How Surgeons Think to Avoid Error: A Case Study of the Neurovascular Bundle Sparing During a Robotic Prostatectomy.

OBJECTIVE: To illustrate how experts efficiently navigate a "slowing down moment" to obtain optimal surgical outcomes using the neurovascular bundle sparing during a robotic prostatectomy as a case study. DESIGN: A series of semistructured interviews with four expert uro-oncologists were completed using a cognitive task analysis methodology. Cognitive task analysis, CTA, refers to the interview and extraction of a general body of knowledge. Each interview participant completed four 1 to 2-hour semistructured CTA interviews. The interview data were then deconstructed, coded, and analyzed using a grounded theory analysis to produce a CTA-grid for a robotic prostatectomy for each surgeon, with headings of: surgical steps, simplification maneuvers, visual cues, error/complication recognition, and error/complication management and avoidance. SETTING: The study took place at an academic teaching hospital located in an urban center in Canada. PARTICIPANTS: Four expert uro-oncologists participated in the study. RESULTS: Visual cues, landmarks, common pitfalls, and technique were identified as the 4 key components of the decision-making happening during a slowing down moment in the neurovascular bundle sparing during a robotic prostatectomy. CONCLUSION: The data obtained from the CTA is novel information identifying patterns and cues that expert surgeons use to inform their surgical decision-making and avoid errors. This decision-making knowledge of visual cues, landmarks, common pitfalls and techniques is also generalizable for other surgical subspecialties. Surgeon educators, surgical teaching programs and trainees looking to improve their decision-making skills could use these components to guide their educational strategies.

Comparison of BioLIFT versus LIFT for the treatment of trans-sphincteric anal fistula: a protocol for systematic review and meta-analysis.

INTRODUCTION: Identifying the optimal treatment for anal fistula has been challenging. Since first reported in 2007, the ligation of the intersphincteric fistula tract (LIFT) procedure has reported healing rates between 40% and 95% and is being increasingly adopted. The BioLIFT is an augmentation of the LIFT with an intersphincteric bioprosthetic mesh and has reported healing rates between 69% and 94%. Despite increased costs and potential complications associated with mesh, the evidence comparing healing rates between BioLIFT and LIFT is unknown. This study details the protocol for a systematic review and meta-analysis of BioLIFT and LIFT to compare outcomes associated with each procedure. METHODS AND ANALYSIS: MEDLINE, EMBASE and the Cochrane Database will be searched from inception using a search strategy designed by an information specialist. Randomised controlled trials, prospective and retrospective cohort studies, consecutive series, cross-sectional studies and case series with more than five patients will be included. Both comparative and single group studies will be included. The eligible population will be adult patients undergoing BioLIFT or LIFT for trans-sphincteric anal fistula. The primary outcome will be primary healing rate. Secondary outcomes will capture secondary healing rate and complications. Abstract, full text and data extraction will be completed independently and in duplicate by two reviewers. Study risk of bias will be assessed using Risk of Bias In Non-randomized Studies - of Interventions and the Risk of Bias (RoB 2.0) tool. Quality of evidence for outcomes will be evaluated using Grading of Recommendations, Assessment, Development and Evaluations criteria. A meta-analysis will be performed using a random-effects inverse variance model. Subgroup and sensitivity analyses will be explored in relation to complex fistula characteristics and patients who have undergone previous LIFT. Heterogeneity will be assessed using the I2 statistic. ETHICS AND DISSEMINATION: This review does not require research ethics board approval. This study will be completed in September 2022. The findings of this study will be disseminated through peer-reviewed international conferences and journals. PROSPERO REGISTRATION NUMBER: CRD42020127996.

Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches.

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.

The effect of assessor professional background on interview evaluation during residency selection: A mixed-methods study.

BACKGROUND: Residency interviewer scores are greatly variable and seems to be influenced by personal characteristics of assessors, although factors contributing to variability remain unclear. The study sought to determine how different professional backgrounds influence assessors' scores. METHODS: Fifty-five general surgery applicants rotated through an interview station assessing teamwork. They were scored by surgeons, human-resource managers, pilots, athletes. Pearson's correlation and a repeated-measures ANOVA were used to determine correlations between professions. Structured interviews were used to probe for scoring rationale. RESULTS: Interview scores differed significantly between professions (F (3, 159) = 11.12, p < 0.001. Qualitative analysis revealed that due to the challenge of distinguishing between similarly performing candidates, assessors rely on global impressions informed by personal values. CONCLUSION: Assessor variability is ubiquitous, in part due to the subjective nature of interviews and is associated with personal values. When selecting assessors, programs should choose diverse assessors to assess to ensure a reliable selection process.

Assessment of laparoscopic skills: comparing the reliability of global rating and entrustability tools.

