Application of practice-based learning and improvement in standardized training of general practitioners.

BACKGROUND: In the context of standardized training for general practitioners, the emphasis is still primarily on clinical skills, which does not fully encompass the overall development of general practitioners. This study implemented a practice-based learning and improvement (PBLI) project among students and evaluated its effectiveness based on indicators such as learning outcomes, students' subjective experiences, and annual grades. This study offers recommendations for optimizing general practitioners' teaching and residential training programs. METHODS: 60 residents who participated in the regular training of general practitioners at the First Clinical College of Tongji Medical College of Huazhong University of Science and Technology from January 2019 to January 2022 were selected for this study. They were randomly divided into two groups, the PBLI group, and the control group, using a random number table method. Out of the 60 residents, 31 were assigned to the control group and 29 were assigned to the PBLI group. The participants in the PBLI group received additional PBLI training along with their daily residential training, while the participants in the control group only took part in the latter. The effectiveness of the PBLI program was analyzed by conducting a baseline survey, administering questionnaires, and evaluating examination results. RESULTS: After implementing the program, the PBLI group scored significantly higher than the control group (p < 0.05). Throughout the implementation process, students in the PBLI group expressed high satisfaction with the learning project, particularly with its content and alignment with the training objective. The teacher's evaluation of the PBLI group students surpassed that of the control group in various areas, including literature retrieval, self-study, courseware development, speech ability, and clinical thinking. CONCLUSIONS: The PBLI program aims to encourage resident-centered study in standardized residency training. This approach is beneficial because it motivates students to engage in active learning and self-reflection, ultimately enhancing the effectiveness of standardized residency training.

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair.

INTRODUCTION: Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. METHODS: A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. RESULTS: Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. CONCLUSIONS: This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

Practice-Based Learning and Improvement: Improving Morbidity and Mortality Review Using Natural Language Processing.

INTRODUCTION: Practice-Based Learning and Improvement, a core competency identified by the Accreditation Council for Graduate Medical Education, carries importance throughout a physician's career. Practice-Based Learning and Improvement is cultivated by a critical review of complications, yet methods to accurately identify complications are inadequate. Machine-learning algorithms show promise in improving identification of complications. We compare a manual-supplemented natural language processing (ms-NLP) methodology against a validated electronic morbidity and mortality (MM) database, the Morbidity and Mortality Adverse Event Reporting System (MARS) to understand the utility of NLP in MM review. METHODS: The number and severity of complications were compared between MARS and ms-NLP of surgical hospitalization discharge summaries among three academic medical centers. Clavien-Dindo (CD) scores were assigned to cases with identified complications and classified into minor (CD I-II) or major (CD III-IV) harm. RESULTS: Of 7774 admissions, 987 cases were identified to have 1659 complications by MARS and 1296 by ms-NLP. MARS identified 611 (62%) cases, whereas ms-NLP identified 670 (68%) cases. Less than one-third of cases (299, 30.3%) were detected by both methods. MARS identified a greater number of complications with major harm (457, 46.30%) than did ms-NLP (P < 0.0001). CONCLUSIONS: Both a prospectively maintained MM database and ms-NLP review of discharge summaries fail to identify a significant proportion of postoperative complications and overlap 1/3 of the time. ms-NLP more frequently identifies cases with minor complications, whereas prospective voluntary reporting more frequently identifies major complications. The educational benefit of reporting and analysis of complication data may be supplemented by ms-NLP but not replaced by it at this time.

Video-based coaching for surgical residents: a systematic review and meta-analysis.

