Impact of the COVID-19 Pandemic on the Wellness of Canadian Plastic Surgery Residents.

On top of preexisting burnout, depression, and anxiety among trainees, the COVID-19 pandemic has introduced novel stressors. The objectives of this study were to determine the effects of the COVID-19 pandemic on Canadian plastic surgery residents' practice, wellness, and overall training. Methods: Surveys for program directors and residents were created and disseminated to all English-speaking Canadian plastic surgery residency training programs. Survey results were pooled and presented as a percentage of responses for each question. Results: Response rates were 50% (n = 5/10) and 25% (n = 19/77) for program directors and residents, respectively. All program directors believed that the pandemic has a negative effect on resident wellness, 80% (n = 4/5) of which believed that their residents were coping effectively. They rated program support for resident wellness as neutral or supportive. Most programs (80%; n = 4/5) introduced strategies to support resident well-being. Most trainees (84%; n = 16/19) reported the pandemic as having a negative effect on their well-being, with approximately 50% endorsing worse emotional, social, psychological, and physical wellness, as well as feelings of burnout. Some reported difficulties coping (21%; n = 4/19). Residents felt that their wellness was supported externally by their own resilience (89%; n = 17/19), family members (74%; n = 14/19), friends (74%; n = 14/19), their partner (68%; n = 13/19), or co-residents (53%; n = 10/19). Internal support by their program was rated as neutral or negative (63%; n = 12/19). Conclusions: Our findings of negative effects of the COVID-19 pandemic on the wellness of Canadian plastic surgery trainees are concerning. Programs must implement appropriate identification and support strategies to improve resident well-being.

Can We Reach a Consensus on the Appropriate Use of Before and After Photos in Breast Surgery?

Breast surgery is an area of practice where patients value before and after photographs (BAPs). Consensus is needed to develop guidelines to address the deficit in the literature regarding appropriate use of BAPs, as these may ultimately play a significant role in the breast surgery consent process. METHODS: Expert breast reconstructive surgeons participated in a modified nominal group technique (NGT) to establish expert consensus on categories and criteria to be used when evaluating appropriate use of BAPs as part of informed consent. Endorsement rate of 75% and coefficients of variance within and between rounds were conducted to determine validity of each criteria item's rank order. RESULTS: Eight experts participated in the NGT in-person meeting and subsequent online survey. five of seven categories were endorsed for discussion: purpose, image type, anatomy, results, and photographic integrity. Overall consensus was obtained for six of 11 criteria. Criteria items found to have consensus were: patients considering surgery being the intended photograph audience (100% endorsement, CV1 - CV2 = 0.01), use of photographic images (75% endorsement, CV1 - CV2 = 0.04), defining the standard clinical photograph by having patients in the same body position (100% endorsement, CV1 - CV2 = 0.14), anonymizing images by removing all digital tags (88% endorsement, CV1 - CV2 = 0.03) and patient identifiers (75% endorsement, CV1 - CV2 = 0.00), not limiting the number of photograph sets needed for sufficient representation (100% endorsement, CV1 - CV2 = 0.07), and representing average outcomes (100%, CV1 - CV2 = 0.06). CONCLUSIONS: Early use of this validated and effective technique helps identify potential consensus categories and criteria that surgeons recommend for the use of BAPs in the informed consent process. Further study is required.

What you see is not always what you get: Radiographic-pathologic discordance among benign breast masses.

The differential diagnosis for benign breast masses is broad and ranges from common lesions like fibroadenomas to rare masses like breast hamartomas. Fibroadenomas are proliferative benign masses made up of fibroglandular tissue. Hamartomas are neoplasms comprised of different tissues that are endogenous to the area where they originate. Breast hamartomas specifically, are rare, benign slow growing tumours comprised of fibrotic stroma, adipose, glandular tissue, and epithelial components. Both lesions are painless, firm, and are typically palpable on clinical exam. Given their similarities in composition, diagnosing these masses can be challenging, but may be confirmed with ultrasonography, mammogram, computed tomography, magnetic resonance imaging, or via histological specimen. Once diagnosed, surgical excision is the preferred treatment option. We present a 33-year-old woman with a large left breast mass that gradually increased in size and provide a review of the current literature regarding the challenge of distinguishing between breast fibroadenomas and hamartomas.

Factors That Affect Medical Students' Perception and Impression of a Plastic Surgery Program: The Role of Elective Rotations and Interviews.

