Performance in Irish Selection and Future Performance in Surgical Training.

Importance: Selection processes for surgical training should aim to identify candidates who will become competent independent practitioners and should aspire to high standards of reliability and validity. Objective: To determine the association between measured candidate factors at the time of an Irish selection and assessment outcomes in surgical training, examined via rate of progression to Higher Specialist Training (HST), attrition rates, and performance as assessed through a multimodal framework of workplace-based and simulation-based assessments. Design, Setting, and Participants: This retrospective observational cohort study included data from all successful applicants to the Royal College of Surgeons in Ireland (RCSI) national Core Surgical Training (CST) program. Participants included all trainees recruited to dedicated postgraduate surgical training from 2016 to 2020. These data were analyzed from July 11, 2016, through July 10, 2022. Exposures: Selection decisions were based on a composite score that was derived from technical aptitude assessments, undergraduate academic performance, and a 4-station multiple mini-interview. Main outcomes and measures: Assessment data, attrition rates, and rates of progression to HST were recorded for each trainee. CST performance was assessed using workplace-based and simulation-based technical and nontechnical skill assessments. Potential associations between selection and assessment measures were explored using Pearson correlation, logistic regression, and multiple linear-regression analyses. Results: Data were available for 303 trainees. Composite scores were positively associated with progression to HST (odds ratio [OR], 1.09; 95% CI, 1.05-1.13). There was a weak positive correlation, ranging from 0.23 to 0.34, between scores and performance across all CST assessments. Multivariable linear regression analysis showed technical aptitude scores at application were associated with future operative performance assessment scores, both in the workplace (ß = 0.31; 95% CI, 0.14-0.48) and simulated environments (ß = 0.57; 95% CI, 0.33-0.81). There was evidence that the interpersonal skills interview station was associated with future performance in simulated communication skill assessments (ß = 0.55; 95% CI, 0.22-0.87). Conclusions and Relevance: In this study, performance at the time of Irish national selection, measured across technical and nontechnical domains in a multimodal fashion, was associated with future performance in the workplace and in simulated environments. Future studies will be required to explore the consequential validity of selection, including potential unintended effects of selection and ranking on candidate performance.

Baseline Assessments of Psychomotor Aptitude Are Associated With the Future Operative Performance of Surgical Trainees: A Prospective Observational Cohort Study.

OBJECTIVE: This study sought to investigate the association between validated psychomotor ability tests and future in-theater and simulated operative performance. BACKGROUND: Assessments of visuospatial ability, perceptual ability, and manual dexterity correlate with simulated operative performance. Data showing the predictive value of such assessments in relation to future performance in the workplace is lacking. METHODS: Core surgical residents in Ireland recruited from 2016 to 2019 participated in assessments of baseline perceptual, visuospatial, and psychomotor ability; Pictorial Surface Orientation (PicSOr) testing, digital visuospatial ability testing, and manual dexterity testing. Operative performance was prospectively assessed using the in-theater Supervised Structured Assessment of Operative Performance (SSAOP) tool, and simulation-based Operative Surgical Skill (OSS) assessments performed over a 2-year core training period. SSAOP assessments were scored using a 15-point checklist and a global 5-point operative performance score. OSS assessments were scored using procedure-specific checklists. Univariate correlations and multiple linear regression analyses were used to explore the association between fundamental ability measures and operative performance. RESULTS: A total of 242 residents completed baseline psychomotor ability assessments. Aggregated fundamental ability scores were associated with performance in submitted workplace-based SSAOP assessments using the Total Checklist score ( P =0.002) and Overall Performance scores ( P =0.002), independent of operative experience, and undergraduate centile scores. Aggregated ability scores were also positively associated with simulation-based OSS assessment scores on multivariable analysis ( P =0.03). CONCLUSION: This study indicates that visuospatial, psychomotor, and perceptual ability testing scores are associated with the future operative performance of surgical residents.

Zone calculation as a tool for assessing performance outcome in laparoscopic suturing.

