SAGE(S) advice: application of a standardized train the trainer model for faculty involved in a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) hands-on course.

INTRODUCTION: Currently, no prerequisite teaching qualification is required to serve as faculty for SAGES hands-on courses (SAGES-HOC). The Lapco-Train-the-Trainers (Lapco-TT) is a course for surgical trainers, in which delegates learn a standardized teaching technique for skills acquisition. The aims of this study were to 1) determine if this curriculum could be delivered in a day course to SAGES-HOC faculty and 2) assess the impact of such training on learners' educational experience taught by this faculty at a subsequent SAGES-HOC. METHODS AND PROCEDURES: Six experts attended a one-day Lapco-TT course. SAGES-HOC participants were split into two groups: Group A taught by Lapco-TT trained, and Group B by "untrained" course faculty. Opinion surveys were completed by both the SAGES-HOC learners and the Lapco-TT trained course faculty. Furthermore, the latter underwent self-, learner-, and observer-based evaluation using a previously validated teaching assessment tool (cSTTAR). Mean scores were reported and analyzed [Mann-Whitney U, t test (p < 0.05)]. RESULTS: All 6 Lapco-TT delegates found the course useful (5), and felt that it would influence the way they taught in the OR (4.83), that their course objectives were met (4.83), and that they would recommend the course to their colleagues (4.83). Of the SAGES-HOC participants, compared to Group B (n = 22), Group A learners(n = 10) better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]) and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), and that performance feedback was sufficient (5 vs. 3.9 [p = 0.028]) and effective (5 vs. 3.95 [p = 0.028]). Group A faculty were rated significantly higher by their learners on the cSTTARs than Group B (p < 0.0005). Group A faculty rated themselves significantly lower than both expert observers (p < 0.0005) and compared to the Group B faculty's self-assessment (p < 0.002). CONCLUSIONS: The Lapco-TT course can be delivered effectively over one day and impacts the educational experience of learners at a SAGES-HOC. This could help establish a standardized method of teaching at SAGES-HOCs and thereby increase their value for learners.

Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies.

BACKGROUND: Preparatory courses for senior medical students aim to ease the transition from medical school to residency. We designed a novel adjunct curriculum to enhance students' readiness for surgical internship. This study addresses the feasibility and outcomes of this course. MATERIALS AND METHODS: A curriculum was designed based on ACGME surgical milestones. Students participated in 8 (3h) sessions held over 4 weeks as an adjunct to a well-established intern preparatory course. Course activities involved interactive simulation cases to emphasize care of surgical patients, and skills sessions focused on knot tying and suturing, which were reinforced with home video assignments. Students rated confidence on 14 management skills using a 5-point Likert scale (5 = high confidence). Faculty graded students' technical performance using a global scale (0-10) for 5 suturing exercises. Comparisons between precourse and postcourse data collected for all measures were made using t-tests (α = 0.05). RESULTS: A total of 11 students entering 4 different surgical fields participated. Overall confidence in patient management improved from 2.41 to 3.89 (standard deviation = 0.49, 0.35; p < 0.05). Students' scores on all 5 suturing tasks increased (p < 0.05). CONCLUSIONS: We developed a surgery-specific component to the existing preparatory course at our institution. Students demonstrated increased confidence in ward management skills and increased technical scores in all exercises. Although only 3 sessions were dedicated to technical skills, improvements may highlight the benefit of home video assignments. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum highlights skills specific for surgical residency, while maximizing resources.

From novice to master surgeon: improving feedback with a descriptive approach to intraoperative assessment.

