Development of a comprehensive vascular skills assessment for surgical trainees

Background

Although vascular skills are important to general surgeons, vascular surgery has become a separate specialty, and therefore, there may be an erosion of vascular skills acquired by general surgical trainees. The purpose of this study was to develop a reliable and valid comprehensive vascular skills assessment (CVSA) of both knowledge and technical skills.

Methods

Twenty-four of 38 general surgical residents at the University of British Columbia completed a two-part CVSA consisting of a written examination and a series of 4 technical stations in a skills laboratory. Technical performance was rated using validated scales.

Results

The mean overall CVSA score was 50%. The CVSA demonstrated construct validity, with improvement in scores with increasing postgraduate year level (P = .01). The overall reliability (Cronbach's α) was .90.

Conclusions

The CVSA developed in this study is a comprehensive assessment of vascular skills that is both valid and reliable. It offers an objective and feasible assessment of general surgical trainees' vascular skills.     

Surgical registrars' perceptions of surgical training and capacity in Zambia: Results from three COSECSA affiliated training hospitals

Background

Surgery is a vital component of a comprehensive health system, but there are often personnel limitations in resource constrained areas. Zambia provides post graduate surgical training through two systems to help address this shortage. However, no studies have analyzed surgical trainees' perceptions of these programs.

A thematic review of the use of electronic logbooks for surgical assessment in sub-Saharan Africa

IntroductionEnsuring that surgical training programmes in low- and middle-income countries (LMICs) provide high quality training, including adequate operative experience, is of crucial importance in meeting the goals set out in the Lancet Global Surgery 2030. Electronic logbooks (eLogbooks) have been adopted to monitor both individual trainee progression and the performance of surgical training programmes.MethodsWe performed a thematic review of the current evidence base surrounding the use of eLogbooks for the assessment of surgeons in training in sub-Saharan Africa, with a view to identifying the learning to date and areas for future research.ResultsWhilst there are multiple papers highlighting the use of surgical eLogbooks in high-income countries, we identified only three papers which discussed their use in sub-Saharan Africa. Four common themes emerged which related to the use of surgical eLogbooks throughout sub-Saharan Africa: ease of analysis, centralised databases, discrepancies in reporting and technology limitations.ConclusionsRobust data to demonstrate trainee progression and the quality of surgical training programmes are of crucial importance in ensuring that surgical training programmes can rapidly scale up to deliver large numbers of well-trained surgical providers to address the unmet patient need in LMICs in the next decade. The limited data on the use of well designed, centralised electronic surgical logbooks indicate that this tool may play an important role in providing key data to underpin these training programmes.     

Mental rehearsal: A useful simulation adjunct to surgical training

BackgroundSimulation is an effective adjunct to surgical training. There is increasing interest in the use of mental rehearsal as a form of cognitive simulation. The mental visualisation of a motor skill is recognised to enhance performance; a concept not novel to surgeons. Despite this, mental rehearsal has yet to be formally incorporated into surgical training. This study aims to assess the use of mental rehearsal amongst general surgical trainees and consultants.MethodA six-item questionnaire was designed and electronically circulated to general surgical core trainees, registrars, fellows and consultants. Qualitative and quantitative analysis was independently performed.Results153 responses (consultants = 51.6%, trainees = 48.4%) were received over 3 weeks. 91.5% of surgeons mentally rehearse prior to operating. Its use predominates for complex cases only. There is no difference in case complexity and the surgeon's grade in regard to when mental rehearsal is performed ($\chi$² = 1.027, p = 0.31). Individual mental rehearsal is preferred. Consultants are more likely to mentally rehearse with others, although there was no statistical difference compared to trainees ($\chi$² = 0.239, p = 0.63). Clarification, confidence and anticipation of potential difficulties were the perceived benefits of mental rehearsal reported in 58.6% of responses.ConclusionsMental rehearsal prior to operating appears instinctive for general surgeons irrespective of seniority and case complexity. Whether the efficacy of mental rehearsal on training is sustained and continues as surgeons progress along the training curve are unknown. Alternative methods of surgical training are very much needed. We propose mental rehearsal.     