BACKGROUND: Simulator performance is measured by metrics, which are valued as an objective way of assessing trainees. Certain procedures such as laparoscopic suturing, however, may not be suitable for assessment under traditionally formulated metrics. Our aim was to assess if our new metric is a valid method of assessing laparoscopic suturing. STUDY DESIGN: A software program was developed to order to create a new metric, which would calculate the percentage of time spent operating within pre-defined areas called "zones." Twenty-five candidates (medical students N = 10, surgical residents N = 10, and laparoscopic experts N = 5) performed the laparoscopic suturing task on the ProMIS III(®) simulator. New metrics of "in-zone" and "out-zone" scores as well as traditional metrics of time, path length, and smoothness were generated. Performance was also assessed by two blinded observers using the OSATS and FLS rating scales. This novel metric was evaluated by comparing it to both traditional metrics and subjective scores. RESULTS: There was a significant difference in the average in-zone and out-zone scores between all three experience groups (p < 0.05). The new zone metrics scores correlated significantly with the subjective-blinded observer scores of OSATS and FLS (p = 0.0001). The new zone metric scores also correlated significantly with the traditional metrics of path length, time, and smoothness (p < 0.05). CONCLUSION: The new metric is a valid tool for assessing laparoscopic suturing objectively. This could be incorporated into a competency-based curriculum to monitor resident progression in the simulated setting.

Techniques and outcomes of combined inferior vena cava and visceral resection for benign and malignant disease.

BACKGROUND: Involvement of the inferior vena cava (IVC) by neoplasm has traditionally been considered a contra-indication to curative surgery because of high surgical risks and poor long-term prognosis. Advances in surgical and anaesthetic techniques however have made this feasible. The aim of this study is to evaluate the outcome of combined IVC and visceral resection in a single institution. METHODS: A retrospective review of a prospectively maintained database was performed. Pre-operative clinicopathological data, operative details and post-operative outcomes including overall and disease-free survival were analysed. Clinicopathological data of patients over a seven-year period undergoing combined IVC and visceral resection was reviewed, including overall and disease-free survival. RESULTS: Between 2006 and 2012, 14 patients underwent IVC resection was accompanied by major hepatectomy (8), nephrectomy (6) and multivisceral resection (3). Post resection, the IVC was reconstructed primarily (3); with PTFE tube graft (9) or using a Gore-tex patch graft (2). All patients underwent a R0 resection. There were two postoperative deaths within 30 days. 6 patients had postoperative complications. There was 1 early and one late (after 6 months) IVC thrombosis. With a median follow up of 20 months (range 5-84 months), two patients died of tumour recurrence and ten are alive with (n = 5) or without (n = 5) disease. CONCLUSION: Combined IVC and visceral resection can be safely performed in selected patients. Surgery provides the possibility of negative margins, acceptable perioperative morbidity/mortality and prolonged survival. These factors combined with lack of alternative treatments justify this approach. However, specialist teams should perform the surgery preferably in centres with expertise in liver transplantation.

Incidence and risk factors of delirium in patients post pancreaticoduodenectomy.

BACKGROUND: Post-operative delirium is an important and common complication of major abdominal surgery characterized by acute confusion with fluctuating consciousness. The aim of this study was to establish the incidence of post-operative delirium in patients undergoing a pancreaticoduodenectomy and to determine the risk factors for its development. METHODS: From a prospectively maintained database, a retrospective cohort analysis was performed of 50 consecutive patients who underwent a pancreaticoduodenectomy at the National Surgical Centre for Pancreatic Cancer in St. Vincent's University Hospital, Dublin and whose entire post-operative stay was in this institution, between July 2011 and December 2012. Two independent medical practitioners assessed all data and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder (DSM), fourth edition. Univariate and multivariate analyses were performed. RESULTS: Seven patients (14%) developed post-operative delirium. The median onset was on the second post-operative day. Older age was predictive of an increased risk of delirium post-operatively. Those who developed delirium had a significantly increased length of stay (LOS) as well as a significantly increased risk of developing at least a grade 3 complication (Clavien-Dindo classification). CONCLUSION: This study demonstrates that post-operative delirium is associated with a more complicated recovery after a pancreaticoduodenectomy and that older age is independently predictive of its development. Focused screening may allow targeted preventative strategies to be used in the peri-operative period to reduce complications and costs associated with delirium.

