Cost and logistics of implementing a tissue-based American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for general surgery residents of all clinical years

Background

The cost and logistics of deploying the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) National Technical Skills Curriculum across all training years are not known. This information is essential for residency programs choosing to adopt similar curricula.

Methods

A task force evaluated the authors' institution's existing simulation curriculum and enhanced it by implementing the ACS/APDS modules. A 35-module curriculum was administered to 35 general surgery residents across all 5 clinical years. The costs and logistics were noted, and resident satisfaction was assessed.

Results

The annual operational cost was $110,300 ($3,150 per resident). Cost per module, per resident was $940 for the cadaveric module compared with $220 and $240 for dry simulation and animal tissue–based modules, respectively. Resident satisfaction improved from 2.45 to 4.78 on a 5-point, Likert-type scale after implementing the ACS/APDS modules.

Conclusions

The ACS/APDS skills curriculum was implemented successfully across all clinical years. Cadaveric modules were the most expensive. Animal and dry simulation modules were equivalent in cost. The addition of tissue-based modules was associated with high satisfaction.     

Designing an ethics curriculum to support global health experiences in surgery

Background

The field of global health is rapidly expanding in many medical centers across the US. As a result, medical students have increasing opportunities to incorporate global health experiences (GHEs) into their medical education. Ethics is a critical component of global health curricula, yet little literature exists to direct the further development of didactic training. Therefore, we sought to define ethical encounters experienced by medical students participating in short-term surgical GHEs and create a framework for the design of ethics curriculum specific to global surgery.

Materials and methods

Emory University Departments of Surgery, Urology, and Anesthesia, in partnership with the non-profit organization Project Medishare, have taken annual humanitarian surgical trips to Hinche, Haiti. All medical students returning from the trips in 2011 and 2012 received a 35-question survey to assess demographic data, extent of prior ethics education, frequency of exposure and situational confidence to ethical subject matter, as well as ethical conflicts involved in surgical GHEs. The same comparative data were also collected for domestic clinical clerkships.

Results

Seventeen out of 21 medical students completed the survey. Nearly all (88.3%) students had previous formal ethics training as an undergraduate or in medical school. Ethical issues were commonly encountered during domestic clinical encounters and volunteerism. However, students reported enhanced exposure to the professional obligation of surgeons (P = 0.025) and truth-telling/surgeon–patient relationships (P = 0.044) during surgical volunteerism. Despite increased exposure, situational confidence did not change.

Conclusions

Ethical issues are commonly confronted during GHEs in surgery and differ from domestic clinical encounters. Healthcare ethics curriculum should be designed to meet the needs of medical students involved in global health.     

Evaluation of a blended learning surgical skills course for rural surgeons

Background

Rural surgeons have unique learning needs not easily met by traditional continuing medical education courses.

Methods

A multidisciplinary team developed and implemented a skills curriculum focused on leadership and communication, advanced endoscopy, emergency urology, emergency gynecology, facial plastic surgery, ultrasound, and management of fingertip amputations.

Results

Twenty-five of 30 (89%) rural surgeons who completed a follow-up course evaluation reported that the knowledge acquired during the course had improved their practice and/or the quality of patient care, particularly by refining commonly used skills and expanding the care options they could offer to their patients. The surgeons reported incorporating changes in their communication and interaction with colleagues.

Conclusions

This course was successful, from participants' perspectives, in providing hands-on mentored training for a variety of skills that reflect the broad scope of practice of surgeons in rural areas. Attendees felt that their participation resulted in important behavior and practice changes.     

International surgical clerkship rotation: perceptions and academic performance

Background

Concerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship.

Methods

A 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers.

Results

Twenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions.Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement.Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant.

Conclusions

This study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.     

Defining quality in surgical training: perceptions of the profession

Background

To improve surgical training standards, it is necessary to first define the elements of high-quality training and methods for measuring them.

Methods

Semistructured interviews were conducted with attending (n = 10) and resident (n = 10) general surgeons. An interview topic guide was used to elicit end users' opinions on indicators of training quality and methods to measure them. Interviews were recorded, transcribed verbatim, and coded using a framework to identify emergent themes. Sampling ceased once thematic saturation was achieved.

Results

Key surgical training quality indicators include continuity (80% of participants) and relationship (95%) between trainee and trainer, level of supervision (85%), and an optimal volume (95%) and mix (90%) of operative cases. All surgeons felt that trainee logbook analysis and feedback was essential. The majority (85%) felt that training analysis should be freely available to create accountability for hospitals and attending surgeons (70%) and encourage competition (70%) to drive up standards. Only 30% felt that all attending surgeons should offer training.

