Acquiring basic endoscopy skills by training on the GI Mentor II

Background Achieving proficiency in flexible endoscopy requires a great amount of practice. Virtual reality (VR) simulators could provide an effective alternative for clinical training. This study aimed to gain insight into the proficiency curve for basic endoscope navigation skills with training on the GI Mentor II. Methods For this study, 30 novice endoscopists performed four preset training sessions. In each session, they performed one EndoBubble task and managed multiple VR colonoscopy cases (two in first session and three in subsequent sessions). Virtual reality colonoscopy I-3 was repeatedly performed as the last VR colonoscopy in each session. The assignment for the VR colonoscopies was to visualize the cecum as quickly as possible without causing patient discomfort. Five expert endoscopists also performed the training sessions. Additionally, the performance of the novices was compared with the performance of 20 experienced and 40 expert endoscopists. Results The novices progressed significantly, particularly in the time required to accomplish the tasks (p < 0.05, Friedman’s analysis of variance [ANOVA], p < 0.05, Wilcoxon signed ranks). The experts did not improve significantly, except in the percentage of time the patient was in excessive pain. For all the runs, the performance of the novices differed significantly from that of both the experienced and the expert endoscopists (p < 0.05, Mann–Whitney U). The performance of the novices in the latter runs differed less from those of both the experienced and the expert endoscopists. Conclusions The study findings demonstrate that training in both VR colonoscopy and EndoBubble tasks on the GI Mentor II improves the basic endoscope navigation skills of novice endoscopists significantly.     

Procedural performance in gastrointestinal endoscopy: an assessment and self-appraisal tool

AIMS: Assessing endoscopic technical skills competency in a structured manner is a topical issue, in light of several workforce factors that may affect the training of future endoscopists. To date there has been little attempt to comprehensively assess both generic and specific technical skills in lower gastrointestinal endoscopies; the current study aimed to develop and validate a tool that can assess these varied skills. METHODS: Hierarchical task analyses of generic and specific technical skills were constructed on flexible sigmoidoscopy and colonoscopy after expert panel discussions. Generic technical skills are subtasks (eg, movements of the control wheel) that allow the endoscopist to complete a main task (specific technical skills), for example, reaching the cecum. Weighted Likert scales were then constructed individually for generic and specific technical skills for each procedure. Two observers assessed each procedure independently. RESULTS: A total of 135 endoscopic procedures were performed by 9 consultants and 12 registrars. Mean inter-rater reliability Cronbach alphas were .83 and .80, P < or =.05, for generic and specific skills, respectively, for each procedure. Construct validity results using analysis of variance (ANOVA) for consultants and trainees were significant for each procedure, P = .005, P = .003 for generic, and P = .012, P = .004 for specific technical skills. CONCLUSIONS: This new assessment/self-appraisal tool for lower gastrointestinal endoscopies seems to have face, content, concurrent, and construct validities. The tool has the possibility of being used in training and self-appraisal. We aim to modify and apply this tool to other endoscopic procedures in the future, such as endoscopic retrograde cholangiopancreatography (ERCP), endoluminal and transluminal procedures.     

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.     

Assessment of surgical training

BackgroundThe patient safety imperative has raised expectations regarding the responsibility of medical educators and decision makers to ensure that physicians are competent. Ensuring that trainees are ready for independent practice upon graduation is challenged by reduced work hours such that trainees spend less time in the OR and perform fewer cases than desirable.MethodsThe literature on the assessment of technical and non – technical operative skills and professionalism was reviewed in order to make recommendations to identify barriers to evaluation.DiscussionBarriers to documenting performance deficiencies include uncertainty as to what should be documented, and concerns about the negative impact of critical evaluations on faculty popularity. Additional challenges include a lack of clear standards for performance and effective remediation options.ConclusionsTrainee performance should be evaluated in a rigorous, reliable and meaningful way to ensure that graduates have the skills necessary for safe, independent practice.     