BACKGROUND: Video-based coaching (VBC) is used to supplement current teaching methods in surgical education and may be useful in competency-based frameworks. Whether VBC can effectively improve surgical skill in surgical residents has yet to be fully elucidated. The objective of this study is to compare surgical residents receiving and not receiving VBC in terms of technical surgical skill. METHODS: The following databases were searched from database inception to October 2021: Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. Articles were included if they were randomized controlled trials (RCTs) comparing surgical residents receiving and not receiving VBC. The primary outcome, as defined prior to data collection, was change in objective measures of technical surgical skill following implementation of either VBC or control. A pairwise meta-analyses using inverse variance random effects was performed. Standardized mean differences (SMD) were used as the primary outcome measure to account for differences in objective surgical skill evaluation tools. RESULTS: From 2734 citations, 11 RCTs with 157 residents receiving VBC and 141 residents receiving standard surgical teaching without VBC were included. There was no significant difference in post-coaching scores on objective surgical skill evaluation tools between groups (SMD 0.53, 95% CI 0.00 to 1.01, p = 0.05, I2 = 74%). The improvement in scores pre- and post-intervention was significantly greater in residents receiving VBC compared to those not receiving VBC (SMD 1.62, 95% CI 0.62 to 2.63, p = 0.002, I2 = 85%). These results were unchanged with leave-one-out sensitivity analysis and subgroup analysis according to operative setting. CONCLUSION: VBC can improve objective surgical skills in surgical residents of various levels. The benefit may be most substantial for trainees with lower baseline levels of objective skill. Further studies are required to determine the impact of VBC on competency-based frameworks.

Defining activities in neurovascular microsurgery training: entrustable professional activities for vascular neurosurgery.

BACKGROUND: Entrustable professional activities (EPAs) represent an assessment framework with an increased focus on competency-based assessment. Originally developed and adopted for undergraduate medical education, concerns over resident ability to practice effectively after graduation have led to its implementation in residency training but yet not in vascular neurosurgery. Subjective assessment of resident or fellow performance can be problematic, and thus, we aim to define core EPAs for neurosurgical vascular training. METHODS: We used a nominal group technique in a multistep interaction between a team of experienced neurovascular specialists and a medical educator to identify relevant EPAs. Panel members provided feedback on the EPAs until they reached consent. RESULTS: The process produced seven core procedural EPAs for vascular residency and fellowship training, non-complex aneurysm surgery, complex aneurysm surgery, bypass surgery, arteriovenous malformation resection, spinal dural fistula surgery, perioperative management, and clinical decision-making. CONCLUSION: These seven EPAs for vascular neurosurgical training may support and guide the neurosurgical society in the development and implementation of EPAs as an evaluation tool and incorporate entrustment decisions in their training programs.

VR-haptic and phantom head dental training: Does the order matter? A comparative study from a preclinical fixed prostho-dontics course.

Learning tooth preparation techniques and the finesse required is an important part of preclinical dental education. Being able to practice surgical skills without loss of Frasaco® teeth while being provided with performance analysis data is a boon to students and educators. We investigated the combination of haptics-enhanced virtual reality (Simodont®) and conventional phantom head practice in a preclinical dental course, evaluating the students' performances and perceptions. Forty students were randomized into two groups: Group One began within a VR-haptic setting while Group Two worked with Frasaco® teeth. Halfway through the course the scenarios were switched. A crown preparation test on Frasaco® teeth was conducted at the end of the course. Students' performances and satisfaction were assessed anonymously. Analysis of the students' performances included clinical metrics (occlusal and axial reduction, convergence angle, damage to adjacent teeth). The perceived usefulness of VR-haptic and phantom head simulations was assessed. In Group One, the tooth preparation metrics were more in line with the requested parameters compared to Group Two. All students ranked VR-haptics highly regarding manual dexterity improvement. In conclusion, this study shows that by combining VR-haptics with conventional dental procedures, it is possible to improve important preparation metrics in fixed prosthodontics tooth preparation.

Practical strategies to enhance resident engagement in clinical quality improvement.

BACKGROUND: Engaging residents in meaningful quality improvement (QI) is difficult. Challenges include competing demands, didactics which lack connection to meaningful work, suboptimal experiential learning, unclear accountability, absence of timely and relevant data, and lack of faculty coaches and role models. Various strategies to address these challenges for engagement have been described, but not as a unified approach. This paper describes a bundle of practical strategies to address common challenges to resident engagement in QI, illustrated through the experience of one residency education program. METHODS: 62 categorical residents in the University of Missouri Internal Medicine residency participated in a longitudinal QI curriculum integrated into residency clinic assignments with dedicated QI work sessions and brief just-in-time didactics with mentorship from faculty coaches. Residents completed at least two PDSA (Plan-Do-Study-Act) cycles for their projects. The experience included clear expectations and tools for accountability. Project criteria included importance to patients, residents, and the institution. Residents had access to data related to their own practice. A pre-post survey asked residents to self-assess their level of interest and engagement in QI on a 5-point Likert scale, with 1 = least desired and 5 = most desired result. Data were analyzed by paired t-test. RESULTS: All 62 residents participated in the program as members of ten QI teams. 40/62 residents completed both pre- and post-surveys. Items related to self-assessment of QI in clinical work all changed in the desired direction: likelihood of participation (3.7 to 4.1, p = 0.03), frequency of QI use (3.3 to 3.9, p = 0.001), and opinion about using QI in clinical work (3.9 to 4.0, p = 0.21). Resident assessment of QI priority in clinical work did not change. CONCLUSIONS: We implemented a practical strategies bundle to overcome common challenges to successfully engaging residents in clinical quality improvement. These strategies included QI work integrated into routine clinical assignments, just-in-time didactics, experiential learning with clear expectations and strategic project selection, timely and pertinent data from the residents' own practice, and real-time faculty coaching.

