When surgeons decide to become surgeons: new opportunities for surgical education

Background

When surgeons decide to become surgeons has important implications. If the decision is made prior to or early in medical school, surgical education can be more focused on surgical diseases and resident skills.

Methods

To determine when surgeons – compared with their nonsurgical colleagues – decide on their medical path, residents in surgery, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and emergency medicine were surveyed. Timing of residency choice, demographic data, personal goals, and reason for residency choice were queried.

Results

A total of 234 residents responded (53 surgical residents). Sixty-two percent of surgeons reported that they were “fairly certain” of surgery before medical school, 13% decided during their preclinical years, and 25% decided during their clerkship years. This compares with an aggregate 40%, 7%, and 54%, respectively, for the other 5 residency specialties. These differences were statistically significant (P = .001). When the 234 residents were asked about their primary motivation for choosing their field, 51% pointed to expected job satisfaction and 44% to intellectual curiosity, and only 3% mentioned lifestyle, prestige, or income.

Conclusions

General surgery residents decide on surgery earlier than residents in other programs. This may be advantageous, resulting in fast-tracking of these medical students in acquiring surgical knowledge, undertaking surgical research, and early identification for surgical residency programs. Surgical training in the era of the 80-hour work week could be enhanced if medical students bring much deeper knowledge of surgery to their first day of residency.     

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.     

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.

Need of the hour: Structural heart intervention training for trainee surgeons in India

Cardiothoracic surgery is on the verge of undergoing a major metamorphosis from being a conventional surgical branch to a technologically powered specialty with plenty of emphasis on learning the minimally invasive techniques, and a step forward is the advent of interventional techniques to treat most of the major cardiac ailments. Though the world of interventions has been traditionally dominated by the physicians, it is time we surgeons get ourselves actively involved in learning and performing these interventional procedures to stay relevant. This is not an attempt to disrupt the physician-surgeon harmony but to nurture a symbiotic relationship between the two specialties for advancement in cardiac science and technological growth, ultimately to benefit the patient. In this article, we discuss the Indian and the global scenario of the role of surgeons in the interventional arena and various training modalities available for surgeons to learn the art of cardiac interventions. We tried to understand the impediments in implementing interventional training for surgeons and also propose certain amendments to the way the future cardiothoracic surgeons are trained.     

Evaluation of neurosurgical training of French military surgeons prior to their deployment

BackgroundA specific training course was formalized in 2007 in order to facilitate the management of cranio-encephalic injuries by French military general surgeons during deployment, within the Advanced Course for Deployment Surgery (ACDS). The objective is to evaluate the neurosurgical pre-deployment training course attended by the military surgeons.MethodsFrom June 2019 to September 2019, we conducted a cross-sectional survey in the form of a digital self-completed questionnaire, addressed to all graduated military surgeons working in the French Military Training Hospitals. The survey included: (1) a knowledge assessment; and (2) a self-assessment of the training course. The participating surgeons were classified into two groups according to their participation (group 1) or not (group 2) in the neurosurgical module. The main outcome was the score received on the knowledge assessment.ResultsAmong the 145 military surgeons currently in service, 76 participated in our study (53%), of which 49 were classified in group 1 (64%) and 27 in group 2 (36%). Group 1 surgeons had a significantly higher score than Group 2 at the knowledge assessment (mean 21.0 ± 7.1 vs. 17.8 ± 6.0, P = 0.041). The most successful questions were related to TBI diagnosis and surgical technique, while the least successful questions dealt with “beyond emergency care” and surgical indications.ConclusionThe French pre-deployment neurosurgical training course provides a strong neurosurgical background, sufficient to perform life-saving procedures in a modern conflict situation. However, neurosurgical specialized advice should be solicited whenever possible to assist the in-theatre surgeon in surgical decisions.     

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.     

Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case‐control study

Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case‐control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow‐up (33% vs 76%, P < .001), decrease in 1‐year minor amputation rate (14% vs 3%, P = .007), and decrease in 1‐year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.     

