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.     

A scoping review of assessment methods of competence of general surgical trainees

BackgroundOnly rigorous evaluation of competence will result in the production of safe surgeons that are able to provide the best care for patients. The development of competency-based assessment should ultimately be evidence driven.ObjectivesExplore the volume of existing evidence pertaining to the different objective assessment methods reported in the literature.Eligibility criteriaStudies describing objective assessment of postgraduate general surgical trainees within the last 20 years.Sources of evidencePubMed, Ovid Medline and Web of Sciences.Charting methodsA data chart proforma was designed and data were extracted into tables. Basic numerical analysis of extracted data and narrative synthesis of charted data.ResultsA total of 343 papers were reviewed. 26 were eligible for inclusion. 92% of articles were published from 2008 onwards. 50% have been published in the last five years. The articles originated from 6 different countries, predominantly the United Kingdom (42%), followed by the United States of America (38%). In addition, a small number were published from Canada (8%), Japan (4%), Germany (4%) and Australia (4%). UK publications were predominantly between 2008 and 2014 while the USA had a later predominance between 2015 and 2018. 42% were based on quantitative methodology, 27% had a qualitative approach while 31% had mixed analysis. There were sixteen assessment methods presented. The most common type of assessment was Objective Structured Assessments (27%), which included Objective Structured Assessment of Technical Skill (OSATS) (23%) and Objective Structured Assessment of Non-Technical Skill (4%). Procedure Based Assessment (PBA) (23%) and Entrustability Scales (23%) were also prevalent.ConclusionsThis scoping review has identified a range of different assessment methods. The assessment methods with a higher volume and level of supporting evidence were OSATS, PBAs and Entrustability Scales. There was a lower volume and level of supporting evidence found within this review for the remaining assessment methods.     

Global surgical electives in residency: The impact on training and future practice

Background

The purpose of this study was to evaluate perceptions regarding the value of global surgical electives (GSEs) and pursuit of a career in global surgery amongst residents and surgeons.

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.     

Simulation‐based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part‐task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three‐dimensional printing and computer‐based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.     

Interest in international surgical volunteerism: results of a survey of members of the American Pediatric Surgical Association

Purpose

This study assesses interest in international volunteer work by members of the American Pediatric Surgical Association (APSA) and attempts to identify demographics, motivations, obstacles, and institutional issues of the respondents.

Methods

An online survey service was used to send a 25-question survey to all APSA members with email addresses in November 2009. An answer to all questions was not required. Written comments were encouraged.

Results

The survey was sent to 807 members of whom 316 responded, for a response rate of 39%. International work had been done previously by 48% of respondents, whereas 95% stated that they were interested or perhaps interested in doing so. Most (83%) were interested in operating with local surgeons to teach them how to perform procedures. Altruism was the chief motivation in 75% of respondents. Primary obstacles to doing international work were family obligations and lack of time, although 37% stated that a lack of information about volunteer opportunities was an issue. A significant number of respondents (48%) stated that their institution had no established international collaborations.

Conclusion

This study suggests that there is interest in international volunteerism among many members of APSA. Understanding the issues surrounding surgical volunteerism may facilitate humanitarian involvement among pediatric surgeons.     

The impact of COSECSA in developing the surgical workforce in East Central and Southern Africa

BackgroundThe Association of Surgeons of East Africa (ASEA) was formed in 1952. In 1996 a Steering Committee was formed to transform ASEA into a surgical college. The College of Surgeons of East Central and Southern Africa was officially launched in December 1999 in Nairobi, Kenya. Today the College consists of 14 constituent member countries but trains in 20 countries in Sub-Saharan Africa.ProgrammesCOSECSA runs a 5 year training programme in all the surgical specialties. In the first 2 years trainees do the Membership (MCS) programme. This is followed by 3 years of the Fellowship (FCS) programme. More recently the College has started a 2 year sub-specialty Fellowship in paediatric orthopaedics.GraduatesThe main aim of the College was to expand and improve surgical training in the COSECSA region. This goal was partially realised in December 2020 when the total number of surgeons produced by the College from inception reached 557.RetentionAnother key success story of COSECSA is that the majority of graduates have remained in the region leading to a high retention rate of 88.3%.Women In Surgery Africa (WISA)Since the formation of WISA in 2015 the College has witnessed an increase in the number of female trainees. Currently only 9% of surgeons in the region are women.ConclusionIn its current Strategic Plan (2021–2025) COSECSA aims not only to increase the surgical workforce in the region but also to modernise its training programmes and strengthen its governance structures.     

