The Stigma of Burnout Impeding Formal Help: A Qualitative Study Exploring Residents' Experiences During Training.

Purpose: Burnout is an occupational stress syndrome that gives rise to emotional exhaustion (EE) depersonalization (DP) and reduced personal accomplishment (PA). Increasing rates of burnout among health care professionals has been reported globally. Saudi Arabia appears to be among the highest in prevalence with reports of higher than 70%. Medical residents in training are the highest group at risk. The literature has repeatedly linked burnout among residents with poor academic performance on training exams, impaired quality of life, career choice regret and intentions to abandon medicine. In this study, we explore the factors that contribute to resident burnout, their experiences with burnout and how they choose to mitigate it. Methods: A qualitative design was used to conduct this study in the city of Riyadh, Saudi Arabia. A total of 14 residents from surgical and non-surgical programs were interviewed through in-depth interviews. Interpretive thematic analysis was used in coding and generated coding templates. Categories were repetitively reviewed and revised, expanding to include new data as it emerged and collapsing to remove redundant codes. Categories were organized into the final themes and sub-themes. Results: All participants demonstrated a shared thread of shame in reaching the level of burnout. Three main interlinked themes were identified: Burnout stigma cycle, amalgamated causes of burnout and self-coping with burnout. One of the concerning findings in our study is the participants' pursuit of self-coping strategies and the avoidance of formal help, creating a cycle of suffering in silence. Conclusion: The literature has repeatedly reported high levels of burnout among residents in training. This study has added another dimension to those findings through the exploration of residents actual accounts and appears to link burnout with suboptimal training and working conditions. We have highlighted the pivotal role stigma and shame play in completely preventing residents from seeking professional help.

Boosting Confidence: Enhancing Spinal Cord Stimulator Needle and Lead Placement Through Simulation Training.

Background This pilot study aims to examine the effectiveness of a spinal cord stimulator (SCS) simulator training system in improving the confidence of pain fellows in SCS placement. Methodology Five Ukrainian physicians (neurologists, neurosurgeons, and an anesthesiologist) completed a 10-item survey regarding their confidence in various aspects of SCS placement and their opinions on how effective SCS models were for educational purposes. After placing SCS leads using the SCS simulator, the physicians took the same survey again. The Mann-Whitney U test was used to determine if there was a significant difference in total scores pre and post-simulator training. The software PAST (PAleontological STatistics) was used for statistical analysis. Results Overall, five participants had a 38% statistically significant increase in survey scores before and after the intervention (mean: 4.2 vs. 6.2, p = 0.0055). With regards to each item of the survey, participants had a significantly increased confidence in driving leads (2.6 vs. 5.2, p = 0.008) and in overall technical skills for the SCS procedure after the training (2.8 vs. 5.2, p = 0.0188). Although the other eight survey items were not statistically significant (p > 0.05), participants had a 28% increase in confidence when inserting epidural needles, a 20% increase in interpreting simulated X-rays, a 32% increase in navigating challenging anatomical variations, a 12% increase in identifying key anatomical landmarks, a 20% increase in ensuring the correct placement of the lead, or a 53% increase in preparedness for performing an SCS procedure in a real clinical setting. The participant's perspective on how valuable the stimulator training was for enhancing procedural skills increased by 38% and how well the simulator replicated real-life SCS procedure increased by 52%, although both were statistically insignificant (p > 0.05). Conclusions This pilot study shows that the utilization of simulated neuromodulation training is a viable means of augmenting neuromodulation education by increasing physician's confidence in aspects of the SCS placement procedure. The extent to which simulator training improves procedural skills in a real-life SCS placement needs to be investigated further.

The "July effect" on patients admitted with diabetes ketoacidosis: a national retrospective cohort study.

