Practical Guide to Qualitative Research in Surgical Education.

This Guide to Statistics and Methods provides an overview of the selection and application of qualitative research in surgical education.

"Choose Your Own Threat"-A Modern Paradigm for Academic Surgery.

This Viewpoint discusses a potential shift from academic surgery's triple-threat paradigm (provide high-quality clinical care, perform primary research, and train residents and students) to defining success in ways that allow individual surgeons to focus on their own path based on intrinsic motivation and curiosity.

Resident Operative Autonomy and Attending Verbal Feedback Differ by Resident and Attending Gender.

Objectives: This study tests the null hypotheses that overall sentiment and gendered words in verbal feedback and resident operative autonomy relative to performance are similar for female and male residents. Background: Female and male surgical residents may experience training differently, affecting the quality of learning and graduated autonomy. Methods: A longitudinal, observational study using a Society for Improving Medical Professional Learning collaborative dataset describing resident and attending evaluations of resident operative performance and autonomy and recordings of verbal feedback from attendings from surgical procedures performed at 54 US general surgery residency training programs from 2016 to 2021. Overall sentiment, adjectives, and gendered words in verbal feedback were quantified by natural language processing. Resident operative autonomy and performance, as evaluated by attendings, were reported on 5-point ordinal scales. Performance-adjusted autonomy was calculated as autonomy minus performance. Results: The final dataset included objective assessments and dictated feedback for 2683 surgical procedures. Sentiment scores were higher for female residents (95 [interquartile range (IQR), 4-100] vs 86 [IQR 2-100]; P < 0.001). Gendered words were present in a greater proportion of dictations for female residents (29% vs 25%; P = 0.04) due to male attendings disproportionately using male-associated words in feedback for female residents (28% vs 23%; P = 0.01). Overall, attendings reported that male residents received greater performance-adjusted autonomy compared with female residents (P < 0.001). Conclusions: Sentiment and gendered words in verbal feedback and performance-adjusted operative autonomy differed for female and male general surgery residents. These findings suggest a need to ensure that trainees are given appropriate and equitable operative autonomy and feedback.

The long game: Evolution of clinical decision making throughout residency and fellowship.

BACKGROUND: The purpose of this study was to explore the trajectory of autonomy in clinical decision making. METHODS: We conducted a qualitative secondary analysis of interviews with 45 residents and fellows from the General Surgery and Obstetrics & Gynecology departments across all clinical postgraduate years (PGY) using convenience sampling. Each interview was recorded, transcribed and iteratively analyzed using a framework method. RESULTS: A total of 16 junior residents, 22 senior residents and 7 fellows participated in 12 original interviews. Early in training residents take their abstract ideas about disease processes and make them concrete in their applications to patient care. A transitional stage follows in which residents apply concepts to concrete patient care. Chief residents re-abstract their concrete technical and clinical knowledge to prepare for future surgical practice. CONCLUSIONS: Understanding where each learner is on this pathway will assist development of curriculum that fosters resident readiness for practice at each PGY level.

Unmasking bias and perception of lead surgeons in the operating room: A simulation based study.

BACKGROUND: Perception of a surgeon based on physical attributes in the operating room (OR) environment has not been assessed, which was our primary goal. METHODS: A common OR scenario was simulated using 8 different actors as a lead surgeon with combinations of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). One video scenario with a survey was electronically distributed to surgeons, residents, and OR nurses/staff. The overall rating, assessment, and perception of the lead surgeon were assessed. RESULTS: Of 974 respondents, 64.5% were females. There were significant differences in the rating and assessment based upon surgeon's age (p = .01) favoring older surgeons. There were significant differences in the assessments of surgeons by the study group (p = .03). The positive assessments as well as perceptions trended highest towards male, older, and white surgeons, especially in the stressful situation. CONCLUSION: While perception of gender bias may be widespread, age and race biases may also play a role in the OR. Inter-professional education training for OR teams could be developed to help alleviate such biases.

All Politics Are Local: A Single Institution Investigation of the Educational Impact of Residents and Fellows Working Together.