OBJECTIVE: Securing a residency training position in plastic surgery is highly competitive each year with a limited quota of positions and numerous qualified applicants. Although previous studies have highlighted the importance of residency programs and applicants seeking a "good fit," it remains poorly understood what influences a medical student's impression and desire to train at a certain program over others. The objective of this cross-sectional study was to identify which specific potentially modifiable factors during elective rotations and program interviews were most important to Canadian medical students when ranking plastic surgery programs. METHODS: An electronic survey with 42 questions was administered to Canadian final year medical students who applied through the 2017 Canadian Residency Match Service to the plastic surgery training program at the University of Toronto. The survey consisted of 7-point Likert scale questions related to demographics, general factors affecting impression of a plastic surgery program, and specific factors related to the elective and interview experiences. Survey responses were collected anonymously for analysis. RESULTS: Twenty-three of 46 applicants completed the survey (50% response rate). The most important general factors affecting a medical student's impression and desire to train at a residency program were mentors at a specific program (weighted average, 6.39) and geographic location of a program (weighted average, 5.65). During elective rotations, the most important factors identified were overall impression of resident and staff collegiality (weighted average, 6.57), overall impression of resident happiness (weighted average, 6.52), and having a formal rotation-end debrief evaluation with the supervising staff (weighted average, 6.04). At program interviews, perceiving an atmosphere of collegiality (weighted average, 6.45) and opportunities to interact with residents and faculty at an organized social event (weighted average, 5.95) were considered of greatest importance. CONCLUSIONS: Current applicants to plastic surgery in Canada prioritize resident happiness, program collegiality, and meaningful faculty relationships, such as those with a mentor, when ranking residency programs. Although finding a mutually "good fit" between applicant and program will remain a major aim, these findings indicate the importance of certain tangible, potentially modifiable factors that affect how medical students ultimately perceive and rank plastic surgery programs.

Addressing the Opioid Epidemic: A Review of the Role of Plastic Surgery.

The opioid epidemic has been a growing public health threat in the United States and Canada for the past 30 years, with alarming and steadily increasing opioid-related mortality rates. Originating with well-intentioned efforts by physicians to relieve pain and suffering in their patients, the source of the opioid epidemic and much of its ammunition continues to be the sales of legally produced pharmaceutical opioids. Although surgeons are increasingly recognizing the important role they can play in mitigating this crisis, the recognition and evaluation of the opioid epidemic in plastic surgery has been lacking. The authors identified several aspects of plastic surgery that make judicious prescription of opioids in this field uniquely complex, including high variability of cases managed, large volume of ambulatory procedures, and frequent involvement in collaborative care with other surgical specialties. Additional research in plastic surgery is needed to both increase current knowledge of opioid prescribing practices and provide evidence for recommendations that can successfully combat the opioid epidemic.

Exposure to plastic surgery during undergraduate medical training: A single-institution review.

BACKGROUND: Applications to surgical residency programs have declined over the past decade. Even highly competitive programs, such as plastic surgery, have begun to witness these effects. Studies have shown that early surgical exposure has a positive influence on career selection. OBJECTIVE: To review plastic surgery application trends across Canada, and to further investigate medical student exposure to plastic surgery. METHODS: To examine plastic surgery application trends, national data from the Canadian Resident Matching Service database were analyzed, comparing 2002 to 2007 with 2008 to 2013. To evaluate plastic surgery exposure, a survey of all undergraduate medical students at the University of Toronto (Toronto, Ontario) during the 2012/2013 academic year was conducted. RESULTS: Comparing 2002 to 2007 and 2008 to 2013, the average number of national plastic surgery training positions nearly doubled, while first-choice applicants decreased by 15.3%. The majority of Canadian academic institutions experienced a decrease in first-choice applicants; 84.7% of survey respondents indicated they had no exposure to plastic surgery during their medical education. Furthermore, 89.7% believed their education had not provided a basic understanding of issues commonly managed by plastic surgeons. The majority of students indicated they receive significantly less plastic surgery teaching than all other surgical subspecialties. More than 44% of students not considering plastic surgery as a career indicated they may be more likely to with increased exposure. CONCLUSION: If there is a desire to grow the specialty through future generations, recruiting tactics to foster greater interest in plastic surgery must be altered. The present study suggests increased and earlier exposure for medical students is a potential solution.

