Exploring mentorship in surgery: An interview study on how people stick together.

OBJECTIVE: The objective is to explore the processes contributing to how and why mentors and mentees initiate, maintain and grow in their mentorship relationships in surgery. BACKGROUND: To explore the processes contributing to how and why mentors and mentees initiate, maintain and grow their mentorship relationships in surgery. Evidence suggests that mentorship has a positive impact on physicians' success. Consequently, mentorship programmes have been incorporated into many medicine environments, albeit with variable success. METHODS: We designed an interview-based study using a constructivist grounded theory approach to explore the dynamics of mentorship between junior and experienced surgeons. Recruited mentees were asked to nominate a senior surgeon they identified as a mentor. Both mentee and mentors were then interviewed separately. Transcripts were analysed using constant comparison to a create a final coding framework and to generate themes. RESULTS: We interviewed nine faculty mentors and 10 junior faculty mentees. Our analysis identified key themes describing how to initiate, maintain and grow a mentorship relationship. Mentorship starts with ensuring a 'good fit', persists through satisfying a reciprocal loop with timely communication and deepens the relationship through cycles of mutual investment, learning, and success. Participants also discussed how to navigate through tensions to avoid relationship breakdown, balancing formality and friendship, knowing when to transition a relationship to a new dynamic and finding areas of realistic contribution. CONCLUSIONS: We found that successful mentorship relationships are viewed as dynamic and thus require active investment and shared responsibility between mentees and mentors. Our results also emphasise the value of co-regulation in the relationship, where cycles of mutual investment can contribute to mutual learning and growth.

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.

Coaching in Surgical Education: A Systematic Review.

OBJECTIVE: The objectives of this study were to review the coaching literature to (1) characterize the criteria integral to the coaching process, specifically in surgery, and (2) describe how these criteria have been variably implemented in published studies. BACKGROUND: Coaching is a distinct educational intervention, but within surgery the term is frequently used interchangeably with other more established terms such as teaching and mentoring. METHODS: A systematic search was performed of the MEDLINE and Cochrane databases to identify studies that used coach/coaching as an intervention for surgeons for either technical or nontechnical skills. Study quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: A total of 2280 articles were identified and after screening by title, abstract and full text, 35 remained. Thirteen coaching criteria (a-m) were identified in 4 general categories: 1. overarching goal (a. refine performance of an existing skill set), 2. the coach (b. trusting partnership, c. avoids assessment, d. 2-way communication), the coachee (e. voluntary participation, f. self-reflection, g. goal setting, h. action plan, i. outcome evaluation), and the coach-coachee rapport (j. coaching training, k. structured coaching model, l. non-directive, m. open ended questions). Adherence to these criteria ranged from as high of 73% of studies (voluntary participation of coach and coachee) to as low as 7% (use of open-ended questions). CONCLUSIONS: Coaching is being used inconsistently within the surgical education literature. Our hope is that with establishing criteria for coaching, future studies will implement this intervention more consistently and allow for better comparison and generalization of results.

Competency-Based Education in Minimally Invasive and Robotic Colorectal Surgery.

Minimally invasive and robotic techniques have become increasingly implemented into surgical practice and are now an essential part of the foundational skills of training colorectal surgeons. Over the past 5 years there has been a shift in the surgical educational paradigm toward competency-based education (CBE). CBE recognizes that trainees learn at different rates but regardless, are required to meet a competent threshold of performance prior to independent practice. Thus, CBE attempts to replace the traditional "time" endpoint of training with "performance." Although conceptually sensible, implementing CBE has proven challenging. This article will define competence, outline appropriate assessment tools to assess technical skill, and review the literature on the number of cases required to achieve competence in colorectal procedures while outlining the barriers to implementing CBE.

Brain activation during laparoscopic tasks in high- and low-performing medical students: a pilot fMRI study.

