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.     

Young surgeons' attitudes regarding surgery and professional organizations

Background

Attitudes of young surgeons regarding professional organizations are unclear. We surveyed young surgeons to assess their opinions regarding the role of The American College of Surgeons in the future of surgery.

Methods

A 21-question on-line survey was distributed to all young (age <45 years) ACS members. Questions were related to demographics, membership, educational, and health policy initiatives.

Results

Among 2689 respondents, reimbursement and malpractice were the most important issues to surgeons at all levels of training. Organizational attributes of importance to young surgeons included leadership, educational tools, mentorship, and avenues to participate in organized medicine. They value programs to address patient safety, surgical quality, reimbursement, and health policy.

Conclusions

Methods to recruit and retain young surgeons into medical organizations should include educational efforts, mentorship programs, practice-management courses, health policy reform, and opportunities for involvement in organizational activities.     

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict

Background

Prior research has shown that surgeons who effectively manage operating room conflict engage in a problem-solving stage devoted to modifying systems that contribute to team conflict. The purpose of this study was to clarify how systems contributed to operating room team conflict and clarify what surgeons do to modify them.

Methods

Focus groups of circulating nurses and surgeons were conducted at 5 academic medical centers. Narratives describing the contributions of systems to operating room conflict and behaviors used by surgeons to address those systems were analyzed using the constant comparative approach associated with a constructivist grounded theory approach.

Results

Operating room team conflict was affected by 4 systems-related factors: team features, procedural-specific staff training, equipment management systems, and the administrative leadership itself. Effective systems problem solving included advocating for change based on patient safety concerns.

Conclusions

The results of this study provide clarity about how systems contribute to operating room conflict and what surgeons can do to effectively modify these systems. This information is foundational material for a conflict management educational program for surgeons.     

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.     

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.     

Caring Dilemmas and Coping Strategies for Organ Transplant Recipients and Their Families: Perspective of Health Professionals in Taiwan

Background

Organ transplant health professionals (OTHP) are challenged by more and more sophisticated caring dilemmas raised by organ transplant recipients (OTR) and their families. The purposes of this study were to explore caring dilemmas and the reliable coping strategies applied by OTHPs in Taiwan.

Methods

A qualitative design was used with a purposive sample of OT surgeons and nurses. Data were collected by face-to-face in-depth interviews and analyzed by content analysis.

Results

Sixty subjects (43 females, 17 male) participated in this project. They were 16 OT surgeons and 44 nurses, including RNs (n = 29), nurse practitioners (NP, n = 6), and assistant/head nurses (n = 9). Their ages ranged from 25 to 66 (mean = 38.2) years old. Their OT careers ranged from 3 to 40 (mean = 24.7) years for OT surgeons and 0.5 to 15 (years = 4.3) years for the nursing group. Five types of coping strategies for caring dilemmas were reported: (1) developing clinical paths for complex multiple-OT cases, (2) developing OT-expert training programs for interdisciplinary team members, (3) integrating acute and long-term care teams for difficult OT cases and families, (4) holding case conferences for successful and failed cases, and (5) implementing humanistic care training programs.

Conclusions

The findings of this research provide important coping strategies that can help empower OTHPs to care for complex multiple-OT cases with humanitarian expressions. More discussion about cultivation of interdisciplinary OT experts programs, and integration of caring resources are needed in the near future.     

A survey-based assessment of the Canadian pediatric surgery workforce

Background

There is significant lack of information regarding the Canadian pediatric surgery workforce.

Methods

An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012.

Results

The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006–2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs.

Conclusions

The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada.     

25 años de cirugía laparoscópica en España

Introduction

The introduction of laparoscopic surgery (LS) can be considered the most important advancement in our specialty in the past 25 years. Despite its advantages, implementation and consolidation has not been homogenous, especially for advanced techniques. The aim of this study was to analyse the level of development and use of laparoscopic surgery in Spain at the present time and its evolution in recent years.

Material and methods

During the second half of 2012 a survey was developed to evaluate different aspects of the implementation and development of LS in our country. The survey was performed using an electronic questionnaire.

Results

The global response rate was 16% and 103 heads of Department answered the survey. A total of 92% worked in the public system. A total of 99% perform basic laparoscopic surgery and 85,2% advanced LS. Most of the responders (79%) consider that the instruments they have available for LS are adequate and 71% consider that LS is in the right stage of development in their environment.

Conclusions

Basic laparoscopic surgery has developed in our country to be considered the standard performed by most surgeons, and forms part of the basic surgical training of residents. With regards to advanced LS, although it is frequently used, there are still remaining areas of deficit, and therefore, opportunities for improvement.     

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.     

Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States

Background context

There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that define differences in surgical treatment among surgeons in the United States.

Purpose

To assess the surgical treatment patterns among neurologic and orthopedic spine surgeons in the United States for the treatment of one- and two-time recurrent lumbar disc herniation.

Study design

Electronic survey.

Patient sample

An electronic survey was delivered to 2,560 orthopedic and neurologic surgeons in the United States.

Outcome measures

The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups.

Methods

A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2,560 orthopedic and neurologic surgeons in the United States. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), anterior lumbar interbody fusion (ALIF) with percutaneous screws, ALIF with open posterior instrumentation, or none of these. Significance of p=.01 was used to account for multiple comparisons.

Results

Four hundred forty-five surgeons (18%) completed the survey. Surgeons in practice for 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was a 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent disc herniations, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training, and annual case volume.