关于美容外科医师培训的几点看法

针对目前我国美容外科发展中出现的一些不良现象，文中进行了简要分析。强调了美容外科医师培训的紧迫性和重要性。且着重从培训对象、基地与形式的选择、培训课目和时间的设置安排，以及培训毕业合格证书的发放等几方面阐述了一些个人的看法。     

National survey of College Tutors in the UK regarding training in medical education

BACKGROUND: College Tutors are responsible for the organization of training and should possess the pre-requisite knowledge and skills to facilitate this. METHODS: An anonymized survey of anaesthetic College Tutors in the UK was conducted with regard to training in medical education. RESULTS: A response rate of 65.54% was achieved. Around 16% had a formal postgraduate teaching qualification and another 27% were interested in attaining one. However, 84% were of the opinion that formal teaching qualifications were not essential for College Tutors. The more recently appointed College Tutors (<2 yr experience) had more formal qualifications and thought these were important. Appraisal and assessment courses were considered the most valuable for professional development of the role of the College Tutor, and were identified as challenging. CONCLUSIONS: This survey highlights that training in medical education for College Tutors is inadequate. It is the responsibility of the Colleges and the Postgraduate Deans to ensure College Tutors are supported appropriately to develop the knowledge and skills required for the role.     

Expert and construct validity of the Simbionix GI Mentor II endoscopy simulator for colonoscopy

Objectives The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts. Methods Four groups were selected to perform one hand–eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200–1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost. Results Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51). Conclusion In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.     

腹腔镜保留肾单位术三级培训模式初探

目的 介绍腹腔镜保留肾单位术的三级培训模式.方法 三级培训模式的内容包括体外模拟阶段、动物模型训练和临床实践操作.以小型猪作为实验模型建立腹腔镜保留肾单位术的标准操作方式.临床实践操作又细分为三步进行,包括辅助手术、开展相对简单的腹腔镜手术和进行LNSS. 结果 4名学员均成功完成全部三级培训内容.其中体外模拟培训累计时间平均为70 h.经过体外模拟培训后全部学员均能够熟练地掌握腔镜器械下缝针打结等基本操作技能.4名学员均完成动物模型LNSS 20例,其中半肾切除术6例.肾上极或下极平均手术时间由最初的(120.0±10.9)min降低到在完成12台LNSS时的(69.0±5.2)min,差异有统计学意义(P<0.01).学员在开展后腹腔镜肾囊肿去顶术和上段输尿管切开取石术等相对简单的手术7～9例后,各自成功地完成LNSS手术3例,均未出现术中并发症.LNSS平均手术时间为87 rain,肾脏热缺血时间平均为25 min.结论 "三级培训模式"能够帮助年轻医生掌握LNSS这类高难度复杂性泌尿外科腹腔镜手术,显著地降低手术并发症的发生,提高手术疗效,有利于腹腔镜手术的推广应用.     

Demand for specialised training for the obese trauma patient: National ATLS expert group survey results

BackgroundThe growing incidence of obesity in Western populations continues to place new stressors on health systems. Obese trauma patients present particular challenges across the entirety of the patient care pathway, and are at risk of higher lengths of stay, morbidity, and mortality. This study sought to assess a national group of trauma experts' opinions and knowledge regarding the management of obese trauma.MethodsA questionnaire was circulated to a trauma training providers and national steering committee members at a UK national Advance Trauma Life Support meeting. Demographic, knowledge, and opinion data was collected and collated for analysis.Results109 questionnaires were returned (73% response rate). Broad agreement was reached that obese trauma patients were more challenging to manage (96.2% agreement) and suffered worse outcomes (89.9%). Only 22.2% felt their hospitals possessed appropriate resources to facilitate management. Up to a third of respondents had personally witnesses errors in care due to patient obesity. 90% believed specialist training for obese trauma could improve care.DiscussionThere is broad consensus amongst UK trauma providers that obese trauma patients are at risk of poorer outcomes and errors in care. Knowledge and preparedness of centres to manage these patients is variable. There was broad consensus that specialist training for the management of obese trauma patients may improve outcomes.     

