IHE are often not specific because international preceptors are not familiar with the desired educational outcomes of Canadian residency programs. Residents who choose an elective in a low-income country usually anticipate that they will contribute some medical service to an existing impoverished health care system, and in this setting, they hope to gain exposure to a high operative volume with potentially fewer institutional and administrative obstacles.

Methods

In this paper, we describe one resident''s elective experience in Mbarara, Uganda. In addition to her clinical experience, the resident performed a retrospective audit of surgical admissions. After her elective, we asked the resident to reflect on her experience and to use the Canadian Medical Education Directives for Specialists (CanMEDS) framework to describe the challenges she encountered and to define the learning outcomes gained with respect to each CanMEDS role.

Results

We discovered that the resident had a rich and insightful educational experience when discussed in this context. As a result, we have created a guide for structuring postgraduate IHEs around the CanMEDS roles, using them to ask pre-and postelective questions to develop relevant and practical IHE objectives.

Conclusion

We propose that this guide has the potential to improve both resident preparation before international experience and also subsequent evaluation of resident performance in this ill-defined area. More important, we found that IHEs are a useful vehicle to evaluate resident achievement of the CanMEDS competencies in a way that is reflective, realistic and representative of the multiple challenges involved when working in international health.     

Block to succeed: the Canadian orthopedic resident research experience

Background

We assessed the current state of Canadian orthopedic resident research and the effect of protected block research time on the numbers of grants obtained, research projects completed, submissions for publication, publications and conference presentations.

Methods

We administered a 27-item cross-sectional survey containing quantitative and qualitative questions to postgraduate year (PGY)-3 to -5 residents in all 16 Canadian orthopedic training programs in the academic year of Jul. 1, 2005, to Jun. 30, 2006.

Results

There was an overall response rate of 45% (85/188) from residents in 15 of 16 orthopedic programs: 56% (48/85) of respondents took block research time of at least 1 month (mean 5 mo). The number of months taken was positively correlated with the number of grants obtained (r = 0.28, p = 0.011) and publications (r = 0.23, p = 0.031). Residents who took block time obtained more grants (Fisher exact test 3.54, p = 0.048) and publications (Fisher exact test 6.09, p = 0.012) than those who did not take block time. About 41% (35/85) of respondents said time was the biggest obstacle to research.

Conclusion

Providing protected block research time during residency allows Canadian orthopedic residents greater research success.     

Are Canadian general surgery residents ready for the 80-hour work week? A nationwide survey

Background

The purpose of this study was to describe Canadian general surgery residents’ perceptions regarding potential implementation of work-hour restrictions.

Methods

An ethics review board–approved, Web-based survey was submitted to all Canadian general surgery residency programs between April and July 2009. Questions evaluated the perceived effects of an 80-hour work week on length of training, operative exposure, learning and lifestyle. We used the Fisher exact test to compare senior and junior residents’ responses.

Results

Of 360 residents, 158 responded (70 seniors and 88 juniors). Among them, 79% reported working 75–100 hours per week. About 74% of seniors believed that limiting their work hours would decrease their operative exposure; 43% of juniors agreed (p < 0.001). Both seniors and juniors thought limiting their work hours would improve their lifestyle (86% v. 96%, p = 0.12). Overall, 60% of residents did not believe limiting work hours would extend the length of their training. Regarding 24-hour call, 60% of juniors thought it was hazardous to their health; 30% of seniors agreed (p = 0.001). Both senior and junior residents thought abolishing 24-hour call would decrease their operative exposure (84% v. 70%, p = 0.21). Overall, 31% of residents supported abolishing 24-hour call. About 47% of residents (41% seniors, 51% juniors, p = 0.26) agreed with the adoption of the 80-hour work week.

Conclusion

There is a training-level based dichotomy of opinion among general surgery residents in Canada regarding the perceived effects of work hour restrictions. Both groups have voted against abolishing 24-hour call, and neither group strongly supports the implementation of the 80-hour work week.     

The development of postgraduate surgical training in Guyana

Background

Like many developing countries, Guyana has a severe shortage of surgeons. Rather than rely on overseas training, Guyana developed its own Diploma in Surgery and asked for assistance from the Canadian Association of General Surgeons (CAGS). This paper reviews the initial results of Guyana’s first postgraduate training program.

Methods

We assisted with program prerequisites, including needs assessment, proposed curriculum, University of Guyana and Ministry of Health approval, external partnership and funding. We determined the outputs and outcomes of the program after 2 years, and we evaluated the impact of the program through a quantitative/qualitative questionnaire administered to all program participants.

Results

Five residents successfully completed the 2-year program and are working in regional hospitals. Another 9 residents are in the training program. Twenty-four modules or short courses have been facilitated, alternating Guyanese with visiting Canadian surgical faculty members coordinated through CAGS. A postgraduate structure, including an Institute for Health Sciences Education and Surgical Postgraduate Education Committee, has been developed at the Georgetown Public Hospital Corporation (GPHC). An examination structure similar to Canada’s has been established. Hospital staff morale is greater, surgical care is more standardized and academic opportunities have been enhanced at GPHC. Four regional hospitals have welcomed the new graduates, and surgical services have already improved. Canadian surgeons have a greater understanding of and commitment to surgical development in low-income countries.

Conclusion

Guyana has proven that, with visiting faculty assistance, it can mount its own postgraduate training suitable to national needs and will provide a career path to encourage its own doctors to remain and serve their country.