Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa.

Objective: We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data: Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods: We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results: Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions: We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Perceptions Regarding Mentorship Among General Surgery Trainees With Academic Career Intentions.

OBJECTIVE: Effective mentorship may be an opportunity to mitigate career de-prioritization, improve stress management, and bolster professional growth. Relatively few studies address specific challenges that occur for general surgery trainees. We conducted a focus group-based investigation to determine facilitators/barriers to effective mentorship among general surgery residents, who are intending to pursue an academic career. DESIGN: A semistructured focus group study was conducted to explore residents' attitudes and experiences regarding (1) needs for mentorship, (2) barriers to identifying mentors, and (3) characteristics of successful mentor-mentee interactions. Subjects self-identified and were characterized as either "Mentored" or "Nonmentored." Transcriptions were independently reviewed by 3 coders. Inter-rater reliability between the coders was evaluated by calculating Cohen's kappa for each coded item. SETTING: General surgery residents from 2 academic tertiary hospitals, University of Pittsburgh Medical Center, and University of Washington, participated. PARTICIPANTS: Thirty-four general surgery trainees were divided into 8 focus groups. RESULTS: There were no gender-based differences in mentoring needs among residents. Barriers to establishing a relationship with a mentor, such as lack of exposure to faculty, and time and determination on the part of both mentor and mentee, were exacerbated by aspects of surgical culture including gender dynamics, criticism, and hierarchy. Successful relationships between mentee and mentor were perceived to require personal/professional compatibility and a feeling that the mentor is invested in the mentee, while conflicts of interest and neglect detracted from a successful relationship. CONCLUSIONS: Our investigations demonstrate the importance of surgical hierarchy and culture in facilitating interpersonal interactions with potential mentors. Further studies will be necessary to determine how best to address these barriers.

Concomitant Thyroid Cancer in Patients with Multiple Endocrine Neoplasia Type 1 Undergoing Surgery for Primary Hyperparathyroidism.

BACKGROUND: Compared to those with sporadic primary hyperparathyroidism (SPHP), multiple endocrine neoplasia type 1 (MEN1) patients with primary hyperparathyroidism (MPHP) typically require more extensive dissection and have higher recurrence rates. Little is known about the risk of concomitant thyroid cancer in either setting. This study aimed to determine the rates and characteristics of thyroid cancer for MPHP versus SPHP patients undergoing parathyroidectomy. METHODS: Patients with MPHP (diagnosed by clinical and/or genetic criteria) or SPHP who had initial or reoperative parathyroid exploration from 1967 to 2014 were identified via a prospective database. The thyroid cancer-specific data for MPHP patients (n = 29) were compared to a selected 2:1 age- and sex-matched SPHP cohort (n = 58) who all had concurrent thyroidectomy for any reason. Clinically significant thyroid cancer was defined as >1 cm in diameter. RESULTS: In the MPHP group, 24/29 (83%) thyroidectomies were preoperatively unplanned versus 20/58 (34%) in the SPHP matched cohort (p < 0.01), and in this setting there was no difference in the rate of histologic thyroid cancer (3/24 [13%] vs. 5/20 [25%], p = 0.44). Histologic thyroid cancer was identified in 8/29 (28%) MPHP versus 27/58 (47%) SPHP patients (p = 0.11). Despite observed differences in the time period and extent of thyroidectomy, MPHP patients did not have an increased likelihood of thyroid cancer (surgery before 2005: odds ratio [OR] = 2.57, p = 0.09; total thyroidectomy: OR = 5.47, p < 0.01; MPHP: OR = 1.14, p = 0.83). All MPHP thyroid cancers were characterized as conventional papillary thyroid cancer (PTC), while thyroid cancers in SPHP patients included both PTC (66%) and follicular-variant PTC (34%). No MPHP patient had clinically significant thyroid cancer compared to an incidence of 15/58 (26%) in SPHP patients (p < 0.01). CONCLUSIONS: Although patients with MEN1 have a substantial incidence of thyroid cancer (28%) and undergo more unplanned thyroidectomies during parathyroidectomy than do patients with SPHP, clinically significant thyroid cancer is proportionally uncommon.

