Exploring mentorship in surgery: An interview study on how people stick together.

OBJECTIVE: The objective is to explore the processes contributing to how and why mentors and mentees initiate, maintain and grow in their mentorship relationships in surgery. BACKGROUND: To explore the processes contributing to how and why mentors and mentees initiate, maintain and grow their mentorship relationships in surgery. Evidence suggests that mentorship has a positive impact on physicians' success. Consequently, mentorship programmes have been incorporated into many medicine environments, albeit with variable success. METHODS: We designed an interview-based study using a constructivist grounded theory approach to explore the dynamics of mentorship between junior and experienced surgeons. Recruited mentees were asked to nominate a senior surgeon they identified as a mentor. Both mentee and mentors were then interviewed separately. Transcripts were analysed using constant comparison to a create a final coding framework and to generate themes. RESULTS: We interviewed nine faculty mentors and 10 junior faculty mentees. Our analysis identified key themes describing how to initiate, maintain and grow a mentorship relationship. Mentorship starts with ensuring a 'good fit', persists through satisfying a reciprocal loop with timely communication and deepens the relationship through cycles of mutual investment, learning, and success. Participants also discussed how to navigate through tensions to avoid relationship breakdown, balancing formality and friendship, knowing when to transition a relationship to a new dynamic and finding areas of realistic contribution. CONCLUSIONS: We found that successful mentorship relationships are viewed as dynamic and thus require active investment and shared responsibility between mentees and mentors. Our results also emphasise the value of co-regulation in the relationship, where cycles of mutual investment can contribute to mutual learning and growth.

Short-term and Long-term Outcomes Following Pelvic Pouch Excision: The Mount Sinai Hospital Experience.

