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BACKGROUND: The Surgical Skills and Technology Elective Program (SSTEP) is a voluntary preclerkship surgical bootcamp that uses simulation learning to build procedural knowledge and technical skills before clerkship. METHODS: Eighteen second year students (n = 18) participated in simulation workshops over the course of 7 days to learn clerkship-level procedural skills. A manual was supplied with the program outline. Assessment of the participants involved: 1) a written exam 2) a single videotaped Objective Structured Assessment of Technical Skill (OSATS) station 3) an exit survey to document changes in career choices. RESULTS: Compared to the mean written pre-test score students scored significantly higher on the written post-test (35.83 ± 6.56 vs. 52.11 ± 5.95 out of 73) (p = 0.01). Technical skill on the OSATS station demonstrated improved performance and confidence following the program (10.10 vs. 17.94 out of 25) (p = 0.05). Most participants (72%) re-considered their choices of surgical electives. CONCLUSIONS: A preclerkship surgical skills program not only stimulates interest in surgery but can also improve surgical knowledge and technical skills prior to clerkship.
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Selección de Profesión , Prácticas Clínicas/métodos , Competencia Clínica , Curriculum , Educación de Pregrado en Medicina/normas , Cirugía General/educación , Estudiantes de Medicina , Evaluación Educacional , Estudios de Factibilidad , Humanos , Aprendizaje , Encuestas y CuestionariosRESUMEN
BACKGROUND: Competency-based education and simulation are being used more frequently in surgical skills curricula. We explored a novel student-led learning paradigm, which allows trainees to become more active participants in the learning process while maintaining expert guidance and supervision. METHODS: Twelve first-year orthopedic residents were randomized to either a student-led (SL) or a traditional instructor-led group during an intensive, month-long, laboratory-based technical skills training course. A rigorous qualitative-description approach was used for analysis. RESULTS: Four prominent themes emerged: instructional style, feedback, peer and instructor collaboration, and self-efficacy. Compared with the instructor-led group, there was more peer assistance, feedback, collaboration, and hands-on and active learning observed in the SL group. CONCLUSIONS: The flexible and socially rich nature of the SL learning environment may aid in development of both technical and nontechnical skills early in residency and ultimately privilege later clinical learning.
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Educación Basada en Competencias/métodos , Internado y Residencia/métodos , Modelos Educacionales , Ortopedia/educación , Adulto , Competencia Clínica , Conducta Cooperativa , Retroalimentación Psicológica , Femenino , Humanos , Masculino , Ontario , AutoeficaciaRESUMEN
OBJECTIVE: To develop and evaluate an objective method of technical skills assessment for graduating subspecialists in colorectal (CR) surgery-the Colorectal Objective Structured Assessment of Technical Skill (COSATS). BACKGROUND: It may be reasonable for the public to assume that surgeons certified as competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a surgeon, is not directly assessed at the time of certification by surgical boards. METHODS: A procedure-based, multistation technical skills examination was developed to reflect a sample of the range of skills necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models. Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10 graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global rating score was used as the overall examination score and a passing score was set at "borderline competent for CR practice." RESULTS: The global rating scale demonstrated acceptable interstation reliability (0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to level of training. Nine CR residents but only 3 GS residents were deemed competent. CONCLUSIONS: The Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could be incorporated into the colorectal board examination where it would be the first attempt of a surgical specialty to formally assess technical skill at the time of certification.
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Competencia Clínica , Cirugía Colorrectal/educación , Internado y Residencia , Evaluación Educacional/métodos , HumanosRESUMEN
The current methods used to train residents to become orthopaedic surgeons are based on tradition, not evidence-based models. Educators have only a limited ability to assess trainees for competency using validated tests in various domains. The reduction in resident work hours limits the time available for clinical training, which has resulted in some calls for lengthening the training process. Another approach to address limited training hours is to focus training in a program that allows residents to graduate from a rotation based on demonstrated competency rather than on time on a service. A pilot orthopaedic residency curriculum, which uses a competency-based framework of resident training and maximizes the use of available training hours, has been designed and is being implemented.
