The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Moving Beyond Hemangioma: Interactive, Multidisciplinary, Case-Based Teaching in Vascular Anomalies for Pediatric Residents.

Introduction: Vascular anomalies are a spectrum of disorders, including vascular tumors and malformations, that often require multispecialty care. The rarity and variety of these lesions make diagnosis, treatment, and management challenging. Despite the recognition of the medical complexity and morbidity associated with vascular anomalies, there is a general lack of education on the subject for pediatric primary care and subspecialty providers. A needs assessment and the lack of an available standardized teaching tool presented an opportunity to create an educational workshop for pediatric trainees using the POGIL (process-oriented guided inquiry learning) framework. Methods: We developed a 2-hour workshop consisting of an introductory didactic followed by small- and large-group collaboration and case-based discussion. The resource included customizable content for learning assessment and evaluation. Residents completed pre- and posttest assessments of content and provided written evaluations of the teaching session. Results: Thirty-four learners in pediatrics participated in the workshop. Session evaluations were positive, with Likert responses of 4.6-4.8 out of 5 on all items. Pre- and posttest comparisons of four content questions showed no overall statistically significant changes in correct response rates. Learners indicated plans to use the clinical content in their practice and particularly appreciated the interactive teaching forum and the comprehensive overview of vascular anomalies. Discussion: Vascular anomalies are complex, potentially morbid, and often lifelong conditions; multispecialty collaboration is key to providing comprehensive care for affected patients. This customizable resource offers a framework for trainees in pediatrics to appropriately recognize, evaluate, and refer patients with vascular anomalies.

Residency Application Selection Committee Discriminatory Ability in Identifying Artificial Intelligence-Generated Personal Statements.

OBJECTIVE: Advances in artificial intelligence (AI) have given rise to sophisticated algorithms capable of generating human-like text. The goal of this study was to evaluate the ability of human reviewers to reliably differentiate personal statements (PS) written by human authors from those generated by AI software. SETTING: Four personal statements from the archives of two surgical program directors were de-identified and used as the human samples. Two AI platforms were used to generate nine additional PS. PARTICIPANTS: Four surgeons from the residency selection committees of two surgical residency programs of a large multihospital system served as blinded reviewers. AI was also asked to evaluate each PS sample for authorship. DESIGN: Sensitivity, specificity and accuracy of the reviewers in identifying the PS author were calculated. Kappa statistic for correlation between the hypothesized author and the true author were calculated. Inter-rater reliability was calculated using the kappa statistic with Light's modification given more than two reviewers in a fully-crossed design. Logistic regression was performed with to model the impact of perceived creativity, writing quality, and authorship or the likelihood of offering an interview. RESULTS: Human reviewer sensitivity for identifying an AI-generated PS was 0.87 with specificity of 0.37 and overall accuracy of 0.55. The level of agreement by kappa statistic of the reviewer estimate of authorship and the true authorship was 0.19 (slight agreement). The reviewers themselves had an inter-rater reliability of 0.067 (poor), with only complete agreement (four out of four reviewers) on two PS, both authored by humans. The odds ratio of offering an interview (compared to a composite of "backup" status or no interview) to a perceived human author was 7 times that of a perceived AI author (95% confidence interval 1.5276 to 32.0758, p=0.0144). AI hypothesized human authorship for twelve of the PS, with the last one "unsure." CONCLUSIONS: The increasing pervasiveness of AI will have far-reaching effects including on the resident application and recruitment process. Identifying AI-generated personal statements is exceedingly difficult. With the decreasing availability of objective data to assess applicants, a review and potential restructuring of the approach to resident recruitment may be warranted.

Interdisciplinary Simulation Courses to Train Residents on Communication of Unexpected Complications from Perioperative Care: A Randomized Comparison of Within-Event (Microdebriefing) and Postscenario Debriefing.

INTRODUCTION: Training to disclose bad news in a pluridisciplinary format facilitates communication and improves learning. There are many different debriefing methods described in the literature. The aim of this study was to compare and evaluate the value of final debriefing and microdebriefing with interruptions of the scenario in a simulation program about communication in unexpected complications from perioperative care. METHODS: We conducted a prospective, randomized, single center study between October 2018 and July 2019 in a simulation center. Three scenarios were related to patient or family disclosure of complications which had occurred during gynecologic surgery by a dyad involving 2 residents (a gynecology and an anesthesia resident). All sessions involved 6 residents (3 gynecologist and 3 anesthesiologist). The main outcome measure was the immediate residents' self-assessment of the impact of the course on their medical practice immediately after the session. RESULTS: We performed 15 simulation sessions including 80 residents. Thirty-nine residents were included in final debriefing group and 41 in micro-debriefing group. There was no significant difference on the impact for medical practice between groups (9.3/10 in the micro-debriefing group versus 9.2 in the final debriefing group (p = 0.53)). The overall satisfaction was high in the 2 group (9.1/10 in the 2 groups). CONCLUSION: This study is the first one to compare two debriefing methods in case of breaking bad news simulation. No difference between the 2 techniques was found concerning the students' feelings and short and long-term improvement of their communication skills.