Integrated flexible endoscopy training during surgical residency

Background  New advances in endoscopic surgery make it imperative that future gastrointestinal surgeons obtain adequate endoscopy skills. An evaluation of the 2001–02 general surgery residency endoscopy experience at the University of Missouri revealed that chief residents were graduating with an average of 43 endoscopic cases. This met American Board of Surgery (ABS) and Accreditation Council for Graduate Medical Education (ACGME) requirements but is inadequate preparation for carrying out advanced endoscopic surgery. Our aim was to determine if endoscopy volume could be improved by dedicating specific staff surgeon time to a gastrointestinal diagnostic center at an affiliated Veterans Administration Hospital. Methods  During the academic years 2002–05, two general surgeons who routinely perform endoscopy staffed the gastrointestinal endoscopy center at the Harry S. Truman Hospital two days per week. A minimum of one categorical surgical resident participated during these endoscopy training days while on the Veterans Hospital surgical service. A retrospective observational review of ACGME surgery resident case logs from 2001 to 2005 was conducted to document the changes in resident endoscopy experience. The cases were compiled by postgraduate year (PGY). Results  Resident endoscopy case volume increased 850% from 2001 to 2005. Graduating residents completed an average of 161 endoscopies. Endoscopic experience was attained at all levels of training: 26, 21, 34, 23, and 26 mean endoscopies/year for PGY-1 to PGY-5, respectively. Conclusions  Having specific endoscopy training days at a VA Hospital under the guidance of a dedicated staff surgeon is a successful method to improve surgical resident endoscopy case volume. An integrated endoscopy training curriculum results in early skills acquisition, continued proficiency throughout residency, and is an efficient way to obtain endoscopic skills. In addition, the foundation of flexible endoscopic skill and experience has allowed early integration of surgery residents into research efforts in natural orifice transluminal endoscopic surgery. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons 2006 Annual Meeting, Dallas, Texas, April 2006 (Poster of distinction)     

National survey on the management of prolapse in the UK

AIMS: To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners, and compare practice between urogynaecologists (tertiary centres), gynaecologists with a special interest in urogynaecology and general gynaecologists. METHODS: A postal questionnaire survey was sent to practising consultant gynaecologists in UK Hospitals. They included urogynaecologists in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP. RESULTS: Four hundred fifty-eight responses were received and 398 were completed. For anterior vaginal wall prolapse, anterior colporrhaphy was the procedure of choice in 77% of respondents. With concomitant urodynamic stress incontinence, a Burch was the procedure of choice in 11%, but 79% of respondents would perform a midurethral tape combined with repair. In women with utero-vaginal prolapse the procedure of choice was a vaginal hysterectomy and repair (82%). Twenty-four percent of respondents would operate in women whose family was incomplete. In women with posterior vaginal wall prolapse (PWP), the procedure of choice was posterior colporrhaphy with midline fascial plication (75%). For vault prolapse, 66% of respondents would operate. Thirty-six percent would perform urodynamics prior to surgery. The procedure of choice was an abdominal sacrocolpopexy (38%). CONCLUSION: There are wide variations in the surgical management of prolapse. Management of POP by urogynaecologists varied in some respects from the general gynaecologists, but were similar to the practices of gynaecologists with a designated interest in urogynaecology.     

Physician leadership is a new mandate in surgical training

BACKGROUND: Traditionally, development of physician leadership has occurred at random in surgical training. One possible reason is that surgical educators have focused on detailed instruction on critical patient situations, resuscitation, and technical skills, but they have provided little formal training in the essential leadership skills. METHODS: To determine resident perceptions about the importance of these skills and individual strengths and weaknesses in these areas, a questionnaire was administered to 43 residents in our general surgery program. In part one of the questionnaire, the residents ranked 18 leadership skills on a scale of 1 to 4 in importance ("not important," "minimally important," "somewhat important," and "very important") for career development. The second portion of the questionnaire asked the residents to rate themselves on a similar scale with regard to their personal confidence and competence in these same areas. RESULTS: Twenty-three residents (53%) completed the entire questionnaire. The majority of the residents (92%) rated all 18 leadership skills "somewhat" or "very important" for career development. More than 50% of the residents rated themselves as not competent or minimally competent in 10 of the 18 areas. Ethics was the only area in which >75% of the residents believed themselves to be more than minimally competent. There were no significant differences between postgraduate training levels in any of the parameters calculated. CONCLUSIONS: We conclude that although residents see these nontraditional topics as an important part of their professional education, they do not necessarily feel confident or competent in these areas. Establishing a conscious effort to teach these topics and to emphasize their importance during training will enhance residents' self-image, performance, and potential as future leaders.     

