The Quality of Operative Performance Narrative Feedback: A Retrospective Data Comparison Between End of Rotation Evaluations and Workplace-based Assessments.

OBJECTIVE: To describe the quality of operative performance feedback using evaluation tools commonly used by general surgery residency training programs. SUMMARY OF BACKGROUND DATA: The majority of surgical training programs administer an evaluation through which faculty members may rate and comment on trainee operative performance at the end of the rotation (EOR). Many programs have also implemented the system for improving and measuring procedural learning (SIMPL), a workplace-based assessment tool with which faculty can rate and comment on a trainee's operative performance immediately after a case. It is unknown how the quality of narrative operative performance feedback delivered with these tools compares. METHODS: The authors collected EOR evaluations and SIMPL narrative comments on trainees' operative performance from 3 university-based surgery training programs during the 2016-2017 academic year. Two surgeon raters categorized comments relating to operative skills as being specific or general and as encouraging and/or corrective. Comments were then classified as effective, mediocre, ineffective, or irrelevant. The frequencies with which comments were rated as effective were compared using Chi-square analysis. RESULTS: The authors analyzed a total of 600 comments. 10.7% of EOR and 58.3% of SIMPL operative performance evaluation comments were deemed effective (P < 0.0001). CONCLUSIONS: Evaluators give significantly higher quality operative performance feedback when using workplace-based assessment tools rather than EOR evaluations.

Natural Language Processing and Assessment of Resident Feedback Quality.

OBJECTIVE: To validate the performance of a natural language processing (NLP) model in characterizing the quality of feedback provided to surgical trainees. DESIGN: Narrative surgical resident feedback transcripts were collected from a large academic institution and classified for quality by trained coders. 75% of classified transcripts were used to train a logistic regression NLP model and 25% were used for testing the model. The NLP model was trained by uploading classified transcripts and tested using unclassified transcripts. The model then classified those transcripts into dichotomized high- and low- quality ratings. Model performance was primarily assessed in terms of accuracy and secondary performance measures including sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). SETTING: A surgical residency program based in a large academic medical center. PARTICIPANTS: All surgical residents who received feedback via the Society for Improving Medical Professional Learning smartphone application (SIMPL, Boston, MA) in August 2019. RESULTS: The model classified the quality (high vs. low) of 2,416 narrative feedback transcripts with an accuracy of 0.83 (95% confidence interval: 0.80, 0.86), sensitivity of 0.37 (0.33, 0.45), specificity of 0.97 (0.96, 0.98), and an area under the receiver operating characteristic curve of 0.86 (0.83, 0.87). CONCLUSIONS: The NLP model classified the quality of operative performance feedback with high accuracy and specificity. NLP offers residency programs the opportunity to efficiently measure feedback quality. This information can be used for feedback improvement efforts and ultimately, the education of surgical trainees.

Using Natural Language Processing to Automatically Assess Feedback Quality: Findings From 3 Surgical Residencies.

PURPOSE: Learning is markedly improved with high-quality feedback, yet assuring the quality of feedback is difficult to achieve at scale. Natural language processing (NLP) algorithms may be useful in this context as they can automatically classify large volumes of narrative data. However, it is unknown if NLP models can accurately evaluate surgical trainee feedback. This study evaluated which NLP techniques best classify the quality of surgical trainee formative feedback recorded as part of a workplace assessment. METHOD: During the 2016-2017 academic year, the SIMPL (Society for Improving Medical Professional Learning) app was used to record operative performance narrative feedback for residents at 3 university-based general surgery residency training programs. Feedback comments were collected for a sample of residents representing all 5 postgraduate year levels and coded for quality. In May 2019, the coded comments were then used to train NLP models to automatically classify the quality of feedback across 4 categories (effective, mediocre, ineffective, or other). Models included support vector machines (SVM), logistic regression, gradient boosted trees, naive Bayes, and random forests. The primary outcome was mean classification accuracy. RESULTS: The authors manually coded the quality of 600 recorded feedback comments. Those data were used to train NLP models to automatically classify the quality of feedback across 4 categories. The NLP model using an SVM algorithm yielded a maximum mean accuracy of 0.64 (standard deviation, 0.01). When the classification task was modified to distinguish only high-quality vs low-quality feedback, maximum mean accuracy was 0.83, again with SVM. CONCLUSIONS: To the authors' knowledge, this is the first study to examine the use of NLP for classifying feedback quality. SVM NLP models demonstrated the ability to automatically classify the quality of surgical trainee evaluations. Larger training datasets would likely further increase accuracy.

