A Proposed Blueprint for Operative Performance Training, Assessment, and Certification.

OBJECTIVE: The aim of this study was to propose an evidence-based blueprint for training, assessment, and certification of operative performance for surgical trainees. SUMMARY BACKGROUND DATA: Operative skill is a critical aspect of surgical performance. High-quality assessment of operative skill therefore has profound implications for training, accreditation, certification, and the public trust of the profession. Current methods of operative skill assessment for surgeons rely heavily on global assessment strategies across a very broad domain of procedures. There is no mechanism to assure technical competence for individual procedures. The science and scalability of operative skill assessment has progressed significantly in recent decades, and can inform a much more meaningful strategy for competency-based assessment of operative skill than has been previously achieved. METHODS: The present article reviews the current status and science of operative skill assessment and proposes a template for competency-based assessment which could be used to update training, accreditation, and certification processes. The proposal is made in reference to general surgery but is more generally applicable to other procedural specialties. RESULTS: Streamlined, routine assessment of every procedure performed by surgical trainees is feasible and would enable a more competency-based educational paradigm. In light of the constraints imposed by both clinical volume and assessment bias, trainees should be expected to become proficient and be measured against a mastery learning standard only for the most important and highest-frequency procedures. For less frequently observed procedures, performance can be compared to a norm-referenced standard and, to provide an overall trajectory of performance, analyzed in aggregate. Key factors in implementing this approach are the number of evaluations, the number of raters, the timeliness of evaluation, and evaluation items. CONCLUSIONS: A competency-based operative skill assessment can be incorporated into surgical training, assessment, and certification. The time has come to develop a systematic approach to this issue as a means of demonstrating professional standards worthy of the public trust.

Medical Students' Progress in Detecting and Interpreting Visual and Auditory Clinical Findings.

Phenomenon: Detection of visual and auditory clinical findings is part of medical students' core clinical performance abilities that a medical education curriculum should teach, assess, and remediate. However, there is a limited understanding of how students develop these skills. While training physical exam technical skills has received significant attention and emphasis, teaching and assessing medical students' ability to detect and interpret visual and auditory clinical findings skills has been less systematic. Therefore, the purpose of this study is to investigate how medical students' visual and auditory clinical findings skills progress and develop over their four years of undergraduate medical education. This study will provide educators insights that can guide curriculum refinements that lead to improving students' abilities in this area. Approach: A computer-based progress exam was created to measure the longitudinal development of students' abilities to detect and interpret visual and auditory findings. After pilot testing, sixty test items were developed in collaboration with six clinical faculty members and two medical education researchers. The exam includes detection and description of ECG, x-ray, heart sounds, breath sounds, skin lesions, and movement findings. The exam was administered to students at the beginning of each training year since 2014. Additionally, the exam was administered to the Class of 2017 prior to their graduation. Measurement validity and reliability tests were conducted. Descriptive statistics and ANOVA were used to determine progress. Findings: More than 98% of students in four years of training completed the exam each year. The exam instrument had high reliabilities and demonstrated acceptable concurrent validity when compared with other academic performance data. Findings showed that students' visual and auditory clinical findings skills increased each training year until their fourth year. There was no performance improvement between incoming Year 4 students and graduating Year 4 students. While group means increased, class performance did not become more homogeneous across four years. Longitudinal data showed the same performance patterns as the cross-sectional data. Performance of the bottom quartile of graduating fourth-year students was not significantly higher than the performance of the top quartile of incoming first-year students who had not had formal medical training. Insights: A longitudinal study to follow learners' performance in detecting and interpreting visual and auditory clinical findings can provide meaningful insights regarding the effects of medical training programs on performance growth. The present study suggests that our medical curriculum is not effective in bringing all students to a higher level of performance in detecting and interpreting visual and auditory clinical findings. This study calls for further investigation how medical students can develop visual and auditory detection and interpretation skills in undergraduate medical education. There is a need for planned curriculum and assessment of medical students' skills in detecting and interpreting visual and auditory clinical findings.

How Many Observations are Needed to Assess a Surgical Trainee's State of Operative Competency?

