Putting a price on education: hours and dollars for a general surgery curriculum

Background

In 2005, a new curricular model was implemented for general surgery residents and a Division of Education created for administrative support. These changes forced an evaluation of available resources to maintain a new curricular model.

Methods

A retrospective review of resources expended during curricular sessions (June 2007-June 2008) provided to 42 surgical residents was conducted. Resources were evaluated in terms of the number, division, department, and rank of faculty involved. Contact hours and monetary costs were calculated.

Results

Total numbers of faculty involved in the postgraduate year (PGY)1, PGY2, and PGY3-5 curriculums were 79, 39, and 22, respectively. Faculty teaching time was 321 hours (PGY1), 187 hours (PGY2) and 36 hours (PGY3-5) for a combined 544 hours. Average teaching time commitment for faculty in the Division of Education was 26.5 hours, compared with 6.7 hours for departmental faculty in other divisions (P = .0002). Total monetary cost was $219,254.

Conclusions

The cost to maintain an educational general surgery curriculum is substantial and administrative support must be considered. Faculty with an explicit teaching commitment and responsibility are needed.     

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.     

452例烧伤整形患者麻醉性镇痛剂的临床应用

目的：观察烧伤整形术后患使用阿片类麻醉性镇痛剂的效果。方法：对各类烧伤和整形患术后疼痛的临床表现,麻醉性镇痛剂的使用人数,用药种类,每次剂量及每日用药次数进行回顾性统计分析。结果：在烧伤整形科,由于对疼痛治疗重要性认识不够,导致用药不当并镇痛不足。结论：临床概念上的混淆和“滥用”阿片类药品,是镇痛不足的主要原因,章提出了克服镇痛不足的相应对策。     

Challenges of randomized controlled trial design in plastic surgery

Randomized controlled trials are the gold standard of evidence-based medicine. In the field of plastic surgery, designing these studies is much more challenging than in pharmaceutical medicine. Randomized trials in plastic surgery encompass several road blocks including problems shared with other surgical trials: equipoise, high cost, placebo issues and learning curves following the establishment of a novel approach. In addition, plastic surgery has more subjective outcomes, thus making study design even more difficult in assessing the end result.     

Career development resource for plastic and reconstructive surgery

Plastic surgery is a broad-based discipline with emphasis on areas such as breast, craniomaxillofacial, burn, aesthetic, and hand surgery as well as complex wounds and wound healing. Plastic surgery as a specialty captures a great deal of media attention over many other fields of medicine, so education, training, and credentialing have become an area of national interest. The purpose of this article was to provide information on the organization, basic requirements for training, fellowship, and volunteer opportunities within the specialty.     

膨体聚四氟乙烯在整形美容外科的应用

应用膨体聚四氟乙烯（ｅＰＴＦＥ）治疗颜面部软组织缺损及凹陷畸形，探索整形美容外科的新手术方法，开发软组织填充材料。通过外科手术在真皮下松解，将ｅＰＴＦＥ植入软组织凹陷部位。临床选择隆鼻、眶周围凹陷畸形、先天性唇裂犁状孔周围凹陷及耳轮部分缺损等６４例，术后随访４年，满意率达９７９％。２例因发生感染取出，１例出现组织反应。认为ｅＰＴＦＥ组织相容性好，弹性和硬度与软组织相似，是极有前途的软组织填充物。     

Exposure to plastic surgery during undergraduate medical training: A single-institution review

BACKGROUND:Applications to surgical residency programs have declined over the past decade. Even highly competitive programs, such as plastic surgery, have begun to witness these effects. Studies have shown that early surgical exposure has a positive influence on career selection.OBJECTIVE:To review plastic surgery application trends across Canada, and to further investigate medical student exposure to plastic surgery.METHODS:To examine plastic surgery application trends, national data from the Canadian Resident Matching Service database were analyzed, comparing 2002 to 2007 with 2008 to 2013. To evaluate plastic surgery exposure, a survey of all undergraduate medical students at the University of Toronto (Toronto, Ontario) during the 2012/2013 academic year was conducted.RESULTS:Comparing 2002 to 2007 and 2008 to 2013, the average number of national plastic surgery training positions nearly doubled, while first-choice applicants decreased by 15.3%. The majority of Canadian academic institutions experienced a decrease in first-choice applicants; 84.7% of survey respondents indicated they had no exposure to plastic surgery during their medical education. Furthermore, 89.7% believed their education had not provided a basic understanding of issues commonly managed by plastic surgeons. The majority of students indicated they receive significantly less plastic surgery teaching than all other surgical subspecialties. More than 44% of students not considering plastic surgery as a career indicated they may be more likely to with increased exposure.CONCLUSION:If there is a desire to grow the specialty through future generations, recruiting tactics to foster greater interest in plastic surgery must be altered. The present study suggests increased and earlier exposure for medical students is a potential solution.     