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Educación Basada en Competencias , Ortopedia/educación , Educación Basada en Competencias/organización & administración , Educación Basada en Competencias/normas , Humanos , Modelos Educacionales , Desarrollo de ProgramaRESUMEN
OBJECTIVE: : To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure. BACKGROUND: : Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated. METHODS: : This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills. RESULTS: : Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027). CONCLUSIONS: : Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.).
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Competencia Clínica , Curriculum , Laparoscopía/educación , Adulto , Colecistectomía Laparoscópica/educación , Femenino , Humanos , Curva de Aprendizaje , Masculino , Estudios Prospectivos , Método Simple CiegoRESUMEN
OBJECTIVE: To compare the effectiveness and cost of 2 ex vivo training curricula for laparoscopic suturing. BACKGROUND: Although simulators have been developed to teach laparoscopic suturing, a barrier to their wide implementation in training programs is a lack of knowledge regarding their relative training benefit and their associated cost. METHOD: This prospective single-blinded randomized trial allocated 24 surgical residents to train to proficiency using either a virtual reality (VR) simulator or box trainer. All residents then placed intracorporeal laparoscopic stitches during a Nissen fundoplication on a patient. The operating room (OR) cases were video-recorded and technical proficiency was assessed using 2 validated tools. OR performance of both groups was compared to that of conventionally trained residents and to fellowship-trained surgeons. A cost analysis of box training, VR training, and conventional residency training across Canadian surgical programs was performed. RESULTS: After ex vivo training, no significant differences in laparoscopic suturing in the OR were found between the 2 groups with respect to time (P = 0.74)-global rating score (P = 0.65) or checklist score (P = 0.97). It took conventionally trained residents 6 practice attempts in the OR to achieve the technical proficiency of the ex vivo trained groups (P = 0.83). VR training was more efficient than box training (transfer effectiveness ratio of 2.31 vs 1.13). The annual cost of training 5 residents on the FLS trainer box was $11,975.00, on the VR simulator was $77,500.00, and conventional residency training was $17,380.00. Over 5 years, box training was the most cost-effective option for all programs, and VR training was more cost-effective for programs with more 10 residents. CONCLUSIONS: Training on either a VR simulator or on a box trainer significantly decreased the learning curve necessary to learn laparoscopic suturing. VR training, however, is the more efficient training modality, whereas box training the more cost-effective option.
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Competencia Clínica , Curriculum , Fundoplicación/métodos , Laparoscopía/educación , Técnicas de Sutura/educación , Canadá , Simulación por Computador , Costos y Análisis de Costo , Humanos , Internado y Residencia , Curva de Aprendizaje , Estudios Prospectivos , Método Simple Ciego , Análisis y Desempeño de Tareas , Interfaz Usuario-ComputadorRESUMEN
As the medical education community celebrates the 100th anniversary of the seminal Flexner Report, medical education is once again experiencing significant pressure to transform. Multiple reports from many of medicine's specialties and external stakeholders highlight the inadequacies of current training models to prepare a physician workforce to meet the needs of an increasingly diverse and aging population. This transformation, driven by competency-based medical education (CBME) principles that emphasize the outcomes, will require more effective evaluation and feedback by faculty.Substantial evidence suggests, however, that current faculty are insufficiently prepared for this task across both the traditional competencies of medical knowledge, clinical skills, and professionalism and the newer competencies of evidence-based practice, quality improvement, interdisciplinary teamwork, and systems. The implication of these observations is that the medical education enterprise urgently needs an international initiative of faculty development around CBME and assessment. In this article, the authors outline the current challenges and provide suggestions on where faculty development efforts should be focused and how such an initiative might be accomplished. The public, patients, and trainees need the medical education enterprise to improve training and outcomes now.