Feasibility and Perceived Usefulness of Using Head-Mounted Cameras for Resident Video Portfolios.

BACKGROUND: There is limited guidance on how to longitudinally administer simulation materials or to incorporate video recordings into assessment portfolios of simulated surgical skills. MATERIALS AND METHODS: We launched a longitudinal weekly simulation curriculum for PGY1-PGY3 surgical residents based on the ACS/APDS Curriculum. Residents underwent monthly objective structured assessment of technical skills (OSATS) while wearing head-mounted cameras. Videos of OSATS performance accrued into individual online video portfolios. Residents were surveyed about their attitudes toward video recording. RESULTS: Twenty-seven general surgical residents participated, completing 161 OSATS encompassing 11 distinct skills and generating 258 videos of simulated skills performance. The overall survey response rate was 88%. Residents viewed the curriculum favorably overall, and 36.4% of residents accessed their videos. Of those who did not watch their videos, 78.6% cited not having enough time, whereas 28.6% did not think the videos would be useful. Over 95% of surveyed residents expressed interest in having a video library of attending-performed procedures, 59.1% were interested in having their own operations recorded, and 45.5% were interested in video-based coaching. CONCLUSIONS: Residents viewed longitudinal administration of the ACS/APDS Curriculum positively. Although video recording in simulation is feasible, resident interest may be higher for intraoperative recordings than for simulated skills.

Improving Practice Guideline Adherence Through Peer Feedback: Impact of an Ambulatory Cardiology Curriculum.

PROBLEM: Graduate medical trainees must be prepared to practice in a quality-driven system that values adherence to and documentation of evidence-based care. Few validated approaches exist to teach these skills. Our objective was to develop, implement, and evaluate an ambulatory practice improvement curriculum capitalizing on peer feedback aimed at improving cardiology fellow guideline knowledge, adherence, and chart documentation. INTERVENTION: Four outpatient topics were reviewed in dedicated 1-hour sessions: stable ischemic heart disease, heart failure, atrial fibrillation, and aortic valvular disease. Each session began with peer review, critique, and guideline adherence discussion of deidentified outpatient fellow clinic charts, followed by discussion of clinical guidelines. The open discussion of real clinic notes provided a forum for peer feedback exchange. Before each session and after the final session, participants completed a multiple-choice knowledge assessment and self-assessment of comfort with the guidelines. To evaluate the potential effect on patient care, random clinic chart audits were conducted before and after the curriculum using a chart scoring system. CONTEXT: Although the format is broadly applicable, the specific curriculum content was designed for a cardiology fellowship cohort in a large academic medical center. It was organized and implemented by 2 cardiology fellows under the direction and supervision of program directors. The curriculum was implemented during prescheduled noon conference hours. The intention was to carry forward this ambulatory curriculum in subsequent years and to use the first 4 sessions to study its potential successes and opportunities for improvement. OUTCOME: All 22 general cardiology fellows attended at least two sessions (M = 3.1). Knowledge test scores rose from 52.6% to 73.0% (20.4% increase, p < .001), 95% confidence interval (CI) [13.6%, 27.2%]. Self-reported guidelines knowledge improved by 15.1% (p = .002), 95% CI [6.2%, 24.0%], and self-reported documentation improved by 12.5% (p = .008), 95% CI [3.8%, 21.7%]. Chart audit scores improved by 17.8% (p < .001), 95% CI [10.6%, 25.0%], driven in part by 16.4% improvement in adherence to Class I therapies (p = .001). LESSONS LEARNED: A targeted curriculum combining peer chart review, feedback, and guideline discussion was associated with significant improvement in fellows' knowledge and adherence to evidence-based therapies. Peer assessment and group-based education and feedback can be leveraged to improve trainee education and impact patient care.

