See one, simulate many, do one, teach one: cardiac surgical simulation.

PURPOSE OF REVIEW: To review the cardiac surgical simulation experience with a focus on data supporting its use. RECENT FINDINGS: Simulators have been used to improve trainee performance across multiple surgical domains. Few cardiac surgery residency programs have incorporated the use of simulation individually and Boot Camp programs in the United States and Canada have also introduced surgical simulation early in cardiac surgical training. Simulation curricula have some common elements: component tasks, deliberate practice, progressive operative responsibility, and coaching by an experienced surgeon. Cardiac surgical simulators can range from inexpensive, low-fidelity models for the practice of isolated skills to high-fidelity, operating room-scenarios. Multiple small studies have consistently demonstrated that the use of simulation improves qualitative and quantitative performance measures as well as overall resident confidence in clinical settings. To our knowledge, no study has demonstrated that use of simulation has led to improved quantitative performance measures in the operating room or patient outcomes. The barriers to wider use of surgical simulators include perceived lack of time and resources, the need for sustained practice and the lack of high-quality data to demonstrate clinical benefit. SUMMARY: Incorporation of cardiac surgery simulation has been slow in most residency programs. There is consistent data demonstrating that simulation improves resident performance measures of simulation-based tasks but whether this will lead to improved patient outcomes remains an open question.

History of Surgery for Mitral Stenosis: John Mayow to Charles Bailey.

Mitral stenosis was first described in 1674 by Englishman John Mayow, but surgical intervention for mitral stenosis was proposed over 2 centuries later in 1898. Mitral valve surgery was undertaken in the 1920s with varying success; after 2 decades of staggered progress, mitral valvuloplasty and commissurotomy would be rediscovered by Americans Horace Smithy, Charles Bailey, and Dwight Harken. The evolution of open surgery for mitral stenosis suggests the troubled triumph of humanity over disease while also underlining surgeons' inability to successfully disseminate their pioneering ideas to a community critical of innovation.

American Association for Thoracic Surgery Summer Intern Scholarship-Over a decade of experience.

OBJECTIVE: The study objective was to evaluate the experience of previous American Association for Thoracic Surgery Summer Intern Scholarship recipients. METHODS: A database of recipients of the American Association for Thoracic Surgery Summer Intern Scholarship in Cardiothoracic Surgery provided by the American Association for Thoracic Surgery was analyzed. A questionnaire was sent via email to recipients with 10 questions within the survey to assess the types of exposure during the internship, the impact of the internship on career choices, the current career setting, and any additional thoughts regarding the internship. RESULTS: Between 2007 and 2017, there were 356 awardees of the American Association for Thoracic Surgery Summer Intern Scholarship. These awardees were from 41 different medical schools and went to 39 different sponsoring institutions. Ultimately, 55 (15.5%) medical students chose a career in cardiothoracic surgery, with 153 (43.0%) awardees deciding to pursue a surgical subspecialty. Of those who received our survey, 75 awardees responded (29.2%). A majority of the American Association for Thoracic Surgery Summer Interns were exposed to the sponsoring surgeon (98.7%, n = 74) and operating room (88.0%, n = 66) on at least a weekly basis during the 8-week internship. All of the respondents participated in basic science or clinical research at their sponsoring institution. Some 92.0% (n = 69) of the awardees highly recommended this scholarship to medical students interested in cardiothoracic surgery. CONCLUSIONS: The awardees of the American Association for Thoracic Surgery Summer Intern Scholarship come from a variety of medical schools and visited a diverse group of sponsoring institutions. The 8-week program provides valuable early exposure for medical students to cardiothoracic surgeons, the operating room, and research opportunities. This experience was highly recommended by prior recipients to medical students interested in cardiothoracic surgery.

Virtual Surgical Skills Training in a High School Summer Program.