Background: Competence by design (CBD) residency programs increasingly depend on tools that provide reliable assessments, require minimal rater training, and measure progression through the CBD milestones. To assess intraoperative skills, global rating scales and entrustability ratings are commonly used but may require extensive training. The Competency Continuum (CC) is a CBD framework that may be used as an assessment tool to assess laparoscopic skills. The study aimed to compare the CC to two other assessment tools: the Global Operative Assessment of Laparoscopic Skills (GOALS) and the Zwisch scale. Methods: Four expert surgeons rated thirty laparoscopic cholecystectomy videos. Two raters used the GOALS scale while the remaining two raters used both the Zwisch scale and CC. Each rater received scale-specific training. Descriptive statistics, inter-rater reliabilities (IRR), and Pearson's correlations were calculated for each scale. Results: Significant positive correlations between GOALS and Zwisch (r = 0.75, p < 0.001), CC and GOALS (r = 0.79, p < 0.001), and CC and Zwisch (r = 0.90, p < 0.001) were found. The CC had an inter-rater reliability of 0.74 whereas the GOALS and Zwisch scales had inter-rater reliabilities of 0.44 and 0.43, respectively. Compared to GOALS and Zwisch scales, the CC had the highest inter-rater reliability and required minimal rater training to achieve reliable scores. Conclusion: The CC may be a reliable tool to assess intraoperative laparoscopic skills and provide trainees with formative feedback relevant to the CBD milestones. Further research should collect further validity evidence for the use of the CC as an independent assessment tool.

Contexte: Les programmes de résidence structurés autour de la compétence par conception (CPC) dépendent de plus en plus d'outils qui fournissent des évaluations fiables, nécessitent une formation minimale des évaluateurs et mesurent la progression dans les étapes de la CPC. Pour évaluer les compétences peropératoires, les échelles d'évaluation globale et de confiance sont couramment utilisées mais peuvent nécessiter une formation approfondie. Le Continuum des compétences (CC) est un cadre de la CPC qui peut être utilisé comme outil d'évaluation des compétences laparoscopiques. L'étude visait à comparer le CC à deux autres outils d'évaluation : l'évaluation globale opératoire des compétences laparoscopiques (GOALS) et l'échelle de Zwisch. Méthodes: Quatre chirurgiens experts ont évalué trente vidéos de cholécystectomie laparoscopique. Deux évaluateurs ont utilisé l'échelle GOALS tandis que les deux autres ont utilisé l'échelle Zwisch et le CC. Chacun d'eux avait reçu une formation spécifique à l'échelle utilisée. Des statistiques descriptives, la fiabilité inter-évaluateurs (FIÉ) et des corrélations de Pearson ont été calculées pour chaque échelle. Résultats: Des corrélations positives significatives ont été trouvées entre les échelles GOALS et Zwisch (r=0.75, p<0.001), CC et GOALS (r=0.79, p<0.001), et CC et Zwisch (r=0.90, p<0.001). Le CC avait une fiabilité inter-évaluateurs de 0,74 tandis que les échelles GOALS et Zwisch avaient des fiabilités inter-évaluateurs de 0,44 et 0,43, respectivement. Par rapport aux échelles GOALS et Zwisch, le CC avait la fiabilité inter-évaluateurs la plus élevée et ne nécessitait qu'une formation minimale des évaluateurs pour obtenir des scores fiables. Conclusion: Le CC constituerait un outil fiable pour évaluer les compétences laparoscopiques peropératoires et pour fournir aux stagiaires une rétroaction formatrice pertinente pour les étapes de la CPC. Des recherches supplémentaires devraient être entreprises pour recueillir plus de preuves de validité pour l'utilisation du CC comme outil d'évaluation indépendant.

Outcomes of Patients Undergoing Elective Bowel Resection Before and After Implementation of an Anemia Screening and Treatment Program.