OBJECTIVE: To establish the number of operative performance observations needed for reproducible assessments of operative competency. BACKGROUND: Surgical training is transitioning from a time-based to a competency-based approach, but the number of assessments needed to reliably establish operative competency remains unknown. METHODS: Using a smart phone based operative evaluation application (SIMPL), residents from 13 general surgery training programs were evaluated performing common surgical procedures. Two competency metrics were investigated separately: autonomy and overall performance. Analyses were performed for laparoscopic cholecystectomy performances alone and for all operative procedures combined. Variance component analyses determined operative performance score variance attributable to resident operative competency and measurement error. Generalizability and decision studies determined number of assessments needed to achieve desired reliability (0.80 or greater) and determine standard errors of measurement. RESULTS: For laparoscopic cholecystectomy, 23 ratings are needed to achieve reproducible autonomy ratings and 17 ratings are needed to achieve reproducible overall operative performance ratings. For the undifferentiated mix of procedures, 60 ratings are needed to achieve reproducible autonomy ratings and 40 are needed for reproducible overall operative performance ratings. CONCLUSION: The number of observations needed to achieve reproducible assessments of operative competency far exceeds current certification requirements, yet remains an important and achievable goal. Attention should also be paid to the mix of cases and raters in order to assure fair judgments about operative competency and fair comparisons of trainees.

Readiness of US General Surgery Residents for Independent Practice.

OBJECTIVE: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. BACKGROUND: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. METHODS: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. RESULTS: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%. CONCLUSIONS: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Practice Guidelines for Operative Performance Assessments.

OBJECTIVE: To provide recommended practice guidelines for assessing single operative performances and for combining results of operative performance assessments into estimates of overall operative performance ability. SUMMARY BACKGROUND DATA: Operative performance is one defining characteristic of surgeons. Assessment of operative performance is needed to provide feedback with learning benefits to surgical residents in training and to assist in making progress decisions for residents. Operative performance assessment has been a focus of investigation over the past 20 years. This review is designed to integrate findings of this research into a set of recommended operative performance practices. METHODS: Literature from surgery and from other pertinent research areas (psychology, education, business) was reviewed looking for evidence to inform practice guideline development. Guidelines were created along with a conceptual and scientific foundation for each guideline. RESULTS: Ten guidelines are provided for assessing individual operative performances and 10 are provided for combing data from individual operative performances into overall judgments of operative performance ability. CONCLUSIONS: The practice guidelines organize available information to be immediately useful to program directors, to support surgical training, and to provide a conceptual framework upon which to build as the base of pertinent knowledge expands through future research and development efforts.

Competencies, milestones, and EPAs - Are those who ignore the past condemned to repeat it?

BACKGROUND: The idea of competency-based education sounds great on paper. Who wouldn't argue for a standardized set of performance-based assessments to assure competency in graduating students and residents? Even so, conceptual concerns have already been raised about this new system and there is yet no evidence to refute their veracity. AIMS: We argue that practical concerns deserve equal consideration, and present evidence strongly suggesting these concerns should be taken seriously. METHOD: Specifically, we share two historical examples that illustrate what happened in two disparate contexts (K-12 education and the Department of Defense [DOD]) when competency (or outcomes-based) assessment frameworks were implemented. We then examine how observation and assessment of clinical performance stands currently in medical schools and residencies, since these methodologies will be challenged to a greater degree by expansive lists of competencies and milestones. RESULTS/CONCLUSIONS: We conclude with suggestions as to a way forward, because clearly the assessment of competency and the ability to guarantee that graduates are ready for medical careers is of utmost importance. Hopefully the headlong rush to competencies, milestones, and core entrustable professional activities can be tempered before even more time, effort, frustration and resources are invested in an endeavor which history suggests will collapse under its own weight.

Twenty Questions game performance on medical school entrance predicts clinical performance.

CONTEXT: This study is based on the premise that the game of 'Twenty Questions' (TQ) tests the knowledge people acquire through their lives and how well they organise and store it so that they can effectively retrieve, combine and use it to address new life challenges. Therefore, performance on TQ may predict how effectively medical school applicants will organise and store knowledge they acquire during medical training to support their work as doctors. OBJECTIVES: This study was designed to determine whether TQ game performance on medical school entrance predicts performance on a clinical performance examination near graduation. METHODS: This prospective, longitudinal, observational study involved each medical student in one class playing a game of TQ on a non-medical topic during the first week of medical school. Near graduation, these students completed a 14-case clinical performance examination. Performance on the TQ task was compared with performance on the clinical performance examination. RESULTS: The 24 students who exhibited a logical approach to the TQ task performed better on all senior clinical performance examination measures than did the 26 students who exhibited a random approach. Approach to the task was a better predictor of senior examination diagnosis justification performance than was the Medical College Admission Test (MCAT) Biological Science Test score and accounts for a substantial amount of score variation not attributable to a co-relationship with MCAT Biological Science Test performance. CONCLUSIONS: Approach to the TQ task appears to be one reasonable indicator of how students process and store knowledge acquired in their everyday lives and may be a useful predictor of how they will process the knowledge acquired during medical training. The TQ task can be fitted into one slot of a mini medical interview.