Perception and use of minimal access surgery simulators in pediatric surgery training programs

Background/Purpose

In the current time-restricted training environment, simulator use in surgical teaching is receiving increasing attention. A large body of literature addresses simulators' effectiveness in surgical education. No prior studies assess how widely simulators are actually being used or attitudes about their effectiveness of those involved in training.

Methods

Surveys were e-mailed to all current pediatric surgery trainees and training directors. Queries examined respondents' perceptions about surgical simulators' usefulness and to what extent they are used in their programs. Other questions assessed obstacles to simulator use.

Results

Response rates were high (47% of program directors and 67% of current fellows). Nearly all respondents felt laparoscopic simulators improve training efficiency (88%). About half (55%) report regular simulator availability to trainees. Only 21% of programs have current or planned simulation curricula. Less than half of the training directors (32%) and about half of the fellows (55%) felt they have actually significantly improved trainees' skills.

Conclusions

Trainees and training directors placed significant importance on simulator use in pediatric surgery training. However, most did not feel that simulators had actually improved the trainees' laparoscopic skills. Wider availability of simulation laboratories and protected time for using them would enhance the impact of simulators on pediatric surgery training.     

Imagery practice and the development of surgical skills

BACKGROUND: The purpose of this review is to explore the potential role of imagery practice during the acquisition of surgical skills, imagery practice being the mental rehearsal of a skill. METHODS: The core of this review is derived from a literature search of a computer database (Medline). FINDINGS: The cognitive processing that occurs during times of intense learning involves processes such as dream enactment behavior and imagery practice. These processes complement and augment the more usual forms of practice. CONCLUSIONS: Imagery practice provides a mechanism for the explicit learning of surgical skills.     

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.     

Trauma training in Australia and New Zealand: Results of a survey of advanced surgical trainees

Background : The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training. Methods : A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons. Results : Two hundred and seventy‐two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations. Conclusions : Regional rotations may need to be developed to even out trainees’ experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.     

Necessity for improvement in endoscopy training during surgical residency

Background

The Residency Review Committee for Surgery has recently increased the required number of cases needed to achieve competency in endoscopy training.

Methods

A 10-question survey was sent to program directors for general surgery residencies. Endoscopic training patterns, facilities, perspectives, and residents' performance were examined.

Results

Seventy-one surgery programs (30%) responded to the survey. Of these, 42% (n = 30) had a program size of 3 to 4 residents. Ten percent (n = 7) of all programs could not fulfill the minimum Accreditation Council for Graduate Medical Education (ACGME) requirements. Only 55% (n = 39) of programs had a dedicated rotation in endoscopy and an endoscopic skills training laboratory in their program. Few programs had their residents performing more than 100 cases of gastroscopy (18%) and colonoscopy (21%).

Conclusions

Future endoscopy training for surgical residents needs to be improved to comply with the new requirements. This would include provision of an endoscopic skills laboratory, dedicated endoscopic rotations, and increasing the number of staff surgeons who perform endoscopic procedures.     

New standards and criteria for accreditation of hospitals and posts for surgical training

Accreditation of hospitals, other health-care facilities and the surgical posts involved is an important part of ensuring that trainees are working in an environment where their teaching and learning equip them with the competencies necessary to fulfil the many roles expected of a surgeon. To undertake this accreditation, clear processes and objective measurements are required. Recent external reviews of the College showed the necessity for improvement of its existing accreditation methodology. New processes, standards, criteria, factors to be assessed for each criterion and the minimum requirements for each factor have been developed in a uniform framework for the nine surgical specialties. Each criterion relates to the overall objectives of the educational programmes, and the factors to be assessed are explicit, objective and measurable and should be achievable. Consensus was eventually achieved across the nine specialties. Protected time for teaching and learning and safe working conditions including safe hours were considered by the hospitals to have important consequences for service delivery as well as industrial ramifications for surgeons' and trainees' contracts and required extensive dialogue for a successful resolution. The accreditation process has a potentially significant effect on the availability of surgical services. Publicly available information about the process and requirements, consistency in their application and inclusion in the accreditation team of a hospital representative and surgeon from another region helps to ensure confidence and impartiality.     

