The integration of laparoscopy into a surgical residency and implications for the training environment

Although laparoscopic cholecystectomy is now an accepted part of resident training, the impact of operative laparoscopy (OL) upon the residency environment has not been examined in detail. We reviewed the first 3 years' experience with OL and the process by which it was introduced into our residency program. Data were obtained from our prospective computerized surgical laparoscopic registry as well as from a survey conducted midway in this experience. At that time, a questionnaire was sent to current residents in the program and residents who graduated after the inception of the OL program were interviewed by telephone.OL cases increased each year and comprised a progressively greater percentage of total cases. Residents performed over 97% of cases, with attending surgeons as first assistants. Initially, only senior-level residents participated as surgeons; however, after the first year we noted a significant tendency for cases to filter down the ranks. Junior-level residents have already participated in more laparoscopic than open cholecystectomies and expressed considerable concern about training in open procedures. Graduated residents without exception were able to obtain privileges to perform OL without additional training. They did not feel that resident education was compromised by the advent of laparoscopy. Both current and graduated residents considered didactic sessions including animal laboratories and simulators an important part of training.With appropriate use of didactic sessions, simulators, and animal laboratories, a radically new procedure (OL) can be successfully introduced into a surgical residency program and subsequently taught through conventional means.F. F. Muakkassa is presently in practice in Akron, OHP. B. Wilton is presently in practice in St. Paul, MNPresented at the annual meeting of the Association of Program Directors in Surgery, Dallas, Texas, USA, 27 February 1993     

Reducing medication errors in a surgical residency training program

Medication errors contribute to in-hospital morbidity and mortality. Teaching hospitals and the surgical residency training programs they support should take proactive steps to reduce error frequency. In order to accomplish meaningful error reduction, we must first define the scope and nature of the problem. Pharmacists at the Monmouth Medical Center prospectively recorded medication prescribing errors made by surgical residents during 2 years. These data were reviewed to determine the types of medication errors made most frequently by surgical house officers. Seventy-five medication-prescribing errors were made by surgical house staff in the years 2001 and 2002. Thirty-three of these errors involved orders for antibiotic therapy. Errors that could not be directly attributed to knowledge deficits were responsible for 36 of the 75 errors (48%), whereas specific knowledge deficits were responsible for 39 of the 75 errors (52%). Twentyeight of the 36 errors not directly attributable to knowledge deficits (78%) were made at the postgraduate year one level, whereas only 15 of the 39 knowledge deficit errors (38%) were made at the postgraduate year one level. Though targeted education to address specific knowledge deficits may substantially reduce the occurrence of "knowledge deficit" medication errors within surgical residency training programs, more costly measures such as the implementation of physician computerized order entry will likely be needed to reduce maximally the frequency of medication ordering errors. Many prescribing errors cannot be attributed to specific knowledge deficits.     

Factors affecting choice of surgical residency training program

BACKGROUND: A significant problem facing American surgery today is the lack of participation from women and minorities. In 1995 and 1996, 15.1 and 15.8% of United States general surgical residency graduates were women. Of our 71 graduates in the last 12 years, 38% were women. The aim of this study was to identify the factors influencing our residents' choice of training program and the reasons why our program has a high percentage of female graduates. METHODS: Between 1989 and 2000, 27 women and 44 men completed general surgical training at our university and 44/71 (59%) responded to our survey. The age at residency completion was 34 +/- 2.2 years for men and 33.9 +/- 2.8 years for women. Fifty-five percent of men and 30% of women went on to fellowship training; and 36% of men and 20% of women are in academia. RESULTS: Factors influencing our graduates' selection of training program are: Only 23% of men had a female faculty as their mentor, whereas 90% of women had a male faculty as their mentor during training. Only 59% of men but 80% of women (P < 0.05) agreed that female medical students need role models of successful female faculty members. Fifty-five percent of men and 45% of women would encourage a female medical student to choose surgery as a career, but 82% of men and 50% of women would encourage a male medical student to do so. Ninety-one percent of men and 85% of women would choose surgery as a career again. CONCLUSIONS: A surgical residency training program with strong leadership, good clinical experience, and high resident morale will equally attract both genders. Women may pay more attention to the program's gender mix and geographic location.     