HISTORIQUE: Les candidatures aux programmes de résidence en chirurgie ont diminué depuis dix ans. Même les programmes hautement compétitifs, comme la chirurgie plastique, ont commencé à en ressentir les effets. Les études ont démontré que l'exposition rapide à la chirurgie a une influence positive sur le choix de carrière. OBJECTIF: Examiner les tendances de candidature en chirurgie plastique au Canada, de même que l'exposition des étudiants en médecine générale à la chirurgie plastique. MÉTHODOLOGIE: Pour examiner les tendances de candidature en chirurgie plastique, les chercheurs ont analysé les données nationales tirées de la base de données du Service canadien de jumelage des résidents en comparant les données de 2002 à 2007 à celles de 2008 à 2013. Pour évaluer l'exposition à la chirurgie plastique, ils ont sondé tous les étudiants en médecine de premier cycle à l'université de Toronto, en Ontario, pendant l'année universitaire 2012­2013. RÉSULTATS: Si on compare 2002 à 2007 et 2008 à 2013, le nombre moyen de postes nationaux de formation en chirurgie plastique a pratiquement doublé, tandis que le taux de candidats qui en font leur premier choix a diminué de 15,3 %. La majorité des établissements universitaires canadiens ont observé une diminution des candidats qui en font leur premier choix. Ainsi, 84,7 % des répondants au sondage ont indiqué qu'ils n'avaient pas été exposés à la chirurgie plastique pendant leur formation en médecine. De plus, 89,7 % trouvaient que leur formation ne leur permettait pas de comprendre les problèmes de base que gèrent régulièrement les plasticiens. La majorité des étudiants ont indiqué recevoir beaucoup moins d'enseignement en chirurgie plastique que dans toutes les autres surspécialités chirurgicales. Plus de 44 % des étudiants qui n'envisageaient pas faire carrière en chirurgie plastique ont indiqué qu'ils l'envisageraient peut-être davantage s'ils y étaient plus exposés. CONCLUSION: Si on veut faire croître la spécialité au sein des prochaines générations, il faudra modifier les tactiques de recrutement pour stimuler l'intérêt envers la chirurgie plastique. D'après la présente étude, l'exposition accrue et plus rapide des étudiants en médecine pourrait faire partie des solutions.

Supply versus demand: a review of application trends to Canadian surgical training programs.

Despite increases in medical school enrolment, applications to surgical residency programs in Canada have been in decline over the past decade, with an increasing number of unmatched surgical residency positions. We examined the current status of surgical residency in Canada and analyzed application trends (2002­2013) for surgical training programs across Canada. Our findings suggest that most undergraduate medical schools across Canada are having difficulty fostering interest in surgical careers. We propose that a lack of adequate early exposure to the surgical specialties during undergraduate training is a critical factor. Moving forward, we must examine how the best-performing institutions and surgical programs have maintained interest in pursuing surgical careers and adapt our recruitment methods to both maintain and grow future interest. As Mary Engelbreit said, "If you don't like something, change it; if you can't change it, change the way you think about it."

Visual-spatial ability and fMRI cortical activation in surgery residents.

BACKGROUND: We previously reported that a particular type of visual-spatial ability, mental rotation of visual forms, correlates with surgical performance in residents. In the current study, we used functional magnetic resonance imaging (fMRI) to identify patterns of cortical activation associated with mental rotation ability in those same residents. METHODS: Seventeen surgery residents underwent fMRI scan while performing a mental rotations test (MRT) and a perceptual matching task as a control (CON) for nonimagery components, such as visual attention. A contrast analysis (MRT greater than CON) revealed cortical regions engaged during mental rotation by all participants, and parametric statistical analysis identified regions having the strongest association with MRT performance. RESULTS: Significant bilateral (left greater than right) activation was seen in all participants for rotation-versus-perceptual CON contrast. Better MRT performance was associated with greater activation in several cortical regions related to visual imagery and motion processing. COMMENTS: Surgery residents represent a unique population in which to study individual differences in visual-spatial abilities and associated neural substrates because they may relate to technical skills. These findings suggest that variation in performance on spatially complex tasks involving imagery may reflect different spatial problem-solving strategies in surgery students.

The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures.

OBJECTIVE: To evaluate the impact of bench model fidelity on the acquisition of technical skill using clinically relevant outcome measures. METHODS: Fifty junior surgery residents participated in a 1-day microsurgical training course. Participants were randomized to 1 of 3 groups: 1) high-fidelity model training (live rat vas deferens; n = 21); 2) low-fidelity model training (silicone tubing; n = 19); or 3) didactic training alone (n = 10). Following training, all participants were assessed on the high- and low-fidelity bench models. Immediate outcome measures included procedure times, blinded, expert assessment of videotaped performance using checklists and global rating scales, anastomotic patency, suture placement precision, and final product ratings. Delayed outcome measures (obtained from the live rat vas deferens 30 days following training) included anastomotic patency, presence of a sperm granuloma, and the presence of sperm on microscopy. RESULTS: Following training, checklist (P < 0.001) and global rating scores (P < 0.001) on the bench model simulators were higher among subjects who received hands-on training, irrespective of model fidelity. Immediate anastomotic patency rates of the rat vas deferens were higher with increasing model fidelity training (P = 0.048). Delayed anastomotic patency rates were higher among subjects who received bench model training, irrespective of model fidelity (P = 0.02). Rates of sperm presence on microscopy were higher among subjects who received high-fidelity model training compared with subjects who received didactic training (P = 0.039) but did not differ among subjects in the high- and low-fidelity groups. CONCLUSIONS: Surgical skills training on low-fidelity bench models appears to be as effective as high-fidelity model training for the acquisition of technical skill among novice surgeons.

Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill.

PURPOSE: We evaluated the durability of laboratory based technical skills training in urological microsurgery using bench model simulators. METHODS AND MATERIALS: A total of 50 junior surgery residents (post-graduate years 1 to 3) were recruited to participate in a focused training program in urological microsurgery. Prior to training subjects were randomized to receive hands-on training with bench model simulators (silicone tubing or live rat vas deferens, 40) or didactic training alone (10). Four months following the original training program the technical performance of 18 returning subjects (13 from the bench model and 5 from the didactic training group) was reevaluated using a high fidelity, live animal model (vasovasostomy and rat vas deferens). Outcome measures included blinded, expert assessment of videotaped performance using checklists and global rating scores, and evaluation of anastomotic patency. RESULTS: The retention test checklist (p <0.001), global rating scores (p <0.001) and anastomotic patency rates (p = 0.05) in the live animal model remained significantly higher for subjects who originally received hands-on bench model training compared with those who received didactic training alone. The number of interim practice opportunities with microsurgery correlated significantly with expert global ratings of surgical performance irrespective of the nature of training (r = 0.54, p = 0.02). CONCLUSIONS: Laboratory based technical skills training with bench models can lead to a significant retention of technical skill by novice surgeons. Measured performance improvements appear to be durable with time. However, the opportunity for repeat hands-on practice appears to maximize the retention of technical skill.

Visual-spatial ability correlates with efficiency of hand motion and successful surgical performance.

BACKGROUND: This study examines the influence of visual-spatial ability and manual dexterity on surgical performance across 3 levels of expertise. METHODS: Dental students, surgical residents, and staff surgeons completed standardized tests of manual dexterity and visual-spatial ability and were assessed objectively while performing the rigid fixation of an anterior mandible on bench model simulations. Outcome variables included expert assessment of technical performance and efficiency of hand motion during the procedure (recorded using electromagnetic sensors). RESULTS: Visual-spatial scores correlated significantly with surgical performance scores within the group of dental students (r=.40 to.73), but this was not the case for residents or staff surgeons. For all groups, manual dexterity did not correlate with hand motion parameters. There were no differences between groups in visual-spatial ability or manual dexterity, but highly significant differences were seen in surgical performance scores (P<.001), in that surgeons outperformed residents, who in turn outperformed students. CONCLUSIONS: Among novices, visual-spatial ability is associated with skilled performance on a spatially complex surgical procedure. However, advanced trainees and experts do not score any higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time. Thus, the use of these tests for the selection of residents is not currently recommended; they may be of more use in identifying those novice trainees (ie, those with lower test scores) who might benefit most from brief supplementary instruction on specific technical tasks.

Residency training in plastic surgery: a survey of educational goals.

With the advent of integrative plastic surgical training programs, requirements for earlier specialization decisions, and an increasing subspecialization within the practice of plastic surgery, the educational goals of residency training may have changed. The duration and extent of training required are also currently being questioned. This study was performed to better understand the necessary roles of plastic surgery residencies and to determine how these demands might optimally be met. Of 151 practicing plastic surgeons in the Ontario, Canada, region, 81 (53.6 percent) responded to a survey. General agreement was that 2 years was an optimal length of time for core surgical training, which should then be followed by at least 3 years of plastic surgical training. Opinions on the ideal length of time training in specific medical and surgical disciplines are discussed. Overall, respondents thought that two thirds of training should occur in tertiary care centers, with the remaining time spent at smaller community centers and private clinics. Nearly half of respondents thought that research training should be a mandatory part of the residency, although the amount of protected time for this activity varied substantially. Most thought that unrestricted elective time should also be available. Academic plastic surgeons rated the importance of research training (p < 0.01), critical appraisal skills (p < 0.05), and teaching skills (p < 0.05) as significantly more important than did their nonacademic colleagues. The authors present results from the Ontario region and a template for determining optimal characteristics for training programs. Further investigation may be of timely importance during a foreseeable future transition from traditional to integrative plastic surgery residency training.