Virtual reality and computer-enhanced training devices equally improve laparoscopic surgical skill in novices

BACKGROUND: The study aim was to compare the effectiveness of virtual reality and computer-enhanced videoscopic training devices for training novice surgeons in complex laparoscopic skills. METHODS: Third-year medical students received instruction on laparoscopic intracorporeal suturing and knot tying and then underwent a pretraining assessment of the task using a live porcine model. Students were then randomized to objectives-based training on either the virtual reality (n=8) or computer-enhanced (n=8) training devices for 4 weeks, after which the assessment was repeated. RESULTS: Posttraining performance had improved compared with pretraining performance in both task completion rate (94% versus 18%; P<0.001*) and time [181+/-58 (SD) versus 292+/-24*]. Performance of the 2 groups was comparable before and after training. Of the subjects, 88% thought that haptic cues were important in simulators. Both groups agreed that their respective training systems were effective teaching tools, but computer-enhanced device trainees were more likely to rate their training as representative of reality (P<0.01). CONCLUSIONS: Training on virtual reality and computer-enhanced devices had equivalent effects on skills improvement in novices. Despite the perception that haptic feedback is important in laparoscopic simulation training, its absence in the virtual reality device did not impede acquisition of skill.     

Cognitive skills training in digital era: A paradigm shift in surgical education using the TaTME model

Surgical competence is a complex, multifactorial process, requiring ample time and training. Optimal training is based on acquiring knowledge and psychomotor and cognitive skills. Practicing surgical skills is one of the most crucial tasks for both the novice surgeon learning new procedures and surgeons already in practice learning new techniques. Focus is placed on teaching traditional technical skills, but the importance of cognitive skills cannot be underestimated. Cognitive skills allow recognizing environmental cues to improve technical performance including situational awareness, mental readiness, risk assessment, anticipating problems, decision-making, adaptation, and flexibility, and may also accelerate the trainee's understanding of a procedure, formalize the steps being practiced, and reduce the overall training time to become technically proficient. The introduction and implementation of the transanal total mesorectal excision (TaTME) into practice may be the best demonstration of this new model of teaching and training, including pre-training, course attendance, and post-course guidance on technical and cognitive skills. To date, the TaTME framework has been the ideal model for structured training to ensure safe implementation. Further development of metrics to grade successful learning and assessment of long term outcomes with the new pathway will confirm the success of this training model.     

Computer-based laparoscopic and robotic surgical simulators: performance characteristics and perceptions of new users

Background  This study aimed to define perceptions of the need and the value of new simulation devices for laparoscopic and robot-assisted surgery. The initial experience of surgeons using both robotic and nonrobotic laparoscopic simulators to perform an advanced laparoscopic skill was evaluated. Methods  At the 2006 Society of American Gastroesophageal Surgeons (SAGES) meeting, 63 Learning Center attendees used a new virtual reality robotic surgery simulator (SEP Robot) and either a computer-enhanced laparoscopic simulator (ProMIS) or a virtual reality simulator (SurgicalSIM). Demographic and training data were collected by an intake survey. Subjects then were assessed during one iteration of laparoscopic suturing and knot-tying on the SEP Robot and either the ProMIS or the SurgicalSIM. A posttask survey determined users’ impressions of task realism, interface quality, and educational value. Performance data were collected and comparisons made between user-defined groups, different simulation platforms, and posttask survey responses. Results  The task completion rate was significantly greater for experts than for nonexperts on the virtual reality platforms (SurgicalSIM: 100% vs 36%; SEP Robot: 93% vs 63%; p < 0.05). Prior robot use was predictive of task completion on the SEP Robot, and nonexperts were more likely to complete the virtual reality task on the SEP Robot than on the SurgicalSIM. Experts performed better than nonexperts for all performance measures on the ProMIS. All the survey scores pertaining to realism except image quality were higher for the ProMIS than for either virtual reality trainer. Conclusion  The task completion rate was the best discriminant of expert performance on both virtual reality platforms, whereas simulator metrics best discriminated expertise for the videoscopic platform. Similar comparisons for the virtual reality platforms were not feasible because of the low task completion rate for nonexperts. The added degrees of freedom associated with the robotic surgical simulator instruments facilitated completion of the task by nonexperts. All platforms were perceived as effective training tools.