BACKGROUND: A developmental and descriptive approach to assessing trainee intraoperative performance was explored. METHODS: Semistructured interviews with 20 surgeon educators were recorded, transcribed, deidentified, and analyzed using a grounded theory approach to identify emergent themes. Two researchers independently coded the transcripts. Emergent themes were also compared to existing theories of skill acquisition. RESULTS: Surgeon educators characterized intraoperative surgical performance as an integrated practice of multiple skill categories and included anticipating, planning for contingencies, monitoring progress, self-efficacy, and "working knowledge." Comments concerning progression through stages, broadly characterized as "technician," "anatomist," "anticipator," "strategist," and "executive," formed a narrative about each stage of development. CONCLUSIONS: The developmental trajectory with narrative, descriptive profiles of surgeons working toward mastery provide a standardized vocabulary for communicating feedback, while fostering reflection on trainee progress. Viewing surgical performance as integrated practice rather than the conglomerate of isolated skills enhances authentic assessment.

Development and implementation of the Structured Training Trainer Assessment Report (STTAR) in the English National Training Programme for laparoscopic colorectal surgery.

BACKGROUND: There is a lack of educational tools available for surgical teaching critique, particularly for advanced laparoscopic surgery. The aim was to develop and implement a tool that assesses training quality and structures feedback for trainers in the English National Training Programme for laparoscopic colorectal surgery. METHODS: Semi-structured interviews were performed and analysed, and items were extracted. Through the Delphi process, essential items pertaining to desirable trainer characteristics, training structure and feedback were determined. An assessment tool (Structured Training Trainer Assessment Report-STTAR) was developed and tested for feasibility, acceptability and educational impact. RESULTS: Interview transcripts (29 surgical trainers, 10 trainees, four educationalists) were analysed, and item lists created and distributed for consensus opinion (11 trainers and seven trainees). The STTAR consisted of 64 factors, and its web-based version, the mini-STTAR, included 21 factors that were categorised into four groups (training structure, training behaviour, trainer attributes and role modelling) and structured around a training session timeline (beginning, middle and end). The STTAR (six trainers, 48 different assessments) demonstrated good internal consistency (α = 0.88) and inter-rater reliability (ICC = 0.75). The mini-STTAR demonstrated good inter-item reliability (α = 0.79) and intra-observer reliability on comparison of 85 different trainer/trainee combinations (r = 0.701, p = <0.001). Both were found to be feasible and acceptable. The educational report for trainers was found to be useful (4.4 out of 5). CONCLUSIONS: An assessment tool that evaluates training quality was developed and shown to be reliable, acceptable and of educational value. It has been successfully implemented into the English National Training Programme for laparoscopic colorectal surgery.

Design, delivery, and validation of a trainer curriculum for the national laparoscopic colorectal training program in England.

OBJECTIVE: To validate the delivery and efficacy of the national laparoscopic colorectal surgery "training the trainer" (Lapco TT) curriculum. BACKGROUND: The National Training Programme in Laparoscopic Colorectal Surgery designed the Lapco TT curriculum to improve, standardize, and benchmark the quality of training. Evidence for such courses rarely extends beyond subjective feedback. METHODS: The Lapco TT curriculum tailors key teaching skills for laparoscopic colorectal surgery: training structure, skills deconstruction, trainer intervention, and performance enhancing feedback. Ten Lapco TT courses were delivered to 65 national Lapco trainers since 2010. The course was validated at Kirkpatrick's 4 levels of evaluation: (i) pre- and post-course interviews reflecting initial reaction; (ii) training quality assessment on simulated scenarios using the Structured Training Trainer Assessment Report (STTAR) tool; (iii) follow-up interviews at 4 to 6 months; and (iv) delegate performance ratings, by their trainees, using the mini-STTAR and the delegates' trainees learning curves before and after the course. RESULTS: There were significant improvements in training in the post-course simulated scenario, especially in the "set" (P < 0.001). Delegates described improved framework and structure in their native training environment, which aided difficult training situations. Findings mirrored in performance ratings by their trainees: overall (4.37 vs 4.46, P = 0.040), agreed learning points (3.65 vs 4.00, P = 0.042), encouraged self-reflection (3.67 vs 3.94, P = 0.046), and encouraged team awareness (3.53 vs 4.05, P = 0.045). The learning curve of delegates' trainees improved after the course. CONCLUSIONS: The Lapco TT curriculum improved training performance in the short- and long-term, provided a structured training framework, and enhanced the learning curve of delegates' trainees.