Biomedical knowledge, clinical cognition and diagnostic justification: a structural equation model.

CONTEXT: The process whereby medical students employ integrated analytic and non-analytic diagnostic strategies is not fully understood. Analysing academic performance data could provide a perspective complementary to that of laboratory experiments when investigating the nature of diagnostic strategy. This study examined the performance data of medical students in an integrated curriculum to determine the relative contributions of biomedical knowledge and clinical pattern recognition to diagnostic strategy. METHODS: Structural equation modelling was used to examine the relationship between biomedical knowledge and clinical cognition (clinical information gathering and interpretation) assessed in Years 1 and 2 of medical school and their relative contributions to diagnostic justification assessed at the beginning of Year 4. Modelling was applied to the academic performance data of 133 medical students who received their md degrees in 2011 and 2012. RESULTS: The model satisfactorily fit the data. The correlation between biomedical knowledge and clinical cognition was low-moderate (0.26). The paths between these two constructs and diagnostic justification were moderate and slightly favoured biomedical knowledge (0.47 and 0.40 for biomedical knowledge and clinical cognition, respectively). CONCLUSIONS: The findings suggest that within the first 2 years of medical school, students possessed separate, but complementary, cognitive tools, comprising biomedical knowledge and clinical pattern recognition, which contributed to an integrated diagnostic strategy at the beginning of Year 4. Assessing diagnostic justification, which requires students to make their thinking explicit, may promote the integration of analytic and non-analytic processing into diagnostic strategy.

Consumer acceptability of no added sugar pound cakes under blind and informed testing conditions.

Stevia is an emerging natural high-intensity sweetener. There are negative perceptions of zero-calorie sweeteners, but studies that provide knowledge of these sweeteners improve their perception. This study evaluated consumer acceptability of a zero-sugar bakery product under blind and informed conditions (n = 96) along with physicochemical analysis of the products. Rebaudioside A (Reb A) and the new types of stevia (Rebs D and M) with sugar as a control were used to formulate pound cakes. Panelists evaluated the overall hedonic impressions (aroma, texture, flavor, and aftertaste) and intensity (sweetness and bitterness) of the cakes under blind and informed conditions with an enforced 2-week break between evaluations. During the informed session, a document was provided prior to evaluating samples that included stevia's health benefits and the nutritional facts panels for the cakes. The cakes underwent volatile profile (electronic nose [e-nose]) and water activity (aw ) analysis. Overall, stevia cakes showed an increase in flavor and texture liking during the informed session when compared to the blind session, but only Reb A showed a significant difference (p < 0.05). The increase in liking scores indicated that information positively affected the consumer's perception of the stevia-sweetened cakes attributes. The e-nose confirmed differences in aroma. There was a significant difference in aw of the samples Rebs A, D, M versus sucrose (p < 0.05). No significant differences were observed among the Rebs (p > 0.05). This study illustrates that stevia, despite non-browning or fermenting, can be used in a practical baking application, and product-related information impacts consumer acceptability. PRACTICAL APPLICATION: This study demonstrates that product-related information may have an impact on the consumer acceptability of the product. Through potential labeling improvements, overall consumer perception and acceptability of zero-sugar added or low-sugar products could be improved. This study also illustrates that stevia, despite being a non-browning or fermenting sugar alternative, can be used in a practical baking application.

Impact Performance of 3D Printed Spatially Varying Elastomeric Lattices.