BACKGROUND: Few studies have reported surgical outcomes following pouch excision and fewer have described the long-term sequelae. Given the debate regarding optimal surgical management following pouch failure, an accurate estimation of the morbidity associated with this procedure addresses a critical knowledge gap. OBJECTIVE: The objective of this study was to review our institutional experience with pouch excision with a focus on indications, short-term outcomes, and long-term reintervention rates. DESIGN: This was a retrospective cohort study. SETTING: This study was conducted at Mount Sinai Hospital, Toronto, Ontario Canada. PARTICIPANTS: Adult patients registered in the prospectively maintained IBD database with a diagnosis of pelvic pouch failure between 1991 and 2018 were selected. INTERVENTION: The patients had undergone pelvic pouch excision was measured. MAIN OUTCOMES AND MEASURES: Indications for excision, incidence of short-term and long-term complications, and long-term surgical reintervention were the primary outcomes. In addition, multivariable logistic regression models were fitted to identify predictors of chronic perineal wound complications and the effect of preoperative diversion. The positive predictive value of a clinical suspicion of Crohn's disease of the pouch was also evaluated. RESULTS: One hundred forty cases were identified. Fifty-nine percent of patients experienced short-term complications and 49.3% experienced delayed morbidity. Overall, one-third of patients required long-term reoperation related to perineal wound, stoma, and hernia complications. On multivariable regression, immunosuppression was associated with increased odds of perineal wound complications, and preoperative diversion was not associated with perineal wound healing. Crohn's disease was suspected in 24 patients preoperatively but confirmed on histopathology in only 6 patients. LIMITATIONS: This is a retrospective chart review of a single institution's experience, whereby complication rates may be underestimates of the true event rates. CONCLUSIONS: Pouch excision is associated with high postoperative morbidity and long-term reintervention due to nonhealing perineal wounds, stoma complications, and hernias. Further study is required to clarify risk reduction strategies to limit perineal wound complications and the appropriate selection of patients for diversion alone vs pouch excision in IPAA failure. See Video Abstract at http://links.lww.com/DCR/B348. RESULTADOS A CORTO Y LARGO PLAZO DESPUÉS DE LA EXTIRPACIÓN DE LA BOLSA PéLVICA: LA EXPERIENCIA DEL HOSPITAL MOUNT SINAÍ: Pocos estudios han informado resultados quirúrgicos después de la escisión de bolsa pélvica (reservorio ileoanal) y menos han descrito las secuelas a largo plazo. Dado el debate sobre el manejo quirúrgico óptimo después de la falla de la bolsa, una estimación precisa de la morbilidad asociada con este procedimiento aborda una brecha crítica de conocimiento.El objetivo de este estudio fue revisar nuestra experiencia institucional con la extirpación de la bolsa con un enfoque en las indicaciones, los resultados a corto plazo y las tasas de reintervención a largo plazo.Estudio de cohorte retrospectivo.Hospital Mt Sinaí, Toronto, Ontario, Canadá.Pacientes adultos registrados en la base de datos de EII mantenida prospectivamente con un diagnóstico de falla de la bolsa pélvica entre 1991 y 2018.Escisión de bolsa pélvica.Las indicaciones para la escisión, la incidencia de complicaciones a corto y largo plazo y la reintervención quirúrgica a largo plazo fueron los resultados primarios valorados. Además, se ajustaron modelos de regresión logística multivariable para identificar predictores de complicaciones de la herida perineal crónica y el efecto de la derivación preoperatoria. También se evaluó el valor predictivo positivo de una sospecha clínica de enfermedad de Crohn de la bolsa.Se identificaron 140 casos. El 59% de los pacientes desarrollaron complicaciones a corto plazo y el 49,3% con morbilidad tardía. En general, 1/3 de los pacientes requirieron una reoperación a largo plazo relacionada con complicaciones de herida perineal, estoma y hernia. En la regresión multivariable, la inmunosupresión se asoció con mayores probabilidades de complicaciones de la herida perineal y la derivación preoperatoria no se asoció con la cicatrización de la herida perineal. La enfermedad de Crohn se sospechó en 24 pacientes antes de la operación, pero se confirmó por histopatología en solo 6 pacientes.Revisión retrospectiva del cuadro de la experiencia de una sola institución por la cual las tasas de complicaciones pueden ser subestimadas de las tasas de eventos reales.La escisión de la bolsa se asocia con una alta morbilidad postoperatoria y una reintervención a largo plazo debido a complicaciones de heridas perineales, complicaciones del estoma y hernias. Se requieren más estudios para aclarar las estrategias de reducción de riesgos para limitar las complicaciones de la herida perineal y la selección adecuada de pacientes para la derivación sola versus la escisión de la bolsa en caso de falla de reservorio ileoanal. Consulte Video Resumen en http://links.lww.com/DCR/B348.

The American Society of Colon and Rectal Surgeons Assessment Tool for Performance of Laparoscopic Colectomy.

BACKGROUND: The lack of consensus for performance assessment of laparoscopic colorectal resection is a major impediment to quality improvement. OBJECTIVE: The purpose of this study was to develop and assess the validity of an evaluation tool for laparoscopic colectomy that is feasible for wide implementation. DESIGN: During the pilot phase, a small group of experts modified previous assessment tools by watching videos for laparoscopic right colectomy with the following categories of experience: novice (less than 20 cases), intermediate (50-100 cases), and expert (more than 500 cases). After achieving sufficient reliability (κ > 0.8), a user-friendly tool was validated among a large group of blinded, trained experts. SETTING: The study was conducted through the American Society of Colon and Rectal Surgeons Operative Competency Evaluation Committee. PATIENTS: Raters were from the Operative Competency Evaluation Committee of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES: Assessment tool reliability and internal consistency were measured. RESULTS: From October 2014 through February 2015, 4 groups of 5 raters blinded to surgeon skill level evaluated 6 different laparoscopic right colectomy videos (novice = 2, intermediate = 2, expert = 2). The overall Cronbach α was 0.98 (>0.9 = excellent internal consistency). The intraclass correlation for the overall assessment was 0.93 (range, 0.77-0.93) and was >0.74 (excellent) for each step. The average scores (scale, 1-5) for experts were significantly better than those in the intermediate category, with a mean (SD) of 4.51 (0.56) versus 2.94 (0.56; p = 0.003). Videos in the intermediate group scored more favorably than beginner videos for each individual step and overall performance (mean (SD) = 3.00 (0.32) vs 1.78 (0.42); p = 0.006). LIMITATIONS: The study was limited by rater bias to technique and style. CONCLUSIONS: The unique and robust methodology in this trial produced an assessment tool that was feasible for raters to use when assessing videotaped laparoscopic right hemicolectomies. The potential applications for this new tool are widespread, including both training and evaluation of competence at the attending level. See Video Abstract at http://links.lww.com/DCR/A369, http://links.lww.com/DCR/A370, http://links.lww.com/DCR/A371.