Is competency assessment at the specialist level achievable? A study for the national training programme in laparoscopic colorectal surgery in England.

OBJECTIVES: To develop, validate, and implement a competency assessment tool (CAT) for technical surgical performance in the context of a summative assessment process for the National Training Programme in Laparoscopic Colorectal Surgery (NTP). BACKGROUND: The NTP is an educational initiative by the National Cancer Action Team in England to safely increase the uptake of laparoscopic colorectal surgery. It is the first competency-based national educational initiative for specialist surgeons (consultants), and performance assessment is an integral part of the program. METHODS: Content validity was sought using expert opinion by semistructured interviews and the Delphi method. For validity and reliability studies, NTP apprentices and experts were asked to submit video-recorded cases. Construct validity was established between delegates who passed the assessment and those who failed. Concurrent validity was tested by comparing scores with error counts as identified by observational clinical human reliability analysis. A fully crossed design, using generalizability theory methods and D-studies, was used for reliability. FINDINGS: Interviews and the Delphi method revealed a list of characteristics for assessment. A hybrid structure combining task-specific and generic items was used to include important characteristics into the assessment format. Fifty-four cases were submitted. Overall reliability reached G(ACI) = 0.803 when using 2 cases and 2 assessors. Experts scored significantly better than apprentices (3.19 vs 2.60; P = 0.004), and apprentices who passed had better scores than those who failed (2.95 vs 2.28; P < 0.001). There was an inverse correlation between CAT scores and observational clinical human reliability analysis error counts (ρ = -0.520, P < 0.001). The combination of both methods reached overall sensitivity of 100%, specificity of 83.3%, a positive predictive value of 93.8%, and a negative predictive value of 100%. CONCLUSIONS: The CAT can reliably assess technical performance in laparoscopic colorectal surgery. The use of CATs to judge specialist technical performance before embarking on independent practice of new procedures is achievable on a national scale and can be adapted by other specialties.

Learning curve and case selection in laparoscopic colorectal surgery: systematic review and international multicenter analysis of 4852 cases.

BACKGROUND: The learning curve for laparoscopic colorectal surgery has not been conclusively analyzed. No reliable framework for case selection during training is available. OBJECTIVE: The aim of this study was to analyze the length of the learning curve of laparoscopic colorectal surgeons and to recommend a case selection framework at the early stage of independent practice. DATA SOURCES: Medline (1988-2010, October week 4) and Embase (1988-2010) were used for the literature review, databases were retrieved from the authors, and expert opinion was surveyed. STUDY SELECTION: Studies describing the learning curve of laparoscopic or laparoscopically assisted colorectal surgery were selected. INTERVENTION: No interventions were performed. MAIN OUTCOME MEASURES: Learning curves were analyzed by using risk-adjusted, bootstrapped cumulative sum curves. Conversions and complications were independent variables in a multilevel random-effects regression model. Recommendations are based on analysis of ORs and a structured expert opinion gauging process. RESULTS: Twenty-three studies were identified, showing great disparity on the length of the learning curve. Seven studies, representing 4852 cases (19 surgeons), were analyzed. Risk-adjusted cumulative sum charts demonstrated the length of the learning curves to be 152 cases for conversions, 143 for complications, 96 for operating time, 87 for blood loss, and 103 for length of stay. Body mass index and pelvic dissection (rectum), especially in male patients, independently increased the risk of complication and conversion. The expert survey revealed that increasing T stage and complicated inflammatory disease are likely to increase the complexity of the case. Based on this evidence, a framework for case selection in training was proposed. LIMITATIONS: The generalizability of the study results maybe reduced because of inconsistent data quality and individual variations in the length of the learning curve CONCLUSIONS: This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.

Observational clinical human reliability analysis (OCHRA) for competency assessment in laparoscopic colorectal surgery at the specialist level.