Conclusions

Surgical training quality needs to be robustly assessed. Transparency in training outcomes will create competition and raise standards of surgical education.     

Hand motion patterns of Fundamentals of Laparoscopic Surgery certified and noncertified surgeons

Background

With the increasing use of simulation in surgical training there is an increasing need for low cost methods of objective assessment.

Methods

Hand-motion data (3 degrees of freedom) were acquired using microelectromechanical gyroscope tracking devices worn on both hands during an intracorporeal suture/knot-tying laparoscopic task performed by FLS-certified and non-FLS-certified surgeons. Each data sample was processed into a symbolic time series, and the Lempel-Ziv complexity metric was calculated for each hand for the whole task and the first 60 seconds of the task from the dominant hand.

Results

FLS-certified surgeons had more complex hand-motion patterns. This was statistically significant only for the dominant hand (P = .02) but was still statistically significant when calculated from the first 60 seconds of the task (P = .04) and therefore independent of the total time taken to complete the task.

Conclusions

Hand-motion patterns were quantified and shown to be different between FLS-certified and non-FLS-certified surgeons using low-cost microelectromechanical technology and the Lempel-Ziv complexity metric.     

Development and validation of a composite scoring system for robot-assisted surgical training—the Robotic Skills Assessment Score

Background

A standardized scoring system does not exist in virtual reality-based assessment metrics to describe safe and crucial surgical skills in robot-assisted surgery. This study aims to develop an assessment score along with its construct validation.

Materials and methods

All subjects performed key tasks on previously validated Fundamental Skills of Robotic Surgery curriculum, which were recorded, and metrics were stored. After an expert consensus for the purpose of content validation (Delphi), critical safety determining procedural steps were identified from the Fundamental Skills of Robotic Surgery curriculum and a hierarchical task decomposition of multiple parameters using a variety of metrics was used to develop Robotic Skills Assessment Score (RSA-Score). Robotic Skills Assessment mainly focuses on safety in operative field, critical error, economy, bimanual dexterity, and time. Following, the RSA-Score was further evaluated for construct validation and feasibility. Spearman correlation tests performed between tasks using the RSA-Scores indicate no cross correlation. Wilcoxon rank sum tests were performed between the two groups.

Results

The proposed RSA-Score was evaluated on non-robotic surgeons (n = 15) and on expert-robotic surgeons (n = 12). The expert group demonstrated significantly better performance on all four tasks in comparison to the novice group. Validation of the RSA-Score in this study was carried out on the Robotic Surgical Simulator.

Conclusion

The RSA-Score is a valid scoring system that could be incorporated in any virtual reality-based surgical simulator to achieve standardized assessment of fundamental surgical tents during robot-assisted surgery.     

Reliable assessment of general surgeons' non-technical skills based on video-recordings of patient simulated scenarios

Background

Nontechnical skills are essential for safe and efficient surgery. The aim of this study was to evaluate the reliability of an assessment tool for surgeons' nontechnical skills, Non-Technical Skills for Surgeons dk (NOTSSdk), and the effect of rater training.

Methods

A 1-day course was conducted for 15 general surgeons in which they rated surgeons' nontechnical skills in 9 video recordings of scenarios simulating real intraoperative situations. Data were gathered from 2 sessions separated by a 4-hour training session.

Results

Interrater reliability was high for both pretraining ratings (Cronbach's α = .97) and posttraining ratings (Cronbach's α = .98). There was no statistically significant development in assessment skills. The D study showed that 2 untrained raters or 1 trained rater was needed to obtain generalizability coefficients >.80.

Conclusions

The high pretraining interrater reliability indicates that videos were easy to rate and Non-Technical Skills for Surgeons dk easy to use. This implies that Non-Technical Skills for Surgeons dk (NOTSSdk) could be an important tool in surgical training, potentially improving safety and quality for surgical patients.     

Can medical students achieve skills proficiency through simulation training?

Background

The purpose of this study was to determine whether third-year medical students can become proficient in open technical skills through simulation laboratory training.

Methods

A total of 204 students participated in a structured curriculum including bladder catheterization, breast examination, and knot-tying. Proficiency was documented using global rating scales and validated, objective, model-based metrics.

Results

For catheterization and breast examination, all trainees showed proficiency, and self-rated comfort increased in more than 90%. For knot-tying, 83% completed the curriculum; 57% and 44% of trainees showed proficiency for 2- and 1-handed tasks, respectively. Objective performance scores improved significantly for 2- and 1-handed knot-tying (62.9-94.4 and 49.2-89.6, respectively; P < .001) and comfort rating also increased (28%-91% and 19%-80%, respectively; P < .001).

Conclusions

Objective scores and trainee self-ratings suggest that this structured curriculum using simulator training allows junior medical students to achieve proficiency in basic surgical skills.     