BACKGROUND: Patients with anemia undergoing elective colorectal cancer surgery are known to have significantly higher rates of postoperative complications and worse outcomes. OBJECTIVE: This study aimed to improve rates of anemia screening and treatment in patients undergoing elective colon and rectal resections through a quality improvement initiative. DESIGN: We compared a historical cohort of patients before implementation of our anemia screening and treatment quality improvement program to a prospective cohort after implementation. SETTINGS: This study was conducted at a tertiary care hospital. PATIENTS: This study included all adult patients with a new diagnosis of colon or rectal cancer without evidence of metastatic disease between 2017 and 2019. INTERVENTIONS: The interventions include the anemia screening and treatment quality improvement program. MAIN OUTCOME MEASURES: The primary outcome was hospital cost per admission. RESULTS: This study includes a total of 84 patients who underwent elective colon or rectal resection before implementation of our anemia quality improvement project and 88 patients who underwent surgery after. In the preimplementation cohort 44 of 84 patients (55.9%) were anemic compared to 47 of 99 patients (54.7%) in the postimplementation cohort. Rates of screening (25%-86.4%) and treatment (27.8%- 63.8%) were significantly increased in the postimplementation cohort. Mean total cost per admission was significantly decreased in the postimplementation cohort (mean cost $16,827 vs $25,796; p = 0.004); this significant reduction was observed even after adjusting for relevant confounding factors (ratio of means: 0.74; 95% CI, 0.65-0.85). The mechanistic link between treatment of anemia and reductions in cost remains unknown. No significant difference was found in rates of blood transfusion, complications, or mortality between the groups. LIMITATIONS: The study limitation includes before-after design subjected to selection and temporal biases. CONCLUSIONS: We demonstrate the successful implementation of an anemia screening and treatment program. This program was associated with significantly reduced cost per admission. This work demonstrates possible value and benefits of implementation of an anemia screening and treatment program. See Video Abstract at http://links.lww.com/DCR/C15 .RESULTADOS DE LOS PACIENTES SOMETIDOS A RESECCIÓN INTESTINAL ELECTIVA ANTES Y DESPUÉS DE LA IMPLEMENTACIÓN DE UN PROGRAMA DE DETECCIÓN Y TRATAMIENTO DE ANEMIA. ANTECEDENTES: Se sabe que los pacientes anémicos que se someten a una cirugía electiva de cáncer colorrectal tienen tasas significativamente más altas de complicaciones posoperatorias y peores resultados. OBJETIVO: Mejorar las tasas de detección y tratamiento de la anemia en pacientes sometidos a resecciones electivas de colon y recto a través de una iniciativa de mejora de calidad. DISEO: Comparamos una cohorte histórica de pacientes antes de la implementación de nuestro programa de detección de anemia y mejora de la calidad del tratamiento con una cohorte prospectiva después de la implementación. ENTORNO CLINICO: Hospital de atención terciaria. PACIENTES: Todos los pacientes adultos con un nuevo diagnóstico de cáncer de colon o recto sin evidencia de enfermedad metastásica entre 2017 y 2019. INTERVENCIONES: Detección de anemia y programa de mejora de la calidad del tratamiento. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el costo hospitalario por ingreso. RESULTADOS: Un total de 84 pacientes se sometieron a resección electiva de colon o recto antes de la implementación de nuestro proyecto de mejora de calidad de la anemia y 88 pacientes se sometieron a cirugía después. En la cohorte previa a la implementación, 44/84 (55,9 %) presentaban anemia en comparación con 47/99 (54,7 %) en la cohorte posterior a la implementación. Las tasas de detección (25 % a 86,4 %) y tratamiento (27,8 % a 63,8 %) aumentaron significativamente en la cohorte posterior a la implementación. El costo total medio por admisión se redujo significativamente en la cohorte posterior a la implementación (costo medio $16 827 vs. $25 796, p = 0,004); esta reducción significativa se observó incluso después de ajustar los factores de confusión relevantes (proporción de medias: 0,74, IC del 95 %: 0,65 a 0,85). El vínculo mecánico entre el tratamiento de la anemia y la reducción de costos sigue siendo desconocido. No hubo diferencias significativas en las tasas de transfusión de sangre, complicaciones o mortalidad entre los grupos. LIMITACIONES: El diseño de antes y después está sujeto a sesgos temporales y de selección. CONCLUSIONES: Demostramos la implementación exitosa de un programa de detección y tratamiento de anemia. Este programa se asoció con un costo por admisión significativamente reducido. Este trabajo demuestra el valor y los beneficios posibles de la implementación de un programa de detección y tratamiento de la anemia. Consulte Video Resumen en http://links.lww.com/DCR/C15 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Trust Me, I Know Them: Assessing Interpersonal Bias in Surgery Residency Interviews.

Background: Residency selection integrates objective and subjective data sources. Interviews help assess characteristics like insight and communication but have the potential for bias. Structured multiple mini-interviews may mitigate some elements of bias; however, a halo effect is described in assessments of medical trainees, and degree of familiarity with applicants may remain a source of bias in interviews. Objective: To investigate the extent of interviewer bias that results from pre-interview knowledge of the applicant by comparing file review and interview scores for known versus unknown applicants. Methods: File review and interview scores of applicants to the University of Ottawa General Surgery Residency Training Program from 2019 to 2021 were gathered retrospectively. Applicants were categorized as "home" if from the institution, "known" if they completed an elective at the institution, or "unknown." The Kruskal-Wallis H test was used to compare median interview scores between groups and Spearman's rank-order correlation (rs) to determine the correlation between file review and interview scores. Results: Over a 3-year period, 169 applicants were interviewed; 62% were unknown, 31% were known, and 6% were home applicants. There was a statistically significant difference (P=.01) between the median interview scores of home, known, and unknown applicants. Comparison of groups demonstrated higher positive correlations between file review and interview scores (rs=0.15 vs 0.36 vs 0.55 in unknown, known, and home applicants) with increasing applicant familiarity. Conclusions: There is an increased positive correlation between file review and interview scores with applicant familiarity. The interview process may carry inherent bias insufficiently mitigated by the current structure.

Video-based interviewing in medicine: a scoping review.