Development of a Tool to Assess Surgical Resident Competence On-Call: The Western University Call Assessment Tool (WUCAT).

BACKGROUND: A central tenet of competency-based medical education is the formative assessment of trainees. There are currently no assessments designed to examine resident competence on-call, despite the on-call period being a significant component of residency, characterized by less direct supervision compared to daytime. The purpose of this study was to design a formative on-call assessment tool and collect valid evidence on its application. METHODS: Nominal group technique was used to identify critical elements of surgical resident competence on-call to inform tool development. The tool was piloted over six months in the Division of Plastic & Reconstructive Surgery at our institution. Quantitative and qualitative evidence was collected to examine tool validity. RESULTS: A ten-item tool was developed based on the consensus group results. Sixty-three assessments were completed by seven staff members on ten residents during the pilot. The tool had a reliability coefficient of 0.67 based on a generalizability study and internal item consistency was 0.92. Scores were significantly associated with years of training. We found the tool improved the quantity and structure of feedback given and that the tool was considered feasible and acceptable by both residents and staff members. CONCLUSIONS: The Western University Call Assessment Tool (WUCAT) has multiple sources of evidence supporting its use in assessing resident competence on-call.

Exploring the Experiences of Undergraduate Medical Students on Surgical Placement - A Qualitative Study.

OBJECTIVE: Multiple elements in the clinical learning environment have been found to influence medical students' learning experiences. A rich area of research, many factors are already known to influence students' experiences of learning which go on to impact later training choices. However, there is a knowledge gap specifically related to undergraduate medical students' experiences of surgical placement. This study aims to explore the lived experiences of medical students in their surgery rotation(s). DESIGN: A phenomenological study using semistructured interviews was conducted. Transcribed interview recordings were thematically analyzed using an iterative approach. SETTING: Participants were studying in a large medical school in the north of England. PARTICIPANTS: Fitting with the method, 6 undergraduate medical students, with at least 1 surgery placement took part in the study. RESULTS: Participants described issues including knowing the details of clinical opportunities, the clinical environment, and the portfolio; having a sense of involvement and previous surgical experiences; teaching and assessments; observation; and interactions. These experiences were also found to influence later career aspirations. CONCLUSIONS: The findings suggest that undergraduate surgical learning experiences can be influenced by various themes: knowing the details of progression, the clinical environment, having a sense of involvement and previous experiences, constructive alignment of teaching and assessment, and professional identity formation. Future studies can explore methods such as personalized learning outcomes to enhance the overall learning experience of medical students.

A Scoping Review of the Literature on Entrustable Professional Activities in Surgery Residency Programs.

OBJECTIVE: Entrustable professional activities (EPAs) are a crucial component of contemporary postgraduate medical education with many surgery residency programs having implemented EPAs as a competency assessment framework to assess and provide feedback on the performance of their residents. Despite broad implementation of EPAs, there is a paucity of evidence regarding the impact of EPAs on the learners and learning environments. A first step in improving understanding of the use and impact of EPAs is by mapping the rising number of EPA-related publications from the field of surgery. The primary objective of this scoping review is to examine the nature, extent, and range of articles on the development, implementation, and assessment of EPAs. The second objective is to identify the experiences and factors that influence EPA implementation and use in practice in surgical specialties. DESIGN: Scoping review. Four electronic databases (Medline, Embase, Education Source, and ERIC) were searched on January 20, 2022, and then again on July 19, 2023. A quasi-statistical content analysis was employed to quantify and draw meaning from the information related to the development, implementation, assessment, validity, reliability, and experiences with EPAs in the workplace. PARTICIPANTS: A total of 42 empirical and nonempirical articles were included. RESULTS: Four thematic categories describe the topic areas in included articles related to: 1) the development and refinement of EPAs, including the multiple steps taken to develop and refine unique EPAs for surgery residency programs; 2) the methods for implementing EPAs; 3) outcomes of EPA use in practice; 4) barriers, facilitators, and areas for improvement for the implementation and use of EPAs in surgical education. CONCLUSIONS: This scoping review highlights the key trends and gaps from the rapidly increasing number of publications on EPAs in surgery residency, from development to their use in the workplace. Existing EPA studies lack a theoretical and/or conceptual basis; future development and implementation studies should adopt implementation science frameworks to better structure and operationalize EPAs within surgery residency programs.