Creation and Implementation of an Online Tool for Feedback on Resident Teaching: A Pilot Study.

OBJECTIVE: There are few assessments of the competence and growth of surgical residents as educators. We developed and piloted an observation-based feedback tool (FT) to provide residents direct feedback during a specific teaching session, as perceived by medical students (MS). We hypothesized that residents' performance would improve with frequent, low stakes, observation-based feedback. SETTING: This prospective study took place at an academic general surgery program. PARTICIPANTS: Focus groups of MS, surgical residents, and faculty informed FT development. MS completed the FT regarding resident teaching. DESIGN: The FT utilized 5 slider-bar ratings (0 to 100) about the teaching encounter and a checklist of 16 desirable teaching behaviors. QR codes and weekly email links were distributed for 12 months (6 clerkship blocks) to promote use. Residents were sent their results after each block. A survey after each block assessed motivation for use and gathered feedback on the FT. Descriptive statistics were used for analysis (medians, IQRs). Primary measures of performance were median of the slider-bar scores and the number of teaching behaviors. RESULTS: The FT was used 111 times; 37 of 46 residents were rated by up to 65 MS. The median rating on the slider-bars was 100 and the median number of desirable teaching behaviors was 12; there were no differences based on gender or PGY level. 10 residents had 5 or more FT observations during the year. Four residents had evaluations completed in 4 or more blocks and 19 residents had evaluations completed in at least 2 blocks. Over time, 13 residents had consistent slider-bar scores, 1 resident had higher scores, and 5 residents had lower scores (defined as a more than 5-point change from initial rating). Frequency of use of the FT decreased over time (38, 32, 9, 21, 7, 5 uses per block). The post-use survey was completed by 24 MS and 19 residents. Most common reasons for usage were interest in improving surgical learning environment, giving positive feedback (MS), and improving teaching skills (residents). Most common reasons for lack of usage from residents were "I did not think I taught enough to ask for feedback," "I forgot it existed," and "I did not know it existed." CONCLUSIONS: The FT did not lead to any meaningful improvement in resident scores over the course of the year. This may be due to overall high scores, suggesting that the components of the FT may require reevaluation. Additionally, decreased utilization of the instrument over time made it challenging to assess change in performance of specific residents, likely due to lack of awareness of the FT despite frequent reminders. Successful implementation of observation-based teaching assessments may require better integration with residency or clerkship objectives.

Use of Simulation For Training Advanced Colorectal Procedures.

OBJECTIVE: Simulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC). DESIGN: LLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses. SETTING: Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri. PARTICIPANTS: Senior general surgery residents at large academic surgery program. RESULTS: Fifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts. CONCLUSIONS: Surgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning.

OBJECTIVE: Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development. DESIGN: A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time. SETTING: Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system. PARTICIPANTS: General surgery residents in clinical PGY 1-5. RESULTS: Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved. CONCLUSIONS: The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.

Teaching principles of electrosurgery to OBGYN trainees via simulation: A hands-on approach.

BACKGROUND: Surgeons use electrosurgery daily, though most of them are unfamiliar with its basic safety principles. METHOD: We have designed a hands-on simulation session to teach OBGYN trainees principles of electrosurgery with practical implications for safety in the operating room. 15 participants completed post-session surveys. EXPERIENCE: Our experience of serially refining teaching materials and electrosurgery demonstrations resulted in a comprehensive guide to electrosurgery in OBGYN. CONCLUSION: This report will allow surgeon educators to implement simulation training in their institutions.

Desarrollo de la ciencia y la tecnología en las habilidades del internado rotatorio de Cirugía General / Development of science and technology in the skills of a General Surgery rotatory internship

Introducción: El desarrollo científico técnico mundial impone nuevos retos sociales y económicos, y responde a una educación de calidad, que permita la aplicación de este avance en las nuevas tecnologías. Objetivo: Exponer el desarrollo de la ciencia y la tecnología en el mejoramiento de la enseñanza de las habilidades teórico-prácticas en los estudiantes de medicina del internado rotatorio de Cirugía General. Métodos: El estudio empleó la contrastación de métodos teóricos como el histórico-lógico, el análisis documental y la sistematización teórica, para la recolección de información, la construcción, el desarrollo y la conformación final del producto. Conclusiones: Se actualizaron los fundamentos filosóficos, y los conocimientos teóricos del aprendizaje y las nuevas tecnologías para el mejoramiento de la enseñanza de las habilidades teórico-prácticas en los estudiantes de medicina del internado rotatorio de Cirugía General. El desarrollo tecnológico, la enseñanza y la práctica de la ética médica permiten solucionar los problemas de salud de la población en los distintos niveles de atención, lo cual contribuye con la formación integral del futuro médico general(AU)

Introduction: The global scientific-technical development imposes new social and economic challenges, as well as it responds to a quality education, which allows for the application of this advance to new technologies. Objective: To expose the development of science and technology for improving the theoretical-practical skills of medical students during a general surgery rotatory internship. Methods: The study used the opposition of theoretical methods such as the historical-logical, document analysis and theoretical systematization, for the collection of information, construction, development and final conformation of the product. Conclusions: The philosophical foundations were updated, together with the theoretical knowledge about learning and new technologies for improving the teaching of theoretical-practical skills among medical students during a general surgery rotatory internship. Technological development, teaching and practice of medical ethics allow solving the health problems of the population at different levels of care, which contributes to the integral formation of the future general physician(AU)

Improving Resident Knowledge of Ergonomics Guidelines.