BACKGROUND: The Coronavirus 2019 pandemic necessitated a rapid uptake of video-based interviewing within the personnel selection process in healthcare. While video-based interviews have been evaluated previously, we identified a gap in the literature on the implementation of video-based interviews and how they compare to their face-to-face counterparts. METHODS: A scoping review was conducted to consolidate the available literature on the benefits and limitations of video-based interviews and to understand the perceived barriers associated with transitioning away from face-to-face interviews. A search strategy, developed in concert with an academic health sciences librarian, was run on Ovid MEDLINE, Embase, PsycInfo, and Cochrane Central. The search was performed on March 31, 2020, and updated on February 21, 2021. Studies that implemented and evaluated the impact of video-based interviewing in healthcare were included in our study. Review articles and editorials were excluded. RESULTS: Forty-three studies were included in our scoping review, of which 17 were conference abstracts and 26 were peer-reviewed manuscripts. The risk of bias was moderate or high in most studies, with only four studies having a low risk of bias. Both financial costs and opportunity costs associated with the selection process were reported to be improved with video-based interviewing, while no studies explored the impact on environmental costs. Technical limitations, which were not prevalent, were easily managed during the interview process. Overall, video-based interviews were well received by both applicants and interviewers, although most participants still reported a preference for face-to-face interviews. CONCLUSIONS: While video-based interviewing has become necessary during the Coronavirus 2019 era, there are benefits from a financial, opportunistic, and environmental point of view that argue for its continued use even after the pandemic. Despite its successful implementation with minimal technical issues, a preference still remains for face-to-face interviews. Reasons for this preference are not clear from the available literature. Future studies on the role of nonverbal communication during the video-based interview process are important to better understand how video-based interviewing can be optimized. SYSTEMATIC REVIEW REGISTRATION: This scoping review was registered with Open Science Framework.

Comparison of non-operative versus operative management of resectable colorectal cancer in elderly patients: study protocol for a systematic review.

BACKGROUND: In the 2021 Statistics Canada census, 18.5% of the Canadian population were senior (65 years and older), among those 1.7 million (4.5%) were aged 80 years and older. Colorectal cancer (CRC) is the third most common cancer in both men and women, with its highest incidence rate in septu- and octogenarians. As clinicians encounter a growing number of very elderly patients (80 years and older) with resectable colorectal cancer, justifying major surgery in a comorbid population with limited life expectancy is difficult. Therefore, this study aims to systemically review the available literature to compare non-operative management to surgical resection with respect to overall survival and quality of life. METHOD: We designed and registered a study protocol for a systematic review. We will include all patients above the age of 80 with resectable colorectal cancer. We will search MEDLINE, EMBASE, and the Cochrane Database of Controlled Trials from January 2000 onwards. We will include randomized, non-randomized controlled trials and observational studies comparing non-operative versus operative management of resectable colorectal cancer in elderly patients. The primary outcomes will be overall survival and mortality. Secondary outcomes will include quality of life, and health services/ resources utilization (e.g., treatments, change of level of care…). Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using the ROB-2 and ROBIN-I tools. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., study design and methodological quality). DISCUSSION: This systematic review will synthesize the existing data on the management of colorectal cancer in the very elderly patients, and identify the gap in the literature for potential future research. More specifically, we aim to streamline non-operative outcome data on resectable colorectal cancers to aid clinicians' decision-making with respect to survival outcomes and quality of life. The results of this study will be of interest to multiple audiences including patients, their families, caregivers, healthcare professionals, and policy makers. Results will be published in a peer-reviewed journal.

Self-Assessment in General Surgery Applicants: An Insight Into Interview Performance.

INTRODUCTION: Selecting medical students for residency is a competitive process, with a narrow range of scores separating middle-ranked applicants. Self-assessment is a fundamental skill for any competent physician with a demonstrated correlation to diagnostic ability, examination scores, and technical skills, but has yet to be investigated in residency selection. The objective of this study was to investigate the relationship between self-assessment and interview performance as a potential adjunct to discriminate between applicants. METHODS: At the University of Ottawa in 2020, 55 applicants completed a 9-station interview circuit assessing different characteristics or skills important for a career in general surgery, followed by a self-assessment questionnaire evaluating their perceived performance at each station. Pearson's correlation was used to determine the relationship between self-assessment scores (SASs) and interviewer scores (ISs). RESULTS: There was a negative correlation between SASs and ISs for all interview stations. High performers underestimated their interview performance, and low performers overestimated their performance. Seven of the nine stations reached statistical significance (r = 0.60-0.73, P < 0.001). There was significant variability in the SAS of middle-ranked applicants, with a range three times greater than the range of ISs and demonstrating distinct self-assessment skills in candidates with very similar scores. CONCLUSIONS: Although we strive to select applicants who will succeed in residency to become competent physicians, self-assessment skills may be a useful adjunct during the interview process to assist in discriminating between applicants with similar scores.

Hemorrhaging laparoscopic partial nephrectomy - feasibility of a novel simulation model.