Development and Evaluation of a Multi-Institutional Virtual Urology Course for Medical Students.

OBJECTIVE: Urological education has been declining in medical schools, leaving many students without adequate exposure to the fundamentals of the field. We aimed to create a virtual urology course for medical students preparing for subinternships. DESIGN: We created a 4-week curriculum of case-based urology modules with sections on hematuria, bladder cancer, kidney stones, vesicoureteral reflux, prostate cancer, urinary incontinence, and erectile dysfunction. Students completed precourse and postcourse surveys assessing confidence in content knowledge and 4 educational competencies. Faculty completed postcourse surveys. Confidence was scored on a 5-point Likert scale (0-4). SETTING: We offered the course in May 2022 and May 2023. The course was fully virtual and was offered at medical schools across the United States. PARTICIPANTS: The course included 157 medical students from 60 institutions and 44 faculty instructors from 30 institutions. All instructors were urologists representing a range of urological subspecialties. RESULTS: Surveys were completed by 61/157 students (39%) and 33/44 faculty (75%). Median student confidence in content knowledge increased across all disease processes: hematuria (3 vs. 2), bladder cancer (3 vs. 1), kidney stones (3 vs. 2), vesicoureteral reflux (3 vs. 1), prostate cancer (3 vs. 1), urinary incontinence (3 vs. 2), and erectile dysfunction (3 vs. 2) (all p < 0.001). Median confidence scores also increased across all 4 educational competencies: patient evaluation (3 vs. 2), pathophysiology (3 vs. 2), literature appraisal (3 vs. 2), and patient counseling (3 vs. 1) (all p < 0.001). Confidence increases in all areas were maintained at 7-month follow-up. Most students (85%) and faculty (91%) rated the course "excellent" or "very good." CONCLUSIONS: A multi-institutional virtual urology course for medical students led to a durable increase in confidence pertaining to content knowledge and various educational competencies.

A patient follow-up intervention to improve medical decision making at an internal medicine residency program.

OBJECTIVES: Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH). METHODS: Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices. RESULTS: Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies. CONCLUSIONS: Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.

Are COVID-Era General Surgery Interns Starting Residency Behind on Basic Surgical Skills?

OBJECTIVE: To compare incoming general surgery interns' performance on a basic skills assessment before and after the COVID pandemic. DESIGN: A retrospective cohort study compared surgical skill performances of incoming general surgery interns. Each underwent an evidence-based standardized assessment (pretest) with 12-basic surgical knot tying and suturing tasks. A post-test was administered after a 3-month self-directed skills curriculum. Student's t-tests compared proficiency scores from pre-COVID vs. COVID-era general surgery interns before and after curriculum completion. p < 0.05 was significant. SETTING: Data was collected from surgical residents in an academic general surgery program in the United States. PARTICIPANTS: General surgery interns from 2017 to 2019 (pre-COVID) and 2021 to 2022 (COVID-era) were included. Interns with missing data or extreme outliers were excluded. A total of 100 interns in general surgery were included in the pretest cohort (59 pre-COVID, 41 COVID-era) and 101 interns were in the post-test cohort (66 pre-COVID, 35 COVID-era). RESULTS: COVID-era interns scored significantly lower on the pretest compared to pre-COVID interns (COVID-era 721.9+/-268.8 vs. pre-COVID 935.9+/- 228.0, p < 0.001). After the skills curriculum both cohorts improved their proficiency scores. However COVID-era interns still scored significantly lower (COVID-era 1255.0+/-166.3 vs. pre-COVID 1369.8+/-165.6, p = 0.001). CONCLUSIONS: This analysis objectively described deficits in fundamental surgical skills for incoming interns whose medical school education was disrupted by the COVID-19 pandemic. A targeted surgical skills curriculum partially remediated these deficiencies. However, many surgical interns may need additional intervention and potentially more time in order to fully develop their surgical skills and meet the competency requirements required for advancement.

