The impact of intensive laparoscopic training course with structured assessment and immediate feedback on residents' operative performance in animal lab.

INTRODUCTION: The objective of this study was to examine the impact of an intensive laparoscopic training course incorporating structured assessment and immediate feedback on residents' operative performance in animal lab. METHODS: Surgical residents participated in a 2-day intensive laparoscopic training course. They performed the same procedures on two consecutive days on live pigs. Junior residents (PGY1-2) performed laparoscopic cholecystectomy and incisional hernia repair and the senior residents (PGY3-5) performed laparoscopic Nissen fundoplication, splenectomy, and low anterior colon resection. Assessment tools with proven validity evidence (global and procedure-specific rating tools for operative assessment of laparoscopic skills) were used to assess their operative performance. Faculty assessment and self-assessments were completed immediately after each procedure on both days. The Wilcoxon rank test was used to examine the effect of training on resident performance after one repetition. RESULTS: Forty surgical residents (20 junior and 20 senior residents) participated. There was a significant improvement in general laparoscopic skills during incisional hernia repair and Nissen fundoplication using global rating scales (p < 0.05). Moreover, there was an improvement in their performance during cholecystectomy, incisional hernia repair, and low anterior colectomy when procedure-specific skills assessments were used (p < 0.05). There was a positive correlation between residents' self-reported confidences and their operative performance CONCLUSION: Trainees showed significant improvements in performance in general and procedure-specific laparoscopic skills in a wide range of procedures after an intensive training course. This study demonstrates the benefit of a structured training curriculum in improving operative performance in basic and advanced laparoscopic skills in a simulated environment. Future studies are needed to examine the duration of training required to achieve skill retention and competency.

Development of a bariatric surgery specific risk assessment tool for perioperative myocardial infarction.

BACKGROUND: Perioperative myocardial infarction (PMI) is a feared complication after surgery. Bariatric surgery, due to its intraabdominal nature, is traditionally considered an intermediate risk procedure. However, there are limited data on MI rates and its predictors in patients undergoing bariatric surgery. OBJECTIVES: To enumerate the prevalence of PMI after bariatric surgery and develop a risk assessment tool. SETTING: Bariatric surgery centers, United States. METHODS: Patients undergoing bariatric surgery were identified from the MBSAQIP participant use file (PUF) 2016. Preoperative characteristics, which correlated with PMI were identified by multivariable regression analysis. PUF 2015 was used to validate the scoring tool developed from PUF 2016. RESULTS: We identified 172,017 patients from PUF 2016. Event rate for MI within 30 days of the operation was .03%; with a mortality rate of 17.3% in patients with a PMI. Four variables correlated with PMI on regression, including history of a previous MI (odds ratio [OR] = 8.57, confidence interval [CI] = 3.4-21.0), preoperative renal insufficiency (OR = 3.83, CI = 1.2-11.4), hyperlipidemia (OR = 2.60, CI = 1.3-5.1), and age >50 (OR = 2.15, CI = 1.1-4.2). Each predicting variable was assigned a score and event rate for MI was assessed with increasing risk score in PUF 2015; the rate increased from 9.5 per 100,000 operations with a score of 0 to 3.2 per 100 with a score of 5. CONCLUSION: The prevalence of MI after bariatric surgery is lower than other intraabdominal surgeries. However, mortality with PMI is high. This scoring tool can be used by bariatric surgeons to identify patients who will benefit from focused perioperative cardiac workup.

Faculty feedback versus residents' self-assessment of operative performance: Different but complementary.

BACKGROUND: Surgical training requires development of both technical and cognitive skills. The study analyzed feedback by faculty and residents' self-assessments during a laparoscopic training course to identify structure of feedback in this context and compared the focus of trainees to faculty. METHODS: This study collected assessments by surgical residents and faculty during an intensive laparoscopic training course at a single institution. The residents' operative performance was assessed using validated assessment tools including free text feedback. Assessments were completed immediately following procedures. Feedback was analyzed using qualitative method. RESULTS: Eighty (80) residents participated. Three themes were identified: Assessment, instruction and occasion. Faculty provided significantly more feedback than trainees. Moreover, the content of feedback was different. Residents focused on technical performance, while faculty commented on technical and cognitive skills, efficiency and level of independence. Errors were mainly addressed by faculty. CONCLUSION: This study demonstrated differences in cognitive focus of trainees and faculty. Text feedback is informative in understanding perceived challenges. Faculty provided explicit assessment and instruction for improvement. The effectiveness of self-assessment and feedback should be further studied.

Don't fix it if it isn't broken: a survey of preparedness for practice among graduates of Fellowship Council-accredited fellowships.