BACKGROUND: Most general surgery residents pursue fellowship; there is limited understanding of the impact residents and fellows have on each other's education. The goal of this exploratory survey was to identify these impacts. MATERIALS AND METHODS: Surgical residents and fellows at a single academic institution were surveyed regarding areas (OR assignments, the educational focus of the team, roles and responsibilities on the team, interpersonal communication, call, "other") hypothesized to be impacted by other learners. Impact was defined as "something that persistently affects the clinical learning environment and a trainee's education or ability to perform their job". Narrative responses were reviewed until dominant themes were identified. RESULTS: Twenty-three residents (23/45, 51%) and 12 fellows (12/21, 57%) responded. Responses were well distributed among resident year (PGY-1:17% [4/23], PGY-2, 35% [8/23], PGY-3 26% [6/23], PGY-4 9% [2/23%], PGY-5 13% [3/23]). Most residents reported OR assignment (14/23, 61%) as the area of primary impact, fellows broadly reported organizational categories (Roles and responsibilities 33%, educational focus 16%, interpersonal communication 16%). Senior residents reported missing out on operations to fellows while junior residents reported positive impacts of operating directly with fellows. Residents of all levels reported that fellows positively contributed to their education. Fellows, senior residents, and junior residents reported positive experiences when residents and fellows operated together as primary surgeon and assistant. CONCLUSIONS: Residents and fellows impact one another's education both positively and negatively. Case allocation concerns senior residents, operating together may alleviate this, providing a positive experience for all trainees. Defining a unique educational role for fellows and delineating team expectations may maximize the positive impacts in this relationship.

Evaluation of leadership curricula in general surgery residency programs.

The rapid and dynamic surgical environment requires leaders that can help guide their teams to desired outcomes while delivering patient-centered care. The need for early implementation of leadership curricula has been identified; however, most available leadership curricula are tailored for faculty and not embedded within surgery training. The ideal intervention(s) to close this gap while addressing the unique challenges of the demanding surgical training are yet to be identified. This manuscript reviews the current status of residency leadership programs and the relationship of leadership to other essential aspects for optimal training of future surgeon leaders. The use of best practice medical education frameworks is key to help guide effective and sustainable evidence-based leadership curricula. The collaboration, standardization, and publication of leadership curricula for surgery residents can serve as prototypes to address specific needs at different training institutions with the aim of equipping surgeons with the necessary leadership tools for their success.

Education Morbidity and Mortality: Reviving Intraoperative Teaching and Learning.

BACKGROUND: Using the platform of morbidity and mortality conference, we developed and executed a combined faculty-resident intervention called "Education M&M" to discuss challenges faced by both parties in the operating room (OR), identify realistic solutions, and implement action plans. This study aimed to investigate the impact of this intervention on resident OR training. MATERIALS AND METHODS: Two resident case presentations were followed by audience discussion and recommendations regarding actionable solutions aimed at improving resident OR training from an expert faculty panel. Postintervention surveys were completed by participants immediately and 2 mo later to assess perceived short and long-term impact on OR teaching and/or learning and the execution of two recommended solutions. Descriptive statistical analysis was applied. RESULTS: Immediate post-intervention surveys (n = 44) indicated that 81.8% of participants enjoyed the M&M "a lot"; 90.1% said they would use some or a lot of the ideas presented. Awareness of OR teaching/learning challenges before and after the M&M improved from 3.0 to 3.7 (P = 0.00001) for faculty and 3.0 to 3.9 for trainees (P = 0.00004). Understanding of OR teaching and/or learning approaches improved from 3.1 to 3.7 for faculty (P = 0.00004) and 2.7 to 3.9 for trainees (P = 0.00001). In 2-mo post-intervention surveys, most residents had experienced two recommended solutions (71% and 88%) in the OR, but self-reported changes to faculty behavior did not reach statistical significance. CONCLUSIONS: A department-wide education M&M could be an effective approach to enhance mutual communication between faculty members and residents around OR teaching/learning by identifying program-specific challenges and potential actionable solutions.

Efficiency of Increasing Prospective Resident Entrustment in the Operating Room.

BACKGROUND: Prospective resident entrustment (i.e., trust an attending surgeon intends to give to a resident in the near future) in the operating room (OR) closely associates with granted future autonomy. However, the process of determining resident entrustment takes time and effort. Thus, this study aimed to assess the efficiency of granting incremental resident entrustment for upcoming surgical cases. METHODS: We analyzed prospective resident entrustment of 6 chief residents in 76 cases of laparoscopic cholecystectomy, laparoscopic colectomy, ventral hernia, and inguinal hernia scored by attending surgeon, resident, and a surgeon observer. Matched direct costs and operative time were extracted from hospital billing. We assessed the efficiency of granting incremental prospective resident entrustment with direct cost per minute incurred in the evaluated case. Effect size was computed to assess the differences between groups. RESULTS: Sixty-three cases (82.9%) were matched; 47.6% (30/63) of matched cases received prospective resident entrustment score ≥ 4. The direct cost per minute increased in three procedures (laparoscopic cholecystectomy, laparoscopic colectomy, and ventral hernia) with increased intention of granting incremental resident entrustment. Inguinal hernia was the only procedure in which chiefs were entrusted with future independence while the direct cost per minute decreased. CONCLUSIONS: Our findings demonstrate more time and effort are required (except for inguinal hernia) for residents to be entrusted with increased independence in the future. Faculty and resident development programs are recommended to improve the efficiency of the process of granting incremental operative entrustment to optimize resident training quality and cost of care delivery.