BACKGROUND: The COVID-19 pandemic has disrupted components of traditional education with shifts toward virtual platforms. This report describes the virtual approach to basic surgical skills training during a high school program in the summers of 2020 and 2021. METHODS: Two 2-week sessions were held by Zoom (Zoom Video Communications) with 99 students in 2020 and 198 students in 2021. Each student was sent surgical supplies and instruments. Interactive lectures were held each morning, and basic surgical skills instruction was provided each afternoon. After the session, survey links were distributed to students to complete an anonymous 37-item questionnaire regarding surgical skills confidence, simulation kit satisfaction, and technical difficulties. RESULTS: Of the 297 students, 270 (90.9%) completed the questionnaire, including 91 (91.9%) in 2020 and 179 (90.4%) in 2021. On a scale of 1 (fair) to 5 (excellent), students in 2020 and 2021 reported similar confidence in instrument handling (4-5: 90.0% vs 86.3%; P = .38), suturing skin (4-5: 88.9% vs 82.8%; P = .19), and thoracic aorta suturing (4-5: 73.3% vs 73.6%; P = .97). Students reported greater confidence in 2020 in knot tying (4-5: 98.9% vs 87.9%; P = .002), coronary vessel suturing (4-5: 82.2% vs 65.5%; P < .001), and valve model suturing (4-5: 68.5% vs 50.3%; P = .005) than students in 2021. Students had similar satisfaction rates with the program (extremely or somewhat satisfied: 92.3% vs 86.0%; p = .51) between 2020 and 2021. CONCLUSIONS: Virtual education carries the potential for basic surgical skills training for a more widespread audience with less access to direct surgical education. Further research is needed to optimize teaching finer surgical skills.

Digital Health Primer for Cardiothoracic Surgeons.

The burgeoning demands for quality, safety, and value in cardiothoracic surgery, in combination with the advancement and acceleration of digital health solutions and information technology, provide a unique opportunity to improve efficiency and effectiveness simultaneously in cardiothoracic surgery. This primer on digital health explores and reviews data integration, data processing, complex modeling, telehealth with remote monitoring, and cybersecurity as they shape the future of cardiothoracic surgery.

Enhanced Recovery After Surgery: A Narrative Review of its Application in Cardiac Surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a perioperative patient management strategy that is being adopted rapidly across surgical specialties worldwide. Components of ERAS work collaboratively throughout the perioperative course to achieve significant benefits for both the patient and the entire health care system. The use of ERAS in cardiac surgery (ERAS-C) could lead to similar improvements, but currently, use of ERAS-C programs is lacking and not well defined. METHODS: A literature search was performed of the Medline database to capture relevant studies discussing ERAS-C. Key concepts were extracted from these articles and grouped according to appropriate perioperative stages. Supporting literature was also included, briefly discussing the historical progression of cardiac surgery to enhanced recovery pathways, potential limitations to these pathways in cardiac surgery, and the first studies evaluating the use of an ERAS program with cardiac surgery patients. RESULTS: Initial results of ERAS-C studies have shown similar benefits to those of other surgical fields, including decreased hospital and intensive care unit lengths of stay (1-4 days and 4-20 hours, respectively), improved perioperative pain control (25%-60% decreased opioid usage), and improvements in early postoperative mobility and oral diets. Results especially beneficial to cardiac surgery have also been reported, such as an 8% to 14% decreased incidence of postoperative atrial fibrillation. CONCLUSIONS: This review presents pertinent current research related to the implementation of ERAS programs in the field of cardiac surgery and provides a call to action for further investigation and adaption of ERAS in cardiac surgery.

WITHDRAWN: Commentary: Collaborative education in surgery.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Artificial Intelligence: Can Information be Transformed into Intelligence in Surgical Education?

Artificial intelligence (AI) is being rapidly integrated into various medical applications. Although early application of AI has been achieved in image-based, as well as statistical computational models, translation into procedure-based specialties such as surgery may take longer to achieve. A potential application of AI in surgical education is as a teaching coach or mentor that interacts with the used via virtual and/or augmented reality. The question arises as to whether machines will achieve the wisdom and intelligence of human educators.

American Board of Thoracic Surgery 10-Year Maintenance of Certification Exam Improves and Validates Knowledge Acquisition.