BACKGROUND: Up to 20% of medical students are unable to reach competency in laparoscopic surgery. It is unknown whether these difficulties arise from heterogeneity in neurological functioning across individuals. We sought to examine the differences in neurological functioning during laparoscopic tasks between high- and low-performing medical students using functional magnetic resonance imaging (fMRI). METHODS: This prospective cohort study enrolled North American medical students who were within the top 20% and bottom 20% of laparoscopic performers from a previous study. Brain activation was recorded using fMRI while participants performed peg-pointing, intracorporeal knot tying (IKT), and the Pictorial Surface Orientation (PicSOr) test. Brain activation maps were created and areas of activation were compared between groups. RESULTS: In total, 9/12 high and 9/13 low performers completed the study. High performers completed IKT faster and made more successful knot ties than low performers [standing: 23.5 (5.0) sec vs. 37.6 (18.4) sec, p = 0.03; supine: 23.2 (2.5) sec vs. 72.7 (62.8) sec, p = 0.02; number of successful ties supine, 3 ties vs. 1 tie, p = 0.01]. Low performers showed more brain activation than high performers in the peg-pointing task (q < 0.01), with no activation differences in the IKT task. There were no behavioral differences in the PiCSOr task. CONCLUSIONS: This study is the first to show differences between low and high performers of laparoscopic tasks at the brain level. This pilot study has shown the feasibility of using fMRI to examine laparoscopic surgical skills. Future studies are needed for further exploration of our initial findings.

Developing the Blueprint for a General Surgery Technical Skills Certification Examination: A Validation Study.

INTRODUCTION: There is a recognized need to develop high-stakes technical skills assessments for decisions of certification and resident promotion. High-stakes examinations requires a rigorous approach in accruing validity evidence throughout the developmental process. One of the first steps in development is the creation of a blueprint which outlines the potential content of examination. The purpose of this validation study was to develop an examination blueprint for a Canadian General Surgery assessment of technical skill certifying examination. METHODS: A Delphi methodology was used to gain consensus amongst Canadian General Surgery program directors as to the content (tasks or procedures) that could be included in a certifying Canadian General Surgery examination. Consensus was defined a priori as a Cronbach's α ≥ 0.70. All procedures or tasks reaching a positive consensus (defined as ≥80% of program directors rated items as ≥4 on the 5-point Likert scale) were then included in the final examination blueprint. RESULTS: Two Delphi rounds were needed to reach consensus. Of the 17 General Surgery Program directors across the country, 14 (82.4%) and 10 (58.8%) program directors responded to the first and second round, respectively. A total of 59 items and procedures reached positive consensus and were included in the final examination blueprint. CONCLUSIONS: The present study has outlined the development of an examination blueprint for a General Surgery certifying examination using a consensus-based methodology. This validation study will serve as the foundational work from which simulated model will be developed, pilot tested and evaluated.

Passing a Technical Skills Examination in the First Year of Surgical Residency Can Predict Future Performance.

BACKGROUND: The ability of an assessment to predict performance would be of major benefit to residency programs, allowing for early identification of residents at risk. OBJECTIVE: We sought to establish whether passing the Objective Structured Assessment of Technical Skills (OSATS) examination in postgraduate year 1 (PGY-1) predicts future performance. METHODS: Between 2002 and 2012, 133 PGY-1 surgery residents at the University of Toronto (Toronto, Ontario, Canada) completed an 8-station, simulated OSATS examination as a component of training. With recently set passing scores, residents were assigned a pass/fail status using 3 standards setting methods (contrasting groups, borderline group, and borderline regression). Future in-training performance was compared between residents who had passed and those who failed the OSATS, using in-training evaluation reports from resident files. A Mann-Whitney U test compared performance among groups at PGY-2 and PGY-4 levels. RESULTS: Residents who passed the OSATS examination outperformed those who failed, when compared during PGY-2 across all 3 standard setting methodologies (P < .05). During PGY-4, only the contrasting groups method showed a significant difference (P < .05). CONCLUSIONS: We found that PGY-1 surgical resident pass/fail status on a technical skills examination was associated with future performance on in-training evaluation reports in later years. This provides validity evidence for the current PGY-1 pass/fail score, and suggests that this technical skills examination may be used to predict performance and to identify residents who require remediation.

Practice does not always make perfect: need for selection curricula in modern surgical training.