Preoperative Anti-tumor Necrosis Factor Therapy in Patients with Ulcerative Colitis Is Not Associated with an Increased Risk of Infectious and Noninfectious Complications After Ileal Pouch-anal Anastomosis.

BACKGROUND: There are conflicting data regarding the effect of previous exposure to anti-tumor necrosis factor (anti-TNF) therapy on complication rates after pelvic pouch surgery for patients with ulcerative colitis (UC). In particular, there is concern surrounding the rates of pouch leaks and infectious complications, including pelvic abscesses, in anti-TNF-treated subjects who require ileal pouch-anal anastomosis (IPAA) surgery. METHODS: A retrospective study was performed in UC subjects who underwent IPAA between 2002 and 2013. Demographic data, clinical data, use of anti-TNF therapy, steroids, immunosuppressants, and surgical outcomes were assessed. RESULTS: Seven hundred seventy-three patients with UC/IPAA were reviewed. Fifteen patients were excluded from the analysis because of missing data. There were 196 patients who were exposed to anti-TNF therapy and 562 patients who were not exposed to anti-TNF therapy preoperatively. There were no significant differences in the postoperative IPAA leak rate between those exposed to anti-TNF therapy and the control group (n = 26 [13.2%] versus 66 [11.7%], respectively, P = 0.44). In addition, there were no significant differences in the postoperative 2-stage IPAA leak rate in those who had been operated on within 15 days from the last anti-TNF dose (n = 10), within 15 to 30 days (n = 17), or 31 to 180 days (n = 54) (10%, 5.9%, and 14.8% respectively, P = 0.43) nor were there differences based on the presence of detectable infliximab serum levels. CONCLUSIONS: Preoperative anti-TNF therapy in patients with UC is not associated with an increased risk of infectious and noninfectious complications after IPAA including pelvic abscesses, leaks, and wound infections.

Subtotal colectomy in severe ulcerative and Crohn's colitis: what benefit does the laparoscopic approach confer?

BACKGROUND: Comparative outcome data for laparoscopic and open subtotal colectomy in IBD are lacking and often difficult to interpret owing to low case volumes, heterogeneity in case mix, and variation in laparoscopic technique. OBJECTIVE: This study aimed to determine the safety of laparoscopic subtotal colectomy in severe colitis and to determine whether the laparoscopic approach improved short-term outcomes in comparison with the open approach. DESIGN: This was a retrospective cohort study using data from a prospectively maintained clinical database. SETTING: This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS: All patients undergoing subtotal colectomy for either ulcerative or Crohn's colitis between 2000 and 2011 were included. INTERVENTION: A standardized operative technique was used for both laparoscopic and open subtotal colectomies. Cases performed by non-laparoscopic surgeons were excluded. MAIN OUTCOME MEASURES: Perioperative outcome measures were operative duration, estimated blood loss, total morphine requirement, and length of postoperative stay. Postoperative outcome measures were the rates of minor and major complications. RESULTS: Laparoscopic subtotal colectomies were performed in 131 of 290 cases (45.2%). Nine patients required conversion to an open procedure (6.9%). The uptake of laparoscopic subtotal colectomy increased from 10.2% in 2000/2001 to 71.7% in 2010/2011. Regression analysis with propensity-score adjustment for operative approach revealed that the operative duration was 25.5 minutes longer in laparoscopic cases (95% CI 12.3-38.6; p < 0.001), but that patients experienced fewer minor complications (OR 0.47; 95% CI 0.23-0.96; p = 0.04) and required less morphine (adjusted difference, -72.8 mg; 95% CI 4.9-141; p = 0.04). LIMITATIONS: The inherent selection bias of this retrospective cohort study may not be accounted for by multivariate analysis with propensity-score adjustment. CONCLUSIONS: Laparoscopic subtotal colectomy is safe and may reduce the rate of minor postoperative complications. The increase in operative duration reflects the technical demands associated with this procedure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A160).