Conclusions

Significant differences exist among US spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences and to define the most cost-effective surgical strategies for these common lumbar pathologies as the United States moves closer to a value-based health-care system.     

Lights, camera, surgery: a novel pilot project to engage medical students in the development of pediatric surgical learning resources

Background/Purpose

It is important to engage junior medical students in the pediatric surgical environment to showcase possible future career choices. Our aim was to assess how the students valued their experience in the realm of clinical learning, exposure to surgical careers, and development of skill sets necessary for creating learning resources.

Methods

A novel pilot project entitled Lights, Camera, Surgery engaged 13 medical students in the production of instructional videos of basic surgical procedures. An electronic survey questionnaire allowed the students to provide formal feedback on the project outcomes.

Results

Of the students who responded, 87.5% expressed appreciation of the enhanced clinical experience. All of the students either agreed or strongly agreed that the project afforded them valuable leadership experience, practical skills in creating educational learning resources, and opportunities to explore careers in surgery. All of the students either agreed or strongly agreed that the project allowed them to gain valuable skills in educational video production. The project videos are now available as educational tools.

Conclusions

Engaging medical students in the production of surgical videos potentially improves leadership skills and promotes the use of educational resources while affording them opportunities to explore pediatric surgery as a future career choice.     

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.     

The impact of brief team communication,leadership and team behavior training on ad hoc team performance in trauma care settings

Background

Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care.

Methods

Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations.

Results

Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention.

Conclusions

Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.     

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.     

Face validity of a Wii U video game for training basic laparoscopic skills

Background

Although the positive effects of playing video games on basic laparoscopic skills have been studied for several years, no games are actually used in surgical training. This article discusses the face validity of the first video game and custom-made hardware, which takes advantage of these effects.

Methods

Participants were recruited at the Chirurgendagen 2013 and the Society of American Gastrointestinal and Endoscopic Surgeons 2014 annual meeting. In total, 72 laparoscopic surgeons completed a demo of the game and filled in a questionnaire.

Results

On a 1-to-10 scale, the mean score for hardware realism was 7.2 and the mean score for usefulness as a training tool was 8.4. Participants did not mind the fact that the workspace does not look like an abdominal cavity, but do have some trouble with the absence of tactile feedback.

Conclusion

We obtained face validity for both the hardware and the usefulness of Underground, a video game made for training basic laparoscopic skills.     

Anatomic guide and sonography for surgical repair of leg muscle lacerations

Background

There were over 110,000 leg laceration cases reported in the United States in 2011. Currently, muscle laceration is repaired by suturing epimysium to epimysium. Tendon-to-tendon repair is stronger, restores the muscle's resting length, and leads to a better functional recovery. Tendons retract into the muscle belly following laceration and surgeons have a difficult time finding them. Many surgeons are unfamiliar with leg muscle anatomy and the fact that the leg muscles have long intramuscular tendons that are not visible in situ. A surgical anatomic guide exists to help surgeons locate forearm tendons; no such guide exists for tendons in the leg.

Materials and methods

The leg tendon ends of 11 cadavers were dissected, measured, and recorded as percentages of leg length. High-frequency ultrasound was used to locate tendon ends in three additional cadavers. These locations were compared with the actual tendon ends located via dissection.

Results

There was little variation in tendon end position within the cadaver group, between men and women or right and left legs. The data are presented as an anatomic guide to inform surgeons of the tendon ends' likely locations in the leg.

Conclusion

The location of leg intramuscular tendon ends is predictable and the anatomic guide will help surgeons locate tendon ends and perform tendon-to-tendon repairs. Ultrasound is a potentially effective tool for detection of accurate location of repairable tendon ends in leg muscle lacerations.     

Surgeon commitment to trauma care decreases missed injuries

Study objective

Missed injuries sustain an important issue concerning patient safety and quality of care. The purpose of this study is to examine the effect of surgeon commitment to trauma care on missed injuries. We hypothesised that surgeons committed to the trauma service has less missed injuries than surgeons not committed to the trauma service would have.

Methods

By retrospective analysis of 976 adult patients admitted to the trauma intensive care unit (ICU) at an urban, university-based trauma centre. Missed injuries were compared between two groups; in group 1 the patients were evaluated and treated by the surgeons who were committed to the trauma service and in group 2 the patients were evaluated and treated by surgeons practicing mainly in other specialties.

Results

Patients had significantly lower rates of missed major or life-threatening injuries when treated by group 1 surgeons. Logistic regression model revealed significant factors associated with missed major or life-threatening injuries including ISS and groups in which patients were treated by different group surgeons.

Conclusions

Physicians will perform better when they are trained and interested in a specific area than those not trained, or even not having any particular interest in that specific area. Surgeons committed to the trauma service had less missed injuries in severely injured patients, and it is vital to improve patient safety and quality of care for trauma patients. Staff training and education for assessing severely injured patients and creating an open culture with detection and reduction of the potential for error are important and effective strategies in decreasing missed injuries and improving patient safety.     

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.     

Accounting for early job turnover in recent pediatric surgery fellowship graduates: An American Pediatric Surgical Association Membership and Credentials Committee study

Purpose

Employment opportunities for graduating pediatric surgeons vary from year to year. Significant turnover among new employees indicates fellowship graduates may be unsophisticated in choosing job opportunities which will ultimately be satisfactory for themselves and their families. The purpose of this study was to assess what career, life, and social factors contributed to the turnover rates among pediatric surgeons in their first employment position.