BACKGROUND: There are no valid and reliable tools to assess competency in advanced laparoscopic surgery at a specialist level. The observational clinical human reliability analysis (OCHRA) may have the required characteristics of such a tool. The aim of this study was to evaluate construct and concurrent validity of OCHRA for competency assessment at a specialist level. METHODS: Thirty-two video-recorded laparoscopic colorectal resections, performed by experts and delegates of the National Training Program in England, were evaluated. Each video was analysed using OCHRA by identifying errors enacted during surgery. The number of tissue-handling, instrument-misuse, and consequential errors was recorded using video-rating software. Times spent on dissecting (D) and on exposing (E) tissues were also measured (D/E ratio). In addition, two independent expert surgeons globally assessed each video regarding competency (pass vs. fail). Logistic regression was used to predict outcomes. RESULTS: A total of 399 errors were identified. There was a significant difference when comparing the expert, pass, and fail groups for total errors (median counts for experts = 4, pass = 10, fail = 17; P < 0.001). When comparing the pass and fail groups excluding experts, differences could be found for tissue-handling errors (7 vs. 12; P = 0.005), but not for consequential errors (4 vs. 7; P = 0.059) and instrument-handling errors (4 vs. 5; P = 0.320). The D/E ratio was significantly lower for delegates than for experts (0.6 vs. 1.0; P = 0.001). When all four independent variables were used to predict delegates who passed or failed, the area under the receiver operating characteristic curve was 0.867, sensitivity was 71.4%, and specificity was 90.9%. CONCLUSION: OCHRA is a valid tool for assessing competency at a specialist level in advanced laparoscopic surgery. It has the potential to be used for recertification and revalidation of specialists.

Analysis of laboratory-based laparoscopic colorectal surgery workshops within the English National Training Programme.

BACKGROUND: This study aimed to determine and compare the opinions of trainees and trainers attending courses using two simulation models (fresh frozen cadavers or anaesthetized pigs) and to assess trainees' degree of insight into both the difficulty of different procedures and their operative performance in the simulated environment. METHODS: Trainers and trainees attending the training courses completed questionnaires. Performance was evaluated using the Global Assessment Score (GAS). RESULTS: Data were collected over a 12-month period from 26 trainers and 77 trainees. The overall satisfaction was high after attendance at either course (4.50 vs. 4.49; p=0.83). When the opinions of the trainees and trainers in cadaveric and animal courses were compared, the findings rated the animal model as superior in terms of tissue quality (3.97 vs. 3.55; p=0.02), persistence of air leak (1.43 vs. 2.40; p<0.001), and lack of disturbance by odor (4.24 vs. 3.41; p<0.001). The cadaveric model provided more realistic simulation for port placement (4.02 vs. 3.11; p<0.001) and anatomy (4.25 vs. 3.00; p<0.001) and was perceived to be superior as a training model (4.53 vs. 3.61; p=0.001). The trainees demonstrated good insight into procedure difficulty and their operative performance. The trainees and trainers were shown to have a good concordance of scores. The trainees were more inclined to underrate and the peers to overrate their performance. CONCLUSIONS: Trainees appear to have a good insight into procedure difficulty and their ability. Both training models have advantages and disadvantages, but overall, the cadaveric model is perceived to have a higher fidelity and greater educational value.

Development, validation and implementation of a monitoring tool for training in laparoscopic colorectal surgery in the English National Training Program.