BACKGROUND: It is hypothesized that not all surgical trainees are able to reach technical competence despite ongoing practice. The objectives of the study were to assess a trainees' ability to reach technical competence by assessing learning patterns of the acquisition of surgical skills. Furthermore, it aims to determine whether individuals' learning patterns were consistent across a range of open and laparoscopic tasks of variable difficulty. METHODS: Sixty-five preclinical medical students participated in a training curriculum with standardized feedback over forty repetitions of the following laparoscopic and open technical tasks: peg transfer (PT), circle cutting (CC), intracorporeal knot tie (IKT), one-handed tie, and simulated laparotomy closure. Data mining techniques were used to analyze the prospectively collected data and stratify the students into four learning clusters. Performance was compared between groups, and learning curve characteristics unique to trainees who have difficulty reaching technical competence were quantified. RESULTS: Top performers (22-35%) and high performers (32-42%) reached proficiency in all tasks. Moderate performers (25-37%) reached proficiency for all open tasks but not all laparoscopic tasks. Low performers (8-15%) failed to reach proficiency in four of five tasks including all laparoscopic tasks (PT 7.8%; CC 9.4%; IKT 15.6%). Participants in lower performance clusters demonstrated sustained performance disadvantage across tasks, with widely variable learning curves and no evidence of progression towards a plateau phase. CONCLUSIONS: Most students reached proficiency across a range of surgical tasks, but low-performing trainees failed to reach competence in laparoscopic tasks. With increasing use of laparoscopy in surgical practice, screening potential candidates to identify the lowest performers may be beneficial.

Strategies for increasing the feasibility of performance assessments during competency-based education: Subjective and objective evaluations correlate in the operating room.

BACKGROUND: Competency-based education necessitates assessments that determine whether trainees have acquired specific competencies. The evidence on the ability of internal raters (staff surgeons) to provide accurate assessments is mixed; however, this has not yet been directly explored in the operating room. This study's objective is to compare the ratings given by internal raters vs an expert external rater (independent to the training process) in the operating room. METHODS: Raters assessed general surgery residents during a laparoscopic cholecystectomy for their technical and nontechnical performance. RESULTS: Fifteen cases were observed. There was a moderately positive correlation (rs = .618, P = .014) for technical performance and a strong positive correlation (rs = .731, P = .002) for nontechnical performance. The internal raters were less stringent for technical (mean rank 3.33 vs 8.64, P = .007) and nontechnical (mean rank 3.83 vs 8.50, P = .01) performances. CONCLUSIONS: This study provides evidence to help operationalize competency-based assessments.

Setting Performance Standards for Technical and Nontechnical Competence in General Surgery.

OBJECTIVES: The objectives of this study were to (1) create a technical and nontechnical performance standard for the laparoscopic cholecystectomy, (2) assess the classification accuracy and (3) credibility of these standards, (4) determine a trainees' ability to meet both standards concurrently, and (5) delineate factors that predict standard acquisition. BACKGROUND: Scores on performance assessments are difficult to interpret in the absence of established standards. METHODS: Trained raters observed General Surgery residents performing laparoscopic cholecystectomies using the Objective Structured Assessment of Technical Skill (OSATS) and the Objective Structured Assessment of Non-Technical Skills (OSANTS) instruments, while as also providing a global competent/noncompetent decision for each performance. The global decision was used to divide the trainees into 2 contrasting groups and the OSATS or OSANTS scores were graphed per group to determine the performance standard. Parametric statistics were used to determine classification accuracy and concurrent standard acquisition, receiver operator characteristic (ROC) curves were used to delineate predictive factors. RESULTS: Thirty-six trainees were observed 101 times. The technical standard was an OSATS of 21.04/35.00 and the nontechnical standard an OSANTS of 22.49/35.00. Applying these standards, competent/noncompetent trainees could be discriminated in 94% of technical and 95% of nontechnical performances (P < 0.001). A 21% discordance between technically and nontechnically competent trainees was identified (P < 0.001). ROC analysis demonstrated case experience and trainee level were both able to predict achieving the standards with an area under the curve (AUC) between 0.83 and 0.96 (P < 0.001). CONCLUSIONS: The present study presents defensible standards for technical and nontechnical performance. Such standards are imperative to implementing summative assessments into surgical training.

Optimizing the Selection of General Surgery Residents: A National Consensus.