Modernizing assessment of surgical trainees in the workplace

Surgical training has evolved significantly over the last few decades. The old model of an informal apprenticeship and ad-hoc mentoring by a single or small team of consultant supervisors has been slowly replaced with formal assessment against a standardized specialty curriculum and annual review of competence by a panel of trainers. The introduction of new surgical curricula from August 2021 has continued this modernization of surgical assessment with greater emphasis on quality of interactions between trainer and trainee. The requirement of a fixed number of work-place based assessments to be completed per year has been dropped. There is a move to competency-based assessment rather than time based. Competencies have been divided into core competencies (Generic Professional Capabilities) and key competencies of a speciality (Capabilities in Practice). These will be assessed by a group of consultant supervisors, and structured and constructive feedback will be provided using the multi-consultant report, a tool designed to give defined feedback that can be actioned by trainees. Trainees will be able to measure their performance against tangible goals and see their progressions towards acquiring the skills required of a day one consultant.     

Visual spatial perception and surgical competence

BACKGROUND: Proficiency in visual spatial perception (VSP) is a hypothetical component of surgical competence. METHODS: Four tests of VSP, taken from the Cognitive Laterality Battery (CLB), were administered to 301 surgeons and surgical residents. Mean scores on each test were compared by Student t tests to those of the normative sample (n = 251) on which the test was originally standardized. RESULTS: Mean scores on two of the tests (Orientation, Touching Blocks) were significantly greater (P <0.01) for the study sample than for the normative sample, while mean scores on the other two subtests (Form Completion, Localization) were not. CONCLUSIONS: Surgeons tend to outperform the general population on tests of high-level VSP abilities (ie, envisioning depth and mentally manipulating two-dimensional representations of three-dimensional structures) identified previously as correlates of surgical skill acquisition. VSP proficiency is a valid component of surgical competence that should perhaps be included in career selection discussions with medical students and in assessment of the competence of surgeons.     

Geographic maldistribution of general surgery PGYI residents: another US surgical desert

Background

Practicing general surgeons are unevenly distributed across the country. This study evaluates the geographic distribution of categorical, general surgery (GS) PGYI positions per capita.

Methods

Data were obtained from the 2012 National Resident Matching Program match and the 2010 US Census.

Results

The mean for GS PGYI positions per 10⁶ population was 3.85 ± .61; 27 states fell below this value. The 7 American College of Surgeons (ACS) regions ranged from a low of 1.4 ± .50 (Intermountain) to a high of 9.89 ± 4.41 (Northeast). The mean (2.18 ± .34) for the 19 state membership of the Southwestern Surgical Congress was below the mean for the country.

Conclusions

There is a maldistribution of GS PGYI positions compared with state and regional populations, particularly in rural areas. This mirrors the maldistribution of practicing general surgeons across the United States. Additional GS residences and resident positions are urgently needed to correct this “Surgical Desert” of graduate surgical education.     

Nondesignated preliminary residents in general surgery: 25-year outcomes

Background

This study assesses the outcomes of nondesignated preliminary (NDP) residents in general surgery (GS) at an independent, nonuniversity training program.

Methods

Records of all NDP residents from 1984–1985 through 2008–2009 were reviewed, and residents' careers were followed. Designated preliminary and categorical residents were excluded.

Results

Sixty-two residents completed the NDP year. Three of these residents also completed a second postgraduate NDP year. A total of 60 NDPs (97%) continued in accredited postgraduate programs. Forty-eight graduates (77%) pursued surgery-associated careers: 26 (42%) in GS and 22 (35%) in other surgery-related specialties. Eleven of the 26 NDPs who entered GS (42%) became categorical residents in our program. All NDP GS graduates are board certified, board eligible, or are residents in training.

Conclusions

After a preliminary year in GS, NDPs continued in postgraduate medical education followed by board certification, usually in GS or surgery-related specialties. NDPs often obtain categorical positions in the parent GS program.     