Impact of a surgical oncologist on general surgery residency training program

BACKGROUND: To assess the impact of adding a surgical oncologist to our faculty we examined the operative experience in our program before and after the addition. METHODS: Operative case numbers reported to the American Board of Surgery over a 10-year period were analyzed. This time period encompassed 5 years before and after the addition of a surgical oncologist to our faculty. All defined category case numbers were examined using t test analysis. Significance was defined as a P value of less than 0.05. RESULTS: The overall caseload increased in the time period after the faculty addition. There was a statistically significant increase in skin/soft tissue, breast, esophagus, small intestine, large intestine, live, spleen, and endocrine cases. No statistical significance was seen in head/neck, stomach, pancreas, and biliary cases. CONCLUSIONS: The addition of a surgical oncologist to our faculty coincides with a statistically significant increase in areas of skin/soft tissue, breast, esophagus, small intestine, large intestine, liver, spleen, and endocrine. Other areas not statistically significant may reflect referral patterns or this particular oncologist's preferences of practice.     

Unplanned return to operating room in a community hospital-based obstetrics and gynecology residency

The American College of Obstetricians and Gynecologists clinical indicator for unplanned return to the operating room during the same admission in an obstetrics and gynecology residency is reviewed in this article. A retrospective chart review of all gynecologic surgeries during a 3-year period was evaluated for this indicator. An incidence of 0.03% was noted, with 3 of 1,492 procedures meeting the definition of this indicator. The incidence of this clinical indicator is uncommon in a community hospital-based obstetrics and gynecology residency.     

Our experience with early integration of laparoscopic cholecystectomy in surgical residency training

Laparoscopic cholecystectomy is now a method of choice in treating symptomatic cholelithiasis. The aim of this study was to assess an early integration of surgical residents into performing laparoscopic cholecystectomies and the significance of the integration for their training.Since February 1992 laparoscopic cholecystectomy (LC) has been performed in our institutions. During the 1st year 253 LCs were done by 4 surgeons—2 residents (in postgraduate years 3 and 4) and 2 staff surgeons; the 2nd year the team was extended and 301 LCs were performed. The residents operated on 364 cases (66%); the overall conversion rate was 5.4%; in the group of patients operated by residents (R) it was 3.8%; in the group operated by staff surgeons (SS) it was 8.4%. The complication rates did not exceed literature reports. The overall complication rate was 3.4%, in the R group 3.0% and in the SS group 4.2%. It may be concluded that surgical residents can perform LC without additional complications after initial experience with the open technique and appropriate hands-on laboratory training period before starting LC. Continuous training in advanced open biliary procedures should be assured for senior surgical residents.Partially presented at the XCIV Annual Congress of Japan Surgical Society, Tokyo, Japan, 29–31 March 1994     

Incorporation of laparoscopy into a surgical endoscopy training program.

The impact of introducing laparoscopy as part of the overall gastrointestinal endoscopy case load performed by residents was reviewed. During 1990, there was a significant increase (56.9%) in the number of flexible diagnostic endoscopic procedures performed compared with 1989. When the total number of laparoscopic procedures was considered, the increase was 117%. Residents participated in the "surgeon's" position in 59% of the therapeutic laparoscopic procedures and as either surgeon or "first assistant" in 86% of all therapeutic laparoscopic procedures and 94% of all diagnostic laparoscopic procedures. Complication rates for diagnostic laparoscopic procedures were low in 1989 (0.03%) and 1990 (0.2%). Complication rates for therapeutic laparoscopic procedures were also low (4%). There was no difference in the complication rate for cases in which residents were in the surgeon's position (4%) versus cases in which they were not (4%). Introduction of laparoscopic procedures into a surgical residency program can be done safely, especially in cases in which an established program in endoscopy exists.     

Validation of a novel robotic-assisted partial nephrectomy surgical training model

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic‐assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic‐assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training.

OBJECTIVE

• ? To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic‐assisted partial nephrectomy (RAPN).

METHODS

• ? We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (≥100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post‐study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey–kramer test.

RESULTS

• ? The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as ‘very realistic’ (median visual analogue score 7/10) (face validity). Experts also rated the model as an ‘extremely useful’ training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P= 0.0002) as well as individual metrics, including ‘depth perception,’‘bimanual dexterity,’‘efficiency,’‘tissue handling,’‘autonomy,’‘precision,’ and ‘instrument and camera awareness’ (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05).

CONCLUSION

• ? Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.

     

Introduction of cardiac surgery residency program at an earlier stage in surgical training

Objective

Reform of the Japanese postgraduate residency program has dramatically influenced the recruitment system. Because shortage of young cardiac surgeons is anticipated, an effective program for residents who want to become cardiac surgeons must be established at an earlier stage in surgical training.