Laparoscopy training in United States obstetric and gynecology residency programs.

OBJECTIVES: To assess laparoscopic training curriculums in US Obstetrics and Gynecology residency programs. METHODS: A list of E-mail addresses was obtained for the accredited Obstetrics and Gynecology residency programs in the US from the CREOG Directory of Obstetric-Gynecologic Residency Programs and Directors. An E-mail survey containing 8 questions regarding laparoscopy training was sent to all residency directors with current E-mail addresses. RESULTS: Seventy-four residency directors responded to the survey for a response rate of 41%. Residency programs from all sections of the US were included in the study. Results of the survey indicate that 69% of residency programs had implemented a formal laparoscopy training program. At least half of the program directors surveyed stated that lack of faculty time and funds were the main barriers to laparoscopic surgery training. Seventy-two percent of those surveyed thought that in the future the health-care industry would demand proof of competency in laparoscopy as standard of care. CONCLUSIONS: Most US Obstetrics and Gynecology residency programs have implemented a formal laparoscopy training curriculum, use more than one method to train their residents, and involve almost half of their faculty on average in training residents to perform laparoscopic surgery.     

Spaced education improves the feedback that surgical residents give to medical students: a randomized trial

Background

Surgery residents teach medical students; feedback is one critical teaching skill. We investigated whether feedback given by surgery residents to students could be improved through an online spaced education program.

Methods

Surgery residents were randomized to receive either a weekly spaced education e-mail during a 9-month period containing teaching bullets on how to provide effective feedback, or no intervention. Medical students rated the frequency and quality of feedback they received from the residents.

Results

Students reported 45% (67 of 149) of the spaced education residents gave frequent feedback, compared with 31% (55 of 175) of control residents (relative risk [RR], 1.43; P = .016). Students reported resident feedback was “helpful in their learning” in 92% (132 of 143) of their evaluations of spaced education residents, compared with 82% (132 of 161) of their evaluations of control residents (RR, 1.13; P = .01).

Conclusions

Educational programs using feedback bullets e-mailed weekly can significantly improve the frequency and quality of feedback that surgical residents provide medical students.     

Training in mitral valve surgery need not affect early outcomes and midterm survival: a multicentre analysis

Objective: Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience. Methods: We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences. Results: Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p = 0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p = 0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p = 0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p = 0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 ± 52 vs 136 ± 50 min, p = 0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p = 0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p = 0.059). At 6 years, survival was similar (79 ± 1.4% vs 78 ± 4.0%, p = 0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 ± 58 vs 137 ± 52 min, p = 0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p > 0.99) and any mortality/morbidity (28% vs 24%, p = 0.52). Six-year survival between matched pairs was also similar (74 ± 7.2% vs 80 ± 4.4%, p = 0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and without propensity-score adjustment. Conclusions: Trainee outcomes are not inferior even when corrected for risk. This suggests that excellent operative training and supervision can be achieved in mitral valve surgery.     

美容整形门诊手术的麻醉处理

总结１９９３～１９９５年４２０例美容门诊手术麻醉资料情况后，提出美容整形外科门诊手术大都是在局部麻醉下进行的，这时的整形外科医师具有手术医师和麻醉医师双重身份，对美容整形医生来说，掌握好局麻药的药理、熟练的麻醉技术对麻醉的安全和手术的成功是非常重要的，同时运用心理治疗对加强美容门诊的麻醉效果有很好的作用。     

Three components of education in burn care: surgical education, inter-professional education, and mentorship

Education in burn care can be divided into three main components: surgical education, inter-professional education, e.g. critical care education and mentorship. To date these components have been used in varying degrees in most health institutions and to even lesser extent in burn care. The aim of this paper is to highlight each component and how these have been utilized in other fields to develop teams and foster education, and how they can be translated for burn teams. These ideas are not novel; however, this paper aims to shed light on how these concepts can be implemented in burn care, thus not only improving education, but also enabling recruitment and retention of health care providers in this field.     

Internet use by plastic surgery patients pre-operatively in a university teaching hospital in the United Kingdom

Internet use amongst the United Kingdom's adult population is widespread and on the increase. We noticed that numerous patients attending our clinics had sought information about procedures on the Internet. We distributed a questionnaire to 100 consecutive patients attending for elective plastic surgery procedures. The response rate was 61%. However, only 12% (seven out of 61) of the patients who responded had researched their operation on the Internet. The median age of those who did search the Internet was 34 years compared to 53 years for those who did not. All who searched the Internet were having reconstructive procedures, and all felt their operation was of a cosmetic nature. Viewing photographic images was the most common reason given to look up the procedures. They all felt that searching the Web helped in their understanding of the operation, and they all felt that providing such information on hospital websites would be useful. The use of the Internet is not as widespread among plastic surgery patients as we had anticipated.     