Predicting prospective resident entrustment: From evaluation to action.

OBJECTIVE: We aimed to identify potential variables predictive of a resident achieving faculty future entrustment as a way to enhance attending surgeons' planning of teaching in the operating room leading to improved resident operative autonomy in practice. METHODS: We reviewed 273 resident performance evaluations from 91 surgical cases that were collected from 11 general surgery chief residents and 16 attending surgeons between April 2018 and June 2019 using a validated evaluation instrument. The primary outcome measure was prospective resident entrustment estimated by the rater for future similar cases. We used descriptive statistics and the boosted tree analysis model to find potential predictors for the outcome measure and examine test-retest reliability by procedure. RESULTS: Step-specific guidance (r = 0.77, p < 0.0001) was the variable most highly associated with prospective resident entrustment in bivariate linear analysis. The boosted tree analysis demonstrated step-specific guidance was the strongest predictor for prospective resident entrustment in the OR, and its predictive importance was much higher than the overall guidance (0.64 > 0.18). Test-retest reliability was from 0.93 to 0.98 across procedures, indicating the likelihood that attending surgeons granted future autonomy complied with their evaluation of prospective resident entrustment was high. CONCLUSIONS: By assessing step-specific guidance, attending surgeons can reliably judge residents' future entrustment and potentially better plan for operative teaching/supervision that may lead to granting a surgical resident operative autonomy on similar cases in the future. Our findings provide insight into prospective faculty development of surgical teaching aimed at improving resident readiness for independent practice.

A Novel Operative Coaching Program for General Surgery Chief Residents Improves Operative Efficiency.

INTRODUCTION: We evaluated the effect of an operative coaching (OC) model on general surgery chief residents' operative efficiency (OE) measured by operative times. We hypothesized that higher levels of entrustment surgeons intend to offer resident in future similar cases are associated with improved OE. MATERIALS AND METHODS: From July 2018 to June 2019, we used a validated instrument to score prospective resident entrustment in 228 evaluations of 6 chief residents during 12 OC sessions each (3 lap colectomy, 3 lap cholecystectomy, 3 ventral hernia, 3 inguinal hernia). Operative times of matched case CPT codes performed by coached chiefs (N = 500) were matched via CPT code to the cases of uncoached chiefs in the academic year 2016-2017 (N = 478). Statistical analysis was performed using Pearson correlation and one-way ANOVA. RESULTS: Prospective entrustment scores from coached chief residents were associated with significantly shorter operative times in matched complex cases (CC) (r = -0.58, p = 0.0047). A similar trend was observed in noncomplex cases (NCC) (r = -0.29, p = 0.18). Compared to the historical cohort, coached chief residents showed a decrease in mean operative time during complex cases (p = 0.0008, d = 0.44), but an increase in mean operative times for noncomplex cases (p < 0.0001, d = 0.33). CONCLUSIONS: An OC model improves chief residents' prospective entrustment leading to increased OE in cases with greater levels of operative complexity, showing a decrease in mean operative time compared to uncoached residents in certain procedures. This is the first report showing formal coaching may be a method to enhance chief resident OE.

The confidence gap: Findings for women in plastic surgery.

BACKGROUND: In a surgical field, where surgeons are, "sometimes wrong, but never in doubt," lack of confidence can have detrimental effects on career advancement. In other fields there is evidence that a gap exists between women and men in the amount of confidence they display, and that confidence is a proxy for success. METHODS: This study used the General Self Efficacy Scale and Rosenberg Self-Esteem Scale confidence surveys to assess self confidence amongst female trainees and attending plastic surgeons, to search for baseline characteristics associated with higher confidence scores. RESULTS: Of the 73 participants, protective factors associated with increased female plastic surgeon confidence include age, parity, more advanced academic status, and mentorship. CONCLUSIONS: In order to matriculate into a surgical training program, there must be a measure of confidence and resiliency, but further work needs to be done to identify and address gender gaps in training and early academic careers.