Background: Every July, new residents begin training across the United States, but it is unclear whether this affects the mortality rate of critically ill patients such as those with diabetes ketoacidosis (DKA). Methods: This national retrospective cohort study included patients aged 18 years or older admitted to acute care with DKA between 2016 and 2020. Data were obtained from the National Inpatient Sample Database. We compared patients admitted in July and August with those admitted during the remaining months and assessed the primary endpoint of all-cause inpatient mortality. We also obtained an odds ratio adjusted for confounders using multivariate logistic regression analysis. Secondary endpoints included length of hospital stay, total hospital charges, the crude rate of mechanical ventilation, acute kidney injury requiring hemodialysis, and vasopressor requirement. Hypothesis testing was conducted using the chi-square test for categorical variables and Student's t test for continuous variables. A two-tailed P value of < 0.05 was considered statistically significant. Results: Of the 269,095 hospitalizations identified over 5 years with a discharge diagnosis of DKA, 250,990 met the inclusion criteria. During July and August, 42,668 (17%) hospitalizations occurred, and 208,322 (83%) occurred during the remaining months. The mean age of the patients was 47 years, and there was no significant difference among the cohorts (P = 0.41). Female patients represented 54% of the total patients, and there was no difference between the cohorts (P = 0.68). Of the admitted patients, 61% were White, 21% were Black, and 11% were Hispanic, with no differences between the cohorts (P = 0.38). Medicare (35%) and Medicaid (30%) were the primary payers for most patients, and approximately 25% had private insurance. There were no differences between the cohorts in terms of primary payers (P = 0.49). The mean length of stay was 7 days, and the total hospitalization cost was $85,509. Admission in July or August did not increase the odds of inpatient mortality (adjusted odds ratio 0.96, P = 0.58). Conclusions: In this retrospective cohort study of patients admitted with DKA, inpatient care during July and August did not increase the odds of inpatient mortality.

Young urologists and kidney transplantation training: A survey designed by the French Transplantation Committee of the French Association of Urology (CTAFU) and the French Association of Urologists in training (AFUF).

OBJECTIVE: In France, kidney transplantations (KT) are mainly performed by urologist. Young urologists and residents are involved in this activity mostly performed in emergency. How do they feel about KT training? Is KT an attractive part of the urologist activity? METHODS: This survey has been designed in the form of a questionnaire by the French Committee of Kidney Transplantation (CTAFU) and the French Association of Urologists in training (AFUF). It has been sent by e-mail to all the AFUF members. Interest in KT and performance of the training were evaluated. RESULTS: In total, 126 members filed the form. Among the residents, 51.5% feel secure to perform KT at the end of their residency. KT is considered as an interesting surgery for 92.1% of the participants: 76.5% are willing to get involved in KT during their residency/fellowship. Among the participants, 44% are willing to continue a long-term involvement. Among the residents, 65.9% consider their practical training insufficient: 56.8% have been supervised for a KT performance during their residency and 86% declare a lack of practical training and had a patient-based learning. Among the residents, 92.1% declare an insufficient theorical training. Among the residents, 33.3% say the schedules of transplantation limit their interest in KT. Among the participants, 34.4% receive a transplant bonus in addition to the usual on-call salary. CONCLUSION: Young urologists wish to continue their involvement in KT activity, but improved theoretical and practical training are essential. In addition, the conditions under which this activity is performed and remunerated are a matter of concern.

Can an in-person hands-on applicator-based teaching session improve trainee knowledge and comfort with complex gynecologic brachytherapy?