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.     

Objective assessment of gastrointestinal endoscopy skills using a virtual reality simulator.

BACKGROUND: This study was carried out to validate the role of virtual reality computer simulation as a method of assessment of psychomotor skills in gastrointestinal endoscopy. We aimed to investigate whether the GI Mentor II computer system (Simbionix Ltd.) was able to differentiate between subjects with different experience with GI endoscopy. METHODS: Twenty-eight subjects were included in the study. They were divided into 3 groups according to their experience with GI endoscopy: experienced [group 1, performed > 200 endoscopic procedures, (n = 8)] residents [group 2, performed < 50 endoscopic procedures, (n = 10)] and medical students [group 3, never performed GI endoscopy, (n = 10)]. All participants received identical pretest instruction on the simulator. Assessment of endoscopic skills was performed during a simulated colonoscopy and was based on parameters measured by the computer system: time, percentage of mucosa surface examined, efficiency of screening, time with a clear view, excessive local pressure, pain, time with pain, loop formation, and total time with a loop. RESULTS: Significant differences in performance existed between surgeons in the 3 groups. Experienced surgeons demonstrated best performance parameters, followed by the residents and the medical students. Significant differences in time (Kruskal-Wallis test, P < 0.001), percentage of mucosa surface examined (P = 0.001), efficiency of screening (P = 0.001), time with a clear view (P = 0.001), pain experienced (P = 0.004), time with pain (P = 0.012), loop formation (P < 0.001), time with a loop (P < 0.001), and excessive local pressure (P = 0.001) were demonstrated. Significant differences existed between group 1 and 2 and 1 and 3 (Mann-Whitney test, P < 0.05). Differences between groups 2 and 3 did not reach statistical significance (P > 0.05). CONCLUSIONS: The VR simulator was able to differentiate between subjects with different endoscopic experience. This indicates that the GI Mentor measures skills relevant for gastrointestinal endoscopy and can be used in training programs as an assessment tool.     

Collaborative Overview of coronaVIrus impact on ORTHopaedic training in the UK (COVI - ORTH UK)

IntroductionCOVID-19 was declared a pandemic by the World Health Organization on the 11th of March 2020 with the NHS deferring all non-urgent activity from the 15th of April 2020. The aim of our study was to assess the impact of COVID-19 on Trauma and Orthopaedic trainees nationally.MethodsTrauma and Orthopaedic (T&O) specialty trainees nationally were asked to complete an electronic survey specifically on the impact of COVID-19 on their training. This UK based survey was conducted between May 2020 and July 2020.ResultsA total of 185 out of 975 (19%) T&O specialty trainees completed the survey. Redeployment was experienced by 25% of trainees. 84% of respondents had experienced a fall in total operating numbers in comparison with the same time period in 2019. 89% experienced a fall in elective operating and 63% experienced a fall in trauma operating. The pandemic has also had an effect on the delivery of teaching, with face to face teaching being replaced by webinar-based teaching. 63% of training programmes delivered regular weekly teaching, whilst 19% provided infrequent sessions and 11% provided no teaching.ConclusionThis study has objectively demonstrated the significant impact of the COVID-19 pandemic on all aspects of T&O training.     

Deployment of the Surgical Life-saving Module (SLM) in 2017: Lessons learned in setting up and training operational surgical units