Strictureplasty in selected Crohn's disease patients results in acceptable long-term outcome.

BACKGROUND: Strictureplasty is an alternative to resection in patients with Crohn's disease. OBJECTIVE: The objective of this study was to evaluate the long-term results of patients who have undergone strictureplasty. DESIGN: This is a retrospective cohort study. SETTING: This study was conducted at a tertiary referral center, Mount Sinai Hospital, Toronto, Ontario, Canada. PATIENTS: All patients who had a strictureplasty of the small bowel between 1985 and 2010 were identified from a prospective database. MAIN OUTCOME MEASURES: The main outcomes were short-term complications, need for further surgery, and surgery-free survival. Multivariate analysis was performed to determine factors affecting the need for further surgery. Quality of life was measured by use of the short version of the Inflammatory Bowel Disease Questionnaire. RESULTS: Ninety-four patients (42 women; age at first strictureplasty, 33.4 ± 9.7 years) underwent 119 operations (range per patient, 1-4). The number of strictureplasties was 278 (range, 1-11), including 9 in the duodenum and 269 in the jejunum-ileum. The most common type of procedure was the Heineke-Mickulicz (258, 92.8%). Median follow-up of the patients was 94 months (interquartile range, 27-165 months). The surgery-free survival at 5 and 10 years was 70.7% (95% CI 59.8, 81.7) and 26.6% (95% CI 13.6, 39.6). In multivariate analysis, only age at the time of first strictureplasty was associated with the need for further surgery. Fifty-seven (64.8%) patients returned the questionnaire. The average score was 5.2 ± 1.2 (range, 2.2-7.0) with no significant differences between patients with or without previous surgery (p = 0.22), with or without simultaneous resection (p = 0.71) or with or without further surgery (p = 0.11). LIMITATIONS: This study was limited by its sample size and retrospective design. CONCLUSIONS: Strictureplasty is a safe procedure with acceptable long-term outcomes. The risk of needing further surgery is high, which reflects the complexity of this disease. Younger age is associated with a higher risk of need for further surgery. However, most patients have a satisfactory quality of life.

Objective assessment of technical skill.

Objective assessment of technical skill is an important component of skills training: trainees require that deficiencies are clearly and objectively identified if a model of deliberate practice with feedback on skill acquisition is to be employed. There are several types of reliable and valid assessments for technical skill currently available.

Ex vivo technical skills training transfers to the operating room and enhances cognitive learning: a randomized controlled trial.

BACKGROUND: Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated. METHODS: We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script. RESULTS: The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03). CONCLUSIONS: Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.

Development of an objective evaluation tool to assess technical skill in laparoscopic colorectal surgery: a Delphi methodology.

BACKGROUND: Laparoscopic colorectal surgery (LCS) is an advanced procedure for which no objective tools exist to assess technical skill. The aim of this study was to determine expert consensus regarding items required on a rating scale for LCS, using a Delphi technique. METHODS: Experts rated the substeps of LCS from 1 to 5. Responses were returned to the panel until consensus (Cronbach's α ≥ .80) was reached. Substeps that 80% of experts rated as ≥4 were included in the final instrument. RESULTS: Initially, α values were .81 for sigmoid colectomy, .77 for right (medial-to-lateral) colectomy, and .74 for the lateral-to-medial approach. In the second round, α values were .83 for medial-to-lateral right colectomy and .82 for lateral-to-medial colectomy. CONCLUSIONS: The Delphi method allowed the determination of consensus regarding the essential steps to be included in a tool designed to measure technical competence in LCS.

A moderated journal club is more effective than an Internet journal club in teaching critical appraisal skills: results of a multicenter randomized controlled trial.