BACKGROUND: Surgical programs strive to recruit trainees who will graduate as competent surgeons; however, selection processes vary between institutions. The purpose of the present study was to (1) solicit program directors' (PDs) opinions on the proportion of trainees who have difficulty achieving competence and (2) establish consensus on the desired attributes of general surgery (GS) candidates and the technical skills that would be most indicative of future performance. METHODS: Delphi consensus methodology was used. An open-ended questionnaire, followed by a closed-ended questionnaire, formulated as a 5-point Likert scale, was administered. A Cronbach α ≥ 0.8 with 80% of responses in agreement (4-agree and 5-strongly agree) determined the threshold for consensus. RESULTS: The first and second rounds were completed by 14 and 11, of a potential 17, GS PDs, respectively. PDs felt that 5% or less of trainees have difficulty reaching competence in clinical knowledge, 5% to 10% in decision-making, and 5% to 15% in technical skill by the time of completion of training. Consensus was excellent (α = 0.92). The top attributes for success in GS included work ethic and passion for surgery. Technical skills that felt to be most appropriate were open tasks (one-handed tie and subcuticular suture) and laparoscopic tasks (coordination, grasping, and cutting). CONCLUSION: PDs indicate that of the 3 domains, the largest proportion of trainees had difficulty reaching competence in technical skill. Consensus among PDs suggests that top personal attributes include work ethic and passion for surgery. Consensus of technical tasks for inclusion into selection was basic open and laparoscopic skills.

Training on an inexpensive tablet-based device is equally effective as on a standard laparoscopic box trainer: A randomized controlled trial.

BACKGROUND: The aim of the study was to assess whether an inexpensive tablet-based box trainer (TBT) is at least equally effective compared with a standard box trainer (SBT) to learn basic laparoscopic skills (BLS). BLS training outside the operating room has been shown to be beneficial for surgical residency. However, simulation trainers are expensive and are not consistently available in all training centers. Therefore, TBT and other homemade box trainers were developed. METHODS: Medical students were randomized to either a TBT or an SBT and trained 4 fundamentals of laparoscopic surgery (FLS) tasks for 1 hour twice a week for 4 weeks. A baseline test before the training period and a posttraining test were performed. All students then completed a questionnaire to assess their assigned box trainer. The primary outcome measure was the improvement in total test scores. Improvement in the scores for the 4 individual FLS tasks was chosen as a secondary outcome measure. RESULTS: Thirty-two medical students were recruited. Baseline test scores did not differ significantly between the groups. BLS improved significantly in both groups for the total score and for all 4 tasks separately. Participants in the TBT group showed a greater improvement of total scores than those in the SBT group, although this did not reach statistical significance; noninferiority of the TBT compared with the SBT concerning the improvement of total scores could be demonstrated. Regarding the individual FLS tasks, noninferiority of the TBT could be shown for the pattern cutting and the suturing with intracorporeal knot-tying task. The acceptance of the TBT by the trainees was very good. CONCLUSION: Learning BLS on a homemade TBT is at least equally effective as on an SBT, with the advantage of being very cost saving. Therefore, this readily available box trainer may be used as an effective, flexible training device outside the operating room to improve accessibility to simulation training.

International assessment practices along the continuum of surgical training.

BACKGROUND: The objectives of this study were to assemble an international perspective on (1) current, and (2) ideal technical performance assessment methods, and (3) barriers to their adoption during: selection, in-training, and certification. METHODS: A questionnaire was distributed to international educational directorates. RESULTS: Eight of 10 jurisdictions responded. Currently, aptitude tests or simulated tasks are used during selection, observational rating scales during training and nothing is used at certification. Ideally, innate ability should be determined during selection, in-training evaluation reports, and global rating scales used during training, whereas global and procedure-specific rating scales used at the time of certification. Barriers include lack of predictive evidence for use in selection, financial limitations during training, and a combination with respect to certification. CONCLUSIONS: Identifying current and ideal evaluation methods will prove beneficial to ensure the best assessments of technical performance are chosen for each training time point.

Predictive value of background experiences and visual spatial ability testing on laparoscopic baseline performance among residents entering postgraduate surgical training.