Trainee Autonomy in Minimally Invasive General Surgery in the United States: Establishing a National Benchmark.

OBJECTIVE: Minimally invasive surgery (MIS) is an integral component of General Surgery training and practice. Yet, little is known about how much autonomy General Surgery residents achieve in MIS procedures, and whether that amount is sufficient. This study aims to establish a contemporary benchmark for trainee autonomy in MIS procedures. We hypothesize that trainees achieve progressive autonomy, but fail to achieve meaningful autonomy in a substantial percentage of MIS procedures prior to graduation. SETTING/PARTICIPANTS: Fifty General Surgery residency programs in the United States, from September 1, 2015 to March 19, 2020. All Categorical General Surgery Residents and Attending Surgeons within these programs were eligible. DESIGN: Data were collected prospectively from attending surgeons and categorical General Surgery residents. Trainee autonomy was assessed using the 4-level Zwisch scale (Show and Tell, Active Help, Passive Help, and Supervision Only) on a smartphone application (SIMPL). MIS procedures included all laparoscopic, thoracoscopic, endoscopic, and endovascular/percutaneous procedures performed by residents during the study. Primary outcomes of interest were "meaningful autonomy" rates (i.e., scores in the top 2 categories of the Zwisch scale) by postgraduate year (PGY), and "progressive autonomy" (i.e., differences in autonomy between PGYs) in MIS procedures, as rated by attending surgeons. Primary outcomes were determined with descriptive statistics, one-way analysis of variance (ANOVA) and Z-tests. Secondary analyses compared (i) progressive autonomy between common MIS procedures, and (ii) progressive autonomy in MIS vs. non-MIS procedures. RESULTS: A total of 106,054 evaluations were performed across 50 General Surgery residency programs, of which 38,985 (37%) were for MIS procedures. Attendings performed 44,842 (42%) of all evaluations, including 16,840 (43%) of MIS evaluations, while residents performed the rest. Overall, meaningful autonomy in MIS procedures increased from 14.1% (PGY1s) to 75.9% (PGY5s), with significant (p < 0.001) increases between each PGY level. Meaningful autonomy rates were higher in the MIS vs. non-MIS group [57.2% vs. 48.0%, p < 0.001], and progressed more rapidly in MIS vs. non-MIS, (p < 0.05). The 7 most common MIS procedures accounted for 83.5% (n = 14,058) of all MIS evaluations. Among PGY5s performing these procedures, meaningful autonomy rates (%) were: laparoscopic appendectomy (95%); laparoscopic cholecystectomy (93%); diagnostic laparoscopy (87%); upper/lower endoscopy (85%); laparoscopic hernia repair (72%); laparoscopic partial colectomy (58%); and laparoscopic sleeve gastrectomy (45%). CONCLUSIONS: US General Surgery residents receive progressive autonomy in MIS procedures, and appear to progress more rapidly in MIS versus non-MIS procedures. However, residents fail to achieve meaningful autonomy in nearly 25% of MIS cases in their final year of residency, with higher rates of meaningful autonomy only achieved in a small subset of basic MIS procedures.

Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs.

OBJECTIVE: Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs. DESIGN: After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics. SETTING: An anonymous electronic survey was distributed to interested programs in early 2019. PARTICIPANTS: US General Surgery trainees and attending surgeons. RESULTS: A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection. CONCLUSIONS: Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning.