INTRODUCTION: With the emergence of imaged-based planning and hybrid applicators the complexity of gynecologic brachytherapy has dramatically increased. Despite the known advantages of brachytherapy, notable national declines in utilization of brachytherapy have been documented. Clearly improved education in the sphere of gynecologic brachytherapy is needed. We hypothesize that a hands-on applicator-based training session would improve trainee comfort with gynecologic brachytherapy. METHODS AND MATERIALS: An in-person, applicator-based, hands-on training session was held with trainees from both radiation and gynecologic oncology programs. Trainees practiced assembling and handling applicators while receiving instruction on clinical scenarios in which various applicators are used in gynecologic cancer brachytherapy. Pre- and post-session, participants were administered an objective test of 10 pictorial-based case vignettes to quantify ability to select the correct applicator based on the interpretation of T2-weighted MR images. Participants additionally received a subjective survey to quantify comfort and experience with gynecologic brachytherapy using Likert-type question formatting. RESULTS: A total of 14 trainees participated. Most common case volume experience was 0-10 intracavitary (57%), 0-10 hybrid (71%), and 0-10 interstitial (71%). Pre-session, the most common answer to comfort level was "not comfortable still learning" for all brachytherapy types, and most common answer to largest gap in knowledge was all facets of brachytherapy. Average case-based test score was 3.5/10 pre-session versus 5.3/10 post-session (p = 0.028). Post-session, all respondents reported improved comfort level with brachytherapy. Post-session, most common answer to largest gap in knowledge was applicator/patient selection, and applicator/patient selection was also the largest area of identified improvement. 100% of participants felt repeating the session in the future would be helpful. CONCLUSIONS: Hands-on training with applicators improves both subjective and objective comfort with gynecologic brachytherapy. With 100% of participants requesting to implement this session into resident training, we suggest national opportunities might exist to expand educational processes and improve utilization of complex gynecologic brachytherapy in practice.

Application of the combination of CBL teaching method and SEGUE framework to improve the doctor-patient communication skills of resident physicians in otolaryngology department.

BACKGROUND: To explore the feasibility and effectiveness of applying CBL teaching method and SEGUE Framework in the doctor-patient communication skills of resident physicians in the department of otolaryngology. METHODS: This is an observational study to compare the score changes in doctor-patient communication skills of 120 resident physicians, before and after using CBL combined SEGUE Framework teaching method. The effects of gender, age, grade, educational background and marital status on SEGUE score were analyzed. RESULTS: Through the combined application of CBL teaching method and SEGUE Framework, the SEGUE score of 120 resident physicians was significantly improved. There was no significant difference in SEGUE score among different sex and marital status of resident physicians. SEGUE score is positively correlated with age; Different grades and educational backgrounds have significant effects on SEGUE score. CONCLUSION: The combination of CBL teaching method and SEGUE Framework is feasible and effective in the education program of doctor-patient communication skills for resident physicians in the department of otolaryngology, and worthy of popularization and application in other medical specialties.

Teledermatology Practice in a Department that Was Relocated Multiple Times during the COVID-19 Pandemic.

The COVID pandemic inherently impacts clinical activity in Dermatological practices throughout all sectors. Under these circumstances, our service has implemented teledermatology in order to act both as a filter for reducing in-hospital admittance or face-to-face interactions, and as a straightforward solution to solve the issues faced by patients and family doctors within our area. Live consultations rely on the resident physician's capacity to take a detailed patient history in the limited time allotted, while the subsequent case-discussion with the leading-physician has good didactic value. The establishment of a quality international collaboration through teledermatology would further facilitate a more accurate and faster diagnosis, even for patients traveling for business or tourism.

Barriers to research among residents in oral and maxillofacial surgery.

PURPOSE/OBJECTIVES: Research is an integral part of oral and maxillofacial surgery (OMS) residency training. This study aimed to identify the current barriers perceived by OMS residents toward conducting research during training. METHODS: A cross-sectional, questionnaire-based study was conducted. The survey was distributed to 670 OMS residents across the United States in 2021 and consisted of questions regarding demographics, residency program requirements and resources, and perceived barriers to research. Data were analyzed using descriptive statistics, Fisher's exact tests, Kruskal-Wallis tests, and post hoc Dunn's test with a statistical significance of P < 0.05. RESULTS: The response rate was 24.2%. Most participants' programs had a minimum research requirement to complete a residency (80%). The top three reported barriers to completing research were lack of time (84%), limited access to research mentors or supervisors (37%), and lack of access to biostatistical support (31%). Factors associated with these barriers included the lack of a research director, supervisor, mentor, assistant, or statistician. There was no significant difference between residents in programs with protected research time versus those without. CONCLUSIONS: OMS residents generally viewed research experience during residency as beneficial but reported important barriers, most notably: insufficient time. Although most OMS training programs in the US require research for completion, many do not provide adequate time to facilitate this process. Compared with literature from over a decade ago, it appears little progress has been made to remedy similar barriers to research. Addressing this deficiency may increase the quantity and quality of research, furthering the profession.

