Laparoscopic Simulation in Reverse and Side Alignment Impact on Forward Alignment Performance: A Randomized Controlled Trial.

BACKGROUND: The influence of visual-spatial discordance during training on laparoscopic skills is poorly understood. It has been proposed that training in visual-spatial discordant situations can improve performance in the forward alignment, which was the basis of our hypothesis. Our study's aim was to conduct a randomized control trial to explore the impact of simulated training in visual-spatial discordant situations on forward alignment performance. METHODS: The participants were 80 medical students who were randomized into four groups. Group A served as the control and performed all peg transfers in the forward alignment. Groups B, C, and D experienced varied rounds of either increasing or decreasing sensorimotor discordance. The students were trained and tested using the peg transfer task used in the Fundamentals of Laparoscopic Surgery curriculum. Based on the group, each student performed 10 peg transfer practice rounds in their assigned alignment. After each practice session, each student was tested and scored in forward alignment performance. A baseline test, followed by three practice sessions, and three tests were done. RESULTS: Group A (control) demonstrated a statistically significant overall increase in scoring of 37.1% from baseline when compared to the final test. Groups B, C, and D showed improvements of 3.7%, 27.1%, and 19.3%, respectively, between baseline and the final test, yet none demonstrated consistent linear improvements. On multi-variate analysis, students who practiced in the side or reverse alignment positions scored 25 and 37 points lower, respectively, than students who practiced in the forward alignment. CONCLUSION: Our study suggests that training in visual-spatial discordant conditions does not lead to the development of forward alignment laparoscopic skills. This could have important implications when developing future laparoscopic skills training curriculums. To our knowledge, this is the largest study to date assessing the impacts of training in visual-spatial discordance situations on performance in the forward alignment.

Hernia recurrence and infection rate in elective complex abdominal wall repair using biologic mesh.

BACKGROUND: Elective complex ventral hernia repairs, done using synthetic mesh in patients with comorbidities, can result in mesh related complications such as hernia recurrence or infection. We studied hernia recurrence and surgical site occurrences after elective complex repairs in predominately clean cases using biologic mesh and examined the impact of several comorbidities. METHODS: A retrospective chart review was completed on patients who underwent elective repair with biologic mesh in clean/clean-contaminated settings between 2012 and 2015 with a minimum of 1-year follow-up. Multiple comorbid conditions, including diabetes, chronic obstructive pulmonary disease, steroid use, smoking history and previous hernia repairs were identified. Post-operative complications including recurrence and infections were ruled out by computed tomography, clinical exam, and/or by telephone survey. RESULTS: 40 patients were identified. 85% (n = 34) had class 1 wounds. 25% (n = 10) experienced a hernia recurrence. 10% (n = 4) of patients developed postoperative infection, none required mesh explantation or re-operation. No statistically significant association was found between the comorbidities assessed and recurrence/infection rates. CONCLUSIONS: We present the first study analyzing clinical outcomes of complex ventral hernia repairs using biologic mesh in predominately clean settings. This study being non-comparative limits definitive conclusions, but our aim is to add to the growing literature on biologic mesh to help future researchers performing comparative trials of synthetic versus biologic meshes.

Comprehensive Multicenter Graduate Surgical Education Initiative Incorporating Entrustable Professional Activities, Continuous Quality Improvement Cycles, and a Web-Based Platform to Enhance Teaching and Learning.

BACKGROUND: It is increasingly important for faculty to teach deliberately and provide timely, detailed, and formative feedback on surgical trainee performance. We initiated a multicenter study to improve resident evaluative processes and enhance teaching and learning behaviors while engaging residents in their education. STUDY DESIGN: Faculty from 7 US postgraduate training programs rated resident operative performances using the perioperative briefing, intraoperative teaching, debriefing model, and rated patient visits/academic performances using the entrustable professional activities model via a web-based platform. Data were centrally analyzed and iterative changes made based on participant feedback, individual preferences, and database refinements, with trends addressed using the Plan, Do, Check, Act improvement methodology. RESULTS: Participants (92 surgeons, 150 residents) submitted 3,880 assessments during July 2014 through September 2017. Evidence of preoperative briefings improved from 33.9% ± 2.5% to 95.5% ± 1.5% between April and September 2014 compared with April and September 2017 (p < 0.001). Postoperative debriefings improved from 10.6% ± 2.7% to 90.2% ± 2.5% (p < 0.001) for the same period. Meaningful self-reflection by residents improved from 28.6% to 67.4% (p < 0.001). The number of assessments received per resident during a 6-month period increased from 6.4 ± 6.2 to 13.4 ± 10.1 (p < 0.003). Surgeon-entered assessments increased from 364 initially to 685 in the final period, and the number of resident assessments increased from 308 to 445. We showed a 4-fold increase in resident observed activities being rated. CONCLUSIONS: By adopting recognized educational models with repeated Plan, Do, Check, Act cycles, we increased the quality of preoperative learning objectives, showed more frequent, detailed, and timely assessments of resident performance, and demonstrated more effective self-reflection by residents. We monitored trends, identified opportunities for improvement and successfully sustained those improvements over time, applying a team-based approach.