3-D Printed Fracture Models Improve Resident Performance and Clinical Outcomes in Operative Fracture Management.

OBJECTIVE: To determine if preoperative examination of patient additive manufactured (AM) fracture models can be used to improve resident operative competency and patient outcomes. DESIGN: Prospective cohort study. Seventeen matched pairs of fracture fixation surgeries (for a total of 34 surgeries) were performed. Residents first performed a set of baseline surgeries (n = 17) without AM fracture models. The residents then performed a second set of surgeries randomly assigned to include an AM model (n = 11) or to omit it (n = 6). Following each surgery, the attending surgeon evaluated the resident using an Ottawa Surgical Competency Operating Room Evaluation (O-Score). The authors also recorded clinical outcomes including operative time, blood loss, fluoroscopy duration, and patient reported outcome measurement information system (PROMIS) scores of pain and function at 6 months. SETTING: Single-center academic level one trauma center. PARTICIPANTS: Twelve orthopaedic residents, between postgraduate year (PGY) 2 and 5, participated in this study. RESULTS: Residents significantly improved their O-Scores between the first and second surgery when they trained with AM models for the second surgery (p = 0.004, 2.43 ± 0.79 versus 3.73 ± 0.64). Similar improvements were not observed in the control group (p = 0.916, 2.69 ± 0.69 versus 2.77 ± 0.36). AM model training also significantly improved clinical outcomes, including surgery time (p = 0.006), fluoroscopy exposure time (p = 0.002), and patient reported functional outcomes (p = 0.0006). CONCLUSIONS: Conclusions: Training with AM fracture models improves the performance of orthopaedic surgery residents during fracture surgery.

Proactive Coaching in General Surgery Internship: Incorporating Well-being Practices into Resident Professional Life.

OBJECTIVE: Coaching can provide learners with space to reflect on their performance while ensuring well-being and encouraging professional achievement and personal satisfaction outside of traditional mentorship and teaching models. We hypothesized that a proactive coaching program for general surgery interns coupled with individualized learning plans would help build foundational skills necessary for residency success and facilitate the incorporation of well-being practices into resident professional life. Here, we present the development, implementation, and outcomes of a novel well-being coaching program for surgical interns. DESIGN AND SETTING: A well-being coaching program was developed and implemented from July 2020 through June 2021 at a single university-based surgical residency program. To assess impact of the coaching program, we designed a mixed-methods study incorporating end-of-program survey results as well as participant narratives from commitment-to-act statements for thematic content. PARTICIPANTS: All 32 general surgery interns participated in aspects of the coaching program. RESULTS: The end-of-program survey was completed by 19/32 (59%) interns and commitment-to-act statements were completed by 22/32 (69%). The majority (89%) of survey respondents "agreed" or "strongly agreed" that the longitudinal intern coaching program helped them reach goals they had set for themselves this academic year; 15/19 (79%) noted that the coaching experience was effective in promoting well-being practices in their life. Well-being and professional goals were identified as major themes in the end-of-the-year commitment-to-act statements. Statements specifically mentioned resources highlighted and skills taught in our coaching program such as mindfulness techniques, gratitude journals, and self-compassion strategies. CONCLUSIONS: Our study illustrates the effectiveness of a coaching pilot program on promoting well-being practices in a university-based general surgery internship and can be a roadmap with proven efficacy and measurable outcomes.

Validation of Use of Flipped Classroom for Surgery Core Clerkships.