Indigenizing and co-producing the ACGME anesthesiology milestone in Taiwan: a Delphi study and subgroup analysis.

BACKGROUND: To implement the ACGME Anesthesiology Milestone Project in a non-North American context, a process of indigenization is essential. In this study, we aim to explore the differences in perspective toward the anesthesiology competencies among residents and junior and senior visiting staff members and co-produce a preliminary framework for the following nation-wide survey in Taiwan. METHODS: The expert committee translation and Delphi technique were adopted to co-construct an indigenized draft of milestones. Descriptive analysis, chi-square testing, Pearson correlation testing, and repeated-measures analysis of variance in the general linear model were employed to calculate the F values and mean differences (MDs). RESULTS: The translation committee included three experts and the consensus panel recruited 37 participants from four hospitals in Taiwan: 9 residents, 13 junior visiting staff members (JVSs), and 15 senior visiting staff members (SVSs). The consensus on the content of the 285 milestones was achieved after 271 minor and 6 major modifications in 3 rounds of the Delphi survey. Moreover, JVSs were more concerned regarding patient care than were both residents (MD = - 0.095, P < 0.001) and SVSs (MD = 0.075, P < 0.001). Residents were more concerned regarding practice-based learning improvement than were JVSs (MD = 0.081; P < 0.01); they also acknowledged professionalism more than JVSs (MD = 0.072; P < 0.05) and SVSs (MD = 0.12; P < 0.01). Finally, SVSs graded interpersonal and communication skills lower than both residents (MD = 0.068; P < 0.05) and JVSs (MD = 0.065; P < 0.05) did. CONCLUSIONS: Most ACGME anesthesiology milestones are applicable and feasible in Taiwan. Incorporating residents' perspectives may bring insight and facilitate shared understanding to a new educational implementation. This study helped Taiwan generate a well-informed and indigenized draft of a competency-based framework for the following nation-wide Delphi survey.

A patient-specific, interactive, multiuser, online mixed-reality neurosurgical training and planning system.

OBJECTIVE: Mixed-reality simulation is an emerging tool for creating anatomical models for preoperative planning. Its use in neurosurgical training (NT) has been limited because of the difficulty in real-time interactive teaching. This study describes the development of a patient-specific, interactive mixed-reality NT system. The authors took cases of intracranial tumor resection or neurovascular compression (NVC) as examples to verify the technical feasibility and efficacy of the mixed-reality NT system for residents' training and preoperative planning. METHODS: This study prospectively enrolled 40 patients who suffered from trigeminal neuralgia, hemifacial spasms, or intracranial tumors. The authors used a series of software programs to process the multimodal imaging data, followed by uploading the holographic models online. They used a HoloLens or a standard iOS device to download and display the holographic models for training. Ten neurosurgical residents with different levels of surgical experience were trained with this mixed-reality NT system. Change in surgical strategy was recorded, and a questionnaire survey was conducted to evaluate the efficacy of the mixed-reality NT system. RESULTS: The system allows the trainer and trainee to view the mixed-reality model with either a HoloLens or an iPad/iPhone simultaneously online at different locations. Interactive manipulation and instant updates were able to be achieved during training. A clinical efficacy validation test was conducted. The surgeons changed their exploration strategy in 48.3% of the NVC cases. For residents with limited experience in surgery, the exploration strategy for 75.0% of all patients with NVC was changed after the residents were trained with the mixed-reality NT system. Of the 60 responses for intracranial tumors, the trainee changed the surgical posture in 19 (31.7%) cases. The change of the location (p = 0.0338) and size (p = 0.0056) of craniotomy are significantly related to the experience of the neurosurgeons. CONCLUSIONS: The mixed-reality NT system is available for local or real-time remote neurosurgical resident training. It may effectively help neurosurgeons in patient-specific training and planning of surgery for cases of NVC and intracranial tumor. The authors expect the system to have a broader application in neurosurgery in the near future.