Perioperative self-reflection among surgical residents.

BACKGROUND: We studied prevalence and predictors of meaningful self-reflection among surgical residents and with prompting/structured interventions, sought to improve/sustain resident skills. METHODS: Residents from six programs recorded 1032 narrative self-reflective comments (120 residents), using a web-based platform. If residents identified something learned or to be improved, self-reflection was deemed meaningful. Independent variables PGY level, resident/surgeon gender, study site/Phase1: July2014-August2015 vs. Phase2: September2015-September2016) were analyzed. RESULTS: Meaningful self-reflection was documented in 40.6% (419/1032) of entries. PGY5's meaningfully self-reflected less than PGY1-4's, 26.1% vs. 49.6% (p = 0.002). In multivariate analysis, resident narratives during Phase 2 were 4.7 times more likely to engage in meaningful self-reflection compared to Phase1 entries (p < 0.001). Iterative changes during Phase2 showed a 236% increase in meaningful self-reflection, compared to Phase1. CONCLUSIONS: Surgical residents uncommonly practice meaningful self-reflection, even when prompted, and PGY5/chief residents reflect less than more junior residents. Substantial/sustained improvements in resident self-reflection can occur with both training and interventions.

Do female surgeons learn or teach differently?

BACKGROUND: Gender and/or gender-stereotypes might influence surgical education. We hypothesized that female surgeons might focus their learning and teaching differently from male surgeons. METHODS: Residents and surgeons (multi-institutional) individually recorded preoperatively discussed learning objectives (LO) for matching cases. Narratives were classified as knowledge-based, skill-based, or attitude-based. Multinomial logistic regression analyses, LO = dependent variable; independent variables = resident/surgeon gender, PGY level, timing of entry-to-procedure date, and quarters-of-year. RESULTS: 727 LOs from 125 residents (41% female) and 49 surgeons (20% female) were classified. Female residents were 1.4 times more likely to select knowledge over skill. With female surgeons, residents were 1.6 and 2.1 times more likely to select knowledge over skill and attitude over skill than if the surgeon was male. PGY 4/5 residents chose attitude-based LOs over junior residents. CONCLUSION: Resident, surgeon gender and year-of-training influence learning objectives. Whether this reflects gender stereotyping by residents or differences in attending teaching styles awaits further exploration.

A taxonomy of perioperative surgical learning: Trending resident skill acquisition.

BACKGROUND: Resident and curriculum evaluation require tracking surgical resident operative performance, yet what and when to measure remains unclear. METHODS: From a multi-institutional database, we reviewed 611 resident/surgeon-paired assessments of ACGME Milestones and modified OPRS ratings for different cases and postgraduate years. RESULTS: Faculty Milestone ratings increased with each PGY (p=<0.001) and correlated with resident self-ratings (ICC = 0.83). Mean OPRS scores increased in small increments with substantial intra-year variability. Progression among individual OPRS subcategories was not apparent from more global analyses. Interestingly, male faculty offered lower ratings than female faculty. CONCLUSIONS: Milestones and modified mean OPRS ratings suggest residents are learning, yet lack sufficient discrimination for promotion or curricular analysis. Differential progression through OPRS subcategories suggests a taxonomy of surgical learning that can be tailored to focus on different skills at each point in the training continuum. The effect of faculty gender on resident ratings awaits further study.

Impact of objectively assessing surgeons' teaching on effective perioperative instructional behaviors.

IMPORTANCE: Advancing surgical technology and decreasing resident learning hours have limited exposure to perioperative training, necessitating more effective and efficient perioperative teaching by faculty surgeons. Participation in collaborative efforts and process improvement can change behaviors and enhance teaching. OBJECTIVES: To promote deliberate teaching of residents, change resident perception of their teachers, and produce sustainable improvements by objectively measuring surgeons' perioperative teaching performance. DESIGN, SETTING, AND PARTICIPANTS: This 3-phase observational study of surgeons' perioperative teaching behaviors included university-based surgeons, general surgery residents, and preclinical student observers and involved elective cases at a 600+ bed tertiary hospital. Initially, we measured teaching behaviors by surgeons unaware of study objectives, provided aggregate and confidential individual feedback, and developed standardized preoperative briefings and postoperative debriefings. Phase 2 applied a deliberate teaching model and reinforced behaviors with continuous process improvement efforts (Plan, Do, Check, Act) and repeat observations. Phase 3 used resident prompts to enhance teaching behaviors and demonstrate sustainability. Resident surveys conducted 3 times assessed perceptions of deliberate guidance by faculty when compared with national benchmarks. INTERVENTIONS: Introduction of deliberate faculty preprocedural focusing and postprocedural reinforcement to facilitate resident learning. MAIN OUTCOMES AND MEASURES: More frequent and complete perioperative teaching by faculty and the perception of enhanced teaching by residents. RESULTS: Faculty more commonly and more completely performed the 10-step preoperative briefings and postoperative debriefings (P < .001) during phase 2 (250% improvement over baseline). Intraoperative teaching styles significantly improved and residents' survey-reported assessments of faculty teaching improved over national data for describing procedural steps (P = .02) and requests for resident self-evaluation (P = .006). CONCLUSIONS AND RELEVANCE: Objective recording of teaching behavior frequency motivated adoption of deliberate guided teaching behaviors by surgeons, resulting in both subjective reports by residents of more frequent teaching and objective recording of parallel improvements. A deliberate focus on objectively assessing surgeon educators' periprocedural teaching may motivate improved teaching.