Vascular surgery training, exposure, and knowledge during general surgery residency: implications for the future

BACKGROUND: Vascular surgery (VS) has been removed from the Canadian general surgery (GS) objectives and has become a primary certificate specialty in the United States, leaving its status in GS uncertain. The purpose of this study was to determine GS residents' perceived competence in VS and to assess their knowledge of VS. METHODS: GS residents at a university-based program answered (1) a survey of attitudes and experience in VS and (2) a short-answer examination to assess fundamental vascular knowledge. RESULTS: Twenty-nine of 35 residents participated (83%). Residents reported being inadequately trained in 10 of 13 procedures surveyed despite 6 of these being reported as essential. Although 26 of 29 residents reported an intention to perform vascular procedures, none planned on pursuing a fellowship. The mean examination score was 47%. CONCLUSIONS: Despite mandatory VS rotations, GS residents feel inadequately trained in VS and have marginal knowledge. Current trainees may lack the skills and abilities to deal with vascular emergencies.     

Program directors' views on general surgery resident travel for transplant rotations

Background

Some program directors in surgery (PDs) must maintain transplant rotations at nonintegrated (away) hospitals. This study investigated the opinions of PDs related to resident travel for transplant surgery experience.

Methods

An Internet-based survey was e-mailed to 251 PDs in the United States.

Results

Altogether, 131 PDs (52%) responded. Of those, 66% have a transplant service at integrated hospitals. Small majorities of PDs believed transplant rotations offer a good educational experience (59%) and comply with duty hours (71%). Few PDs believed transplant rotations provide excellent operative experience (47%) and mandate service over education (38%). PDs leading community-affiliated and smaller programs employed away rotations more commonly. Affected PDs used commuting (48%) and purchased temporary housing (52%). Most believed travel is a poor aspect of the experience (78%) and transplant rotations should become an optional component of residency training (60%). PDs using away hospitals more often believed this content area should be eliminated.

Conclusions

Although away transplant rotations minimally impact opinions of PDs related to select educational issues, most PDs challenge the existing paradigm of transplant surgery as essential content.     

Laparoscopic cholecystectomy performed by surgical trainees.

OBJECTIVE: The aim of this study was to assess morbidity, mortality, and outcome in select patients after laparoscopic cholecystectomy performed by consultants or by Specialist Registrars (SpRs) and Senior House Officers (SHO), in the General Hospital of Ioannina 'G. Hatzikosta' in northwestern Greece. METHODS: Between January 1, 2001 and December 31, 2005, 1370 laparoscopic cholecystectomies were performed, 445 (33%) by SpRs and SHO and 925 (67%) by consultants. Patients included 982 (71.3%) women and 388 (28.7%) men. The mean age was 46.2 years (range, 17 to 79). All patients had routine blood tests (including liver function tests), electrocardiography, chest x-ray, and abdominal ultrasound scan performed preoperatively. All patients received a general anesthesia, and the standard Reddick and Olsen technique was performed. The Harmonic scalpel was used in all cases. RESULTS: Four conversions (0.3%) were required to an open procedure, (2 in the SpRs and SHO group and 2 in the group of consultants), because of impossible recognition of anatomy around Calot's triangle. The mean operative time was 57 minutes (range, 33 to 97) for SpRs and SHO, while for the consultants it was 49 minutes (range, 27 to 78, P=0.25). Mortality rate was 0% in both groups. There were 44 major complications (2.7%), 17 in the SHO and SpRs group (3.7%) and 27 in the consultant group (1.7%, P=0.11). The complications included bowel thermal injury (consultants [cons], 1; residents [res], none); bile duct injury (cons, 1; res, none); bile leak (cons, 3; res, 5); hemorrhage (cons, 2; res, 2); hematomas at the trocar sites (cons, 5; res, 4); inflammation of the port site at the umbilicus (cons, 4; res, 5); paralytic ileus (cons, 4; res, 3); and hemorrhage from the subxiphoid trocar (cons, 2; res, 3), which stopped spontaneously. The mean hospital stay was 1.3 days, while all the patients resumed their normal activities after 11.7 days (range, 7 to 19). CONCLUSION: Supervised laparoscopic cholecystectomy performed by trainees does not increase surgical morbidity and does not compromise surgical outcome.     

Veterans Affairs general surgery service: the last bastion of integrated specialty care

Background

In a time of increasing specialization, academic training institutions provide a compartmentalized learning environment that often does not reflect the broad clinical experience of general surgery practice. This study aimed to evaluate the contribution of the Veterans Affairs (VA) general surgery surgical experience to both index Accreditation Council for Graduate Medical Education (ACGME) requirements and as a unique integrated model in which residents provide concurrent care of multiple specialty patients.

