Assessing the stops framework for coping with intraoperative errors: Evidence of efficacy, hints of hubris, and a bridge to abridging burnout.

BACKGROUND: Answering calls in the literature, we developed and introduced an evidence-based tool for surgeons facing errors in the operating room: the STOPS framework (stop, talk to you team, obtain help, plan, succeed). The purpose of this research was to assess the impact of presenting this psychological tool on resident coping in the operating room and the related outcome of burnout while examining sex differences. METHODS: In a natural experiment, general surgery residents were invited to attend 2 separate educational conferences regarding coping with errors in the operating room. Three months later, all residents were asked to fill out a survey assessing their coping in the operating room, level of burnout, and demographics. We assessed the impact of the educational intervention by comparing those who attended the coping conferences with those who did not attend. RESULTS: Thirty-five residents responded to the survey (65% response rate, 54% female respondents, 49% junior residents). Our hypothesized moderated mediation model was supported. Sex was found to moderate the impact of the STOPS framework-female residents who attended the coping educational conference reported higher coping self-efficacy, whereas attendance had no statistically significant impact on male levels of coping self-efficacy. In turn, higher coping self-efficacy was associated with lower levels of burnout. CONCLUSION: Our results suggest that there is evidence of efficacy in this instruction-female residents presented this material report higher levels of coping in the operating room compared to those who did not receive the framework. Further, increase in coping ability was associated with reduced levels of burnout for both genders.

Expanded Access to Video-Based Laparoscopic Skills Assessments: Ease, Reliability, and Accuracy.

OBJECTIVE: Video-based performance assessments provide essential feedback to surgical residents, but in-person and remote video-based assessment by trained proctors incurs significant cost. We aimed to determine the reliability, accuracy, and difficulty of untrained attending staff surgeon raters completing video-based assessments of a basic laparoscopic skill. Secondarily, we aimed to compare reliability and accuracy between 2 different types of assessment tools. DESIGN: An anonymous survey was distributed electronically to surgical attendings via a national organizational listserv. Survey items included demographics, rating of video-based assessment experience (1 = have never completed video-based assessments, 5 = often complete video-based assessments), and rating of favorability toward video-based and in-person assessments (0 = not favorable, 100 = favorable). Participants watched 2 laparoscopic peg transfer performances, then rated each performance using an Objective Structured Assessment of Technical Skill (OSATS) form and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS). Participants then rated assessment completion ease (1 = Very Easy, 5 = Very Difficult). SETTING: National survey of practicing surgeons. PARTICIPANTS: Sixty-one surgery attendings with experience in laparoscopic surgery from 10 institutions participated as untrained raters. Six experienced laparoscopic skills proctors participated as expert raters. RESULTS: Inter-rater reliability was substantial for both OSATS (k = 0.75) and MISTELS (k = 0.85). MISTELS accuracy was significantly higher than that of OSATS (κ: MISTELS = 0.18, 95%CI = [0.06,0.29]; OSATS = 0.02, 95%CI = [-0.01,0.04]). While participants were inexperienced with completing video-based assessments (median = 1/5), they perceived video-based assessments favorably (mean = 73.4) and felt assessment completion was "Easy" on average. CONCLUSIONS: We demonstrate that faculty raters untrained in simulation-based assessments can successfully complete video-based assessments of basic laparoscopic skills with substantial inter-rater reliability without marked difficulty. These findings suggest an opportunity to increase access to feedback for trainees using video-based assessment of fundamental skills in laparoscopic surgery.

Implementation of a Brief Evidence-Based Intraoperative Coping Curriculum.

BACKGROUND AND RATIONALE: Recent research has called for further resident training in coping with errors and adverse events in the operating room. To the best of our knowledge, there currently exists no evidence-based curriculum or training on this topic. MATERIALS AND METHODS: Synthesizing three prior studies on how experienced surgeons react to errors and adverse events, we developed the STOPS framework for handling surgical errors and adverse events (Stop, Talk to your team, Obtain help, Plan, Succeed). This material was presented to residents in two teaching sessions. RESULTS AND CONCLUSION: In this paper, we describe the presentation of, and the uniformly positive resident reaction to, the STOPS framework: an empirically based psychological tool for surgeons who experience operative errors or adverse events.

Scrubbing With Aristotle: Cultivating Surgical Wisdom through Inflection Points.