BACKGROUND: General surgery residency may not adequately prepare residents for independent practice. It is unclear; however, if non-ACGME-accredited fellowships are better meeting training needs. The purpose of this mixed-method study was to determine perceived preparedness for practice and to identify gaps in fellowship training. METHODS: A survey was developed using an iterative qualitative methodology based on interviews and focus groups of graduated fellows and program directors. Five central themes emerged and were used as a framework: professional development, job marketability, autonomy, networking, and practice management. The survey was then circulated by email to fellows who graduated from Fellowship Council (FC)-accredited programs within the past 3 years. RESULTS: Of 201 respondents (response rate = 41 %), 95 and 97 % were highly satisfied with their operative and non-operative experiences; 83 % acquired jobs aligned with their skills and expectations, while 17 % sought additional training after fellowship. Respondents who intended to learn a given procedure felt competent after fellowship to perform 51(85 %) of the 60 procedures listed. They would have liked more experience in advanced therapeutic endoscopy, complex and revisional bariatric surgery, and uncommon laparoscopic procedures such as esophagectomy, adrenalectomy, and common bile duct exploration. Thirty-one percent expressed the desire for more autonomy in the management of complications. Educational gaps existed mostly in areas of coding and billing (42 %), hiring administrative staff (42 %), and managing insurance issues (34 %). CONCLUSIONS: FC-accredited fellowships seem to adequately prepare surgeons for independent practice and bridge training gaps after residency. Graduates are highly satisfied with the individualized training experience and acquire desired jobs aligned with their career goals.

Surgical skills curricula in American College of Surgeons Accredited Education Institutes: An international survey.

BACKGROUND: A clear understanding of simulation-based curricula in use at American College of Surgeons Accredited Education Institutes (ACS-AEIs) is lacking. METHODS: A 25-question online survey was sent to ACS-AEIs. RESULTS: The response rate approached 60%. The most frequent specialties to use the ACS-AEIs are general surgery and obstetrics/gynecology (94%). Residents are the main target population for programming/training (96%). Elements of the ACS/Association of Program Directors in Surgery Surgical Skills Curriculum are used by 77% of responding ACS-AEIs. Only 49% of ACS-AEIs implement the entire curriculum and 96% have independently developed their own surgical skills curricula. "Home-grown" simulators have been designed at 71% of ACS-AEIs. Feasibility (80%), evidence of effectiveness (67%), and cost (60%) were reasons for curriculum adoption. All programs use operative assessment tools for resident performance, and 53% use Messick's unitary framework of validity. Most programs (88%) have financial support from their academic institute. Majority of ACS-AEIs had trainees evaluate their faculty instructors (90%), and the main form of such faculty evaluation was postcourse surveys (97%). CONCLUSION: This study provides specific information regarding simulation-based curricula at ACS-AEIs.

Reduced Survival in Bariatric Surgery Candidates Delayed or Denied by Lack of Insurance Approval.

Bariatric surgery reduces mortality for Americans who meet candidacy criteria and have insurance coverage. Unfortunately, some medically suitable candidates are denied or delayed during insurance approval processes. The long-term impact of such care delays on survival is unknown. Using a prospectively maintained bariatric intake database, we identified consecutive applicants who were evaluated and medically cleared by our multidisciplinary care team and for whom insurance approval was requested. We compared survival in those who were initially approved by their insurance carriers (controls) and those who were initially denied coverage (subjects). Mortality was determined using the Social Security Death Index. Kaplan-Meier survival curves were plotted and the log-rank test for significance was applied. From August 2003 to December 2008, 463 patients (391 females, mean age 45 ± 10 years, mean body mass index 52.5 ± 9.4 kg/m(2)) were medically cleared for a bariatric procedure. Of these, 363 were approved by insurance on initial request, whereas 100 were denied. Given the study's intention to measure the aggregate impact of delays and denials, nine patients who later came to operation after appeal or coverage change were maintained in the subject cohort. During 0- to 113-month follow-up, six subjects (6%) died compared with seven controls (1.9%), corresponding to a statistically significant survival benefit for patients initially approved for bariatric surgery without delay or denial (P < 0.001). In conclusion, access to bariatric surgical care was impeded by insurance certification processes in 22 per cent of medically acceptable candidates. Processes that delay or restrict efficient access to bariatric surgery are associated with a 3-fold mortality increase.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool.

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.

Quantitative and qualitative analysis of performance during advanced laparoscopic fellowship: a curriculum based on structured assessment and feedback.

BACKGROUND: The objective of this study was to examine the acquisition of advanced laparoscopic technical and cognitive skills during a fellowship. METHODS: During a yearlong fellowship, consecutive assessments were completed by a fellow and 1 attending for 3 advanced procedures. The Global Operative Assessment of Laparoscopic Skills, Objective Structured Assessment of Technical Skills, and procedure-specific rating tools and free-text feedback were used. Descriptive statistics, the t test, linear mixed-effects regression, and qualitative analysis of feedback were performed. RESULTS: Seventy-six cases were included. Average ratings increased for each assessment area every month (P < .001). There were significant differences between ratings by assessors with more stringent ratings by the fellow. While the attending focused on efficiency and safety, the fellow focused on technical issues, with later expanded attention to advanced cognitive aspects. CONCLUSIONS: These assessment tools can be used as a quantitative index to monitor fellows' learning curve. In combination with narrative feedback, such data can provide measures to direct improvement during self-directed learning.

Technical skills assessment toolbox: a review using the unitary framework of validity.

OBJECTIVE: The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity. BACKGROUND: Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency. METHODS: A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills. RESULTS: A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables. CONCLUSIONS: This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.

GOALS-incisional hernia: a valid assessment of simulated laparoscopic incisional hernia repair.

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.