INTRODUCTION: Intraoperative surgical complications pose significant potential risks to patients. Uncontrolled bleeding during laparoscopic partial nephrectomy is one such event that requires collaboration and communication between surgical team members. We developed and evaluated a multidisciplinary surgical simulation scenario and model of intraoperative hemorrhage during a laparoscopic partial nephrectomy to facilitate the practice of these crucial non-technical skills. METHODS: A simulation scenario using a novel, titratable, bleeding partial nephrectomy model was developed. The operating room simulation consisted of an intubated mannequin placed in the lateral decubitus position and laparoscopic renal model. The multidisciplinary simulation scenario included anesthesia and urology residents and progressed from bleeding to a pulseless electrical activity arrest. The degree of renal model bleeding was modified based on the progression of the urology resident. After the scenario, participants were debriefed and completed a post-simulation survey assessing: 1) their perception of the simulated scenario; and 2) their teaching of non-technical skills in their residency training. RESULTS: The porcine model was successfully reproduced for nine consecutive weeks and functioned well to simulate bleeding from a laparoscopic partial nephrectomy site; the bleeding was able to be titrated based on resident progression and excision of the simulated tumor. All residents stated the scenario was valuable to assess and improve non-technical surgical skills and that their exposure to practice non-technical skills in their existing curriculum could be improved. CONCLUSIONS: Simulating an intraoperative bleeding partial nephrectomy, combined with an intraoperative crisis scenario, is a feasible, immersive, and reproducible model and can challenge residents' non-technical skills.

A chance for reform: The environmental impact of travel for general surgery residency interviews.

BACKGROUND: In light of the global climate emergency, it is worth reconsidering the current practice of medical students traveling to interview for residency positions. We sought to estimate carbon dioxide (CO2) emissions associated with travel for general surgery residency interviews in Canada, and the potential avoided emissions if interviews were restructured. METHODS: An eight-item survey was constructed to collect data on cities visited, travel modalities, and costs incurred. Applicants to the University of Ottawa General Surgery Program during the 2019/20 Canadian Resident Matching Service (CaRMS) cycle were invited to complete the survey. Potential reductions in CO2 emissions were modeled using a regionalized interview process with either one or two cities. RESULTS: Of a total of 56 applicants, 39 (70%) completed the survey. Applicants on average visited 10 cities with a mean total cost of $4,866 (95% CI=3,995-5,737) per applicant. Mean CO2 emissions were 1.82 (95% CI=1.50-2.14) tonnes per applicant, and the total CO2 emissions by applicants was estimated to be 101.9 (95% CI=84.0 - 119.8) tonnes. In models wherein interviews are regionalized to one or two cities, emissions would be 57.9 tonnes (43.2% reduction) and 84.2 tonnes (17.4% reduction), respectively. Overall, 74.4% of respondents were concerned about the environmental impact of travel and 46% would prefer to interview by videoconference. CONCLUSION: Travel for general surgery residency interviews in Canada is associated with a considerable environmental impact. These findings are likely generalizable to other residency programs. Given the global climate crisis, the CaRMS application process must consider alternative structures.

CONTEXTE: Compte tenu de la situation d'urgence climatique mondiale, il convient de reconsidérer l'usage actuel selon lequel les étudiants en médecine se déplacent pour se présenter aux entrevues en vue d'obtenir un poste de résidence. Nous avons tenté d'estimer les émissions de dioxyde de carbone (CO2) causées par les déplacements pour les entretiens de résidence en chirurgie générale au Canada, et les émissions potentielles évitées si les entretiens étaient organisés autrement. MÉTHODES: Un sondage comportant huit questions a été élaboré pour recueillir les données sur les villes visitées, les modalités de voyage et les coûts encourus. Les candidats au programme de chirurgie générale de l'Université d'Ottawa au cours du cycle 2019/20 du Service canadien de jumelage des résidents (CaRMS) ont été invités à y répondre. Les réductions potentielles des émissions de CO2 ont été modélisées à l'aide d'un processus d'entrevue régionalisé avec une ou deux villes. RÉSULTATS: Sur un total de 56 candidats, 39 (70 %) ont répondu au sondage. Les candidats ont visité en moyenne 10 villes, pour un coût total moyen de 4 866 dollars (IC 95 % = 3 995-5 737) par candidat. Les émissions moyennes de CO2 étaient de 1,82 (IC 95 % = 1,50-2,14) tonne par candidat, et le total des émissions de CO2 pour l'ensemble des candidats était estimé à 101,9 (IC 95 % = 84,0 - 119,8) tonnes. D'après les modèles où les entrevues sont régionalisées avec une ou deux villes, les émissions seraient respectivement de 57,9 tonnes (43,2 % de réduction) et 84,2 tonnes (17,4 % de réduction). Dans l'ensemble, 74,4 % des personnes interrogées se disent préoccupées par l'impact environnemental des déplacements et 46 % préféreraient que l'entretien se fasse par vidéoconférence. CONCLUSION: Les déplacements pour les entrevues de résidence en chirurgie générale au Canada ont un impact environnemental considérable. Ces conclusions sont probablement généralisables à d'autres programmes de résidence. Compte tenu de la crise climatique mondiale, il conviendrait d'envisager d'autres modalités d'organisation des entrevues pour le processus de candidatures du CaRMS.