INTRODUCTION: The National Training Program for laparoscopic colorectal surgery (LCS) provides supervised training to colorectal surgeons in England. The purpose of this study was to create, validate, and implement a method for monitoring training progression in laparoscopic colorectal surgery that met the requirements of a good assessment tool. METHODS: A generic scale for different tasks in LCS was created under the guidance of a national expert group. The scores were defined by the extent to which the trainees were dependent on support (1 = unable to perform, 5 = unaided (benchmark), 6 = proficient). Trainers were asked to rate their trainees after each supervised case; trainees completed a similar self-assessment form. Construct validity was evaluated comparing scores of trainees at different experience levels (1-5, 6-10, 11-15, 16+) using the Wilcoxon signed-rank test and ANOVA. Internal consistency was determined by Crohnbach's alpha, interrater reliability by comparing peer- and self-assessment (interclass correlation coefficient, ICC). Proficiency gain curves were plotted using CUSUM charts. RESULTS: Analysis included 610 assessments (333 by trainers and 277 by trainees). There was high interrater reliability (ICC = 0.867), internal consistency (α = 0.920), and construct validity [F(3,40) = 6.128, p < 0.001]. Detailed analysis of proficiency gain curves demonstrates that theater setup, exposure, and anastomosis were performed independently after 5 to 15 sessions, and the dissection of the vascular pedicle took 24 cases. Mobilization of the colon and of the splenic/hepatic flexure took more than 25 procedures. Median assessment time was 3.3 (interquartile range (IQR) 1-5) minutes and the tool was accepted as useful [median score 5 of 6 (IQR 4-5)]. DISCUSSION: A valid and reliable monitoring tool for surgical training has been implemented successfully into the National Training Program. It provides a description of an individualized proficiency gain curve in terms of both the level of support required and the competency level achieved.

Systematic review on mentoring and simulation in laparoscopic colorectal surgery.

OBJECTIVE: To identify and evaluate the influence of mentoring and simulated training in laparoscopic colorectal surgery (LCS) and define the key components for learning advanced technical skills. BACKGROUND: Laparoscopic colorectal surgery is a complex procedure, often being self-taught by senior surgeons. Educational issues such as inadequate training facilities or a shortfall of training fellowships may result in a slow uptake of LCS. The effectiveness of mentored and simulated training, however, remains unclear. METHODS: We conducted a systematic search, using Ovid databases. Four study categories were identified: mentored versus nonmentored cases, training case selection, simulation, and assessment. We performed a meta-analysis and a mixed model regression on the difference of the main outcome measures (conversion rates, morbidity, and mortality) for mentored trainees and expert surgeons. We also compared conversion rates of mentored and nonmentored. Meta-analysis of risk factors for conversion was performed using published and unpublished data sets requested from various investigators. For studies on simulation, we compared scores of surveys on the perception of different training courses. RESULTS: Thirty-seven studies were included. Pooled weighted outcomes of mentored cases (n = 751) showed a lower conversion rate (13.3% vs 20.5%, P = 0.0332) compared with nonmentored cases (n = 695). Compared to expert case series (n = 5313), there was no difference in conversion (P = 0.2835), anastomotic leak (P = 0.8342), or mortality (P = 0.5680). A meta-analysis of training case selection data (n = 4444) revealed male sex (P < 0.0001), previous abdominal surgery (P = 0.0200), a BMI greater than 30 (P = 0.0050), an ASA of less than 2 (P < 0.0001), colorectal cancer (P < 0.0001) and intra-abdominal fistula (P < 0.0001), but not older than 64 years (P = 0.4800), to significantly increase conversion risk. Participants on cadaveric courses were highly satisfied with the teaching value yet trainees on an animal course gave less positive feedback. Structured assessment for LCS has been partially implemented. CONCLUSION: This review and meta-analysis supports evidence that trainees can obtain similar clinical results like expert surgeons in laparoscopic colorectal surgery if supervised by an experienced trainer. Cadaveric models currently provide the best value for training in a simulated environment. There remains a need for further research into technical skills assessment and the educational value of simulated training.

Pitfalls in Portacath location using the landmark technique: case report.

A 34 year old woman diagnosed with breast cancer and liver metastases underwent a left subclavian Portacath insertion. During the procedure, the clinical features and the findings of intra-operative investigations provided conflicting evidence of the catheter position. This report highlights the potential difficulties in establishing long-term central venous access, the limitations of common investigations and safety issues relating to the process of subclavian line insertion.