Additive manufacturing is catalyzing a new class of volumetrically varying lattice structures in which the dynamic mechanical response can be tailored for a specific application. Simultaneously, a diversity of materials is now available as feedstock including elastomers, which provide high viscoelasticity and increased durability. The combined benefits of complex lattices coupled with elastomers is particularly appealing for anatomy-specific wearable applications such as in athletic or safety equipment. In this study, Siemens' DARPA TRADES-funded design and geometry-generation software, Mithril, was leveraged to design vertically-graded and uniform lattices, the configurations of which offer varying degrees of stiffness. The designed lattices were fabricated in two elastomers using different additive manufacturing processes: (a) vat photopolymerization (with compliant SIL30 elastomer from Carbon) and (b) thermoplastic material extrusion (with Ultimaker™ TPU filament providing increased stiffness). Both materials provided unique benefits with the SIL30 material offering compliance suitable for lower energy impacts and the Ultimaker™ TPU offering improved protection against higher impact energies. Moreover, a hybrid lattice combination of both materials was evaluated and demonstrated the simultaneous benefits of each, with good performance across a wider range of impact energies. This study explores the design, material, and process space for manufacturing a new class of comfortable, energy-absorbing protective equipment to protect athletes, consumers, soldiers, first responders, and packaged goods.

A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study.

OBJECTIVE: This study evaluated operative performance rating (OPR) characteristics and measurement conditions necessary for reliable and valid operative performance (OP) assessment. BACKGROUND: Operative performance is a signature surgical-practice characteristic that is not measured systematically and specifically during residency training. METHODS: Expert surgeon raters from multiple institutions, blinded to resident characteristics, independently evaluated 8 open and laparoscopic OP recordings immediately after observation. RESULTS: A plurality of raters agreed on operative performance ratings (OPRs) for all performances. Using 10 judges adjusted for rater idiosyncrasies. Interrater agreement was similar for procedure-specific and general items. Higher post graduate year (PGY) residents received higher OPRs. Supervising-surgeon ratings averaged 0.51 points (1.2 standard deviations) above expert ratings for the same performances. CONCLUSIONS: OPRs have measurement properties (reliability, validity) similar to those of other well-developed performance assessments (Mini-CEX [clinical evaluation exercise], standardized patient examinations) when ratings occur immediately after observation. OPRs by blinded expert judges reflect the level of resident training and are practically significant differences as the average rating for PGY 4 residents corresponded to a "Good" performance whereas those for PGY 5 residents corresponded to a "Very Good" performance. Supervising surgeon ratings are higher than expert judge ratings reflecting the effect of interpersonal factors on supervising surgeon ratings. Use of local and national norms for interpretation of OPRs would adjust for these interpersonal factors. The OPR system provides a practical means for measuring operative performance, which is a signature characteristic of surgical practice.

The case of the entitled resident: a composite case study of a resident performance problem syndrome with interdisciplinary commentary.

BACKGROUND: Residents with performance problems create substantial burden on programs and institutions. Understanding the nature and quality of performance problems can help in learning to address performance problems. AIM: We sought to illuminate the effects of resident performance problems and the potential solutions for those problems from the perspectives of people with various roles in health care. METHODS: We created a composite portrait from several residents who demonstrated a cluster of common performance characteristics and whose chronic or serious maladaptive behavior and response to situations created problems for themselves, for their clinical colleagues, and for faculty of their residency program. The composite was derived from in-depth interviews of program directors and review of resident records. We solicited practitioners from multiple fields to respond to the portrait by answering a series of questions about severity, prognosis, and how and whether one could reliably remediate a person with these performance characteristics. We present their perspectives in a manner borrowed from the New England Journal of Medicine's "Case Records of the Massachusetts General Hospital." RESULTS: We created a composite portrait of a resident whose behavior suggested he felt entitled to benefits his peers were not entitled to. Experts reflecting on his behavior varied in their opinion about the effect the resident would have on the health care system. They suggested approaches to remediation that required substantial time and effort from the faculty. CONCLUSION: Programs must balance the needs of individual residents to adjust their behaviors with the needs of the health care system and other people within it.

The efficacy of a targeted remediation process for students who fail standardized patient examinations.