Surgical educators and researchers have well-considered a breadth of topics related to surgery. However, there is one concept that is notably absent in this corpus: surgical wisdom. In this perspective, we draw on work from Aristotle and psychology research to introduce the concept of phronesis, which we believe is useful for understanding surgical wisdom. We further illustrate how this concept can be a useful tool for surgical educators through the discussion of four distinct functions of phronesis, and illustrating the ability of these functions to help learners cultivate knowledge at important decision points, or inflection points, in surgical training and a surgical career.

The good, the bad, and the ugly: Operative staff perspectives of surgeon coping with intraoperative errors.

BACKGROUND: Intraoperative errors are inevitable, and how surgeons respond impacts patient outcomes. Although previous research has queried surgeons on their responses to errors, no research to our knowledge has considered how surgeons respond to operative errors from a contemporary first-hand source: the operating room staff. This study evaluated how surgeons react to intraoperative errors and the effectiveness of employed strategies as witnessed by operating room staff. METHODS: A survey was distributed to operating room staff at 4 academic hospitals. Items included multiple-choice and open-ended questions assessing surgeon behaviors observed after intraoperative error. Participants reported the perceived effectiveness of the surgeon's actions. RESULTS: Of 294 respondents, 234 (79.6%) reported being in the operating room when an error or adverse event occurred. Strategies positively associated with effective surgeon coping included the surgeon telling the team about the event and announcing a plan. Themes emerged regarding the importance of the surgeon remaining calm, communicating, and not blaming others for the error. Evidence of poor coping also emerged: "Yelling, feet stomping and throwing objects onto the field. [The surgeon] cannot articulate needs well because of anger." CONCLUSION: These data from operating room staff corroborates previous research presenting a framework for effective coping while shedding light on new, often poor, behaviors that have not emerged in prior research. Surgical trainees will benefit from the now-enhanced empirical foundation on which coping curricula and interventions can be built.

STOPS: A Coping Framework for Surgeons Who Experience Intraoperative Error.

OBJECTIVE: To investigate the steps faculty surgeons take upon experiencing intraoperative error and synthesize these actions to offer a framework for coping with errors. BACKGROUND: While intraoperative errors are inevitable, formal training in error recovery is insufficient and there are no established curricula that teach surgeons how to deal with the intraoperative error. This is problematic because insufficient error recovery is detrimental to both patient outcomes and surgeon psychological well-being. METHODS: We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with faculty surgeons from 3 hospitals. Surgeons described recent experiences with intraoperative error. Interviews were transcribed and coded. Analysis allowed for development of themes regarding responses to errors and coping strategies. RESULTS: Twenty-seven surgeons (30% female) participated. Upon completion of the analysis, themes emerged in 3 distinct areas: (1) Exigency, or a need for training surgical learners how to cope with intraoperative errors, (2) Learning, or how faculty surgeons themselves learned to cope with intraoperative errors, and (3) Responses, or how surgeons now handle intraoperative errors. The latter category was organized into the STOPS framework: Intraoperative errors could produce STOPS: Stop, Talk to your Team, Obtain Help, Plan, Succeed. CONCLUSIONS AND RELEVANCE: This study provides both novel insight into how surgeons cope with intraoperative errors and a framework that may be of great use to trainees and faculty alike.

Revealing hidden experiences: Gendered microaggressions and surgical faculty burnout.

BACKGROUND: Studies report higher burnout in women faculty surgeons compared to men. However, few studies have examined underlying mechanisms for these gendered differences. Gendered differences in microaggression experiences may explain part of the relationship between gender and burnout. We aimed to investigate the relationship between gender, gendered microaggressions, and burnout and test the hypothesis that microaggressions contribute to the relationship between gender and burnout. METHODS: In this 2021 study, a survey was distributed to surgical faculty at 7 institutions. Variables included gender identity, race, average hours worked recently, the Oldenburg Burnout Inventory, and a modified Racial and Ethnic Microaggressions Scale to assess gendered microaggressions. To assess the relationship between surgical faculty gender and burnout, and if this relationship could be explained by microaggressions, a mediation model was tested. RESULTS: A total of 109 participants (40% female) completed the survey and were included in analysis. The hypothesized indirect effect of gender on burnout (M = 2.70/5, SD = 0.81), through gender-based microaggressions (M = 1.7/5, SD = 1.9), was significant, B = -0.25, SE B = 0.09, confidence interval (-0.44 to -0.09): women surgeons reported higher levels of gendered microaggressions, which predicted higher levels of burnout. The overall model was significant (R2 = .16, F[6,102] = 3.33, P < .01). Race, specialty, hours worked, and years of experience were all not significant in the model. CONCLUSION: Gendered microaggressions mediate the relationship between gender and burnout, providing a potential mechanism for the higher rates of burnout in women surgeons evident in prior research. These multi-institutional data provide a focus for targeted initiatives that could decrease both burnout rates and the impact of gender bias on surgical faculty.