Methods

Institutional review board approval was obtained for retrospective analysis of electronic medical records involving all surgical cases performed by the general surgery service from 2005 to 2009 at the Nashville VA. Over a 5-year span general surgery residents spent an average of 5 months on the VA general surgery service, which includes a postgraduate year (PGY)-5, PGY-3, and 2 PGY-1 residents. Surgeries involved the following specialties: surgical oncology, endocrine, colorectal, hepatobiliary, transplant, gastrointestinal laparoscopy, and elective and emergency general surgery. The surgeries were categorized according to ACGME index requirements.

Results

A total of 2,956 surgeries were performed during the 5-year period from 2005 through 2009. Residents participated in an average of 246 surgeries during their experience at the VA; approximately 50 cases are completed during the chief year. On the VA surgery service alone, 100% of the ACGME requirement was met for the following categories: endocrine (8 cases); skin, soft tissue, and breast (33 cases); alimentary tract (78 cases); and abdominal (88 cases). Approximately 50% of the ACGME requirement was met for liver, pancreas, and basic laparoscopic categories.

Conclusions

The VA hospital provides an authentic, broad-based, general surgery training experience that integrates complex surgical patients simultaneously. Opportunities for this level of comprehensive care are decreasing or absent in many general surgery training programs. The increasing level of responsibility and simultaneous care of multiple specialty patients through the VA hospital systems offers a crucial experience for those pursuing a career in general surgery.     

Novel method for assessment and selection of trainees for higher surgical training in general surgery

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty-two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short-listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree's or diplomas that had been obtained through part-time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short-listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post-graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability alpha = 0.89 and good statistical power (range 0.95-0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.     

A focused curriculum in surgical oncology for the third-year medical students

Background

Educating medical students in surgical subspecialty fields can be challenging, and the optimal timing and curriculum remain unknown. Despite advocacy for earlier exposure, competing core clerkship rotations often leave little time for subspecialty fields. We report our experience with a novel, short, and focused curriculum in surgical oncology for the third-year medical students.

Methods

A 2-wk (2009–2010) and a 4-wk (2010–2011) curriculum in surgical oncology were developed for the third-year students at a tertiary-referral cancer center, including formal didactics, rotation in clinical service of students' choosing (breast, gastrointestinal, endocrine, or melanoma), and case-based learning and presentation. Paired pre- and postrotation questionnaires were prospectively completed, including 20 items assessing knowledge and four items assessing experience. Grading was anonymous, and change in score was assessed by Wilcoxon signed-rank test.

Results

Paired questionnaires from 47 students (2-wk rotation, n = 26; 4-wk rotation, n = 21) showed a median improvement of three points (21.4%) from pre- to posttests (P < 0.001). The improvement did not differ by the length of rotation or by the specific clinical service. Nearly all (93%) reported a positive and inspiring experience. The most valuable avenue of learning was reported as the time spent with resident or fellow or attending (92%), followed by self-directed reading (62%) and didactic lectures (28%).

Conclusions

A short and focused curriculum in surgical oncology, including structured didactics and clinical rotation, had positive impact for the third-year students. Given the increasing work-hour limits, it is important to note that the time spent in the clinical setting continues to be ranked as the most educationally valuable by medical students.     

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.     

Medical student operative experience correlates with a match to a categorical surgical program

BACKGROUND: Interest in general surgical residencies has decreased significantly. Because medical student clerkship experiences may affect specialty preferences, we attempted to determine if the degree of exposure to surgical procedures influenced career choices. METHODS: Operations observed by students who completed the third-year surgical clerkship between 1998 and 1999 were reviewed. These 146 medical students, who matched to residency training programs in March 2000, were then divided into three groups based upon residency fields. Surgical case exposures were then compared between the groups. RESULTS: The total number of operations observed was similar between the groups. However, students who matched into categorical general surgical programs participated in significantly more abdominal and general surgical procedures than those matching in surgical subspecialty or nonsurgical residencies (P < 0.01). CONCLUSIONS: There appears to be a correlation between surgical case exposure during the third-year clerkships and future residency fields. Thus, the degree of exposure to surgical procedures may influence medical student career choices.