Mind the Gap: The Autonomy Perception Gap in the Operating Room by Surgical Residents and Faculty.

OBJECTIVE: Examine the concordance of perceived operative autonomy between attendings and resident trainees. DESIGN: Faculty and trainees rated trainee operative autonomy using the 4-level Zwisch scale over a variety of cases and training years. The respective ratings were then compared to explore the effects of experience, gender, case complexity, trainee, trainer, and other covariates to perceived autonomy. SETTING: This study was conducted over 14 general surgery programs in the United States, members of the Procedural Learning and Safety Collaborative. PARTICIPANTS: Participants included faculty and categorical trainees from 14 general surgery programs. RESULTS: A total of 8681 observations was obtained. The sample included 619 unique residents and 457 different attendings. A total of 598 distinct procedures was performed. In 60% of the cases, the autonomy ratings between trainees and attendings were concordant, with only 3.5% of cases discrepant by more than 1 level. An autonomy perception gap was modeled based on the discrepancy between the trainee and attending Zwisch ratings for the same case. The mean Zwisch score expected for a trainee was lower than the attending across all scenarios. Trainees were more likely to perceive relatively more autonomy in the second half of the year. The autonomy perception gap decreased with increasing case complexity. As trainees gained experience, the perception gap increased with trainees underestimating autonomy. CONCLUSIONS: Trainees and attendings generally demonstrated concordance on autonomy perception scores. However, in 40% of cases, a perception gap exists between trainee and attending with the trainee generally underestimating autonomy. The gap worsens as the trainee progresses through residency. This perception gap suggests that attendings and trainees could be better aligned on teaching goals and expectations.

A Preoperative Educational Time-Out is Associated with Improved Resident Goal Setting and Strengthens Educational Experiences.

OBJECTIVE: The purpose of this study was to assess the impact of a preoperative Educational Time-Out (ETO) with structured postoperative feedback on resident preoperative goal-setting and the educational experience of a clinical rotation. DESIGN: A preoperative ETO was developed during which trainees and faculty jointly identified an operative goal and discussed the trainee's operative autonomy. Postoperative feedback with a smartphone application was encouraged. From November 2016 to October 2017, the intervention was piloted with 1 surgical service. Outcomes included ETO completion rate, goal setting rate, and subjects' perception of the impact of the ETO on identification of performance deficits, trainee autonomy, and receipt of feedback. Data were analyzed using descriptive statistics. SETTING: This study was performed in an institutional hospital setting. PARTICIPANTS: Third-year general surgery residents and surgical faculty in the Department of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center took part in the intervention. RESULTS: Seven residents and 7 attending surgeons participated in this study. Residents performed a median of 15 procurements during an average of 6.5 weeks each on service. The ETO completion rate was 83%. Resident-reported preoperative goal setting increased after the intervention (from 36% to 78%, p = 0.015). Subjects reported a positive impact of the intervention, with high resident agreement that the ETO helped identify deficits (82% median agreement), increased autonomy (82% median agreement), and increased receipt of feedback (84% median agreement). Residents and attendings agreed that the educational experience was stronger due to the ETO (median 81% and 77%, respectively). CONCLUSIONS: The ETO intervention improved rates of resident preoperative goal setting and strengthened perceived educational experiences. Resident participants also reported improvements in autonomy and rates of postoperative feedback. Broader implementation of this brief preoperative pause is an easy way to emphasize procedural education in the operating room.

Using smartphones for trainee performance assessment: A SIMPL case study.

Workplace-based assessments are used by raters to evaluate observed performance of trainees in actual clinical practice. These types of assessments are of growing interest, especially because observed performance is prioritized within the larger competency-based medical educational movement. Implementation of workplace-based assessments has, however, been challenging. This article describes the motivations and implications for workplace-based assessments that leverage smartphone technology. It does so in reference to an app called SIMPL (System for Improving and Measuring Procedural Learning) in order to highlight some of the challenges and benefits one might encounter during implementation of similar systems.