Simulation as Soothsayer: Simulated Surgical Skills MMIs During Residency Interviews are Associated With First Year Residency Performance.

OBJECTIVE: The main consideration during residency recruitment is identifying applicants who will succeed during residency. However, few studies have identified applicant characteristics that are associated with competency development during residency, such as the Accreditation Council for Graduate Medical Education milestones. As mini multiple interviews (MMIs) can be used to assess various competencies, we aimed to determine if simulated surgical skills MMI scores during a general surgery residency interview were associated with Accreditation Council for Graduate Medical Education milestone ratings at the conclusion of intern year. DESIGN: Retrospective cohort study. Interns' Step 1 and 2 clinical knowledge (CK) scores, interview day simulated surgical skills MMI overall score, traditional faculty interview scores, average overall milestone ratings in the spring of residency, and intern American Board of Surgery In-Training Examination (ABSITE) percentile scores were gathered. Two multiple linear regression were performed analyzing the association between Step 1, Step 2 CK, MMI, and traditional faculty interview scores with (1) average overall milestone rating and (2) ABSITE percentile scores, controlling for categorical/preliminary intern classification. SETTING: One academic medical center PARTICIPANTS: General surgery interns matriculating in 2020-2021 RESULTS: Nineteen interns were included. Multiple linear regression revealed that higher overall simulated surgical skills MMI score was associated with higher average milestone ratings (ß = .45, p = 0.03) and higher ABSITE score (ß = .43, p = 0.02) while neither Step 1, Step 2 CK, nor faculty interview scores were significantly associated with average milestone ratings. CONCLUSIONS: Surgical residency programs invest a tremendous amount of effort into training residents, thus metrics for predicting applicants that will succeed are needed. Higher scores on a simulated surgical skills MMIs are associated with higher milestone ratings 1 year into residency and higher intern ABSITE percentiles. These results indicate a noteworthy method, simulated surgical skills MMIs, as an additional metric that may select residents that will have early success in residency.

The Effect of Advanced Practice Providers on ACGME Colon and Rectal Surgery Resident Diagnostic Index Case Volumes.

OBJECTIVE: Prior to 2015 residents in our Accreditation Council for Graduation Medical Education (ACGME) colon and rectal surgery training program were in charge of managing, with faculty oversight, the outpatient anorectal clinic at our institution. Starting in 2015 advanced practice providers (APPs) working in the division assumed management of the clinic. The effect of APPs on ACGME resident index diagnostic case volumes has not been explored. Herein we examine ACGME case log graduate statistics to determine if the inclusion of APPs into our anorectal clinic practice has negatively affected resident index diagnostic anorectal case volumes. DESIGN: ACGME year-end program reports were obtained for the years 2011 to 2019. Program anorectal diagnostic index volumes were recorded and compared to division volumes. Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) tests were conducted to assess whether the number of cases per year (for each respective case type) prior to the introduction of APPs into the anorectal clinic (2011-2014) differed from the number of cases per year with the APP clinic in place (2015-2018). A p-value <0.05 was considered statistically significant. SETTING: Mayo Clinic, Rochester, Minnesota (quaternary referral center). PARTICIPANTS: Colon and rectal surgery resident year-end ACGME reports (2011-2019). RESULTS: ANOVAs revealed a marginally significant (p = 0.007) downtrend for hemorrhoid diagnostic codes, and a significant uptrend (p = 0.000) for fistula cases. Controlling for overall division volume, ANCOVA only reveled significance for fistula cases (p = 0.004) with the involvement of APPs. CONCLUSIONS: At our institution we found the inclusion of APPs into our anorectal clinic practice did not negatively affect colon and rectal surgery resident ACGME index diagnostic anorectal case volumes. Inclusion of APPs into a multidisciplinary practice can promote resident education by allowing trainees to pursue other educational opportunities without hindering ACGME index case volumes.

Virtual interviews - Utilizing technological affordances as a predictor of applicant confidence.