Health Education England,Local Education and Training Boards (LETBs) and reform of healthcare education: implications for surgical training

Background

National Health Service (NHS) reforms have changed the structure of postgraduate healthcare education and training. With a Government mandate that promotes multi-professional education and training aligned with policy driven initiatives, this article highlights concerns over the impact that these changes may have on surgical training.

Discussion

The creation of Health Education England (HEE) and its local education and training boards (LETBs), which are dominated by NHS healthcare providers, should result in greater accountability of employers in workforce planning, enhanced local responsibility and increased transparency of funding allocation. However, these changes may also create a potential poacher-turned-gamekeeper role of employers, who now have responsibility for junior doctors’ training. Analysis of LETB membership reveals a dearth of representation of surgeons, who comprise only 2% of board members, with the input of trainees also seemingly overlooked. A lack of engagement with the LETBs by the independent sector is a concern with increasing numbers of training opportunities potentially being lost as a result.The new system also needs to recognise the specific training needs required by the craft specialties given the demands of technical skill acquisition, in particular regarding the provision of simulation training facilities and trainer recognition. However, training budget cuts may result in a disproportionate reduction of funding for surgical training. Surgical training posts will also be endangered, opportunities for out-of-programme experience and research may also decline and further costs are likely to be passed onto the trainee.

Summary

Although there are several facets to the recent reforms of the healthcare education and training system that have potential to improve surgical training, concerns need to be addressed. Engagement from the independent sector and further clarification on how the LETBs will be aligned with commissioning services are also required. Surgical training is in danger of taking a back seat to Government mandated priorities. Representation of trainees and surgeons on LETB committees is essential to ensure a surgical viewpoint so that the training needs of the future consultant workforce meet the demands of a 21^st century health service.     

Feasibility and efficacy of gamification in general surgery residency: Preliminary outcomes of residency teams

BackgroundComprehensive studies evaluating the efficacy of team-based competition (“Gamification”) in surgery have not been performed. Board pass rates and resident satisfaction may improve if surgical residents are involved in competition.MethodsResidents at Montefiore Medical Center (Bronx, New York) were surveyed and separated into teams during a draft. Each resident’s performance was converted into a point system. Resident scores were combined into a team score and presented as a leaderboard. Awards were given. ABSITE, ACGME residency satisfaction, and ABS qualifying exam pass rates were compared.ResultsSixty percent of residents are inspired to improve their performance during gamification. ABSITE average percentile score improved from 28 to 43. ABS qualifying exam pass rates improved from 73% to 100%. Resident satisfaction improved from 65% to 88%. The point system allowed for establishing “growth curves” for each resident enabling enhanced assessment of residents.ConclusionsA comprehensive team-based competition inspires performance, is feasible, and seems to improve ABSITE scores, ABS pass rates, and satisfaction while being a tool for assessment of performance.     

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.     

Simulation in laparoscopic surgery: a concurrent validity study for FLS

Background  Current assessments using the fundamentals of laparoscopic surgery (FLS) tasks are labour intensive and depend heavily on expert raters. Hand motion analysis may offer an alternative method of objective evaluation of FLS performance. Purpose  The aim of this study was to assess whether a correlation exists between the expert rated assessments of the FLS tasks and computer-based assessment of motion efficiency using the Imperial College surgical assessment device (ICSAD). Methods  We recruited 26 volunteer subjects who were stratified into three experience groups: juniors (PGY1–3) (N = 13), seniors (PGY4,5) (N = 7) and staff surgeons (N = 6). All subjects performed four FLS tasks: (1) peg transfer, (2) pattern cut, (3) endoloop and (4) intracorporeal suturing. Performance was assessed by both standard FLS expert rating and motion analysis using ICSAD. Group differences were analyzed using the Kruskal–Wallis test, and Spearman coefficient analyses were employed to compare FLS and ICSAD scores. Results  FLS expert-derived scores discriminated effectively between experience groups for all tasks (p < 0.05). Motion efficiency scores discriminated between experience groups for tasks 1, 3 and 4 for number of movements (p < 0.05), tasks 1 and 4 for total distance (p < 0.05) and tasks 1, 2, 3 and 4 for total time (p < 0.005). There was a significant correlation between total FLS expert scores and the motion efficiency metrics of total distance, number of movements and total time (Spearman coefficient and p values of 0.81, < 0.001; 0.76; < 0.001; and 0.93, < 0.001, respectively). Conclusion  There is a high correlation between FLS standard scoring and motion efficiency metrics. The use of ICSAD for the objective assessment of FLS tasks may in the future offer an adjunctive method of evaluation. ICSAD metrics are potentially less labour intensive due to the instant and fully automated computerized scoring that it provides. Paper Presented at: Canadian Association of General Surgeons 2007 Meeting Toronto, ON, Canada. *CAGS 2007 Poster Prize winner*.