The impact of aptitude on the learning curve for laparoscopic suturing.

BACKGROUND: Within surgery, several specialties demand advanced technical skills, specifically in the minimally invasive environment. METHODS: Two groups of 10 medical students were recruited on the basis of their aptitude (visual-spatial ability, depth perception, and psychomotor ability). All subjects were tested consecutively using the ProMIS III simulator until they reached proficiency performing laparoscopic suturing. Simulator metrics, critical error scores, observed structured assessment of technical skills scores, and Fundamentals of Laparoscopic Surgery scores were recorded. RESULTS: Group A (high aptitude) achieved proficiency after a mean of 7 attempts (range, 4-10). In group B (low aptitude), 30% achieved proficiency after a mean of 14 attempts (range, 10-16). In group B, 40% demonstrated improvement but did not attain proficiency, and 30% failed to progress. CONCLUSIONS: Distinct learning curves for laparoscopic suturing can be mapped on the basis of fundamental ability. High aptitude is directly related to earlier completion of the learning curve. A proportion of subjects with low aptitude are unable to reach proficiency despite repeated attempts.

Does aptitude influence the rate at which proficiency is achieved for laparoscopic appendectomy?

BACKGROUND: The attainment of technical competence for surgical procedures is fundamental to a proficiency-based surgical training program. We hypothesized that aptitude may directly affect one's ability to successfully complete the learning curve for minimally invasive procedures. The aim was to assess whether aptitude has an impact on ability to achieve proficiency in completing a simulated minimally invasive surgical procedure. The index procedure chosen was a laparoscopic appendectomy. STUDY DESIGN: Two groups of medical students with disparate aptitude were selected. Aptitude (visual-spatial, depth perception, and psychomotor ability) was measured by previously validated tests. Indicators of technical proficiency for laparoscopic appendectomy were established by trained surgeons with an individual case volume of more than 150. All subjects were tested consecutively on the ProMIS III (Haptica) until they reached predefined proficiency in this procedure. Simulator metrics, critical error scores, and Objective Structured Assessment of Technical Skills (OSATS) scores were recorded. RESULTS: The mean numbers of attempts to achieve proficiency in performing a laparoscopic appendectomy for group A (high aptitude) and B (low aptitude) were 6 (range 4 to 7) and 14 (range 10 to 18), respectively (p < 0.0001). Significant differences were found between the 2 groups for path length (p = 0.014), error score (p = 0.021), and OSATS score (p < 0.0001) at the initial attempt. CONCLUSIONS: High aptitude is directly related to a rapid attainment of proficiency. These findings suggest that resource allocation for proficiency-based technical training in surgery may need to be tailored according to a trainee's natural ability.

Role and feasibility of psychomotor and dexterity testing in selection for surgical training.

The practice of Surgery has undergone major changes in the past 20 years and this is likely to continue. Knowledge, judgement and good technical skills will no longer be enough to safely practice surgery and interventional procedures. Fundamental abilities (e.g. psychomotor skills, visuospatial ability and depth perception) are critically important for catheter-based interventions, NOTES, robotic surgery and other procedural interventions of the future. Not all individuals possess the same amount of these innate fundamental abilities and those less endowed are likely to struggle during surgical training and thereafter in surgical practice. In contrast to other high-skill professions/industries (e.g. aviation) we do not have a tradition of testing prospective surgical trainees for abilities/attributes that we now recognize as being important for surgical practice. Instead, we continue to rely on surrogate markers of future potential (e.g. academic record). However, many studies have shown that psychomotor ability is an important predictor of both learning rate and performance for complex laparoscopic tasks. Psychomotor skills, visuospatial ability and depth perception can all be tested objectively by validated tests. At the Royal College of Surgeons in Ireland, all short-listed candidates for Higher Surgical Training now undergo formal testing of both technical skills and fundamental abilities (psychomotor skills, visuospatial ability and depth perception). Reports on each candidate's performance are supplied to the interview committee. Furthermore, a prospective database is being kept for correlation with future surgical performance. We believe that selection into surgical training should take account of attributes that we know are important for safe and efficient surgical practice.