BACKGROUND: Current remediation strategies for students failing standardized patient examinations represent poorly targeted approaches since the specific nature of clinical performance weaknesses has not been defined. PURPOSE: The purpose is to determine the impact of a specifically targeted clinical performance course required of students who failed a clinical performance examination. METHODS: A month-long clinical performance course, targeted to treat specific types of clinical performance deficiencies, was designed to remediate students failing standardized patient examinations in 2007 (n=8) and 2008 (n=5). Participating students were assessed on pre- and postperformance measures, including multiple-choice tests that measured diagnostic pattern recognition and clinical data interpretation and clinical performance measures using standardized clinical encounters. Comparisons between average pre- and postintervention performance scores were computed using paired sample t tests. Results were adjusted for regression toward the mean. RESULTS: In both 2007 and 2008, the mean preintervention clinical data interpretation and standardized patient examination scores were below the criterion referenced passing standard set for the clinical competency exam. In both years the mean postintervention scores for the participants were above the passing standard for these two examinations. Pre- and postintervention differences were statistically significant in both cases. CONCLUSIONS: This study provides insight into the reasons that students fail clinical performance examinations and elucidates one method by which such students may be successfully remediated.

Bilateral use of the vertical expandable prosthetic titanium rib attached to the pelvis: a novel treatment for scoliosis in the growing spine.

OBJECT: Few options exist for the treatment of severe, early onset scoliosis. Goals of treatment include stabilizing curve progression while allowing for normal spine, chest, and lung growth. The vertical expandable prosthetic titanium rib (VEPTR) is a novel device designed to control the spine deformity while permitting lung and spine growth. In this paper the authors report their experience with using bilateral VEPTRs from the ribs to the pelvis for children with severe, early onset scoliosis. METHODS: Eleven children were identified who had been treated with bilateral VEPTRs from the ribs to the pelvis. The authors conducted a retrospective review and collected the following data: clinical diagnosis, age at surgery, number of lengthening procedures, and complications. In addition, pre- and postoperative radiographs were reviewed to measure maximum Cobb angle (both thoracic and lumbar), thoracic height, total spine height as measured from T-1 to S-1, thoracic kyphosis (T2-12), and lumbar lordosis (L1-S1). RESULTS: The average patient age at surgery was 71 months; the mean preoperative thoracic Cobb angle was 81.7 degrees . This angle was corrected to 50.6 degrees immediately postoperatively, and this correction was maintained; at the most recent follow-up the curves averaged 58 degrees . Similarly, the preoperative kyphosis (T2-12) angle measured 43 degrees preoperatively, 23 degrees immediately postoperatively, and 37 degrees at the most recent follow-up evaluation. The patients underwent a total of 41 lengthening procedures (average 3.7 lengthening procedures per patient), and overall spine length increased from 23.1 cm preoperatively, to 27.3 cm immediately postoperatively, to 29.4 cm at the final follow-up (an average of 25 months). Four (36.4%) of the 11 patients experienced complications. CONCLUSIONS: The VEPTR offers a viable treatment option for children with severe, early onset scoliosis. It achieves and maintains spinal deformity correction, while allowing for continued spine and chest-wall growth. Complication rates are similar to those reported for other growing systems.

Getting Real: Aligning the Learning Needs of Clerkship Students With the Current Clinical Environment.

The authors present follow-up to a prior publication, which proposed a new model for third-year clerkships. The new model was created to address deficiencies in the clinical year and to rectify a recognized mismatch between students' learning needs and the realities of today's clinical settings. The new curricular model was implemented at Southern Illinois University School of Medicine in academic year 2016-2017. Guiding principles were developed. These were to more deeply engage students in experiential learning through clinical immersion; to pair individual faculty with individual students over longer periods of time so real trust could be developed; to provide students with longitudinal clinical reasoning education under controlled instructional conditions; to simplify goals and objectives for the core clerkships and align them with student learning needs; and to provide students with individualized activities to help them explore areas of interest, choose their specialty, and improve areas of clinical weakness before the fourth year. The authors discuss reactions by faculty and students to the new curriculum, which were mostly positive, as well as several outcomes. Students showed very different attitudes toward what they defined as success in the clerkship year, reflective of their deeper immersion. Students spent more time working in clinical settings and performed more procedures. Performance on Step 2 Clinical Knowledge and Clinical Skills was unchanged from traditional clerkship years. The 2015 article called for rethinking the third-year clerkships. The authors have shown that such change is possible, and the new curriculum can be implemented with successful early outcomes.

Do End-of-Rotation Evaluations Adequately Assess Readiness to Operate?

