Do Surgeons React?: A Retrospective Analysis of Surgeons' Response to Harassment of a Colleague During Simulated Operating Theatre Scenarios.

OBJECTIVE: To assess and report on surgeons' ability to identify and manage incidences of harassment. BACKGROUND: The Royal Australasian College of Surgeons is committed to driving out discrimination, bullying, harassment, and sexual harassment from surgical training and practice, through changing the culture of the workplace. To eradicate these behaviors, it is first critical to understand how the current workforce responds to these actions. METHODS: A retrospective analysis of video data of an operating theatre simulation was conducted to identify how surgeons, from a range of experience levels, react to instances of harassment. Thematic analysis was used to categorize types of harassment and participant response characteristics. The frequency of these responses was assessed and reported. RESULTS: The type of participant response depended on the nature of harassment being perpetuated and the seniority of the participant. In the 50 instances of scripted harassment, active responses were enacted 52% of the time, acknowledgment responses 16%, and no response enacted in 30%. One senior surgeon also perpetuated the harassment (2%). Trainees were more likely to respond actively compared with consultants. CONCLUSION: It is apparent that trainees are more aware of instances of harassment, and were more likely to intervene during the simulated scenario. However, a large proportion of harassment was unchallenged. The hierarchical nature of surgical education and the surgical workforce in general needs to enable a culture in which the responsibility to intervene is allowed and respected. Simulation-based education programs could be developed to train in the recognition and intervention of discrimination, bullying, harassment and sexual harassment.

Practical applications of rapid review methods in the development of Australian health policy.

Rapid reviews (RRs) are a method of evidence synthesis that can provide robust evidence to support policy decisions in a timely manner. Herein we describe the methods used to conduct RRs and present an illustrative case study to describe how RRs can be used to inform contemporary Australian health policy. The aim of the present study was to explore several important aspects of how RRs can inform decision makers. RRs are conducted within limited time frames of as little as 4 weeks. Policy questions may focus on issues of efficacy, service delivery and service organisation rather than reimbursement of new services, which is better answered by a more comprehensive assessment. RRs use flexible and pragmatic methods, which aim to balance the objectivity and rigour required of the reviews within limited time frames. This flexibility allows for great variation across products with regard to length, depth of analysis and methods used. As a result, RRs can be specifically tailored to address targeted policy questions and are a useful tool in the development of Australian health policy.

The efficacy of laparoscopic skills training in a Mobile Simulation Unit compared with a fixed site: a comparative study.

BACKGROUND: Laparoscopic skills development via simulation-based medical education programs has gained support in recent years. However, the impact of training site type on skills acquisition has not been examined. The objective of this research was to determine whether laparoscopic skills training outcomes differ as a result of training in a Mobile Simulation Unit (MSU) compared with fixed simulation laboratories. METHODS: An MSU was developed to provide delivery of training. Fixed-site and MSU laparoscopic skills training outcomes data were compared. Fixed-site participants from three Australian states were pooled to create a cohort of 144 participants, which was compared with a cohort derived from pooled MSU participants in one Australian state. Data were sourced from training periods held from October 2009 to December 2010. LapSim and Fundamentals of laparoscopic surgery (FLS) simulators were used at the MSU and fixed sites. Participants self-reported on demographic and experience variables. They trained to a level of competence on one simulator and were assessed on the other simulator, thus producing crossover scores. No participants trained at both site types. RESULTS: When FLS-trained participants were assessed on LapSim, those who received MSU training achieved a significantly higher crossover score than their fixed-site counterparts (p < 0.001). Compared with baseline data, MSU LapSim-trained participants assessed on FLS displayed a performance increase of 23.1 %, whereas MSU FLS-trained participants assessed on LapSim demonstrated a 12.4 % increase in performance skills. Participants at fixed sites displayed performance increases of 5.2 and 10.9 %, respectively. CONCLUSIONS: Mobile Simulation Unit-delivered laparoscopic simulation training is not inferior to fixed-site training.

Graphical User Interface Development for a Hospital-Based Predictive Risk Tool: Protocol for a Co-Design Study.