BACKGROUND: Previous "high-stakes" examinations by the American Board of Thoracic Surgery (ABTS) required remote testing, were noneducational, and were not tailored to individual practices. Given the ABTS mission of public safety and diplomate education, the ABTS Maintenance of Certification (MOC) examination was revised in 2015 to improve the educational experience and validate knowledge acquired. METHODS: The ABTS-MOC Committee developed a web-based, secure examination tailored to the specialty-specific practice profile (cardiac, general thoracic, cardiothoracic, congenital) of the individual surgeon. After an initial answer to each question, an educational critique was reviewed before returning to the initial question and logging a second (final) response. Intraexam learning was assessed by comparing scores before and after reading the critique. Diplomate feedback was obtained. RESULTS: A total of 988 diplomates completed the 10-year MOC examination between 2015 and 2017. Substantive learning was demonstrated with an 18%, 17%, 20%, and 9% improvement in cardiac, general thoracic, cardiothoracic, and congenital final scores, respectively. This improvement was most notable among diplomates with the lowest initial scores. Fewer diplomates failed the new exam (<1% vs 2.3%). Diplomate postexam survey highlighted marked improvements in clinical relevance (35% vs 78%), convenience (37% vs 78%), and learning (15% vs 45%). Over 80% acknowledged educational value, and 97% preferred the new format. CONCLUSIONS: The new MOC process demonstrates increased knowledge acquisition through a convenient, secure, web-based practice-focused examination. This approach provides feedback, identifies baseline knowledge gaps for individual diplomates, and validates new knowledge attained.

Evolving strategies for the treatment of valvular heart disease: Preclinical and clinical pathways for percutaneous aortic valve replacement.

To decrease the morbidity associated with conventional surgery for calcific aortic stenosis, there has been increasing interest in catheter-based treatment using a stent or frame mounted bioprosthetic valve. Critical to its success is knowledge of pathoanatomy, risk of embolization of calcific debris, and issues associated with device anchoring and paravalvular leaks. In the absence of a chronic animal model of aortic stenosis, development of a catheter-based device has been an iterative process based on experimental and early clinical data gathered abroad, where marketing may be permitted with less clinical data than required in the United States. This process has persuaded many companies to circumvent the time delays occasioned by the FDA regulatory validation of iterative design changes by performing initial studies outside the United States. Because percutaneous aortic valve replacement is considered a Class III device, premarket approval, including defining the patient population, inclusion and exclusion criteria, control population, and interpretable clinical endpoints, is required. In the early clinical experience, percutaneous aortic valve replacement has been directed at high-risk patients who were considered "very poor" or "non-surgical" candidates. Defining and identifying patients for the clinical trial may be challenging, in part because of the difficult selection of an appropriate control group, e.g., conventional aortic valve replacement, best medical management, and/or balloon valvuloplasty.

Congenital coronary artery anomalies presenting in late adulthood with concurrent acquired heart disease: report of two cases.

Congenital coronary anomalies can be found in up to 1% of patients undergoing angiography. The most severe of these lesions become symptomatic in early childhood, while others can remain without consequence. However, while being silent in the early decades of life, these asymptomatic anomalies can contribute to the presentation of acquired heart disease and can themselves become clinically significant. We describe the clinical course of two patients with congenital coronary artery anomalies presenting beyond the fifth decade of life with concurrent acquired heart disease.

Leadership Oversight for Patient Safety Programs: An Essential Element.

Leadership in the realm of quality oversight and endorsing a culture of safety is paramount. The stakeholders, ranging from the surgeons to the Chair of the Board have to be engaged and really understand the importance of leadership support. Clarity of leadership support, innovation in process improvement as well as performance management and accountability are the foundational components of a strong culture of safety. Alignment of all stakeholders and continuous improvement that is supported by leadership will ensure the best outcomes for surgical patients.

Does cramming work? Impact of National Web-Based Thoracic Surgery Curriculum login frequency on thoracic surgery in-training exam performance.

OBJECTIVE: Web-based curricula provide login data that can be advantageously used to characterize and analyze study habits. We sought to compare thoracic surgical trainee In-Training Examination percentiles with regard to their study habits (ie, cramming), as characterized by curriculum login frequency to the national Web-based Thoracic Surgery Curriculum. Furthermore, we then aimed to characterize the curriculum login frequency of trainees as stratified by their performance on the In-Training Examination and their improvement on the In-Training Examination over subsequent years. METHODS: We performed a retrospective review of trainees who accessed the curriculum before the 2014 In-Training Examination, with curriculum login data collected from site analytics. Scores were compared between trainees who crammed (≥30% increase in logins in the month before the In-Training Examination) and those who did not. Trainees were stratified on the basis of 2014 In-Training Examination percentile and improvement in percentile from 2013 to 2014 into high, medium, and low scorers and improvers. RESULTS: Of 256 trainees who took the 2014 In-Training Examination, 63 (25%) met criteria as crammers. Crammers increased total study sessions immediately before the In-Training Examination (P < .001), but without impact on 2014 In-Training Examination percentile (P = .995) or year-to-year improvement (P = .234). Stratification by In-Training Examination percentile demonstrated that highest scoring trainees used the curriculum more frequently in the final month than medium-range scorers (P = .039). When stratified by extent of year-to-year improvement, those who improved the most accessed the curriculum significantly more often in the last month compared with baseline (P = .040). Moreover, those with greatest improvement logged in more in the final month than those with least improvement (P = .006). CONCLUSIONS: Increasing the frequency of study periods on the national Web-based thoracic surgery curriculum before the In-Training Examination may have a unique benefit to trainees who initially score low to allow them to significantly improve their subsequent year In-Training Examination performance.