BACKGROUND: Evidence Based Reviews in Surgery (EBRS) is an Internet journal club that is effective in teaching critical appraisal skills to practicing surgeons. The objective of this randomized controlled trial was to determine whether teaching critical appraisal skills to surgical residents through the Internet is as effective as a moderated in-person journal club. STUDY DESIGN: Twelve general surgery programs were cluster-randomized to an Internet group (6 programs; 227 residents; 23 to 47 residents/program) or a moderated journal club (6 programs, 216 residents, 21 to 72 residents/program). Each EBRS package includes a clinical and methodological article plus clinical and methodological reviews. Residents in the Internet group were required to complete 8 EBRS packages online plus participate in an online discussion group. Residents in the moderated group were required to attend 8 journal clubs moderated by a faculty member. All residents completed a validated test assessing expertise in critical appraisal. RESULTS: In the Internet group, only 18% of residents completed at least 1 EBRS package compared with 96% in the moderated group. One hundred and thirty (57.8%) residents in the Internet group completed the test compared with 157 (72.7%) in the moderated group. The residents in the moderated group scored considerably better on the critical appraisal test, with a mean score of 42.1 compared with 37.4 in the Internet group (p = 0.05), with a moderate effect size of 0.6 SD. CONCLUSIONS: A moderated journal club is considerably better in teaching critical appraisal skills to surgical residents. This is likely because of the low participation in the Internet journal club.

Assessing outcomes following surgery for colorectal cancer using quality of care indicators.

BACKGROUND: We sought to assess the feasibility of applying Cancer Care Ontario's quality of care indicators to a single institution's colorectal cancer (CRC) database. We also sought to assess their utility in identifying areas that require improvement. METHODS: We included patients who had surgery for CRC between 1997 and 2006 at Mount Sinai Hospital, Toronto, Ont. We excluded patients who had transanal excisions, carcinoma in situ or recurrences that required pelvic exenteration, as well as those whose information was incomplete. We obtained data from a prospective database and verified the data with hospital and office charts. We evaluated trends over a 10-year period using the Cochran-Armitage trend test. RESULTS: During the study period there were 1005 surgical procedures performed in 987 patients with a mean age of 65.6 (standard deviation 15) years; the male:female ratio was 1:2. The most frequent tumour sites were the rectum and sigmoid colon (68%). Over the 10-year period, 9 indicators improved, including the proportion of patients with CRC identified by screening (p < 0.001), the proportion of patients who received preoperative liver imaging (p = 0.05), the proportion of rectal cancer patients who received preoperative pelvic imaging (p = 0.04), the proportion of patients with stage II or III rectal cancer who received radiotherapy (p = 0.03), the proportion of surgical specimens with more than 12 lymph nodes (p < 0.001), the proportion of pathology reports that included quantitative distal (p = 0.004) and radial (p < 0.001) margin measurements, the proportion of patients with an anastomotic leak (p = 0.03), the proportion of patients who received a colonoscopy 1 year after surgery (p < 0.001) and the proportion of operative reports that were complete (p < 0.001). CONCLUSION: The use of quality of care indicators to assess the quality of colorectal surgery is feasible. This study provides benchmarks that can be used to assess changes in the quality of CRC care at our institution.

Observation, reflection, and reinforcement: surgery faculty members' and residents' perceptions of how they learned professionalism.

PURPOSE: To explore perceptions of how professionalism is learned in the current academic environment. Professionalism is a core competency in surgery (as in all of medical practice), and its presence or absence affects all aspects of clinical education and practice, but the ways in which professional values and attitudes are best transmitted to developing generations of surgeons have not been well defined. METHOD: The authors conducted 34 semistructured interviews of individual surgery residents and faculty members at two academic institutions from 2004 to 2006. Interviews consisted of open-ended questions on how the participants learned professionalism and what they perceived as challenges to learning professionalism. Two researchers analyzed the interview transcripts for emergent themes by using a grounded-theory approach. RESULTS: Faculty members' and residents' perceptions of how they learned professionalism reflected four major themes: (1) personal values and upbringing, including premedical education experiences, (2) learning by example from professional role models, (3) the structure of the surgery residency, and (4) formal instruction on professionalism. Of these, role modeling was the dominant theme: Participants identified observation, reflection, and reinforcement as playing key roles in their learning from role models and in distinguishing the sometimes blurred boundary between positive and negative role models. CONCLUSIONS: The theoretical framework generated out of this study proposes a focus on specific activities to improve professional education, including an active approach to role modeling through the intentional and explicit demonstration of professional behavior during the course of everyday work; structured, reflective self-examination; and timely and meaningful evaluation and feedback for reinforcement.