Surgical resident perspective on deceased donor organ procurement

Background

Deceased donor organ procurement provides unparalleled opportunity for surgical residents with extensive surgical exposure. We hypothesize that surgical residents regard organ donation positively and organ procurement enhances their education.

Methods

We conducted an institutional review board approved anonymous national survey to evaluate organ procurement experiences and attitudes of general surgical residents.

Results

Three hundred ninety-seven residents representing all postgraduate years responded, with 97% completion rate. Organ procurement increased with training level (92% seniors vs 53% interns). Over 85% agree organ procurement is a good educational and operative experience, and 73% believe that it will benefit their future surgical career. About 68% agree that organ procurement provided knowledge of anatomy and exposures; under 10% felt organ procurement could be duplicated with simulation. Presence of transplant program did not affect attitudes or experience. Eighty-eight percent women versus77% men plan to donate their own organs.

Conclusion

Results indicate that surgical residents value organ procurement, and it remains an essential encounter that applies to general surgery.     

Cognitive training: How can it be adapted for surgical education?

Background

There is a need for new approaches to surgical training in order to cope with the increasing time pressures, ethical constraints, and legal limitations being placed on trainees. One of the most interesting of these new approaches is “cognitive training” or the use of psychological processes to enhance performance of skilled behaviour. Its ability to effectively improve motor skills in sport has raised the question as to whether it could also be used to improve surgical performance. The aim of this review is to provide an overview of the current evidence on the use of cognitive training within surgery, and evaluate the potential role it can play in surgical education.

Efecto de la simulación quirúrgica en la implementación clínica de procedimientos colorrectales laparoscópicos

Introduction

Advanced laparoscopic surgery requires supplementary training outside the operating room. Clinical simulation with animal models or cadavers facilitates this learning.

Objective

We measured the impact on clinical practice of a laparoscopic colorectal resection training program based on surgical simulation.

Material and methods

Between March 2007 and March 2012, 163 surgeons participated in 30 courses that lasted 4 days, of 35 hours (18 h in the operating room, 12 h in animal models, and 4 h in seminars). In May 2012, participants were asked via an on-line survey about the degree of implementation of the techniques in their day-to-day work.

Results

Seventy surgeons (47%) from 60 different hospitals answered the survey. Average time elapsed after the course was 11.5 months (2-60 months). A total of 75% initiated or increased the number of surgeries performed after the training. The increase in practice was > 10 cases/month in 19%, and < 5 cases/month in 56% of surgeons. 38% of participants initiated this surgical approach.

Conclusions

Seventy five percent of the surveyed surgeons increased the clinical implementation of a complicated surgical technique, such as laparoscopic colorectal surgery, after attending a training course based on clinical simulation.     

Can professionalism be taught? Encouraging evidence

Background

Teaching and assessing the Accreditation Council for Graduate Medical Education (ACGME) competencies of Professionalism and Communication have proven to be a challenge for surgical residency training programs. This study used innovative pedagogic approaches and tools in teaching these two competencies. The purpose of this study was to determine whether the learners actually are assimilating and using the concepts and values communicated through this curriculum.

Methods

A six-station Objective Structured Clinical Examination (OSCE) was designed using standardized patients to create varying Professionalism and Communication scenarios. The surgical resident learners were evaluated using these OSCEs as a baseline. The faculty then facilitated a specially designed curriculum consisting of six interactive sessions focusing on information gathering, rapport building, patient education, delivering bad news, responding to emotion, and interdisciplinary respect. At the conclusion of this curriculum, the surgical resident learners took the same six-station OSCE to determine if their professionalism and communication skills had improved.

Results

The surgical resident learners were rated by the standardized patients according to a strict task checklist of criteria at both the precurricular and postcurricular OSCEs. Improvement in the competencies of Professionalism and Communication did achieve statistical significance (P = .029 and P = .011, respectively).

Conclusions

This study suggests that the Communication and Professionalism ACGME competencies can be taught to surgical resident learners through a carefully crafted curriculum. Furthermore, these newly learned competencies can affect surgical resident interactions with their patients positively.     

Accuracy and content of medical student midclerkship self-evaluations

Background

Midclerkship self-evaluations (MCSEs) require students to reflect on their knowledge, skills, and behaviors. We hypothesized that MCSEs would be consistent with supervisor midpoint evaluations during a surgical clerkship.

Methods

MCSEs of 153 students who completed our surgery clerkship in 2 academic years were compared with supervisor midclerkship evaluations. The quantitative domains of the MCSE and supervisor evaluation were compared for accuracy. Identified areas of strengths and weakness were evaluated for thematic consistency.