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

INTRODUCTION: Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology. METHODS: A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories. RESULTS: Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness. CONCLUSIONS: On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize structural failures, and to achieve situational awareness contributed to the morbidities and mortalities. Future research may determine if focused training in these areas improves patient outcomes.

Disparities between resident and attending surgeon perceptions of intraoperative teaching.

BACKGROUND: This study aimed to assess attending surgeon and resident recall of good and poor intraoperative teaching experiences and how often these experiences occur at present. METHODS: By web-based survey, we asked US surgeons and residents to describe their best and worst intraoperative teaching experiences during training and how often 26 common intraoperative teaching behaviors occur in their current environment. RESULTS: A total of 346 residents and 196 surgeons responded (51 programs; 26 states). Surgeons and residents consistently identified trainee autonomy, teacher confidence, and communication as positive, while recalling negatively contemptuous, arrogant, accusatory, or uncommunicative teachers. Residents described intraoperative teaching behaviors by faculty as substantially less frequent than faculty self-reports. Neither sex nor seniority explained these results, although women reported communicative behaviors more frequently than men. CONCLUSIONS: Although veteran surgeons and current trainees agree on what constitutes effective and ineffective teaching in the operating room, they disagree on how often these behaviors occur, leaving substantial room for improvement.

Patient misunderstanding of the academic hierarchy is prevalent and predictable.

BACKGROUND: Medical personnel introduce themselves to patients using titles that reflect their level of training, although these titles may not be inherently obvious to the patient. This study explored patient understanding of commonly used physician and student titles. MATERIALS AND METHODS: A survey was developed asking patients to match six mutually exclusive medical titles to six levels of training. Categories included attending physician, chief resident, resident, intern, medical student, and pre-medical student. Respondent age, gender, medical training, employment in a healthcare field, educational level, income, and number of visits to a physician per y were requested. A brief intervention was then performed in which a second group of patients were advised of the designations and then asked to match the same categories. RESULTS: A total of 365 surveys were collected from the first group and 102 from the second group. Respondents accurately identified the level of training required for all six titles in only 44.5% of surveys collected, and in 52.0% after the intervention. Patients with at least some college education or income>$50,000 per y were more likely to answer correctly (P<0.001). On the other hand, even respondents with graduate degrees or incomes>$100,000 per y had difficulty correctly identifying the training of all team members. CONCLUSIONS: Patients do not understand the distinctions in training of surgical team members, especially those patients with decreased income or education; therefore, clinicians may wish to pay particular attention to these introductions. The survey did identify this as being important to patients.

What is an hour-lecture worth?

BACKGROUND: Although there are many ways to convey knowledge, attitudes, and techniques when teaching residents and students, the most optimal method (lecture, online lecture, online tutorial, simulator practice, and so on) is yet to be determined. METHODS: This study was designed to be a prospective analysis of change in resident behavior, and the model chosen was resident compliance with alcohol screening during admissions to the trauma service. Baseline values were determined the month before the educational "intervention," which was planned to be a 1-hour lecture during Grand Rounds on the importance of screening for alcohol disuse syndromes. After the "intervention," results were analyzed at 3 points in time: during the first month after the lecture and then at 3 and 12 months. RESULTS: Resident compliance with alcohol usage screening rose from 53% at baseline to 80% at 1 year. CONCLUSIONS: This straightforward model of utility of a lecture showed a significant change in resident behavior.

Assessing the competencies in general surgery residency training.

BACKGROUND: Accreditation Council for Graduate Medical Education (ACGME) competencies have increased the focus on education. A 1-year study of observational assessments was conducted. METHODS: "Point of Observation" evaluations were completed by faculty for postgraduate year (PGY) I and II surgery residents. Resident procedures and patient office visits were rated in 9 categories, using a Likert scale. Interns were expected to perform at a novice level (0-30%) and PGY II residents at an advanced level, with improvements expected. RESULTS: PGY I and II residents showed overall improved scores (12% and 6%, respectively) over 1 year. Intern improvements in 9 categories were linear, ranging from 0% to 48%. PGY II resident scores were more variable, with improvements noted in 6 categories ranging from 10% to 30%. Three categories declined in scores, ranging from 2% to 18%. CONCLUSIONS: Competencies bring emphasis to education and measurable outcomes. Early efforts have proven valuable in identifying curriculum and learning needs.