The Impact of Surgeon Experience on Script Concordance Test Scoring.

OBJECTIVE: The Script Concordance Test (SCT) is a test of clinical decision-making that relies on an expert panel to create its scoring key. Existing literature demonstrates the value of specialty-specific experts, but the effect of experience among the expert panel is unknown. The purpose of this study was to explore the role of surgeon experience in SCT scoring. DESIGN: An SCT was administered to 29 general surgery residents and 14 staff surgeons. Staff surgeons were stratified as either junior or senior experts based on years since completing residency training (<15 versus >25 years). The SCT was scored using the full expert panel, the senior panel, the junior panel, and a subgroup junior panel in practice <5 years. A one-way ANOVA was used to compare the scores of first (R1) and fifth (R5) year residents using each scoring scheme. Cognitive interviews were analyzed for differences between junior and senior expert panelist responses. RESULTS: There was no statistically significant difference between the mean score of six R1s and five R5s using the full expert panel (R1 69.08 versus R5 67.06, F1,9 = 0.10, P = 0.76), the junior panel (R1 66.73 versus R5 62.50, F1,9 = 0.35, P = 0.57), or the subgroup panel in practice <5 years (R1 61.07 versus R5 58.79, F1,9 = 0.18, P = 0.75). However, the average score of R1s was significantly lower than R5s when using the senior faculty panel (R1 52.04 versus R5 63.26, F1,9 = 26.90, P = 0.001). Cognitive interview data suggests that some responses of junior experts demonstrate less confidence than those of senior experts. CONCLUSIONS: SCT scores are significantly affected by the responses of the expert panel. Expert differences between first and fifth year residents were only demonstrated when using an expert panel consisting of senior faculty members. Confidence may play a role in the response selections of junior experts. When constructing an SCT expert panel, consideration must be given to the experience of panel members.

Comparing 2 Approaches for the File Review of Residency Applications.

BACKGROUND: The residency selection process relies on subjective information in applications, as well as subjective assessment of applications by reviewers. This inherent subjectivity makes residency selection prone to poor reliability between those reviewing files. OBJECTIVES: We compared the interrater reliability of 2 assessment tools during file review: one rating applicant traits (ie, leadership, communication) and the other using a global rating of application elements (ie, curriculum vitae, reference letters). METHODS: Ten file reviewers were randomized into 2 groups, and each scored 7 general surgery applications from the 2019-2020 cycle. The first group used an element-based (EB) scoring tool, while the second group used a trait-based (TB) scoring tool. Feedback was collected, discrimination capacities were measured using variation in scores, and interrater reliability (IRR) was calculated using intraclass correlation (ICC) in a 2-way random effects model. RESULTS: Both tools identified the same top-ranked and bottom-ranked applicants; however, discrepancies were noted for middle-ranked applicants. The score range for the 5 middle-ranked applicants was greater with the TB tool (6.43 vs 3.80), which also demonstrated fewer tie scores. The IRR for TB scoring was superior to EB scoring (ICC [2, 5] = 0.82 vs 0.55). The TB tool required only 2 raters to achieve an ICC ≥ 0.70. CONCLUSIONS: Using a TB file review strategy can facilitate file review with improved reliability compared to EB, and a greater spread of candidate scores. TB file review potentially offers programs a feasible way to optimize and reflect their institution's core values in the process.

Nontechnical Skills (NTS) in the Undergraduate Surgical and Anesthesiology Curricula: Are We Adequately Preparing Medical Students?

OBJECTIVES: Nontechnical skills (NTS) encompass interpersonal, cognitive, and personal resource skills that can mitigate surgical errors and improve patient outcomes. However, inconsistencies in medical student awareness around NTS suggest limited exposure to these skills. This study aimed to determine the prevalence and content of NTS in medical school surgery and anesthesiology education. DESIGN AND SETTING: Learning objectives from clerkship core surgery and anesthesiology rotations were collected from Canadian anglophone medical schools. Two raters independently classified each objective under one of the Non-Technical Skills for Surgeons (NOTSS) or Anaesthetists' Non-Technical Skills (ANTS) "Categories" and "Elements" of NTS, or as a non-NTS objective. Rater disagreements were resolved by group consensus. Group discussion was also held to identify examples of objectives that could help develop future curricula. Descriptive statistics were used to determine the number of NTS objectives from each school and within each NOTSS and ANTS Categories and Elements. RESULTS: Learning objectives were obtained from 12 out of 14 Canadian medical schools. A total of 2116 surgery objectives and 571 anesthesiology objectives were reviewed. Of these, 16 (0.76%) and 26 (4.55%) were identified as NTS objectives in surgery and anesthesiology, respectively. Of the NOTSS and ANTS Categories, "Situation Awareness" and "Decision Making" were represented by only one objective each in both specialties. Approximately half of the NOTSS and ANTS Elements were not represented by a single objective. Group discussion yielded examples of NTS objectives that were excellent, could use improvement, or were too vague to be classified as NTS. CONCLUSIONS: A paucity of objectives in the clerkship perioperative curricula involve NTS. These findings suggest that NTS are unlikely being adequately introduced as critical skillsets of surgeons and anesthesiologists in undergraduate perioperative education. Future curriculum development should involve greater medical student exposure to NTS as key components of their surgery and anesthesiology education.