Methods

A 3-year cardiac surgery residency curriculum was developed for senior residents. The surgical training program includes harvesting of the saphenous vein, radial artery and internal thoracic artery, and repair of abdominal aortic aneurysm and specifies the target number of surgical procedures for each training. Academic training is provided in addition to clinical skills training. Nine residents completed the 3-year program between 2004 and 2012. The number of surgical procedures performed, presentations made at scientific meetings, and scientific papers published were investigated and analyzed.

Results

Each resident participated in 438 operations during 3-year program, 25.9 ± 8.3 (5.9 %) as main operator and 182.2 ± 15.8 (42 %) as first assistant. The average number of procedures per resident over the 3 years was 43.0 ± 6.7 for saphenous vein harvest, 14.4 ± 3.9 for radial artery harvest, 27.9 ± 13.0 for internal thoracic artery harvest, 7.1 ± 4.6 for abdominal aortic aneurysm. In addition, over the 3 years, the mean number of presentations at scientific meetings was 13.2 ± 3.2 and the mean number of publication of scientific papers was 1.9 ± 1.4.

Conclusion

The new cardiac surgery training curriculum for residents worked fairly well. A system for assessment of the program by an authoritative body should be established in the future.     

Significance of the in-training examination in a surgical residency program

The exact role that the American Board of Surgery In-Training Examination plays in resident evaluation remains poorly defined. We have required that all residents take the In-Training Examination annually. An analysis was performed of the results of the In-Training Examination and the Qualifying Examination of the American Board of Surgery for 16 residents who completed their residencies between July 1976 and July 1981. Twelve graduates passed their initial Qualifying Examinations with a mean +/- 1 SEM score of 81 +/- 2. Four graduates failed with a score of 70 +/- 0.3. Corresponding scores on their final In-Training Examinations were 42 +/- 9 and 11 +/- 6 (p less than 0.001). Each year the In-Training Examination Scores obtained by the residents who passed the Qualifying Examination were significantly higher than were those scores obtained by the graduates who failed. Linear regression analysis identified a significant correlation between the graduates' initial (r = 0.676) and final (r = 0.760) In-Training Examination scores and the Qualifying Examination score. In our resident training program, In-Training Examination results correlated well with Qualifying Examination results and may be used as an objective determinant for remedial measures and resident retentions. These data should be developed on a national level. While Board certification was or likely will be accomplished by all our residents, our goal is to strengthen the academic characteristics of the training program to produce uniform success on the initial Qualifying Examination.     

Resident and faculty perceptions of a surgical residency program merger

To evaluate resident and faculty perceptions of a residency merger process.Survey of faculty and residents of a recently merged general surgical residency. Nineteen separate program characteristics were evaluated via a numerical scoring system, and additional written commentary regarding dominant perceived benefits and detriments of the merger was solicited. Statistical significance was evaluated on numerically scored items by applying the Mann-Whitney U test to median values expressed with interquartile ranges, comparing resident and faculty responses.Scoring system responses from faculty and residents were generally similar. The merger was seen as neutral to positive in its impact on academic issues, but it had more negative effects on issues related to overall program atmosphere and morale. Statistically significant differences between resident and faculty responses were noted in 2 areas: teaching conference timing and overall program effectiveness in preparing for practice. Both of these areas were more favorably impacted by the merger from the residents' perspective, and more negatively as judged by the faculty (p < 0.05). Written commentary by both groups similarly emphasized areas of academic strengthening as a positive effect of the merger, and relationship and morale issues as being more negatively impacted.As reflected by resident and faculty perceptions, program mergers may provide opportunities to strengthen and enhance the academic and clinical foundation of residency. This may, however, occur at the expense of morale and relational issues, which may be negatively impacted by program administrative and geographic expansion.     