A prospective evaluation of sexual function and quality of life after ileal pouch-anal anastomosis.

PURPOSE: This study was designed to assess the effect of ileal pouch-anal anastomosis on sexual function and quality of life in men and women. METHODS: Sexual function of patients undergoing ileal pouch-anal anastomosis from February 2005 to June 2006 was prospectively evaluated using the International Index of Erectile Function in men and Female Sexual Function Index in women. Quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire. Preoperative scores were compared with scores at 6 and 12 months postoperatively. RESULTS: Of 110 patients eligible for inclusion, 59 (53.6 percent) agreed to participate. Male sexual function and erectile function scores remained high 12 months after surgery (mean International Index of Erectile Function score 51.7 preoperative vs. 58.3 at 12 months postoperative; P = not significant (NS)). Abnormal sexual function decreased from 33.3 percent before surgery to 22.7 percent 12 months after surgery (P = NS). Female sexual function improved 12 months after surgery (mean Female Sexual Function Index score 19.2 preoperative vs. 27 at 12 months postoperative; P = 0.031). Abnormal sexual function decreased from 73.1 percent before surgery to 25 percent 12 months after surgery (P = 0.001). Quality of life significantly improved after ileal pouch-anal anastomosis in both sexes. CONCLUSIONS: In men, ileal pouch-anal anastomosis does not have an adverse effect on sexual function, whereas sexual function in women seems to improve 12 months after surgery.

Setting up a surgical skills center.

With the increasing use of simulation in medicine, many departments of surgery are considering the development of a surgical skills center. This article focuses on practical issues that must be considered when setting up a surgical skills center. The importance of developing a mission statement and including relevant stakeholders is discussed. The types of curricula that can be developed as well as the appropriate equipment purchased to support different curricula are considerations. Space requirements, funding sources, and staffing are also covered. Setting up a surgical skills center requires institutional buy-in and planning from the outset. Various models of skills centers, depending on local politics, are discussed.

Current assessment and future directions of surgical skills laboratories.

BACKGROUND: Educational, medicolegal, and financial constraints have pushed surgical residency programs to find alternative methods to operating room teaching for surgical skills training. Several studies have demonstrated that the use of skills laboratories is effective and enhances performance; however, little is known about the facilities available to residents. STUDY DESIGN: A survey was distributed to 40 general surgery program directors who, in an earlier questionnaire, indicated that they had skills laboratory facilities at their institutions. The survey included the following sections: demographics, facilities, administrative infrastructure, curriculum, learners, and opinions/thoughts of program directors. RESULTS: Of the 34 program directors that completed the survey, 76% are from a university program. The average facility is 1400 square feet, and most skills laboratories are located in the hospital. Nearly all skills facilities have dry laboratories (90%), and the most common equipment is box trainers (90%). Average start-up costs were $450,000. Sixty-two percent of programs have a skills curriculum for residents. Responders agreed that skills laboratories have a high value and should be part of residency curricula. CONCLUSIONS: The results of this survey provide a preliminary view of skills laboratories. There is variation in the size, location, and availability of simulators in skills laboratory facilities. Variations also exist in types of curricula formats, subspecialties who make use of the laboratory, and some administrative approaches. There is strong agreement among respondents that skills laboratories are a necessary and valuable component of residency education. Results also indicated concerns for recruiting faculty to teach in the skills laboratory, securing ongoing funding, and implementing a skills laboratory curriculum.

Slowing down when you should: a new model of expert judgment.