Combined use of 3D printing and mixed reality technology for neurosurgical training: getting ready for brain surgery.

OBJECTIVE: Learning surgical skills is an essential part of neurosurgical training. Ideally, these skills are acquired to a sufficient extent in an ex vivo setting. The authors previously described an in vitro brain tumor model, consisting of a cadaveric animal brain injected with fluorescent agar-agar, for acquiring a wide range of basic neuro-oncological skills. This model focused on haptic skills such as safe tissue ablation technique and the training of fluorescence-based resection. As important didactical technologies such as mixed reality and 3D printing become more readily available, the authors developed a readily available training model that integrates the haptic aspects into a mixed reality setup. METHODS: The anatomical structures of a brain tumor patient were segmented from medical imaging data to create a digital twin of the case. Bony structures were 3D printed and combined with the in vitro brain tumor model. The segmented structures were visualized in mixed reality headsets, and the congruence of the printed and the virtual objects allowed them to be spatially superimposed. In this way, users of the system were able to train on the entire treatment process from surgery planning to instrument preparation and execution of the surgery. RESULTS: Mixed reality visualization in the joint model facilitated model (patient) positioning as well as craniotomy and the extent of resection planning respecting case-dependent specifications. The advanced physical model allowed brain tumor surgery training including skin incision; craniotomy; dural opening; fluorescence-guided tumor resection; and dura, bone, and skin closure. CONCLUSIONS: Combining mixed reality visualization with the corresponding 3D printed physical hands-on model allowed advanced training of sequential brain tumor resection skills. Three-dimensional printing technology facilitates the production of a precise, reproducible, and worldwide accessible brain tumor surgery model. The described model for brain tumor resection advanced regarding important aspects of skills training for neurosurgical residents (e.g., locating the lesion, head position planning, skull trepanation, dura opening, tissue ablation techniques, fluorescence-guided resection, and closure). Mixed reality enriches the model with important structures that are difficult to model (e.g., vessels and fiber tracts) and advanced interaction concepts (e.g., craniotomy simulations). Finally, this concept demonstrates a bridging technology toward intraoperative application of mixed reality.

Modification of Fundamentals of Laparoscopic Surgery Manual Tasks Simulation Curriculum With the Addition of the Vaginal Cuff Closure Training.

OBJECTIVE: Fundamentals of Laparoscopic Surgery (FLS) is a multiple-choice test and a manual skills exam using simulation that Obstetrics and Gynecology (OBGYN) residents must pass to qualify for board certification. There is insufficient validity evidence supporting the use of FLS as a high-stakes exam. This study examines the correlation between OBGYN residents' performance on the FLS manual tasks and simulated vaginal cuff closure. METHODS: We compared residents' performance on FLS tasks with simulated vaginal cuff suturing on a model. During the first coached simulation session, after completion of training on the standard 5 FLS tasks, residents were coached on vaginal cuff closure using a simulated model placed inside the standard FLS box trainer. At a subsequent session, their performance was scored using the Global Operative Assessment of Laparoscopic Skills Scale (GOALS) and a second task-specific metric, and these scores were compared to their official FLS score. RESULTS: Twenty-nine residents completed the vaginal cuff simulation training between June 2019 and November 2021. Nineteen of the 29 were able to complete the cuff closure with the mean time to completion being 14.5 minutes. We found no correlation between official manual skills FLS scores and vaginal cuff GOALS scores (rho = -0.02, p = 0.90) or cuff closure assessment tool score (rho = -0.015, p = 0.048). There was also no correlation between time to completion for any FLS task and vaginal cuff closure OSAT scores. All residents reported that they found the cuff to be a useful addition to the FLS curriculum. CONCLUSIONS: Our study demonstrated that trainee performance on a simulated vaginal cuff closure model did not correlate with official FLS manual tasks skills. This finding adds to the body of evidence disputing the use of FLS as a high-stakes exam to assess laparoscopic skills in gynecology in the relationship with other variables category.