How do cognitive processes influence script concordance test responses?

INTRODUCTION: The script concordance test (SCT) is a test of clinical decision-making (CDM) that compares the thought process of learners to that of experts to determine to what extent their cognitive 'scripts' align. Without understanding test-takers' cognitive process, however, it is unclear what influences their responses. The objective of this study was to gather response process validity evidence by studying the cognitive process of test-takers to determine whether the SCT tests CDM and what cognitive processes may influence SCT responses. METHODS: Cases from an SCT used in a national validation study were administered and semi-structured cognitive interviews were conducted with ten residents and five staff surgeons. A retrospective verbal probing technique was used. Data was independently analysed and coded by two analysts. Themes were identified as factors that influence SCT responses during the cognitive interview. RESULTS: Cognitive interviews demonstrated variability in CDM among test-takers. Consistent with dual process theory, test-takers relied on scripts formed through past experiences, when available, to make decisions and used conscious deliberation in the absence of experience. However, test-takers' response process was also influenced by their comprehension of specific terms, desire for additional information, disagreement with the planned management, underlying knowledge gaps and desire to demonstrate confidence or humility. CONCLUSION: The rationale behind SCT answers may be influenced by comprehension, underlying knowledge and social desirability in addition to formed scripts and/or conscious deliberation. Having test-takers verbalise their rationale for responses provides a depth of assessment that is otherwise lost in the SCT's current format. With the improved ability to standardise CDM assessment using the SCT, consideration of test-makers improving the SCT construction process and combining the SCT question format with verbal responses may improve the use of the SCT for CDM assessment.

Everyone Is Awesome: Analyzing Letters of Reference in a General Surgery Residency Selection Process.

BACKGROUND: The resident selection process involves the analysis of multiple data points, including letters of reference (LORs), which are inherently subjective in nature. OBJECTIVE: We assessed the frequency with which LORs use quantitative terms to describe applicants and to assess whether the use of these terms reflects the ranking of trainees in the final selection process. METHODS: A descriptive study analyzing LORs submitted by Canadian medical graduate applicants to the University of Ottawa General Surgery Program in 2019 was completed. We collected demographic information about applicants and referees and recorded the use of preidentified quantitative descriptors (eg, best, above average). A 10% audit of the data was performed. Descriptive statistics were used to analyze the demographics of our letters as well as the frequency of use of the quantitative descriptors. RESULTS: Three hundred forty-three LORs for 114 applicants were analyzed. Eighty-five percent (291 of 343) of LORs used quantitative descriptors. Eighty-four percent (95 of 113) of applicants were described as above average, and 45% (51 of 113) were described as the "best" by at least 1 letter. The candidates described as the "best" ranked anywhere from second to 108th in our ranking system. CONCLUSIONS: Most LORs use quantitative descriptors. These terms are generally positive, and while the use does discriminate between different applicants, it was not helpful in the context of ranking applicants in our file review process.

Video-based interviewing in medicine: protocol for a scoping review.

BACKGROUND: Careers in healthcare involve an extensive interview process as transitions are made from one level of training to the next. For physicians, interviews mark the gateway from entrance into medical school, acceptance into residency, fellowships, and subsequent job opportunities. Previous literature outlining the costs associated with face-to-face interviews and concerns regarding the climate crisis has triggered an interest in video-based interviews. Barriers to transitioning away from in-person interviews include concerns regarding lack of rapport between applicants and interviewers, and applicants being less able to represent themselves. In a new era ushered in by COVID where many of us have utilized virtual meetings more than any prior time both personally and for work, we wanted to consolidate the current literature on the use of video-based interviews in healthcare and summarize the findings. METHODS: A scoping review will be conducted to explore the benefits and limitations of video-based interviews for both applicants and interviewers within healthcare fields, as well as the perceived barriers associated with transitioning away from face-to-face interviews. The scoping review methodology outlined by Arksey and O'Malley will be implemented. The search strategy developed by the authors in collaboration with an academic health sciences librarian will be conducted across four electronic databases (Embase, MEDLINE, Cochrane Central, and PsycInfo) and supplemented by a review of the grey literature and reference lists of included studies. The study selection process will be documented using the PRISMA flow diagram, and reasons for exclusion following full-text review will be recorded. The extracted data will be analyzed using quantitative and qualitative analysis. DISCUSSION: Despite previous literature on the costs associated with face-to-face interviews, there has been hesitancy with transitioning to video-based interviews due to concerns of lack of rapport between applicants and interviewers, and applicants being less able to represent themselves. While these limitations have been explored in previous studies, a succinct review of the current literature to guide the effective restructuring of the interview process is lacking. With our scoping review, we hope to fill this gap in the literature to better understand barriers to transitioning from face-to-face interviews and directions for future research.