The study of expertise in medical education has tended to follow a tradition of trying to describe the analytic processes and/or nonanalytic resources that experts acquire with experience. However, the authors argue that a critical function of expertise is the judgment required to coordinate these resources, using efficient nonanalytic processes for many tasks, but transitioning to more effortful analytic processing when necessary. Attempts to appreciate the nature of this transition, when it happens, and how it happens, can be informed by the evaluation of other literatures that are addressing these and related problems. The authors review the literatures on educational expertise, attention and effort, situational awareness, and human factors to examine the conceptual frameworks of expertise arising from these domains and the research methodologies that inform their practice. The authors propose a new model of expert judgment that we describe as a process of slowing down when you should.

Patient care is a collective responsibility: perceptions of professional responsibility in surgery.

BACKGROUND: Changes in training are likely to affect the professionalization process, but such complex social phenomena are poorly studied by quantitative research methodologies. In contrast, qualitative research designs are more effective in exploring complex social processes. The objective of this study was to use a qualitative methodology to explore how professional responsibilities are perceived by surgical trainees and faculty in the current academic environment. METHODS: Semi-structured individual interviews of 43 surgical residents and faculty (ranging from second year residents to senior faculty) were conducted at 2 academic institutions. The interviews consisted of open-ended questions, followed by discussion of 4 written, case-based scenarios on specific issues related to professional responsibilities. All interviews were audio-recorded and transcribed, and then analyzed for emergent themes by 3 researchers using a grounded theory approach. RESULTS: In discussing professional responsibilities, the motivations that shaped participants' responses reflected a balance between 4 major factors: (1) patient care, (2) education, (3) self, and (4) collegial relationships. Patient care was described as being at the center of professional responsibility, but it did not necessarily supersede other factors. Rather, patient care was described as a collective responsibility, operationalized through teamwork, communication, and trust. CONCLUSIONS: Traditional medical ethics have largely focused on professional responsibility from the standpoint of individual healthcare providers. Our findings suggest it is a much more complex construct characterized by competing responsibilities and an evolving perception of patient care as a collective responsibility. Explicit acknowledgment of this framework sets the stage for educational interventions to support residents' professional development and enhance cooperative behavior among participants.

Laboratory-based vascular anastomosis training: a randomized controlled trial evaluating the effects of bench model fidelity and level of training on skill acquisition.

BACKGROUND: Although there is growing evidence that practice on bench model simulators can improve the acquisition of technical skill in surgery, the degree to which these models have to approximate real-world conditions (model fidelity) to optimize learning is unclear. Previous research suggests that low-fidelity models may be adequate for novice learners. The purpose of this study was to assess the effect of model fidelity and surgical expertise on the acquisition of vascular anastomosis skill. METHODS: Twenty-seven surgical residents participated in this institutional review board-approved study. Junior residents (postgraduate year 1 and 2) and senior residents (postgraduate year 4 or higher) were randomized into two groups: low-fidelity (n = 13) and high-fidelity (n = 14) model training. Both groups were given a 3-hour hands-on training session: the low-fidelity group used plastic models, and the high-fidelity group used human cadaver arms (brachial arteries) to practice graft-to-arterial anastomosis. One week later, all subjects participated in an animal laboratory in which they performed a single vascular anastomosis on a live, anesthetized pig (femoral artery). A blinded vascular surgeon scored candidate performance in the animal laboratory by using previously validated end points, including a checklist and final product analysis score. RESULTS: Acquisition of skill was significantly affected by model fidelity and level of training as measured by both the checklist (P = .03) and final product analysis (P = .01; Kruskal-Wallis). Specifically, junior residents practicing on high-fidelity models scored better on the checklist (P = .05) and final product analysis (P = .04). Senior residents practicing on high-fidelity models scored better on final product analysis (P < .05). CONCLUSIONS: Training in the laboratory does improve skill when assessed in a realistic setting. Both expertise groups showed better skill transfer from the bench model to live animals when practicing on high-fidelity models. For vascular anastomosis, it is important to provide appropriate model fidelity for trainees of different abilities to optimize the effectiveness of bench model training.