Brazilian airway surgery survey indicates low overall numbers and need for improved teaching skills.

OBJECTIVES: The Brazilian Society of Thoracic Surgeons conducted an online survey to determine the number of surgeons that perform adult and paediatric airway surgery and to understand the practice patterns along the country. METHODS: Active members were electronically invited to complete the questionnaire through the REDCapR platform. Invitations were sent from January to April 2020. The survey encompassed 40 questions that explored 4 different topics in the assessment of tracheal diseases: (i) surgeon's demography; (ii) institutional profile, (iii) education and training in laryngo-tracheal surgery and (iv) preoperative and postoperative evaluation. RESULTS: Eighty-nine percentage of the responders declared to perform tracheal surgery with a median of 5 tracheal resection procedures per year [interquartile range (IQR) 3-12]. Interaction with other specialties occurs in 37.3% of cases. Access to technology and devices is highly variable across the country. Resident training in airway surgery consists in traditional lectures in 97% of the cases. Training in animals (15.2%), cadavers (12.1%) and simulators (6.1%) are rare. Preoperatory evaluation encompasses flexible bronchoscopy (97.8%) and/or computed tomography (CT) scan of the airways (90.6%). Swallowing (20.1%) and voice (14.4%) disorders are rarely evaluated. Eighty-nine percentage of the surgeons consider bronchoscopy to be the preoperatory gold-standard exam, followed by CT scan (38.8%) and CT-3D reconstruction (37.4%). CONCLUSIONS: Brazilian surgeons refer that airway resection and reconstruction are part of their current practice, but the total number of procedures per surgeon per year is low. Access to high-end technology and equipment is heterogenous. Training offered to residents in most academic institutions relies on traditional lectures.

Impact of resident participation on surgical outcomes in laparoscopically assisted vaginal hysterectomy.

OBJECTIVE: To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field. METHODS: A single-center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non-involvement groups. The primary endpoint was the 30-day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non-involvement. RESULTS: Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30-day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non-involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non-involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68-23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01-1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00-1.00; P < 0.001) were significantly associated with 30-day morbidity, but resident involvement was not statistically significant. CONCLUSION: There was no significant difference in the 30-day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety.

Learning Curves of OBGYN Residents Preparing for the FLS Manual Skills Exam.

OBJECTIVE: To describe obstetrics and gynecology (OBGYN) resident practice patterns and learning curves as they prepare for the Fundamentals for Laparoscopic Surgery (FLS) manual skills exam and to assess the importance of meeting proficiency, based on published standards, for passing the FLS manual skills exam. METHODS: This is a prospective observational study of OBGYN resident physicians from July 2018 to January 2022. Residents recorded details about their FLS practice sessions and proficiency metrics for each task repetition. Manual skills exam scores were then compared to task practice variables. Learning curves were developed from resident practice patterns. RESULTS: Fifty OBGYN residents participated in the study. The median number of repetitions per FLS manual skills task ranged from 3.5 (interquartile range [IQR] 2-7) (Task 3) to 7.5 (IQR 3-14) (Task 1). The average number of hours spent practicing was 5.4 hours (SD 3.4 hours), with a median of 3.7 sessions with faculty and/or fellow guidance and 1 self-practice session. All residents passed the FLS manual skills exam. Only for Task 2 (95% confidence interval [CI] 0.24, 5.21) and for the total number of repetitions for all tasks (95% confidence interval [CI] 0.22, 3.74) was a greater number of practice repetitions associated with higher FLS manual skills exam scores. Notably, postgraduate year, number and type of practice sessions, and the number of hours were not associated with higher scores. For all tasks, learning curves showed the greatest rate of improvement in the first 10 to 15 repetitions before diminishing returns. CONCLUSION: Greater number of practice hours and sessions were not associated with better manual exam scores in a cohort of OBGYN residents with a high proportion of supervised practice sessions. Achieving more advanced proficiency at certain FLS tasks may allow for better performance on the exam.