Physician Burnout: Are We Treating the Symptoms Instead of the Disease?

Despite increasing recognition of physician burnout, its incidence has only increased in recent years, with nearly half of physicians suffering from symptoms of burnout in the most recent surveys. Unfortunately, most burnout research has focused on its profound prevalence rather than seeking to identify the root cause of the burnout epidemic. Health care organizations throughout the United States are implementing committees and support groups in an attempt to reduce burnout among their physicians, but these efforts are typically focused on increasing resilience and wellness among participants rather than combating problematic changes in how medicine is practiced by physicians in the current era. This report provides a brief review of the current literature on the syndrome of burnout, a summary of several institutional approaches to combating burnout, and a call for a shift in the focus of these efforts toward one proposed root cause of burnout.

Experience With the Cardiac Surgery Simulation Curriculum: Results of the Resident and Faculty Survey.

BACKGROUND: The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience. METHODS: Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated. RESULTS: Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditional-track programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%). CONCLUSIONS: The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management.

Simulation-Based Training in Cardiac Surgery.

BACKGROUND: Operating room surgical training has significant limitations. This study hypothesized that some skills could be learned efficiently and safely by using simulation with component task training, deliberate practice, progressive complexity, and experienced coaching to produce safer cardiac surgeons. METHODS: Training modules included cardiopulmonary bypass, coronary artery bypass grafting, aortic valve replacement, massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function. Using deliberate practice, first-year cardiothoracic surgical residents at eight institutions were trained and evaluated on component tasks for each module and later on full cardiac operations. Evaluations were based on five-point Likert-scale tools indexed by module, session, task items, and repetitions. Statistical analyses relied on generalized linear model estimation and corresponding confidence intervals. RESULTS: The 27 residents who participated demonstrated improvement with practice repetitions resulting in excellent final scores per module (mean ± two SEs): cardiopulmonary bypass, 4.80 ± 0.12; coronary artery bypass grafting, 4.41 ± 0.19; aortic valve replacement, 4.51 ± 0.20; massive air embolism, 0.68 ± 0.14; acute intraoperative aortic dissection, 4.52 ± 0.17; and sudden deterioration in cardiac function, 4.76 ± 0.16. The transient detrimental effect of time away from training was also evident. CONCLUSIONS: Overall performance in component tasks and complete cardiac surgical procedures improved during simulation-based training. Simulation-based training imparts skill sets for management of adverse events and can help produce safer surgeons.

The use of endobronchial valve device to eliminate air leak.

UNLABELLED: We evaluated an endobronchial valve device in the treatment of surgically created air leak or pneumothorax by eliminating antegrade flow. METHODS: Six sheep underwent general anesthesia with positive pressure ventilation and left thoracotomy. After division of the mediastinal pleura, the contralateral cranial lobe was identified and a 2.5 cmx1.5 cm laceration created with resultant air leak. Using bronchoscopy, we deployed a valve device in the bronchus of the injured segment. Chest drainage tube was placed and the thoracotomy closed. At 1 week (n=3) and 4 weeks (n=3), the animals underwent general anesthesia, bronchoscopy and right thoracotomy. RESULTS: All animals survived the procedure. Bronchoscopic valve device placement in the segmental bronchus resolved the air leak immediately. After closure of thoracotomy, the chest tube demonstrated minimal drainage with no air leak. At 1 and 4 weeks, bronchoscopy showed no change in device location, and the treated segments were atelectatic with fibrous scar at the injured site. CONCLUSIONS: Collapse of a selected lung segment with resolution of air leak can be achieved using bronchoscopically implanted valve device. The valve device may facilitate treatment of patients with post-surgical or post-traumatic persistent air leak.