Modeling Technical Skills Learning Curves of Incoming Surgical Trainees.

OBJECTIVE: Not all trainees reach technical competency even after completing surgical training. While assessment of technical skill is not part of the residency interview process, identifying under-performers early on may help identify opportunities for individualized, targeted training. The objectives of this study were to (1) create predictive learning curve (LC) models for each of 3 basic laparoscopic tasks to identify performers versus underperformers and (2) evaluate the use of LCs to identify underperformers during selection into surgical training. DESIGN: Predictive LC models were created for laparoscopic pattern cutting (PC), peg transfer (PT) and intra-corporeal knots (IC) over 40 repetitions by 65 novice trainees in 2014. Trainees were categorized as performers and underperformers. Receiver operator characteristic analysis determined the minimum number of repetitions required to predict individual LCs, which were then used to determine the proportion of underperformers. SETTING: Technical performance was assessed onsite at the Canadian Residence Matching Service (CaRMS) interviews, after interview completion (January 2015). PARTICIPANTS: Applicants to general surgery (GS) and gynecology (OBGYN) participated in a skills assessment during. RESULTS: The PC, PT and IC tasks required a minimum of 8, 10, and 5 repetitions respectively, to predict overall performance. Predictive values for each task had excellent sensitivity and specificity: 1.00, 1.00 (PC); 1.00, 1.00 (PT); and 0.94, 1.00 (IC). Eighty applicants completed 8 PC repetitions; 16% were identified as underperformers. CONCLUSIONS: Individual LCs for three different laparoscopic tasks can be predicted with excellent sensitivity and specificity based on 10 repetitions or less. This information can be used to identify trainees who may have difficulty with laparoscopic technical skills early on.

Survey of iron prescribing practices for post-partum anaemia.

OBJECTIVE: Treatment for postpartum anaemia frequently entails iron supplementation, but questions remain regarding its optimal dosing, frequency, and efficacy. Our objective was to learn about the current prescribing practices of obstetrical providers at multiple hospitals, including indications and regimens used; further, we sought to understand how these practices are learned. METHODS: A 10-question web-based survey was developed via expert consensus. The survey was distributed via email to obstetrical providers (including trainees) practising at seven hospitals affiliated with the University of Toronto, including from Obstetrics & Gynaecology (OBGYN), Family Practice (FP-OB) and midwifery. RESULTS: The survey was directly sent to 469 participants and 140 responses were collected from the direct email recruitment pool (response rate 30%). Half of respondents were OBGYN physicians. The most common indication was a post-partum haemoglobin threshold of 90 g/L. Both intravenous and oral formulations were used; the most common oral formulation was ferrous fumarate (77%). Prescribing practices were most commonly shaped using passed-down knowledge. CONCLUSION: Through this survey, we have learned about the most common post-partum iron supplementation indications, formulations and regimens used in both academic and community hospitals in the greater Toronto area. This insight will help inform future studies investigating the efficacy of oral iron supplementation in the treatment of post-partum anaemia.

Avoidable bilateral salpingo-oophorectomy at hysterectomy: a large retrospective study.

OBJECTIVES: Evaluate the proportion of justified bilateral salpingo-oophorectomy (BSO) at hysterectomy, based on pathologic diagnosis, and determine prevalence of avoidable BSO based on pre- and intraoperative considerations and pathologic diagnosis. METHODS: Retrospective review of hysterectomies at seven Ontario, Canada hospitals from 2016 to 2019. Surgeries completed by oncologists or for invasive placentation were excluded. Patient, case, and surgeon characteristics were recorded along with pathologic diagnoses. Avoidable BSO criteria were: preoperative diagnosis of cervical dysplasia or benign diagnosis other than endometriosis, gender dysphoria, risk reduction or premenstrual dysphoric disorder; age < 51 years; absence of intraoperative endometriosis and adhesions; unjustified pathology (where "justified" pathology was endometriosis or (pre)malignant diagnosis except for cervical dysplasia). Patients with avoidable BSO were compared to those having at least one criterion for BSO. Binary logistic regression identified factors most strongly associated with avoidable BSO. RESULTS: Four thousand one hundred ninety-one hysterectomies were completed with 1,422 (33.9%) patients having concomitant BSO. Pathologic diagnosis justified BSO in most patients (1,035/1,422, 72.8%) with endometrial cancer being most common (439/1,422, 30.9%). When preoperative characteristics, intraoperative findings, and pathologic diagnoses were considered, 79 of 1,422 (5.6%) BSOs were avoidable. Compared to cases with at least one criterion for BSO, avoidable BSOs were more frequently completed by generalists (OR 1.80, 95% CI 1.10-2.99, P  = 0.021), for preoperative diagnoses of abnormal uterine bleeding/menorrhagia (OR 3.82, 95% CI 2.35-6.30, P  = 0.001) and fibroids (OR 4.25, 95% CI 2.63-6.92, P  < 0.001). CONCLUSION: Pathologic diagnosis justified most BSOs at hysterectomy. BSO was avoidable in 5.6% of patients, underscoring the need to standardize practice of BSO.

Examining prescribing practices with respect to oral iron supplementation for post-partum anemia: a retrospective review.

PURPOSE: Treatment for post-partum anemia frequently entails oral iron supplementation, but questions remain regarding optimal dosing, frequency, and efficacy. The objective of this study was to describe oral iron prescribing practices in post-partum women delivered via Cesarean section, and identify factors associated with iron supplementation. METHODS: A retrospective review of Cesarean section deliveries at a single tertiary center between May 2019 and April 2020 was undertaken. Patient demographics, hematological indices, indication for Cesarean section and discharge prescriptions were collected. Univariate and multivariable analyses were performed to identify factors associated with oral iron prescription at discharge. RESULTS: During the study period, 1470 women were eligible for inclusion. The mean age at delivery was 34.4 ± 4.9 years and mean gestational age was 37.2 ± 3.6 weeks. Most pregnancies (92%) were singleton. Ninety-six total patients (6.5%) received intravenous iron post-partum. Fourteen percent of women (210/1470) received prescriptions for oral iron at discharge, most commonly ferrous fumarate (61.9%, 130/210). The most common dose provided was 300 mg (145/210). Ante-partum ferritin was available for most patients (64.3%, 945/1470), but only for 17 post-partum patients (1.2%). Factors significantly associated with oral iron prescription were earlier gestational age at birth (aOR 0.93, 95% CI 0.89-0.97), history of complications during pregnancy or labor (aOR 1.92, 95% CI 1.26-2.98), higher blood loss (aOR 2.66, 95% CI 1.36-5.44), post-partum anemia (aOR 6.28, 95%-CI 4.41-8.96), blood transfusion (aOR 5.43, 95%-CI 1.81-18.19) and antenatal iron supplementation (aOR 5.70, 95%-CI 4.02-8.17). CONCLUSIONS: In summary, a relatively small proportion of women following Cesarean section were prescribed oral iron at discharge. We identified several factors associated with post-partum iron supplementation. This information will inform future prospective studies investigating the efficacy of iron supplementation in the treatment of post-partum anemia.