OBJECTIVE: To improve resident knowledge of ergonomics guidelines for surgery, vaginal deliveries and repairs, and documentation. PROJECT SUMMARY: We consulted with a licensed occupational therapist at our institution regarding our difficulties with maintaining proper ergonomics while operating, performing deliveries, and documenting. We conducted two separate sessions: one in the obstetrics workroom regarding techniques to improve the ergonomics of our documentation and one in the operating room and labor and delivery unit to address techniques to avoid injury and promote long-term wellness. The sessions were conducted during morning report at our institution, and the obstetrics and gynecology teams attended both sessions. The sessions were available by videoconference for the entire residency program. Handouts were created to present basic ergonomics guidelines and were provided at the conclusion of the sessions. The handouts summarized the information provided during the sessions and included recommendations for adjustments that could be made in the workroom, operating room, and delivery room. The sessions were conducted during ACOG Wellness Week. OUTCOME: Adjustments were made in the obstetric and gynecology team workrooms to improve ergonomic function. Sessions improved resident knowledge of ergonomics recommendations for vaginal deliveries. Recommendations included guidelines for arm and shoulder position, tucked chins, and appropriate bed height (sitting vs standing). Adjustments were made in the workroom to position the top of the monitor just below eye level and arm's length away, and chairs were adjusted so that the keyboard and mouse height were just below elbow height. Residents were encouraged to keep arms and wrists in a relaxed, neutral position and to sit all the way back in the chair with back supported and feet firmly on the floor. Residents improved their knowledge of ergonomics guidelines and increased awareness of posture and positioning both on the labor and delivery unit and in the operating room. RELEVANCE TO WOMENS HEALTH OR PHYSICIANS IN PRACTICE: Work-related musculoskeletal disorders are prevalent among surgeons and can have a significant effect on productivity and career longevity. If we are able to implement evidence-based guidelines developed by high-quality ergonomics research, we can potentially protect obstetricians and gynecologists from injury and improve overall wellness.

Training Surgery Residents to be Leaders: Construction of a Resident Leadership Curriculum.

SUMMARY: Historically, the traditional pathways into plastic surgery required board eligibility in a surgical specialty such as general surgery, orthopedics, urology, neurosurgery, otolaryngology, or ophthalmology. This requirement resulted in plastic surgery residents who had served as chief residents before plastic surgery training. Their maturity emotionally and surgically allowed them to immediately concentrate on the new language and principles of plastic surgery. They had led others and were capable of leading themselves in a new surgical discipline. Today, medical students typically match into surgical specialties directly out of medical school and need to spend their time learning basic surgical skills and patient care because of the contracted time afforded to them. Formal leadership training has historically been limited in surgical training. The authors set out to delineate the creation, implementation, and perceptions of a leadership program within a surgical residency and provide guideposts for the development of engaged, conscious, and dedicated leaders within the residencies they lead.

The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room.

OBJECTIVE: To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy. BACKGROUND: Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome. METHODS: In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents. RESULTS: In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9). CONCLUSIONS: This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.

Resident education in congenital heart surgery does not compromise outcomes.

OBJECTIVE: Most of all congenital cardiac surgical programs participate in public outcomes reporting. The primary end point is transparency. In this era, academic programs with surgical residents face the challenge of producing outstanding results while allowing residents to learn by doing. We sought to understand the effect of education on our surgical outcomes. METHODS: We collected data for all American Board of Thoracic Surgery index cases done at our institution over a 10-year period. We identified 3406 cases and categorized them into 2 groups according to primary surgeon: attending (2269) versus resident (1137). In a multivariable logistic regression model we examined the effect of operating surgeon on in-hospital mortality, major morbidity, and length of stay. We used propensity score matching subsequently to balance differences between cohorts, and multivariable logistic regression was repeated. RESULTS: Using the entire cohort, multivariable logistic regression model adjusted for age, sex, weight, lack of preoperative comorbidity, presence of preoperative respiratory failure, The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery category, and need for deep hypothermic circulatory arrest, showed a higher odds of survival in the resident cohort (odds ratio, 1.484; 95% confidence interval, 0.998-2.206; P = .05). Propensity score matching identified 1137 pairs of attending and resident cases with well-balanced preoperative variables. Logistic regression modeling using the matched cohort showed equivalent 30-day mortality, 30-day major morbidity, and length of stay. CONCLUSIONS: There was no difference in mortality, major morbidity, or length of stay when similar cases were compared that were operated on by attendings versus those by a resident. Effectively educating congenital heart surgeons without compromising an operation's quality requires thoughtful approach, including case selection and graded responsibility.