Validation of novel and objective measures of microsurgical skill: Hand-motion analysis and stereoscopic visual acuity.

Our purposes were: 1) to establish the predictive validity of stereoscopic visual acuity and microsurgical performance, and 2) to establish the construct and concurrent validity of hand-motion analysis as an objective and sensitive measure of microsurgical performance. Using a surgical microscope, 50 surgical residents completed a standardized microsurgical suturing task at baseline and following microsurgical training. Microsurgical performance was evaluated by blinded, expert microsurgeons using global rating scales. Measures of stereoscopic visual acuity and hand-motion analysis were correlated with expert global rating scores. Global rating scores correlated significantly with number of hand movements (r = -0.47, P = 0.001) and hand-travel distance (r = -0.37, P = 0.008). Economy of hand-motion improved significantly following microsurgical training (number of hand movements, P = 0.046; hand-travel distance, P = 0.04). Measures of stereoscopic visual acuity did not correlate significantly with global rating scores. Hand-motion analysis appears to be an objective and sensitive instrument for assessing microsurgical performance, with evidence of both concurrent and construct validity. The predictive validity of stereoscopic visual acuity and microsurgical performance remains unclear.

Evaluating the effectiveness of a 2-year curriculum in a surgical skills center.

BACKGROUND: This study was a formative evaluation of a 2-year Surgical Skills Center Curriculum (SSCC) using objective measures of surgical performance and self-reported process-oriented evaluations. METHODS: Fifty postgraduate third-year (PGY-3) residents participated in an Objective Structured Assessment of Technical Skills (OSATS) examination. Nineteen residents underwent the SSCC and 31 residents did not. During the SSCC, self-reported student and faculty evaluations were completed after each session. RESULTS: For the OSATS examination, scores were not significantly different between treatment and control groups, on either the checklist (66.4 +/- 6.1 versus 64.1 +/- 10.8) or global rating scale scores (66.9 +/- 6.9 versus 68.0 +/- 9.6). Further comparisons between groups on individual OSATS stations revealed no significant differences between groups. The majority of student and faculty evaluation remarks were highly positive. CONCLUSIONS: The OSATS results failed to support our hypothesis that training on a core procedure in a single session during a SSCC would have an appreciable and sustained effect after 2 years. Self-reported process-oriented evaluations support the utility of our SSCC.

Reconstructive breast surgery: referring physician knowledge and learning needs.

Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.

Teaching technical skills: training on a simple, inexpensive, and portable model.

The purpose of this study was to determine whether surgical residents could significantly improve their performance on a specific surgical procedure after a brief practice session with feedback. Attending plastic surgeons, using valid and reliable checklists and global rating scales, objectively assessed 37 junior surgical residents while performing two-flap Z-plasties on pig thighs (one before and one after a one-on-one, 5-minute practice session with feedback). The total cost per resident was $1.00 (Canadian currency). After the practice session, total checklist scores improved from 7.3 (range, 1 to 9) to 7.9 (range, 5 to 9), and the total global rating scores improved from 29.1 (range, 13 to 41) to 31.9 (range, 19 to 43). Paired Student's t tests revealed significant improvement in both the mean total checklist scores (p < 0.05) and mean total global rating scores (p < 0.01). Also, the global rating score for appearance and quality of the final surgical product significantly improved from 2.7 to 3.3 after the practice session (p < 0.01). There were no significant differences in performance scores between men and women, between first-year and second-year residents, with residents' previous experience with the Z-plasty procedure, or with resident's base surgical specialties. The results of this prospective study indicate that training on a simple and portable model with very brief individualized practice and feedback is an effective and inexpensive way of improving resident performance. A 5-minute practice session with a surgical trainee before performing a procedure on a living patient may significantly improve the patient's surgical performance and produce a superior result.

Effect of visual-spatial ability on learning of spatially-complex surgical skills.

Visual-spatial ability is thought to be important in competency in specific surgical procedures. To test this hypothesis, 37 surgical residents completed six tests of visual-spatial ability, ranging from low-level to high-level visual processing. Using previously validated and objective instruments, we then assessed their ability to complete and learn a spatially-complex surgical procedure. Residents with higher visual-spatial scores in the form-board test and the mental-rotations test did significantly better in the procedure than did those with lower scores. After practice and feedback, residents with lower scores achieved a comparable level of competency. Our results suggest that visual-spatial ability is related to competency and quality of results in complex surgery, and could potentially be used in resident selection, career counselling, and training.