Results

Student MCSE scoring was accurate across evaluated domains most of the time; when students were inaccurate, they tended to underrate themselves. Students and supervisors most often identified cognitive skills as areas for improvement and noncognitive skills predominated as student strengths.

Conclusions

Medical students can accurately identify their strengths and weaknesses in the context of an MCSE. Based on these findings, knowledge acquisition and application by medical students in the clinical setting should be emphasized in undergraduate medical education.     

Pediatric surgeons’ attitudes toward regionalization of neonatal surgical care

Background/Purpose

Research has suggested that high-risk pediatric surgical patients have better outcomes when treated in resource-rich children’s environments. Surgical neonates are a particularly high-risk population and some suggest that regionalization might be a strategy to improve clinical outcomes in neonatal surgical patients. We conducted a national survey of pediatric surgeons in the United States to explore their attitudes toward regionalization of neonatal surgical care.

Methods

Members of the American Pediatric Surgical Association were asked to participate in an anonymous online survey to assess both attitudes toward regionalization, as well as perceptions of the importance of various resources in providing optimal care for surgical neonates.

Results

Overall, 56.2% of participants favored regionalization. Surgeons whose practice was part of a training program tended to favor regionalization more, as did those from larger group practices and those who practiced at free-standing children’s hospital. In addition, surgeons from larger groups and those involved with training programs more strongly favored the premise that a higher level of resource commitment should be available to treat surgical neonates.

Conclusions

The impact of any national strategy to improve neonatal surgical outcomes will be large and multi-faceted. While the majority of pediatric surgeons favor regionalization, our findings demonstrate variation in this view and highlight the necessity for surgeon involvement and education that will be critical in this effort.     

Money matters: a resident curriculum for financial management

Background

A 2005 survey reported 87% of surgery program directors believed practice management training should occur during residency. However, only 8% of program directors believed residents received adequate training in practice management [1]. In addition to the gap in practice financial management knowledge, we recognized the need for training in personal finance among residents. A literature review and needs assessment led to the development of a novel curriculum for surgery residents combining principles of practice management and personal finance.

Methods

An 18-h curriculum was administered over the 2012 academic year to 28 post graduate year 1–5 surgery residents and faculty. A self-assessment survey was given at the onset and conclusion of the curriculum [2]. Pre-tests and post-tests were given to objectively evaluate each twice monthly session's content. Self-perception of learning, interest, and acquired knowledge were analyzed using the Wilcoxon signed ranks test.

Results

Initial self-assessment data revealed high interest in practice management and personal finance principles but a deficiency in knowledge of and exposure to these topics. Throughout the curriculum, interest increased. Residents believed their knowledge of these topics increased after completing the curriculum, and objective data revealed various impacts on knowledge.

Conclusions

Although surgery residents receive less exposure to these topics than residents in other specialties, their need to know is no less. We developed, implemented, and evaluated a curriculum that bridged this gap in surgery education. After the curriculum, residents reported an increase in interest, knowledge, and responsible behavior relating to personal and practice financial management.     

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.     

Backward Planning a Craniomaxillofacial Trauma Curriculum for the Surgical Workforce in Low-Resource Settings

Background

Trauma is a significant contributor to global disease, and low-income countries disproportionately shoulder this burden. Education and training are critical components in the effort to address the surgical workforce shortage. Educators can tailor training to a diverse background of health professionals in low-resource settings using competency-based curricula. We present a process for the development of a competency-based curriculum for low-resource settings in the context of craniomaxillofacial (CMF) trauma education.

Methods

CMF trauma surgeons representing 7 low-, middle-, and high-income countries conducted a standardized educational curriculum development program. Patient problems related to facial injuries were identified and ranked from highest to lowest morbidity. Higher morbidity problems were categorized into 4 modules with agreed upon competencies. Methods of delivery (lectures, case discussions, and practical exercises) were selected to optimize learning of each competency.

Results

A facial injuries educational curriculum (1.5 days event) was tailored to health professionals with diverse training backgrounds who care for CMF trauma patients in low-resource settings. A backward planned, competency-based curriculum was organized into four modules titled: acute (emergent), eye (periorbital injuries and sight preserving measures), mouth (dental injuries and fracture care), and soft tissue injury treatments. Four courses have been completed with pre- and post-course assessments completed.

Conclusions

Surgeons and educators from a diverse geographic background found the backward planning curriculum development method effective in creating a competency-based facial injuries (trauma) course for health professionals in low-resource settings, where contextual aspects of shortages of surgical capacity, equipment, and emergency transportation must be considered.

     

Consensus on Training and Implementation of Enhanced Recovery After Surgery: A Delphi Study

Background

Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.

Methods

A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.

Results

An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.

Conclusions

We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.