IntroductionThe military operations carried out by the French armed forces, occasionally require the use of the Surgical Life-saving Module (SLM), to ensure the surgical support of its soldiers. Due to its extreme mobility and capacity of fast deployment, SLM is particularly useful in small-scale military operations, such as Special Forces missions. In 2017, the French SLM was for the first time used to ensure surgical support of allied forces, which were lacking forward surgical capabilities.Materials and Methodsthe SLM is a mobile, heliborne, airborne, surgical structure with parachuting capability onto land or sea, therefore essentially focused on life-saving procedures, also known as "damage control" surgery. Due to the need for mobility and rapid implementation, the SLM is limited to a maximum of 5 interventions or, in terms of injuries, to 1 or 2 seriously injured patients.ResultsOver a period of 2 months, 5 medical teams were successively deployed with the SLM. A total of 157 casualties were treated. The most common injuries were caused by shrapnel 561%), followed by firearms (36%), and blunt trauma (2.5%). Injuries included the limbs (56%), thorax (18%), abdomen (13%), head (11%), and neck (2%). The average ISS was 8.5 (1–25) with 26 patients presenting with an ISS greater than or equal to 15. The average NISS was 10.8 (1–75) with 34 casualties having an NISS equal to or greater than 15. The surgical procedures were broken down as follows: 126 dressings, 16 laparotomies, 7 thoracotomies, 12 isolated thoracic drains (without thoracotomy), 1 cervicotomy, 12 amputations, 7 limb splints, 2 limb fasciotomies, 2 external fixators and 1 femoral fracture traction.ConclusionsThe numerous SLM deployments in larger operations highlighted its ability to adapt both in terms of equipment and personnel. Continuous management of equipment logistics, robust personnel training, and appropriate organization of the evacuation procedures, were the key elements for optimizing combat casualty care. As a consequence, the SLM appears to be an operational surgical unit of choice during deployments.     

The influence of training level and surgical experience on survival in colorectal cancer

Background and aims The effect of surgical training level, experience, and operation volume on complications and survival in colorectal cancer during a 10-year period in a medium-volume university hospital was retrospectively studied.Patients and methods Four hundred and fifty-six patients were resected for primary colorectal adenocarcinoma during the 10-year period of 1981–1990, and of these, 387 patients underwent resection with curative intent. The surgeons were divided into three groups according to training level and volume: group 1, surgeons in training and other surgeons operating annually on only 1–4 patients; group 2, surgeons specializing in gastrointestinal surgery (average annual volume 4–13 operations); group 3, specialists in gastrointestinal surgery (average annual volume 3–8 operations). Postoperative morbidity and mortality rates, as well as long-term survival rates, were analysed, and comparisons were made between the patients in the three groups.Results There were no statistically significant differences between the three groups in postoperative morbidity or mortality. Cancer-specific 5-year survival rate of all patients was 57%, and that of those resected in the aforementioned three groups was 51%, 63%, and 55%, respectively, P=0.087. The 5-year survival rates for colon cancer were 59% (total), 52%, 69%, and 58%, respectively, P=0.067, and for rectal cancer were 51% (total), 42%, 53%, and 52%, respectively, P=0.585.Conclusion There were no significant differences in the rates of postoperative mortality, morbidity, and long-term overall survival between the volume groups. However, in patients with colon cancer, there was a trend for better survival for those operated on by the surgeons specializing in gastrointestinal surgery, and in rectal cancer patients, a tendency of fewer local recurrences in those operated on by the specialist surgeons.     

Clinic-based training in comparison to home-based training after first-time lumbar disc surgery: a randomised controlled trial

The effectiveness of physiotherapy after first-time lumbar disc surgery is still largely unknown. Studies in this field are heterogeneous and behavioural treatment principles have only been evaluated in one earlier study. The aim of this randomised study was to compare clinic-based physiotherapy with a behavioural approach to a home-based training programme regarding back disability, activity level, behavioural aspects, pain and global health measures. A total of 59 lumbar disc patients without any previous spine surgery or comorbidity participated in the study. Clinic-based physiotherapy with a behavioural approach was compared to home-based training 3 and 12 months after surgery. Additionally, the home training group was followed up 3 months after surgery by a structured telephone interview evaluating adherence to the exercise programme. Outcome measures were: Oswestry Disability Index (ODI), physical activity level, kinesiophobia, coping, pain, quality of life and patient satisfaction. Treatment compliance was high in both groups. There were no differences between the two groups regarding back pain disability measured by ODI 3 and 12 months after surgery. However, back pain reduction and increase in quality of life were significantly higher in the home-based training group. The patients in the clinic-based training group had significantly higher activity levels 12 months after surgery and were significantly more satisfied with physiotherapy care 3 months after surgery compared to the home-based training group. Rehabilitation after first-time lumbar disc surgery can be based on home training as long as the patients receive both careful instructions from a physiotherapist and strategies for active pain coping, and have access to the physiotherapist if questions regarding training arise. This might be a convenient treatment arrangement for most patients.