Laparoscopic skills laboratories: current assessment and a call for resident training standards

BACKGROUND: Numerous protocols for laparoscopic skills training using simulator-based laboratories have proven effective. However, little is known about the availability and uniformity of such facilities. The purpose of this study was to evaluate the prevalence, utilization, and costs of skills laboratories currently in use. METHODS: A survey was mailed to 253 general surgery program directors to determine the perceived value, prevalence, equipment, types of training, supervision, and costs of the labs. RESULTS: One hundred sixty-two (64%) programs completed the survey. Eighty-eight percent of responders consider skills labs effective in improving operating room performance; however, only 55% have skills labs. Of 89 programs with skills labs, 99% have videotrainer equipment (mean 3.8 trainers per lab, range 1 to 15); 46% have virtual reality trainer equipment (mean 1.7 trainers per lab, range 1 to 7). Eighty-two percent of programs teach basic skills using a variety of tasks (Rosser/Southwestern stations, MIST-VR, MISTELS, department-created); 96% teach suturing (intracorporeal, extracorporeal, suture devices). On average, residents train 0.8 hours per week (range 0 to 6). Training is mandatory in 55% and supervised in 73% of the programs. The mean development cost was 133,000 dollars (range 300 dollars to 1,000,000 dollars). CONCLUSIONS: While a large majority of program directors consider skills labs important, 45% of programs have no such facilities. Moreover, significant variability of equipment and training practices exist in currently available labs. Strategies are needed for more widespread implementation of skills labs, and standards should be developed to facilitate uniform adoption of validated curricula that reliably maximize training efficiency and educational benefit.     

The National Pediatric Surgery Simulation Program in France: A tool to develop resident training in pediatric surgery

Background/Purpose

To implement resident curriculum in France based on theoretical teaching and bed side training, the national council known as the “Collège Hospitalier et Universitaire de Chirurgie Pédiatrique” examined the relevance and feasibility of systematically introducing simulation program in the pediatric surgery resident training.

A template for change and response to work hour restrictions

Surgical program directors are seeking how to best meet the work hour restrictions recently mandated by the American College of Graduate Medical Education. Implementation of an 80-hour work week forces major change to graduate medical education, especially surgical education. Creative restructuring of surgical training is necessary to ensure compliance. Developing an innovative solution to meet these requirements must consider programmatic needs, requiring commitment to a change process. The Department of Surgery at Eastern Virginia Medical School experienced a 5-month strategic planning process that generated the Mendoza plan. This plan uses an every third night call model and a night float model to meet site-specific needs. The specifics of the Mendoza plan protect the cornerstone of surgical education, which is continuity of patient care and resident education. The Mendoza plan, and the process leading to its development, may provide insightful information for other surgical residency programs planning to meet work hour guidelines.     

Teaching in the robotic environment: Use of alternative approaches to guide operative instruction

BackgroundWith the rapid growth of robotic-assisted surgery, surgical educators recognize the need to develop appropriate curriculum for trainees. However, the unique robotic learning environment challenges educators to determine the most appropriate ways to instruct surgical residents. The purpose of this study was to characterize the instructional techniques used in the robotic teaching environment by observing attending surgeon's language and behaviors during resident robotic dissection.Study designAttending robotic surgeons guided senior residents through robotic dissection of live porcine tissue. Three observers documented the language, gestures and behaviors occurring at three different stations, and at a fourth station, they obtained video and audio recordings of the instructional interaction. Afterwards, instructors and residents met in separate focus groups. The authors used qualitative content analysis to summarize the type and frequency of teaching behaviors and focus group information to clarify the analysis. We compared the frequency of the behaviors to an existing taxonomy of 16 operative teaching behaviors in open and laparoscopic surgery.ResultsRobotic instructors used 11 of the 16 behaviors previously described for surgical instruction. Frequency of use differed in the robotic environment due to relevance and application of new techniques. New, unique robotic teaching behaviors involved disengaging the resident from the operative console for either onscreen direction or for gesturing with verbal instruction. Focus group participants highlighted these behaviors as essential.ConclusionRobotic instruction uses a different set of instructional approaches compared to open and laparoscopic surgery. New teaching behaviors emerged driven by physical separation within the robotic environment. Robotic faculty development should emphasize these unique features.     