Stakeholder perspectives and status of surgical simulation and skills training in Canadian urology residency program

IntroductionWith the shift to competency-based training, surgical skills lab training (SSLT) may become a mandatory part of Canadian urology residency programs (CURPs). This study aims to identify: 1) the status of SSLT in CURP; 2) stakeholder perspectives on the utility of SSLT; 3) barriers to developing and implementing SSLT; and 4) how to address these barriers.MethodsSurveys were developed and issued to three groups of stakeholders: 1) SSLT directors at all 13 CURPs (response rate 100%); 2) teaching faculty (response rate 33%); and 3) urology residents (response rate 24%). Surveys 2 and 3 were sent to 10 English CURPs. Results were collected through email and SurveyMonkey^®.ResultsNine of 13 CURPs have a dedicated SSLT; 46% of CURP have 1–3 sessions per year, 8% have 5–7, and 30% >7. Most residents have independent lab access, but 80% do so less than once monthly. Over 90% of stakeholders find SSLT useful, of which high-fidelity models are most preferred (faculty rated 3.66/4, residents 3.18/4). Program directors (PDs) identified lack of protected faculty time, funding, and infrastructure as the top three barriers to SSLT implementation. Residents found lack of faculty time, protected academic time, and infrastructure as barriers. PDs viewed protecting faculty time and more funding as potential solutions, while residents suggested protected faculty and academic time, and after-hours lab access.ConclusionsResidents, faculty, and PDs in CURPs view SSLT as useful. Most CURPs have defined SSLT; programs without this have labs for resident use but are underused. To continue to develop and progress SSLT, more time, participation, and funding must be made available.     

Preliminary assessment of a scientific curriculum in a surgical residency program.

A structured, basic science curriculum was instituted for surgical residents of the University of Connecticut (Farmington) Integrated Residency Program during the 1990-1991 academic year in concordance with American Board of Surgery guidelines. The impact of the new program was measured by comparing performance on monthly basic science examinations, the in-training examination, and "mock" oral examinations for the 1990-1991 academic year with that of the preceding academic year. While monthly examination scores improved for the entire group of residents (67.7 vs 64.6), in-training and oral examination scores did not change significantly. Categorical residents generally demonstrated superior performance and greater improvement than did preliminary residents. Data analysis suggested that the new curriculum was an effective educational device and that university-designed monthly examinations were valid testing instruments, but there was an apparent incongruity between the goals of the curriculum and the American Board of Surgery In-Training Examination.     

The importance of teaching surgical history in a general surgery residency program

Because we recently realized our department had a shortcoming in teaching surgical history to our residents, which resulted in near total ignorance of the history of their chosen specialty, we decided to poll all the general surgery residency program directors in the United States regarding the teaching of surgical history. Questionnaires were mailed to 265 programs and 159 (60%) responded. Of this group, 149 (94%) reported that they were convinced that the study of surgical history had an important place in surgical education. However, only 19 of the reporting programs (12%) indicated that they had a formal program for teaching surgical history. With our departmental failing with regard to teaching surgical history, reinforced by the results of our poll, we opted to improve the teaching of history to surgical residents. We began a bimonthly, relatively informal surgical history session with presentations by residents and faculty. This has renewed interest in the history of our specialty of residents and faculty alike. We urge all programs to incorporate a similar surgical history format to benefit the program, but especially to benefit the residents.     

A prospective evaluation of a simulator-based laparoscopic training program for gynecology residents

BACKGROUND: To determine prospectively if simulator-based laparoscopic training could improve laparoscopic skills of gynecology residents. STUDY DESIGN: Twenty-six gynecology residents were enrolled in a laparoscopy training curriculum involving didactics, self-paced learning modules, and graded simulator-based laparoscopic training modules. Six simulator tasks were developed to introduce incremental levels of difficulty. Residents were tested on bead/peg manipulation, passing of a specially designed "key," cutting of lines and circles on a two-layer latex glove, and laparoscopic suturing followed by both intra- and extracorporeal knot tying. Times for each task and penalties for errors were assessed at baseline and after 3 months of training. RESULTS: Twenty-six residents completed initial baseline and 3-month evaluations. Average summary time (including 30-seconds penalties for each error) at baseline was 64 minutes and 36 minutes at 3-month evaluation (p < 0.001). For PGY1 baseline summary times averaged 83 minutes compared with 50 minutes at 3 months (p = 0.006). For PGY4 baseline summary times averaged 49 minutes compared with 28 minutes at 3 months (p = 0.05). All individual tasks demonstrated substantial improvement (p < 0.001) from baseline to 3-month evaluation. Baseline summary scores demonstrated correlation between PGY training year and overall score (p < 0.001) consistent with earlier ability and training. Three-month scores demonstrated equalization of skill level across PGY2 through PGY4. CONCLUSIONS: A dedicated simulator-based laparoscopic training curriculum has the ability to improve basic laparoscopic skills in a gynecologic residency, as measured by timed and scored simulator tasks. Construct validity was demonstrated by measuring substantial improvement in performance with increasing residency training, and with practice.