The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis.

BACKGROUND: Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions. METHODS: Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests. RESULTS: A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%). CONCLUSION: Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis.

Implementation of a Standardized Sub-Intern Curriculum Improves Confidence for those Entering a Surgical Residency.

OBJECTIVE: Medical students often feel underprepared entering surgical residency. We have previously reported the results of a sub-intern needs assessment (SINA) which informed the creation of a standardized sub-internship curriculum. We aimed to determine if implementation of this curriculum into students' scheduled rotations would improve student confidence in their abilities related to the AAMC Core Entrustable Professional Activities for Entering Residency (CEPAERs). DESIGN: We surveyed 4th year medical students during their surgery sub-internship. Sub-interns participated in a weekly series of 2-hour didactic sessions. We utilized interactive lectures and case scenarios addressing the pertinent topics identified in our previous needs assessment. The surveys were administered before and after the rotation and linked using unique identifiers. The surveys assessed confidence in each of the CEPAERs as well as the top 25 topics prioritized by our needs assessment. Self-reported confidence in each of the topics was measured using Likert scales (CEPAER scale 1-5, SINA scale 1-6). Pre- and post-curriculum confidence on a variety of topics were compared using paired t-tests. SETTING: Geisel School of Medicine at Dartmouth/Dartmouth-Hitchcock Medical Center, a tertiary-care academic medical center. PARTICIPANTS: Fourth year medical students participating in their general surgery sub-internship. RESULTS: Twelve medical students participated in general and thoracic surgery sub-internships over the course of the study period. Ten (83%) participated in the didactic curriculum and they all completed both the pre- and postsurvey. 100% of the respondents agreed that the curriculum provided a useful supplement to their clinical experience. With respect to the CEPAERs, students reported improved confidence in 77% of the areas, with statistically significant increases occurring in the following areas: ability to prioritize a differential diagnosis (average Likert rating improved from 3.7 to 4.1, p = 0.04), comfort entering and discussing orders (2.9-3.8, p = 0.007), and overall preparedness to be a surgical intern (3.2-3.8, p = 0.02). Students also reported improvement in confidence in 92% of the basic intern responsibility topics, with statistically significant increases in maintenance fluid calculations (Likert rating 3.5-4.5, p = 0.001), repleting electrolytes (3.8-4.6, p = 0.01), interpretation of chest and abdominal x-rays (4-5, p = 0.02; 3.6-4.5, p=0.004, respectively), management of oliguria (3.2-3.8, p = 0.02), and time management/organization skills (4.5-5.4, p = 0.04). CONCLUSIONS: Implementation of a standardized sub-intern curriculum improved student confidence in 33 of the 38 basic intern responsibilities, core Entrustable Professional Activities, and overall preparedness to be a surgical intern. While limited by a single institution design, we believe these results offer a new avenue for educating and preparing medical students for residency within their existing sub-internships.

Qualities of excellent resident and attending teachers recognized by medical students: A qualitative analysis of nominations for surgical clerkship teaching awards.

BACKGROUND: Effective teaching positively impacts student experience during the surgical clerkship. We sought to better understand how medical students characterize excellent surgical educators and how these characteristics may differ between residents and attendings. METHODS: 289 nominations by third-year medical students for a surgical resident and attending teaching award were examined for thematic content using conventional content analysis. RESULTS: Six major themes emerged: inclusion of students, prioritizing student education, facilitating procedural involvement, utilizing effective educational methods, providing mentorship, and role modeling. Residents were more frequently commended for the first three themes, while residents and attendings were recognized equally for the latter three. CONCLUSIONS: In identifying excellent surgical educators, students emphasized the educators' roles in fostering a positive learning environment where student education is prioritized. Residents were recognized more often than attendings for a broader set of qualities valued by students. Residents as teachers training should be structured to develop these qualities.

A Targeted Needs Assessment for the Development of a Surgical Sub-internship Curriculum.

OBJECTIVE: Medical students often feel inadequately prepared for the responsibilities of surgical internship because of insufficient exposure to resident responsibilities prior to starting residency. This lack of preparation may contribute to burnout and attrition early in residency. Sub-internships should provide these experiences. Significant variation, however, exists in the structure of these rotations. We conducted a targeted needs assessment to inform the development of a didactic curriculum to address gaps in the surgical sub-internship experience and better prepare students for general surgery residency. DESIGN: A 25-item needs assessment survey was developed and distributed to senior medical students in their surgical sub-internship, current junior residents, and prior students (alumni) from the past 4 years who matched into general surgery residencies at other institutions. SETTING: Geisel School of Medicine at Dartmouth/Dartmouth-Hitchcock Medical Center, a tertiary-care academic medical center. PARTICIPANTS: Nine senior medical students; 12 current residents and 14 alumni, including 9 PGY-1, 13 PGY-2, and 4 PGY-3 residents. RESULTS: The topics rated most important by medical students were floor management topics, specifically lines, tubes, and drains, hypotension, post-operative fever, chest pain, oliguria, and post-operative pain. In contrast, there was a wider variety of topics rated highly by residents. Residents emphasized non-technical communication and documentation skills. Residents at every training level rated presenting patients on rounds as the most important skill for incoming interns to acquire, whereas only one-third of medical students considered this to be an essential topic. CONCLUSIONS: Medical students rank management of common clinical problems as the most critical aspect in their preparation for residency. Residents recognized these topics as important, but also placed high emphasis on non-technical communication and documentation skills. The findings from this need's assessment can be used to guide content structure for a sub-intern curriculum.

Crowd-sourced hospital ratings are correlated with patient satisfaction but not surgical safety.

BACKGROUND: Hospital reviews posted online by patients are unsolicited and less structured than Hospital Consumer Assessment of Healthcare Providers and Systems surveys. The differences between online review platforms and their degrees of correlation with validated satisfaction and safety measures are unknown. METHODS: We identified 515 large acute care teaching hospitals in the United States. We collected patient satisfaction results and postsurgical patient safety indicators from Hospital Compare. We also collected hospital star ratings (1-5) from Facebook, Google, and Yelp. Mean ratings were compared with paired t tests. Concordance between ratings websites, Hospital Consumer Assessment of Healthcare Providers and Systems scores, and surgical safety indicators were assessed with Pearson's correlation coefficient. RESULTS: Mean Facebook ratings (3.81, interquartile range 3.5-4.3) were more favorable than Google (3.26, interquartile range 2.8-3.6) or Yelp (2.59, interquartile range 2.3-2.9). Facebook ratings were least strongly correlated with the Hospital Consumer Assessment of Healthcare Providers and Systems recommended hospital score (ρ = 0.356). Google was modestly correlated (ρ = 0.479), and Yelp was most strongly correlated (ρ = 0.500). The negative correlation between crowdsourced rating and composite safety indicator was too small to be meaningful on any platform. CONCLUSION: There is variation between platforms in consumer ratings of hospitals. Ratings on Facebook are more favorable than Google or Yelp. These are independently correlated with Hospital Consumer Assessment of Healthcare Providers and Systems scores. These findings suggest that unstructured consumer reviews generally reflect similar directionality as Hospital Consumer Assessment of Healthcare Providers and Systems satisfaction scores. Users should be aware of the significant difference between platforms. Consumer ratings platforms are not consistently correlated with postsurgical patient safety indicators, so online ratings may not reflect the safety of surgical care received.