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Educación Basada en Competencias , Educación Médica , Evaluación Educacional/normas , Docentes Médicos , Mejoramiento de la Calidad , Desarrollo de Personal , HumanosRESUMEN
OBJECTIVES: To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. DESIGN: Pre- and post intervention survey. SETTING: Eight hospitals participating in a trial of a WHO surgical safety checklist. PARTICIPANTS: Clinicians actively working in the designated study operating rooms at the eight hospitals. SURVEY INSTRUMENT: Modified operating-room version Safety Attitudes Questionnaire (SAQ). MAIN OUTCOME MEASURES: Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. RESULTS: Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. CONCLUSIONS: Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.
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Evaluación de Resultado en la Atención de Salud , Servicio de Cirugía en Hospital/normas , Lista de Verificación , Implementación de Plan de Salud , Humanos , Quirófanos , Innovación Organizacional , Cuidados Posoperatorios , Administración de la SeguridadRESUMEN
PURPOSE: To explore perceptions of how professionalism is learned in the current academic environment. Professionalism is a core competency in surgery (as in all of medical practice), and its presence or absence affects all aspects of clinical education and practice, but the ways in which professional values and attitudes are best transmitted to developing generations of surgeons have not been well defined. METHOD: The authors conducted 34 semistructured interviews of individual surgery residents and faculty members at two academic institutions from 2004 to 2006. Interviews consisted of open-ended questions on how the participants learned professionalism and what they perceived as challenges to learning professionalism. Two researchers analyzed the interview transcripts for emergent themes by using a grounded-theory approach. RESULTS: Faculty members' and residents' perceptions of how they learned professionalism reflected four major themes: (1) personal values and upbringing, including premedical education experiences, (2) learning by example from professional role models, (3) the structure of the surgery residency, and (4) formal instruction on professionalism. Of these, role modeling was the dominant theme: Participants identified observation, reflection, and reinforcement as playing key roles in their learning from role models and in distinguishing the sometimes blurred boundary between positive and negative role models. CONCLUSIONS: The theoretical framework generated out of this study proposes a focus on specific activities to improve professional education, including an active approach to role modeling through the intentional and explicit demonstration of professional behavior during the course of everyday work; structured, reflective self-examination; and timely and meaningful evaluation and feedback for reinforcement.
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Docentes Médicos , Cirugía General/educación , Internado y Residencia , Rol del Médico , Refuerzo Social , Percepción Social , Adulto , Comunicación , Educación de Postgrado en Medicina , Femenino , Cirugía General/normas , Humanos , Aprendizaje , Masculino , Modelos Educacionales , Investigación Cualitativa , Apoyo Social , Encuestas y Cuestionarios , EnseñanzaRESUMEN
The aim of a surgical residency program is to produce competent professionals in a safe and pedagogically efficient environment. For many years, there has been an overemphasis on technical attributes as the fundamental competencies of a trained surgeon. With the advent of new frameworks for defining the outcomes of surgical training, such as CanMeds from the Royal College of Physicians and Surgeons of Canada and the six competencies outlined by the Accreditation Council for Graduate Medical Education in USA, there has been a broadening of the focus of surgical training. Although technical proficiency is definitely an important prerequisite for a successful outcome, other qualities such as intellectual abilities, personality and communication skills, and a commitment to practice are important elements in the profile of a competent surgeon. Recently, there is a growing appreciation for the heterogeneity in achievement of technical competence among our trainees, with some residents able to quickly master technical skill in contrast to others who may never achieve mastery in the technical domain. The questions of how to select, teach and grant privileges for independent practice requires an understanding of the components of surgical competence and implementation of evidence based tools for training and assessment of these competencies.