BACKGROUND: The flipped classroom (FC) is an integrated learning paradigm that equips students with self-directed study materials before scheduled meeting times allowing for the deeper application of acquired knowledge with an instructor. There is limited data on the application of FC to clinical undergraduate medical education and particularly as it applies to a surgical clerkship. METHODS: This study is a four-year retrospective study that includes two cohorts of students who matriculated through two training paradigms, traditional classroom (TC) and FC. Information regarding the FC cohort was collected from June 2018 to July 2020 (N=166). A two-year matched historical cohort of students enrolled in the clerkship and taught with the TC paradigm from June 2016 to July 2018 was used for comparison (N=157). The primary aim of this study is to assess the National Board of Medical Examiners (NBME) surgery shelf performance when the FC model is utilized compared to the TC model. This study will validate a prior similar study that had a smaller cohort with different secondary endpoints. Therefore, the secondary aim of this study assesses how teaching style can affect other performance metrics of a rotation (such as clinical performance, quizzes, Objective Structured Clinical Examinations (OSCE), and practicums) and how time was utilized by faculty, staff, and students. RESULTS: There was no difference in overall NBME surgery shelf performance when comparing the FC to the traditional classroom teaching (68.94 vs 70.34, P= 0.1667). Likewise, there was no difference in quiz performance. The FC did allow instructors to spend more time in other clinical components of the curriculum leading to a significant difference in student practicum (84.2 vs 88.26, P = 0.0186) and OSCE grades (87.54 vs 90.58, P <0.0001). CONCLUSION: The surgery NBME shelf performance is not compromised by FC and therefore can be used as an alternative to traditional classroom setting for teaching medical knowledge to surgery clerkship students. In addition, the FC can improve time management for instructors allowing for improved teaching and development in other components of the surgery curriculum.

Development of an Automated Smartphone-Based Suture Evaluation System.

OBJECTIVE: Quantification of skill level in surgical training is necessary for effective skill development. In this study, we report the development of a smartphone application that automatically and objectively evaluates training in stitching goldfish scoop poi, a fragile material currently used for practice by young surgeons in Japan. METHODS: The application, named "e-Suture," enables the automatic evaluation of surgical technique quality by evaluating the gap between the mark printed on the poi and the insertion/extraction point of the needle (Accuracy), analyzing suture placement (Deflection), detecting tears in the poi material/tissue (Tears), and the time taken to perform the exercise (Time). The algorithm for scoring used a sigmoid function, and the coefficients were adjusted so that the scores of a sample of 20 cases ranged between 20 and 100 points. RESULTS: The e-Suture prototype was completed. The e-Suture-derived ranking for 20 poi after training was significantly correlated with the mean of the rankings evaluated by 9 experts (correlation coefficient: 0.728; p = 0.000). We also tested which items the experts rated as the most important. The overall ratings obtained from the experts correlated with the e-Suture accuracy scoring results with a correlation coefficient of 0.836 (p = 0.000) for Accuracy, 0.31 (p = 0.173) for Deflection, and 0.518 (p = 0.019) for Tear. CONCLUSION: The e-Suture application can easily and accurately quantify and evaluate the suturing skills of novie surgeons. Further studies should improve the accuracy of data to be analyzed by collecting more surgical data and applying it to other surgical techniques.

Take 10: A Resident Well-Being Initiative and Burnout Mitigation Strategy.

OBJECTIVE: Physician training is associated with stressors which contribute to burnout. Individual and institutional level strategies can be employed to address resident burnout; however, time is an often-reported barrier in initiating recommended well-being activities. We hypothesize that brief bursts of well-being activities that are conducive to a resident schedule can mitigate burnout. DESIGN: This is a prospective observational study following burnout after implementation of an institution-wide, well-being initiative called "Take 10." SETTING: In the present study, the "Take 10" initiative, meditating or exercising for a minimum of 10 minutes per day 3 times a week, was encouraged at Vanderbilt University Medical Center, a tertiary care center in Nashville, Tennessee. PARTICIPANTS: Following implementation of the initiative, 254 residents from surgical, procedural, and non-procedural specialties were invited to complete surveys assessing compliance with encouraged "Take 10" activities as well as rates of burnout over a 5-month period. A total of 201 surveys were completed during the study period. RESULTS: Overall, burnout rates were worse for females (Odds Ratio [OR] = 3.7 | Confidence Interval [CI] = 1.57, 9.05), better for those living with others (OR = 0.22 | CI = 0.07, 0.64), and better for those participating in "Take 10" initiatives (OR = 0.71 | CI = 0.58, 0.86). There was a significant difference in resident-reported burnout (Control = 85.3% vs Intervention = 58.2% | p < 0.01) and Resident Well-Being Index score (Control = 3.73 vs Intervention=2.93 | p < 0.01), when "Take 10" initiatives were employed. CONCLUSIONS: "Take 10" is a low cost and low intensity initiative for individuals and programs to use to mitigate burnout.