PURPOSE: In the midst of a pandemic, residency interviews transitioned to a virtual format for the first time. Little is known about the effect this will have on the match process. The study aim is to evaluate resident application processes and perceived outcomes. METHODS: An electronic survey was distributed to 142 colon and rectal surgery residency applicants (95% of total). RESULTS: A total of 77 applicants responded to the survey (54% response rate). Applicants reported high levels of satisfaction with virtual interviews but less comfort. Utilizing the mute button and using notes in a different way from face-to-face interviews were significantly associated with applicant confidence that they ranked the right program highest. A majority of applicants (73%) would recommend virtual interviews next year even if COVID-19 is not a factor. CONCLUSION: While applicants appear generally satisfied with virtual interviews, they also reported less comfort. Applicant confidence was predicted by utilizing the unique technological affordances offered by the virtual platform.

Program Director Opinions of Virtual Interviews: Whatever Makes my Partners Happy.

OBJECTIVE: To assess the processes and outcomes of 2021 colon and rectal surgery match season: one of the first National Resident Matching Program (NRMP) match to conduct uniformly virtual interviews for all programs and candidates due to the Covid-19 pandemic. Since this if the first-year interviews were held entirely virtual for a (NRMP) match season, we sought to determine: (1) How did program directors (PDs) in this year's fellowship conduct their virtual interviews? (2) Were any of these conduct decisions associated with the PD satisfaction with the resulting match? (3) What is the PDs opinion of how interviews should occur next year if COVID-19 is not a factor? DESIGN AND SETTING: The authors sent an anonymous survey to the PDs of all programs participating in the 2021 colon and rectal surgery residency match directly following match day 2020. PARTICIPANTS: Forty-one colon and rectal residency PDs (70% response rate) responded to the survey (78% Male) representing a range of experience (M = 7.61, SD = 5.66, years as PD at current institution), and program type (77.5% Academic, 7.5% Independent Academic Medical Center, 15% Nonacademic). RESULTS: While programs utilized several different platforms, conducted various forms of training for their faculty, and provided applicants with different types of information, interview day(s) across the specialty are reported to have proceeded smoothly. PDs as a whole were very satisfied with their match results this year (M = 4.65, SD = .66), and this satisfaction was not impacted by virtual interview decisions or processes. However, only 55% of PDs agree or strongly agree that next year's interviews should be virtual regardless of COVID-19, a judgement solely influenced by the opinion of other program faculty on virtual interviews, regardless of satisfaction with match or comfort with technology. CONCLUSION: While PDs report high satisfaction with virtual interview processes and outcomes, there is less agreement that colon and rectal surgery residency interviews should move to a solely virtual platform.

Coping with errors in the operating room: Intraoperative strategies, postoperative strategies, and sex differences.

BACKGROUND: Prior work has identified intraoperative and postoperative coping strategies among surgeons and has demonstrated surgical errors to have a significant impact on patient outcomes and physicians. Little research has considered which coping strategies are most common among surgeons and if there exist coping strategy differences among sex or training level. METHODS: An electronic survey was distributed to surgical faculty and trainees at 3 institutions. Variables included coping techniques after making an error in the operating room. Participants were asked to report the effectiveness of their overall coping strategy. RESULTS: A total of 168 participants (56% male, 45% faculty) experienced an operative error and answered questions regarding coping strategies. The only coping strategy significantly associated with positive ratings of coping effectiveness was, upon error, taking a step back and taking time to think and act (r = 0.17; P = .024). There were differences between men and women in both intra and postoperative coping strategies. Men (mean = 3.69/5, standard error = .09) viewed their overall coping strategy as more effective than women (mean = 3.38/5, standard error = .09), t(158.86) = 2.47; P = .015. CONCLUSION: Although both male and female surgeons reported making errors in the operating room, differences exist in the strategies surgeons use to cope with these mistakes, and strategies differ in their ratings of effectiveness.

Faculty perceptions of resident skills decay during dedicated research fellowships.

BACKGROUND: Residents engaging in dedicated research experiences may return to clinical training with less surgical skill. The study aims were 1) to evaluate faculty perceptions of residents skills decay during dedicated research fellowships, and 2) to compare faculty and resident perceptions of residents skills decay. METHODS: Faculty and residents were surveyed on resident research practices and perceptions of resident skills decay. RESULTS: Faculty thought residents returning from research demonstrate less technical skill (Median = 4; 5-point Likert scale, 1 = Strongly disagree, 5 = Strongly agree), demonstrate less confidence (Median = 4), and require more instruction (Median = 4). Both faculty and residents perceived the largest skill reduction in complex procedures, technical surgical skills, and knowledge of procedure steps (p < 0.05). CONCLUSION: While dedicated research experiences provide valuable academic experience, there is a cost to clinical skills retention and confidence specifically in the areas of complex operative procedures and technical surgical skills.