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Educación de Postgrado en Medicina/organización & administración , Educación/organización & administración , Cirugía General/educación , Internado y Residencia/organización & administración , Certificación , Competencia Clínica , Evaluación Educacional , Humanos , Selección de Personal , Competencia Profesional , Rol ProfesionalRESUMEN
BACKGROUND: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery. METHODS: Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. RESULTS: The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). CONCLUSIONS: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
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Complicaciones Posoperatorias/prevención & control , Administración de la Seguridad/métodos , Procedimientos Quirúrgicos Operativos/normas , Humanos , Evaluación de Procesos y Resultados en Atención de Salud , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Administración de la Seguridad/normas , Procedimientos Quirúrgicos Operativos/mortalidadRESUMEN
OBJECTIVE: Resident work hour restrictions have been mandated in the USA largely out of concern that sleep deprivation compromises doctor performance and patient care. However, individuals' ability to recognise the effects of sleep deprivation has not been studied in medical education. We examined the perceived impact of sleep deprivation among different groups of postgraduate medical trainees. METHODS: A survey addressing work hours, sleepiness and daily functioning was mailed to all residents in the internal medicine, surgery and psychiatry programmes at the University of Toronto who were working at 6 different teaching hospitals. The mailing included the Epworth Sleepiness Scale (ESS), measuring acute sleepiness, and a new Sleep Deprivation Impact (SDI) scale, consisting of 12 items designed to measure the perceived impact of sleep deprivation on an individual's own performance. RESULTS: Overall, 62.5% of surgery (95/152) and 59.5% of non-surgery residents (194/326) completed the survey. Surgery residents reported working longer hours per week (83.0 versus 62.5 hours; P < 0.01), and scored higher on the ESS (12.8 versus 9.2; P < 0.01) compared with other residents. Surgery residents scored significantly lower than others on the SDI scale (45.2 versus 51.5, P < 0.01), indicating less perceived impact of sleep deprivation on performance. CONCLUSIONS: These results are consistent with the presence of an underlying culture within surgery in which individuals may be less willing to accept a natural limitation of individual performance. Whether these findings represent an actual resilience to sleep deprivation among surgery residents or a misperception within this group remains to be determined.
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Actitud del Personal de Salud , Competencia Clínica/normas , Cirugía General/educación , Internado y Residencia , Privación de Sueño/psicología , Adulto , Femenino , Humanos , Masculino , Ontario , PercepciónRESUMEN
With the increasing use of simulation in medicine, many departments of surgery are considering the development of a surgical skills center. This article focuses on practical issues that must be considered when setting up a surgical skills center. The importance of developing a mission statement and including relevant stakeholders is discussed. The types of curricula that can be developed as well as the appropriate equipment purchased to support different curricula are considerations. Space requirements, funding sources, and staffing are also covered. Setting up a surgical skills center requires institutional buy-in and planning from the outset. Various models of skills centers, depending on local politics, are discussed.
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Educación Basada en Competencias/organización & administración , Instrucción por Computador , Cirugía General/educación , Desarrollo de Programa , Facultades de Medicina/organización & administración , HumanosRESUMEN
BACKGROUND: Changes in training are likely to affect the professionalization process, but such complex social phenomena are poorly studied by quantitative research methodologies. In contrast, qualitative research designs are more effective in exploring complex social processes. The objective of this study was to use a qualitative methodology to explore how professional responsibilities are perceived by surgical trainees and faculty in the current academic environment. METHODS: Semi-structured individual interviews of 43 surgical residents and faculty (ranging from second year residents to senior faculty) were conducted at 2 academic institutions. The interviews consisted of open-ended questions, followed by discussion of 4 written, case-based scenarios on specific issues related to professional responsibilities. All interviews were audio-recorded and transcribed, and then analyzed for emergent themes by 3 researchers using a grounded theory approach. RESULTS: In discussing professional responsibilities, the motivations that shaped participants' responses reflected a balance between 4 major factors: (1) patient care, (2) education, (3) self, and (4) collegial relationships. Patient care was described as being at the center of professional responsibility, but it did not necessarily supersede other factors. Rather, patient care was described as a collective responsibility, operationalized through teamwork, communication, and trust. CONCLUSIONS: Traditional medical ethics have largely focused on professional responsibility from the standpoint of individual healthcare providers. Our findings suggest it is a much more complex construct characterized by competing responsibilities and an evolving perception of patient care as a collective responsibility. Explicit acknowledgment of this framework sets the stage for educational interventions to support residents' professional development and enhance cooperative behavior among participants.