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.

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.

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.

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.

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.

Is the operative autonomy granted to a resident consistent with operative performance quality.

BACKGROUND: We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality. METHODS: Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as "practice ready performance/meaningfully autonomous" or "not practice ready/not meaningfully autonomous." Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy. RESULTS: A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion. CONCLUSION: Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy.

Effect of Ongoing Assessment of Resident Operative Autonomy on the Operating Room Environment.

OBJECTIVE: We have previously demonstrated the feasibility and validity of a smartphone-based system called Procedural Autonomy and Supervision System (PASS), which uses the Zwisch autonomy scale to facilitate assessment of the operative performances of surgical residents and promote progressive autonomy. To determine whether the use of PASS in a general surgery residency program is associated with any negative consequences, we tested the null hypothesis that PASS implementation at our institution would not negatively affect resident or faculty satisfaction in the operating room (OR) nor increase mean OR times for cases performed together by residents and faculty. METHODS: Mean OR times were obtained from the electronic medical record at Northwestern Memorial Hospital for the 20 procedures most commonly performed by faculty members with residents before and after PASS implementation. OR times were compared via two-sample t-test. The OR Educational Environment Measure tool was used to assess OR satisfaction with all clinically active general surgery residents (n = 31) and full-time general surgery faculty members (n = 27) before and after PASS implementation. Results were compared using the Mann-Whitney rank sum test. RESULTS: A significant prolongation in mean OR time between control and study period was found for only 1 of the 20 operative procedures performed at least 20 times by participating faculty members with residents. Based on the overall survey score, no significant differences were found between resident and faculty responses to the OR Educational Environment Measure survey before and after PASS implementation. When individual survey items were compared, while no differences were found with resident responses, differences were noted with faculty responses for 7 of the 35 items addressed although after Bonferroni correction none of these differences remained significant. CONCLUSIONS: Our data suggest that PASS does not increase mean OR times for the most commonly performed procedures. Resident OR satisfaction did not significantly change during PASS implementation, whereas some changes in faculty satisfaction were noted suggesting that PASS implementation may have had some negative effect with them. Although the effect on faculty satisfaction clearly requires further investigation, our findings support that use of an autonomy-based OR performance assessment system such as PASS does not appear to have a major negative influence on OR times nor OR satisfaction.

Relationship of procedural numbers with meaningful procedural autonomy in general surgery residents.

BACKGROUND: Concerns exist regarding the competency of general surgery graduates with performing core general surgery procedures. Current competence assessment incorporates minimal procedural numbers requirements. METHODS: Based on the Zwisch scale we evaluated the level of autonomy achieved by categorical PGY1-5 general surgery residents at 14 U.S. general surgery resident training programs between September 1, 2015 and December 31, 2016. With 5 of the most commonly performed core general surgery procedures, we correlated the level of autonomy achieved by each resident with the number of procedures they had performed before the evaluation period, with the intent of identifying specific target numbers that would correlate with the achievement of meaningful autonomy for each procedure with most residents. RESULTS: Whereas a definitive target number was identified for laparoscopic appendectomy (i.e. 25), for the other 4 procedures studied (i.e. laparoscopic cholecystectomy, 52; open inguinal hernia repair, 42; ventral hernia repair, 35; and partial colectomy, 60), target numbers identified were less definitive and/or were higher than many residents will experience during their surgical residency training. CONCLUSIONS: We conclude that procedural target numbers are generally not effective in predicting procedural competence and should not be used as the basis for determining residents' readiness for independent practice.

What factors influence attending surgeon decisions about resident autonomy in the operating room?

BACKGROUND: Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. METHODS: We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. RESULTS: Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74). CONCLUSION: Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors.

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.

The Feasibility of Real-Time Intraoperative Performance Assessment With SIMPL (System for Improving and Measuring Procedural Learning): Early Experience From a Multi-institutional Trial.

PURPOSE: Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs. METHODS: Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail. RESULTS: A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures. CONCLUSIONS: SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.