BACKGROUND: Emerging evidence suggests that despite dedicated practice, not all surgical trainees have the ability to reach technical competency in minimally invasive techniques. While selecting residents that have the ability to reach technical competence is important, evidence to guide the incorporation of technical ability into selection processes is limited. Therefore, the purpose of the present study was to evaluate whether background experiences and 2D-3D visual spatial test results are predictive of baseline laparoscopic skill for the novice surgical trainee. METHODS: First-year residents were studied. Demographic data and background surgical and non-surgical experiences were obtained using a questionnaire. Visual spatial ability was evaluated using the PicSOr, cube comparison (CC) and card rotation (CR) tests. Technical skill was assessed using the camera navigation (LCN) task and laparoscopic circle cut (LCC) task. Resident performance on these technical tasks was compared and correlated with the questionnaire and visual spatial findings. RESULTS: Previous experience in observing laparoscopic procedures was associated with significantly better LCN performance, and experience in navigating the laparoscopic camera was associated with significantly better LCC task results. Residents who scored higher on the CC test demonstrated a more accurate LCN path length score (r s(PL) = -0.36, p = 0.03) and angle path (r s(AP) = -0.426, p = 0.01) score when completing the LCN task. No other significant correlations were found between the visual spatial tests (PicSOr, CC or CR) and LCC performance. CONCLUSION: While identifying selection tests for incoming surgical trainees that predict technical skill performance is appealing, the surrogate markers evaluated correlate with specific metrics of surgical performance related to a single task but do not appear to reliably predict technical performance of different laparoscopic tasks. Predicting the acquisition of technical skills will require the development of a series of evidence-based tests that measure a number of innate abilities as well as their inherent interactions.

Can We Predict Technical Aptitude?: A Systematic Review.

OBJECTIVE: To identify background characteristics and cognitive tests that may predict surgical trainees' future technical performance, and therefore be used to supplement existing surgical residency selection criteria. BACKGROUND: Assessment of technical skills is not commonly incorporated as part of the selection process for surgical trainees in North America. Emerging evidence, however, suggests that not all trainees are capable of reaching technical competence. Therefore, incorporating technical aptitude into selection processes may prove useful. METHODS: A systematic search was carried out of the MEDLINE, PsycINFO, and Embase online databases to identify all studies that assessed associations between surrogate markers of innate technical abilities in surgical trainees, and whether these abilities correlate with technical performance. The quality of each study was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation system. RESULTS: A total of 8035 records were identified. After screening by title, abstract, and full text, 52 studies were included. Very few surrogate markers were found to predict technical performance. Significant associations with technical performance were seen for 1 of 23 participant-reported surrogate markers, 2 of 25 visual spatial tests, and 2 of 19 dexterity tests. The assessment of trainee Basic Performance Resources predicted technical performance in 62% and 75% of participants. CONCLUSIONS: To date, no single test has been shown to reliably predict the technical performance of surgical trainees. Strategies that rely on assessing multiple innate abilities, their interaction, and their relationship with technical skill may ultimately be more likely to serve as reliable predictors of future surgical performance.

Objective structured assessment of nontechnical skills: Reliability of a global rating scale for the in-training assessment in the operating room.

BACKGROUND: Nontechnical skills are critical for patient safety in the operating room (OR). As a result, regulatory bodies for accreditation and certification have mandated the integration of these competencies into postgraduate education. A generally accepted approach to the in-training assessment of nontechnical skills, however, is lacking. The goal of the present study was to develop an evidence-based and reliable tool for the in-training assessment of residents' nontechnical performance in the OR. METHODS: The Objective Structured Assessment of Nontechnical Skills tool was designed as a 5-point global rating scale with descriptive anchors for each item, based on existing evidence-based frameworks of nontechnical skills, as well as resident training requirements. The tool was piloted on scripted videos and refined in an iterative process. The final version was used to rate residents' performance in recorded OR crisis simulations and during live observations in the OR. RESULTS: A total of 37 simulations and 10 live procedures were rated. Interrater agreement was good for total mean scores, both in simulation and in the real OR, with intraclass correlation coefficients >0.90 in all settings for average and single measures. Internal consistency of the scale was high (Cronbach's alpha = 0.80). CONCLUSION: The Objective Structured Assessment of Nontechnical Skills global rating scale was developed as an evidence-based tool for the in-training assessment of residents' nontechnical performance in the OR. Unique descriptive anchors allow for a criterion-referenced assessment of performance. Good reliability was demonstrated in different settings, supporting applications in research and education.