Structured Resident Training in Robotic Surgery: Recommendations of the Robotic Surgery Education Working Group.

OBJECTIVE: A universal resident robotic surgery training pathway that maximizes proficiency and safety has not been defined by a consensus of surgical educators or by surgical societies. The objective of the Robotic Surgery Education Working Group was to develop a universal curriculum pathway and leverage digital tools to support resident education. DESIGN: The two lead authors (JP and YN) contacted potential members of the Working Group. Members were selected based on their authorship of peer-review publications, their experience as minimally invasive and robotic surgeons, their reputations, and their ability to commit the time involved to work collaboratively and efficiently to reach consensus regarding best practices in robotic surgery education. The Group's approach was to reach 100% consensus to provide a transferable curriculum that could be applied to the vast majority of resident programs. SETTING: Virtual and in-person meetings in the United States. PARTICIPANTS: Eight surgeons (2 females and 6 males) from five academic medical institutions (700-1541 beds) and three community teaching hospitals (231-607 beds) in geographically diverse locations comprised the Working Group. They represented highly specialized general surgeons and educators in their mid-to-late careers. All members were experienced minimally invasive surgeons and had national reputations as robotic surgery educators. RESULTS: The surgeons initially developed and agreed upon questions for each member to consider and respond to individually via email. Responses were collated and consolidated to present on an anonymized basis to the Group during an in-person day-long meeting. The surgeons self-facilitated and honed the agreed upon responses of the Group into a 5-level Robotic Surgery Curriculum Pathway, which each member agreed was relevant and expressed their convictions and experience. CONCLUSIONS: The current needs for a universal robotic surgery training curriculum are validated objective and subjective measures of proficiency, access to simulation, and a digital platform that follows a resident from their first day of residency through training and their entire career. Refinement of current digital solutions and continued innovation guided by surgical educators is essential to build and maintain a scalable, multi-institutional supported curriculum.

CatStep: Automated Cataract Surgical Phase Classification and Boundary Segmentation Leveraging Inflated 3D-Convolutional Neural Network Architectures and BigCat.

Objective: Accurate identification of surgical phases during cataract surgery is essential for improving surgical feedback and performance analysis. Time spent in each surgical phase is an indicator of performance, and segmenting out specific phases for further analysis can simplify providing both qualitative and quantitative feedback on surgical maneuvers. Study Design: Retrospective surgical video analysis. Subjects: One hundred ninety cataract surgical videos from the BigCat dataset (comprising nearly 4 million frames, each labeled with 1 of 11 nonoverlapping surgical phases). Methods: Four machine learning architectures were developed for segmentation of surgical phases. Models were trained using cataract surgical videos from the BigCat dataset. Main Outcome Measures: Models were evaluated using metrics applied to frame-by-frame output and, uniquely in this work, metrics applied to phase output. Results: The final model, CatStep, a combination of a temporally sensitive model (Inflated 3D Densenet) and a spatially sensitive model (Densenet169), achieved an F1-score of 0.91 and area under the receiver operating characteristic curve of 0.95. Phase-level metrics showed considerable boundary segmentation performance with a median absolute error of phase start and end time of just 0.3 seconds and 0.1 seconds, respectively, a segmental F1-score @70 of 0.94, an oversegmentation score of 0.89, and a segmental edit score of 0.92. Conclusion: This study demonstrates the feasibility of high-performance automated surgical phase identification for cataract surgery and highlights the potential for improved surgical feedback and performance analysis. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The lived experience of Competence by Design: Canadian resident physicians' perspectives.