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Actitud del Personal de Salud , Docentes , Cirugía General/educación , Cirugía General/ética , Atención al Paciente , Responsabilidad Social , Estudiantes de Medicina/psicología , Comunicación , Educación Médica , Ética Médica , Humanos , Entrevistas como Asunto , Grupo de Atención al Paciente , ConfianzaRESUMEN
BACKGROUND: New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients. METHODS: A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments. RESULTS: In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance. CONCLUSIONS: Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement.
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Colonoscopía , Instrucción por Computador , Cirugía General/educación , Medicina Interna/educación , Internado y Residencia , Interfaz Usuario-Computador , Competencia Clínica , Femenino , Humanos , Masculino , Práctica Psicológica , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: We carried out a prospective, randomized, 4-arm study including control arm, blinding of examiners to determine effectiveness of computer-based video instruction (CBVI) and different types of expert feedback (concurrent and summary) on learning of a basic technical skill. METHODS: Using bench models, participants were pre-tested on a suturing and instrument knot-tying skill after viewing an instructional video. The students were subsequently assigned randomly to 4 practice conditions: no additional intervention (control), self study with CBVI, expert feedback during practice trials (concurrent feedback), and expert feedback after practice trials (summary feedback). All participants underwent 19 trials of practice, over 1 hour, in their assigned training condition. The effectiveness of training was assessed both at an immediate post-test and 1 month later at a retention test. Performance was evaluated using both expert-based (Global Rating Scores) and computer-based assessment (Hand Motion Analysis). Data were analyzed using repeated-measures ANOVA. RESULTS: There were no differences in GRS between groups at pre-test. The CBVI, concurrent feedback and summary feedback methods were equally effective initially for the instruction of this basic technical skill to naive medical students and displayed better performance than control (control, 12.71 [10.79 to 14.62]; CBVI, 16.39 [14.38 to 18.40]; concurrent, 16.97 [15.79 to 18.15]; summary, 16.09 [13.57 to 18.62]; P < .001 each). At retention. however, only CBVI and summary feedback groups retained superior suturing and knot-tying performance versus control (control, 8.13 [6.94 to 9.85]; CBVI, 11.92 [10.19 to 14.99] P = .037; concurrent, 9.80 [8.55 to 13.45] P = .635; summary, 111.19 [10.27 to 14.29] P = .037). Hand motion data displayed a similar pattern of results. There were no group differences in the rate of learning (P > .05). CONCLUSION: Our study showed that CBVI can be as effective as summary expert feedback in the instruction of basic technical skills to medical students. Thoughtfully incorporated into technical curricula, CBVI can make efficient use of faculty time and serve as a useful pedagogic adjunct for basic skills training. Additionally, our study provides evidence supporting an increased role of summary feedback to effectively train novices in technical skills.
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Instrucción por Computador , Técnicas de Sutura/educación , Competencia Clínica , Retroalimentación Psicológica , Humanos , Suturas/normas , EnseñanzaRESUMEN
BACKGROUND: Teaching of technical surgical skills to undergraduate medical students in a laboratory setting away from the patient is not common practice. Because of the large volume of students and shortage of available teaching faculty new methods of teaching must be developed for this group of trainees. In this study we examined the effectiveness of computer-based video training, different types of computer-based motion efficiency feedback (with and without expert criteria), and expert feedback on learning of a basic technical skill in medical students. METHODS: Forty-five junior medical students were randomized into 3 groups and learned suturing and knot-tying skills. Group A received computer-generated feedback about the economy of their movements. Group B received the same motion economy feedback, as well as expert reference values. Group C received verbal feedback from an expert. All groups were pre-tested, allowed 18 practice trials, and post-tested, and their skill retention was retested after 1 month. Performance was assessed by expert analysis using an objective structured analysis of technical skill and by computer analysis (Imperial College Surgical Assessment Device [ICSAD]). RESULTS: All groups showed improvement from pre-test to post-test. However, only group C showed retention of skill on delayed performance testing. CONCLUSIONS: Verbal feedback from an expert instructor led to lasting improvements in technical skills performance. Providing information about motion efficiency did not lead to similar improvements.