Measuring the surgical 'learning curve': methods, variables and competency.

OBJECTIVES: To describe how learning curves are measured and what procedural variables are used to establish a 'learning curve' (LC). To assess whether LCs are a valuable measure of competency. PATIENTS AND METHODS: A review of the surgical literature pertaining to LCs was conducted using the Medline and OVID databases. RESULTS: Variables should be fully defined and when possible, patient-specific variables should be used. Trainee's prior experience and level of supervision should be quantified; the case mix and complexity should ideally be constant. Logistic regression may be used to control for confounding variables. Ideally, a learning plateau should reach a predefined/expert-derived competency level, which should be fully defined. When the group splitting method is used, smaller cohorts should be used in order to narrow the range of the LC. Simulation technology and competence-based objective assessments may be used in training and assessment in LC studies. CONCLUSIONS: Measuring the surgical LC has potential benefits for patient safety and surgical education. However, standardisation in the methods and variables used to measure LCs is required. Confounding variables, such as participant's prior experience, case mix, difficulty of procedures and level of supervision, should be controlled. Competency and expert performance should be fully defined.

Development and content validation of a surgical safety checklist for operating theatres that use robotic technology.

OBJECTIVES: To identify and assess potential hazards in robot-assisted urological surgery. To develop a comprehensive checklist to be used in operating theatres with robotic technology. METHODS: Healthcare Failure Mode and Effects Analysis (HFMEA), a risk assessment tool, was used in a urology operating theatre with innovative robotic technology in a UK teaching hospital between June and December 2011. A 15-member multidisciplinary team identified 'failure modes' through process mapping and flow diagrams. Potential hazards were rated according to severity and frequency and scored using a 'hazard score matrix'. All hazards scoring ≥8 were considered for 'decision tree' analysis, which produced a list of hazards to be included in a surgical safety checklist. RESULTS: Process mapping highlighted three main phases: the anaesthesia phase, the operating phase and the postoperative handover to recovery phase. A total of 51 failure modes were identified, 61% of which had a hazard score ≥8. A total of 22 hazards were finalised via decision tree analysis and were included in the checklist. The focus was on hazards specific to robotic urological procedures such as patient positioning (hazard score 12), port placement (hazard score 9) and robot docking/de-docking (hazard score 12). CONCLUSIONS: HFMEA identified hazards in an operating theatre with innovative robotic technologies which has led to the development of a surgical safety checklist. Further work will involve validation and implementation of the checklist.

The surgeon as educator: fundamentals of faculty training in surgical specialties.

OBJECTIVE: To explore faculty training in the field of surgical specialities with a focus on the educational aspect of faculty training. Teaching is an important commitment for academic surgeons alongside duties of patient care, research and continuing professional development. Educating surgical faculty in the skills of teaching is becoming increasingly important and the realisation that clinical expertise does not necessarily translate to teaching expertise has led to the notion that faculty members require formal training in teaching methods and educational theory to teach effectively. The aim of faculty training or development is to increase knowledge and skills in teaching, research and administration of faculty members. MATERIALS AND METHODS: A range of resources, e.g. journal articles, books and online literature was reviewed to investigate faculty development programmes in surgery. Various issues were addressed, e.g. the need for faculty development, evaluating the various types of training programmes and their outcomes, and exploring barriers to faculty training. Recommendations were provided based on the findings. RESULTS: There is increased recognition that faculty members require basic training in educational theory and teaching skills to teach effectively. Most faculty training programmes are workshops and short courses, which use participant satisfaction as an outcome measure. However, there is growing consensus that longer term interventions, e.g. seminar series, longitudinal programmes and fellowships, produce more sustainable change in learning, behaviour and organisational culture. Barriers to faculty development include lack of protected time, reward and recognition for teaching. CONCLUSION: Recommendations are made including better documentation of faculty training interventions within surgery, further investigation into the effectiveness of long- vs short-term interventions, improved methodology, and increased recognition and reward for educational accomplishments.

Introducing the productive operating theatre programme in urology theatre suites.