Training tomorrow’s surgeons: what are we looking for and how can we achieve it?

The aim of a surgical residency program is to produce competent professionals in a safe and pedagogically efficient environment. For many years, there has been an overemphasis on technical attributes as the fundamental competencies of a trained surgeon. With the advent of new frameworks for defining the outcomes of surgical training, such as CanMeds from the Royal College of Physicians and Surgeons of Canada and the six competencies outlined by the Accreditation Council for Graduate Medical Education in USA, there has been a broadening of the focus of surgical training. Although technical proficiency is definitely an important prerequisite for a successful outcome, other qualities such as intellectual abilities, personality and communication skills, and a commitment to practice are important elements in the profile of a competent surgeon. Recently, there is a growing appreciation for the heterogeneity in achievement of technical competence among our trainees, with some residents able to quickly master technical skill in contrast to others who may never achieve mastery in the technical domain. The questions of how to select, teach and grant privileges for independent practice requires an understanding of the components of surgical competence and implementation of evidence based tools for training and assessment of these competencies.     

Global orthopaedic trauma surgeons highlight telenomics during the COVID-19 era: A case for advancing telemedicine in orthopaedics

The Coronavirus (COVID-19) pandemic sparked rapid widespread adoption of telemedicine throughout specialties, including orthopaedics. A succession of factors, starting with payers, followed by provider adoption, and reciprocated by patient approval, created newly accepted telehealth practices that have moved from trial to norm in a short time span. Orthopaedic surgeons believe telehealth will endure as a permanent change to their practice beyond the COVID-19 era, however, many permanent changes must take place by payers, providers, and patients to sustain telehealth into the future. The goal of this paper is to highlight the indelibility of telemedicine adoption in orthopaedic practices globally, characterize the chain of events that led to its large-scale adoption, and catalyze discussion around actionable next steps to sustain its benefits.     

国外公共卫生护士的培养和实践现况及启示

梳理国外对公共卫生护士的培养、实践现况、资质要求及岗位职责,分析对我国公共卫生护理人才培养和实践管理的启示,以期促进我国公共卫生体系建设中公共卫生护理的建设和发展.     

Minimal-access surgery training in the Netherlands: a survey among residents-in-training for general surgery

Background The purpose of this study was to assess the state of surgical training and its possible shortcomings in minimal-access surgery (MAS) among Dutch surgical residents.Methods A pretested questionnaire was distributed to all residents-in-training for general surgery in The Netherlands.Results The questionnaire was sent to 407 surgical residents. The response rate was 65%. Overall, 87.7% of all the responders were highly interested in the autonomous performance of laparoscopic surgery. Residents interested in gastrointestinal (GI) or oncologic surgery (n = 137) are significantly more interested than residents interested in non-GI/oncologic surgery. All the residents (100%) thought it was important to be able to perform the three basic MAS procedures (diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy) autonomously at the end of their surgical training. Other MAS procedures were considered to be advanced procedures. Gastrointestinal/oncologic residents were most interested in performing advanced MAS procedures, although only 17.8% expected to be adequately prepared at the end of their surgical training. Most residents had the opportunity to attend MAS skills education. Irrespective of the format or training method, only 26.9% of residents stated their MAS skills training was objectively evaluated. The residents thought every surgical hospital department in the Netherlands should have a surgeon specialized in laparoscopic surgery (86.9%).Conclusions The current study showed that Dutch residents believe it is very important to perform basic MAS autonomously. Of the GI/oncologic–interested residents, the majority want to be able to perform advanced MAS, but expect to be unable to do so at the end of their training. They attribute this discrepancy to not having enough chance to be the first operator and to lack of volume of procedures in the hospital. Specific and properly implemented, monitored, and evaluated MAS skills training programs in skills laboratory settings could offer a promising environment for overcoming this discrepancy.