Comparison of Ligation of the Intersphincteric Fistula Tract and BioLIFT for the Treatment of Transsphincteric Anal Fistula: A Retrospective Analysis.

BACKGROUND: Ligation of the intersphincteric fistula tract is a sphincter-preserving technique for the treatment of anal fistulas. The BioLIFT modification involves the placement of a biologic mesh in the intersphincteric plane. Advocates of this modification state improved healing rates, however evidence for this is lacking, and this approach costs significantly more. OBJECTIVE: The purpose of this study was to compare the healing rates of the ligation of the intersphincteric fistula tract with the BioLIFT. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a tertiary care hospital from April 2008 to April 2018. PATIENTS: All adult patients with transsphincteric anal fistulas were included. Patients were excluded if they had IBD, more than 1 fistula tract operated on simultaneously, or a previous attempt at repair. MAIN OUTCOME MEASURES: The primary outcome was primary healing of the fistula tract, and secondary outcomes included overall success, complications, and time to recurrence. RESULTS: There were 119 cases (75 ligation of the intersphincteric fistula tract and 44 BioLIFTs). One surgeon performed 84% of the BioLIFT cases. The primary healing rate was 75.0% versus 58.7% (p = 0.08), and the complication rate was 22.7% versus 17.3% (p = 0.48; BioLIFT vs ligation of intersphincteric fistula tract). After multivariate logistic regression, the BioLIFT had a significantly better healing rate (OR = 2.38 (95% CI, 1.01-5.62); p = 0.048). Median follow-up was 9 versus 29 weeks (BioLIFT vs ligation of intersphincteric fistula tract). Kaplan-Meier analysis demonstrated no difference in the time to recurrence (p = 0.48). LIMITATIONS: This study was limited by the retrospective nature, different lengths of follow-up, and varying case numbers between the surgeons. CONCLUSIONS: The BioLIFT modification is safe and effective for the treatment of anal fistulas but has a higher cost. This modification warrants additional prospective studies to establish its benefits over the ligation of the intersphincteric fistula tract procedure. See Video Abstract at http://links.lww.com/DCR/B139. COMPARACIÓN DE LIFT VERSUS BIOLIFT PARA EL TRATAMIENTO DE LA FÍSTULA ANAL TRANSFINTERÉRICA: UN ANÁLISIS RETROSPECTIVO: Ligadura del tracto de la fístula interesfintérica es una técnica para preservación del esfínter en el tratamiento de las fístulas anales. La modificación BioLIFT implica la colocación de una malla biológica en el plano interesfintérico. Protagonistas de la modificación mejoraron las tasas de curación, sin embargo, carecen evidencias definitivas y la técnica eleva costos significativamente.Comparar las tasas de curación de ligadura del tracto de la fístula interesfintérica con el BioLIFT.Estudio de cohorte retrospectivo.Hospital de atención de tercer nivel desde abril de 2008 hasta abril de 2018.Se incluyeron todos los pacientes adultos con fístulas anales transfinteréricas. Los pacientes fueron excluidos si tenían enfermedad inflamatoria intestinal, más de un tracto fistuloso operado simultáneamente o con un intento previo de reparación.El resultado principal fue la curación primaria del tracto fistuloso y los resultados secundarios incluyeron el éxito en general, las complicaciones y tiempo hasta recurrencia.Se registraron 119 casos (75 ligaduras del tracto de la fístula interesfintérica y 44 BioLIFT). Un cirujano realizó el 84% de los casos de BioLIFT. La tasa de curación primaria fue del 75.0% vs 58.7%, p = 0.08, y la tasa de complicaciones fue del 22.7% vs 17.3%, p = 0.48 comparando BioLIFT vs ligadura del tracto de la fístula interesfintérica. Después de la regresión logística multivariada, el BioLIFT tuvo una tasa de curación significativamente mejor (OR 2.38 [IC 95% 1.01-5.62], p = 0.048). La mediana de seguimiento fue de 9 vs 29 semanas (BioLIFT vs ligadura del tracto de la fístula interesfintérica). El análisis de Kaplan-Meier no demostró diferencias en el tiempo hasta la recurrencia (p = 0,48).Este estudio estuvo limitado por ser retrospectivo, las diferentes duraciones de seguimiento y el número variable de casos entre los cirujanos.La modificación BioLIFT es segura y efectiva para el tratamiento de las fístulas anales pero tiene un costo más alto. Esta modificación amerita más estudios prospectivos para establecer los beneficios sobre ligadura del tracto de la fístula interesfintérica. Consulte Video Resumen en hhttp://links.lww.com/DCR/B139.