BACKGROUND: The Productive Operating Theatre (TPOT) is a theatre improvement programme designed by the UK National Health Service. The aim of this study was to evaluate the implementation of TPOT in urology operating theatres and identify obstacles to running an ideal operating list. METHOD: TPOT was introduced in two urology operating theatres in September 2010. A multidisciplinary team identified and audited obstacles to the running of an ideal operating list. A brief/debrief system was introduced and patient satisfaction was recorded via a structured questionnaire. The primary outcome measure was the effect of TPOT on start and overrun times. RESULTS: Start times: 39-41% increase in operating lists starting on time from September 2010 to June 2011, involving 1,365 cases. Overrun times: Declined by 832 min between March 2010 and March 2011. The cost of monthly overrun decreased from September 2010 to June 2011 by GBP 510-3,030. Patient experience: A high degree of satisfaction regarding level of care (77%), staff hygiene (71%) and information provided (72%), while negative comments regarding staff shortages and environment/facilities were recorded. CONCLUSIONS: TPOT has helped identify key obstacles and shown improvements in efficiency measures such as start/overrun times.

Assessing the cost effectiveness of robotics in urological surgery - a systematic review.

OBJECTIVES: Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery. These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes. METHODS: A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study. RESULTS: Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1-1.76 days and 1-5.5 days, respectively) and blood loss (range 482-780 mL and 227-234 mL, respectively) when compared with the open approach (range 2-8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000-$39,215) than both laparoscopic (range US $740-$29,771) and open radical prostatectomy (range US $1870-$31,518). This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1-1.5 days) and length of surgery (range 102-360 min) are unable to compensate for the excess costs. Robotic surgery may require a smaller learning curve (20-40 cases) although the evidence is inconclusive. CONCLUSIONS: Robotic surgery provides similar postoperative outcomes to laparoscopic surgery but a reduced learning curve. Although costs are currently high, increased competition from manufacturers and wider dissemination of the technology could drive down costs. Further trials are needed to evaluate long term outcomes in order to evaluate fully the value of all three procedures in urological surgery.

Keep calm and carry on learning: using Microsoft Teams to deliver a medical education programme during the COVID-19 pandemic.

The outbreak of COVID-19 in the UK in March 2020 required a radical remodelling of the medical workforce at Royal Free London NHS Foundation Trust to prepare for the anticipated surge of hospital admissions. The provision of relevant teaching and training was immediately identified as a priority, particularly for staff due to work outside their regular medical specialty. Rather than deliver face-to-face teaching, doctors at the Trust utilised Microsoft Teams, an online communications and collaboration platform, to deliver a multi-disciplinary Trust-wide education programme responsive to the needs of surveyed medical staff. To date members of 18 departments across the Trust have delivered 51 virtual teaching sessions which have been viewed 3,814 times. During this pandemic the virtual education programme has facilitated rapid dissemination of new information and provided a platform for discussion and unity amongst colleagues with overwhelmingly positive feedback from both learners and teachers.

Learning curves for cardiothoracic and vascular surgical procedures--a systematic review.

OBJECTIVES: The aim of this systematic review is to evaluate the learning curve (LC) literature and identify the LC of cardiothoracic and vascular surgical procedures. SUMMARY AND BACKGROUND: The LC describes an observation that a learner's performance improves over time during acquisition of new motor skills. Measuring the LC of surgical procedures has important implications for surgical innovation, education, and patient safety. Numerous studies have investigated LCs of isolated operations in cardiothoracic and vascular surgeries, but a lack of uniformity in the methods and variables used to measure LCs has led to a lack of systematic reviews. METHODS: The MEDLINE®, EMBASE™, and PsycINFO® databases were systematically searched until July 2013. Articles describing LCs for cardiothoracic and vascular procedures were included. The type of procedure, statistical analysis, number of participants, procedure setting, level of participants, outcomes, and LCs were reviewed. RESULTS: A total of 48 studies investigated LCs in cardiothoracic and vascular surgeries. Based on operating time, the LC for coronary artery bypass surgery ranged between 15 and 100 cases; for endoscopic vessel harvesting and other cardiac vessel surgery between 7 and 35 cases; for valvular surgery, which included repair and replacement, between 20 and 135 cases; for video-assisted thoracoscopic surgery, between 15 and 35 cases; for vascular neurosurgical procedures between 100 and 500 cases, based on complications; for endovascular vessel repairs between 5 and 40 cases; and for ablation procedures between 25 and 60 cases. However there was a distinct lack of standardization in the variables/outcome measures used, case selection, prior experience, and supervision of participating surgeons and a range of statistical analyses to compute LCs was noted. CONCLUSION: LCs in cardiothoracic and vascular procedures are hugely variable depending on the procedure type, outcome measures, level of prior experience, and methods/statistics used. Uniformity in methods, variables, and statistical analysis is needed to derive meaningful comparisons of LCs. Acknowledgment and application of learning processes other than those reliant on volume-outcomes relationship will benefit LC research and training of surgeons.