PURPOSE: Medical educators have developed no standard way to assess the operative performance of surgical residents. Most residency programs use end-of-rotation (EOR) evaluations for this purpose. Recently, some programs have implemented workplace-based "microassessment" tools that faculty use to immediately rate observed operative performance. The authors sought to determine (1) the degree to which EOR evaluations correspond to workplace-based microassessments and (2) which factors most influence EOR evaluations and directly observed workplace-based performance ratings and how the influence of those factors differs for each assessment method. METHOD: In 2017, the authors retrospectively analyzed EOR evaluations and immediate postoperative assessment ratings of surgical trainees from a university-based training program from the 2015-2016 academic year. A Bayesian multivariate mixed model was constructed to predict operative performance ratings for each type of assessment. RESULTS: Ratings of operative performance from EOR evaluations vs workplace-based microassessment ratings had a Pearson correlation of 0.55. Postgraduate year (PGY) of training was the most important predictor of operative performance ratings on EOR evaluations: Model estimates ranged from 0.62 to 1.75 and increased with PGY. For workplace-based assessment, operative autonomy rating was the most important predictor of operative performance (coefficient = 0.74). CONCLUSIONS: EOR evaluations are perhaps most useful in assessing the ability of a resident to become a surgeon compared with other trainees in the same PGY of training. Workplace-based microassessments may be better for assessing a trainee's ability to perform specific procedures autonomously, thus perhaps providing more insight into a trainee's true readiness for operative independence.

Identifying and Addressing High Priority Issues in General Surgery Training and Education.

BACKGROUND: Complex problems are often easier to address when multiple entities collaborate. The Procedural Learning and Safety Collaborative (PLSC) was established to address complex problems in general surgery residency training by connectively engaging multiple residency programs in addressing progressive research questions. STUDY DESIGN: Recently, PLSC members held a national symposium which included leadership from several leading surgical societies to come to a consensus on what are the most critical issues in general surgery education. RESULTS: This paper describes the process used and the end result of this process. This paper describes the process used and the end result of this process.

Value and Barriers to Use of the SIMPL Tool for Resident Feedback.

OBJECTIVE: The System for Improving and Measuring Procedural Learning (SIMPL) is a smart-phone application used to provide residents with an evaluation of operative autonomy and feedback. This study investigated the perceived benefits and barriers to app use. DESIGN: A database of previously performed SIMPL evaluations was analyzed to identify high, low, and never users. Potential predisposing factors to use were explored. A survey investigating key areas of value and barriers to use for the SIMPL application was sent to resident and faculty users. Respondents were asked to self-identify how often they used the app. The perceived benefits and barriers were correlated with the level of usage. Qualitative analysis of free text responses was used to determine strategies to increase usage. SETTING: General surgery training programs who are members of the Procedural Learning and Safety Collaborative. PARTICIPANTS: Surgical residents and faculty. RESULTS: At least 1 SIMPL evaluation was created for 411 residents and 524 faculty. Thirty percent of both faculty and residents were high-frequency users. Thirty percent of faculty were never users. One hundred eighty-eight residents and 207 faculty (response rate 46%) completed the survey. High-frequency resident users were more likely to perceive a benefit for both numerical evaluations (76% vs 30%) and dictated feedback (92% vs 30%). Faculty and residents commonly blamed each other for not creating and completing evaluations regularly (87% of residents, 81% of faculty). Suggested strategies to increase usage included reminders and integration with existing data systems. CONTRIBUTIONS: Frequent users perceive value from the application, particularly from dictated feedback and see a positive impact on feedback in their programs. Faculty engagement represents a major barrier to adoption. Mechanisms which automatically remind residents to initiate an evaluation will help improve utilization but programs must work to enhance faculty willingness to respond and dictate feedback.

The effect of gender on operative autonomy in general surgery residents.

BACKGROUND: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees. METHODS: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis. RESULTS: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training. CONCLUSION: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

Percutaneous Ultrasonic Tenotomy for Refractory Common Extensor Tendinopathy After Failed Open Surgical Release: A Report of Two Cases.

Common extensor tendinopathy (CET) is a common, painful overuse and degenerative condition of the lateral elbow, affecting an estimated 2 million patients per year. Although many cases resolve with conservative treatment, recalcitrant cases may progress to open surgical intervention. For patients who do not improve with surgical management, treatment options are extremely limited. In this article, we present 2 cases of recalcitrant surgically treated CET successfully treated with sonographically guided percutaneous ultrasonic tenotomy with 1-year follow-up. To our knowledge, this is the first publication demonstrating successful treatment of recalcitrant CET after open surgical repair, with the use of ultrasonic tenotomy. LEVEL OF EVIDENCE: V.