PURPOSE: Canadian specialist residency programs are in the process of transitioning to a hybrid time and competence model, Competence by Design (CBD), developed by the Royal College of Physicians and Surgeons Canada. Although there is extensive literature around competency-based medical education (CBME), few studies have evaluated the experience of residents after CBME implementation. The purpose of this study was to obtain a rich perspective on the lived experience of residents. METHODS: We designed a qualitative study with inductive thematic analysis of semistructured interview data. The study population was residents in CBD postgraduate training programs in anesthesiology, internal medicine, or surgery (including all surgical subspecialties) at Dalhousie University (Halifax, NS, Canada). RESULTS: Residents identified the following benefits of their programs and CBD: supportive peers and clinical supervisors, a roadmap for residency, formalized feedback opportunities, and program evolution. Resident-identified drawbacks of CBD included: a lack of transparency around CBD, CBD not as advertised, a lack of buy-in, increased administrative burden, difficulties obtaining evidence for entrustable professional activities (EPAs); the onus for CBD on residents, inconsistent feedback, cumbersome technology, and significant psychological burden. Resident-suggested improvements were reducing the number of EPAs, streamlining EPA requirements, increasing transparency and communication with competence committees, providing incentives and continuous education for clinical supervisors, improving on existing electronic interfaces, and developing technology better suited to the needs of CBD. CONCLUSION: This study highlights that the significant administrative and psychological burden of CBD detracts from clinical learning and enthusiasm for residency. Future research could explore whether overcoming the identified challenges will improve residents' experiences.

RéSUMé: OBJECTIF: Les programmes canadiens de résidence spécialisée sont en train de passer à un modèle hybride de temps et de compétence, soit la compétence par conception (CPC); ce modèle a été élaboré par le Collège royal des médecins et chirurgiens du Canada. Bien qu'il existe une abondante documentation sur la formation médicale fondée sur les compétences (FMFC), peu d'études ont évalué l'expérience des résidentes et résidents après la mise en œuvre de la FMFC. Le but de cette étude était d'obtenir une perspective enrichie quant à l'expérience vécue par les résidents et résidentes. MéTHODE: Nous avons conçu une étude qualitative avec une analyse thématique inductive des données d'entretiens semi-structurés. La population étudiée était composée de résident·es des programmes de formation postdoctorale en anesthésiologie, en médecine interne ou en chirurgie (y compris toutes les surspécialités chirurgicales) à l'Université Dalhousie (Halifax, N.-É., Canada). RéSULTATS: Les personnes interrogées ont identifié les avantages suivants de leurs programmes et de la CPC : le soutien des pairs et des superviseur·es cliniques, une feuille de route pour la résidence, des possibilités de rétroaction officielles et l'évolution du programme. Parmi les inconvénients de la CPC identifiés par les résident·es, mentionnons : un manque de transparence autour de la CPC, une CPC ne correspondant pas à ce qui avait été annoncé, un manque d'adhésion, un fardeau administratif accru, des difficultés à obtenir des preuves de participation à des actes professionnels non supervisés (APNS); le fardeau de la CPC incombant aux résident·es, une rétroaction incohérente, une technologie lourde et un fardeau psychologique important. Les améliorations suggérées par les résident·es comprenaient la réduction du nombre d'APNS, la rationalisation des exigences des APNS, l'augmentation de la transparence et de la communication avec les comités de compétence, l'offre d'incitations et de formation continue aux superviseur·es cliniques, l'amélioration des interfaces électroniques existantes et le développement d'une technologie mieux adaptée aux besoins de la CPC. CONCLUSION: Cette étude souligne que le fardeau administratif et psychologique important de la CPC nuit à l'apprentissage clinique et à l'enthousiasme pour la résidence. Les recherches futures pourraient déterminer si le fait de surmonter les défis identifiés améliorerait l'expérience des résidentes et résidents.