Implementing the Trauma Evaluation and Management (TEAM) Course in Kenya.

BACKGROUND: Trauma training provides crucial knowledge and skills for health-care providers in low- and middle-income countries (LMICs). Although such training has been adapted for physicians and emergency personnel in LMICs, few courses have been offered for medical students. The Trauma Evaluation and Management (TEAM) course, developed by the American College of Surgeons, provides a valuable framework for providing this content to medical students in an LMIC-context. MATERIALS AND METHODS: We implemented the TEAM course at a single medical school in rural Kenya, for final-year medical students, utilizing the multimodal instruction and reference materials provided by the American College of Surgeons. We administered precourse and postcourse assessments, adapted the content for particular low-resource considerations, expanded the course to 2 d, and utilized a multidisciplinary and multinational group of surgical expert instructors. RESULTS: The entire final-year medical school class participated, and all completed pretesting and posttesting (100%, n = 61). Posttesting revealed significant improvement (P < 0.001), demonstrating successful knowledge acquisition, with the greatest improvements among the poorest performing decile on the pretest (P < 0.05). On narrative course feedback (100% completion, n = 61), participants appreciated instructors' interactive teaching style and the course's practical demonstrations, while requesting more time allotment for trauma training. CONCLUSIONS: We describe the feasibility of implementing TEAM training for final-year medical students in Kenya and demonstrate the course's effectiveness in this context as shown by knowledge acquisition. We plan for additional study to assess interval knowledge and skill retention. With refinement based on these results, we plan to repeat and expand trauma-education initiatives for medical students in LMICs.

A qualitative study of gender differences in the experiences of general surgery trainees.

BACKGROUND: Women surgeons continue to face unique challenges to professional advancement. Higher attrition rates and lower confidence among female surgical residents suggest that experiences during residency differ by gender. Few studies have investigated gender-specific experiences during training. This study identifies gender-based differences in the experiences of general surgery residents that could affect professional development. MATERIALS AND METHODS: Male and female general surgery residents at the University of Pittsburgh Medical Center participated in a semi-structured interview study exploring the significance of gender in training. Recurring themes were identified from transcribed interviews using inductive methods. Two individuals independently coded interviews. Themes were compared for male and female residents. Certain themes arose with greater frequency in reference to one gender over the other. RESULTS: Twenty-four male and eighteen female residents participated (87.5%) in the study. Fewer female residents self-identified as a "surgeon" (11.1% versus 37.5%, P < 0.001). Residents felt that patients and physicians more frequently disregarded female residents' professional role (P < 0.001). Female residents also more often mentioned perceiving aggressive behaviors from attendings and support staff (9% versus 1% and 10% versus 3%, respectively). Relative to men, women more often mentioned lack of mentorship (0% versus 8%), discomfort (4% versus 8%), feeling pressured to participate in unprofessional behaviors (2% versus 5%), and having difficulty completing tasks (5% versus 10%, P < 0.001). CONCLUSIONS: Women experience gender-based challenges during surgical training. Further investigation is needed to determine how these experiences affect professional development.

How can surgeons facilitate resident intraoperative decision-making?

BACKGROUND: Cognitive skills such as decision-making are critical to developing operative autonomy. We explored resident decision-making using a recollection of specific examples, from the attending surgeon and resident, after laparoscopic cholecystectomy. METHODS: In a separate semi-structured interview, the attending and resident both answered five questions, regarding the resident's operative roles and decisions, ways the attending helped, times when the attending operated, and the effect of the relationship between attending and resident. Themes were extracted using inductive methods. RESULTS: Thirty interviews were completed after 15 cases. Facilitators of decision-making included dialogue, safe struggle, and appreciation for retraction. Aberrant case characteristics, anatomic uncertainties, and time pressures provided barriers. Attending-resident mismatches included descriptions of transitioning control to the attending. CONCLUSIONS: Reciprocal dialogue, including concept-driven feedback, is helpful during intraoperative teaching. Unanticipated findings impede resident decision-making, and we describe differences in understanding transfers of operative control. Given these factors, we suggest that pre-operative discussions may be beneficial.