Assessing Technical Competence in Surgical Trainees: A Systematic Review.

OBJECTIVE: To systematically examine the literature describing the methods by which technical competence is assessed in surgical trainees. BACKGROUND: The last decade has witnessed an evolution away from time-based surgical education. In response, governing bodies worldwide have implemented competency-based education paradigms. The definition of competence, however, remains elusive, and the impact of these education initiatives in terms of assessment methods remains unclear. METHODS: A systematic review examining the methods by which technical competence is assessed was conducted by searching MEDLINE, EMBASE, PsychINFO, and the Cochrane database of systematic reviews. Abstracts of retrieved studies were reviewed and those meeting inclusion criteria were selected for full review. Data were retrieved in a systematic manner, the validity and reliability of the assessment methods was evaluated, and quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation classification. RESULTS: Of the 6814 studies identified, 85 studies involving 2369 surgical residents were included in this review. The methods used to assess technical competence were categorized into 5 groups; Likert scales (37), benchmarks (31), binary outcomes (11), novel tools (4), and surrogate outcomes (2). Their validity and reliability were mostly previously established. The overall Grading of Recommendations Assessment, Development and Evaluation for randomized controlled trials was high and low for the observational studies. CONCLUSIONS: The definition of technical competence continues to be debated within the medical literature. The methods used to evaluate technical competence predominantly include instruments that were originally created to assess technical skill. Very few studies identify standard setting approaches that differentiate competent versus noncompetent performers; subsequently, this has been identified as an area with great research potential.

Introduction of a comprehensive training curriculum in laparoscopic surgery for medical students: a randomized trial.

BACKGROUND: First- and second-year medical students have limited exposure to basic surgical skills. An introductory, comprehensive, simulation-based curriculum in basic laparoscopic skills may improve medical students' knowledge and technical and nontechnical skills and may raise their interest in a career in surgery. The purpose of this study was to (1) design a comprehensive, simulation-based training curriculum (STC) aimed to introduce junior medical students to basic laparoscopic skills and (2) compare structured and supervised learning and practice to a self-directed approach. METHODS: Twenty-four, pre-clerkship medical students were allocated randomly to either a supervised (STC) or a self-directed learning and practice (SDL) group. Participants in the STC group received structured training in cognitive, and basic technical and nontechnical domains of laparoscopic surgery, whereas the SDL group was invited to engage in SDL in the same domains. RESULTS: At post-training assessment, basic knowledge about laparoscopic surgery, and attitudes toward nontechnical skills were equivalent between STC and SDL groups. The STC group outperformed (mean ± standard deviation) the SDL group on a peg transfer task (58 ± 13 vs 81 ± 19 seconds; P = .005). Participants in the STC group showed significant within-group improvements in knowledge, technical skill, and in 4 of 5 domains of nontechnical skills, whereas participants in the SDL group showed significant within-group improvement in technical skill and in 1 of 5 domains of nontechnical skills. CONCLUSION: Participation in the STC resulted in significant gains in knowledge, technical skill, and attitudes toward nontechnical skills. Exposure of junior medical students to this curriculum before their clinical rotations is expected to enhance learning, maintain motivation, and increase interest in surgery as a future career.

Galanin is highly expressed in bone marrow mesenchymal stem cells and facilitates migration of cells both in vitro and in vivo.

Galanin peptide has recently been found to be highly abundant in early embryonic mouse mesenchyme, while galanin and its receptors are expressed in embryonic mouse stem cells. Bone marrow mesenchymal stem cells (BMMSCs) represent the primary source for adult stem cell therapy. In this study we examined the abundance of galanin and its receptors in BMMSCs and evaluated its possible function. Galanin mRNA and protein were highly expressed in BMMSCs cultures up to four passages, while among the three galanin receptor subtypes (GalR1, GalR2, and GalR3) only GalR2 and to a lesser extent GalR3 were expressed. Using chemotaxis and wound assays we found that galanin protein increased the migration of BMMSCs. Furthermore, increased serum galanin levels in a galanin transgenic model enhanced the mobilization (homing) of injected BMMSCs in vivo. These data suggest a role for galanin in BMMSC migration, probably through activation of the GalR2 receptor.