BACKGROUND: This co-design research method details the iterative process developed to identify health professional recommendations for the graphical user interface (GUI) of an artificial intelligence (AI)-enabled risk prediction tool. Driving the decision to include a co-design process is the belief that choices regarding the aesthetic and functionality of an intervention are best made by its intended users and that engaging these users in its design will promote the tool's adoption and use. OBJECTIVE: The aim of this research is to identify health professional design and uptake recommendations for the GUI of an AI-enabled predictive risk tool. METHODS: We will hold 3 research phases, each consisting of 2 workshops with health professionals, between mid-2023 and mid-2024. A total of 6 health professionals will be sought per workshop, resulting in a total enrollment of 36 health professionals at the conclusion of the research. A total of 7 workshop activities have been scheduled across the 3 workshops; these include context of use, notifiers, format, AI survey-Likert, prototype, AI survey-written, and testing. The first 6 of these activities will be repeated in each workshop to enable the iterative development and refinement of GUI. The last activity (testing) will be performed in the final workshop to examine health professionals' thoughts on the final GUI iteration. Qualitative and quantitative results data will be produced from tasks in each research activity. Qualitative data will be examined through inductive thematic analysis or deductive thematic analysis in accordance with the Nonadoption, Abandonment, and Challenges to the Scale-up, Spread, and Sustainability (NASSS) framework; visual data will be examined in accordance with "framework of interactivity;" and quantitative data will be examined using descriptive statistics. RESULTS: Project registration with the Australia and New Zealand Clinical Trial Registry has been requested (#384098). Finalized design recommendations are expected in early to mid-2024, with a results manuscript to be submitted in mid-2024. This research method has human research ethics approval from the South Australian Department of Health and Wellbeing (#2022/HRE00131) as well as from the Human Research Ethics Committee of the University of South Australia (application ID#204143). CONCLUSIONS: Understanding whether an intervention is needed in a particular situation is just the start; designing an intervention so that it is used within that situation is paramount. This co-design process engages end users to create a GUI that includes the aesthetic and functional details they need in a manner that aligns with their existing work practices. Indeed, interventions that fail to do this may be disliked, and at worst, they may be dangerous. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/47717.

A randomized crossover trial examining low- versus high-fidelity simulation in basic laparoscopic skills training.

BACKGROUND: Previous randomized studies have compared high- versus low-fidelity laparoscopic simulators; however, no proficiency criteria were defined and results have been mixed. The purpose of this research was to determine whether there were any differences in the learning outcomes of participants who had trained to proficiency on low- or high-fidelity laparoscopic surgical simulators. METHODS: We conducted a randomized, prospective crossover trial with participants recruited from New South Wales, Western Australia, and South Australia. Participants were randomized to high-fidelity (LapSim, Surgical Science) or low-fidelity (FLS, SAGES) laparoscopic simulators and trained to proficiency in a defined number of tasks. They then crossed over to the other fidelity simulator and were tested. The outcomes of interest were the crossover mean scores, the proportion of tasks passed, and percentage passes for the crossover simulator tasks. RESULTS: Of the 228 participants recruited, 100 were randomized to LapSim and 128 to FLS. Mean crossover score increased from baseline for both simulators, but there was no significant difference between them (11.0 % vs. 11.9 %). FLS-trained participants passed a significantly higher proportion of crossover tasks compared with LapSim-trained participants (0.26 vs. 0.20, p = 0.016). A significantly higher percentage of FLS-trained participants passed intracorporeal knot tying than LapSim-trained participants (35 % vs. 8 %, p < 0.001). CONCLUSION: Similar increases in participant score from baseline illustrate that training on either simulator type is beneficial. However, FLS-trained participants demonstrated a greater ability to translate their skills to successfully complete LapSim tasks. The ability of FLS-trained participants to transfer their skills to new settings suggests the benefit of this simulator type compared with the LapSim.

Clinical practice visits: a rapid review.

BACKGROUND: Practice visits are a peer review activity where one or more healthcare providers visit the practice of another in the same field. The purpose of this exercise is for visitors to observe and review a host's practice in a non-punitive manner and provide them with constructive feedback as required; ultimately to improve practice quality and patient care. METHODS: A rapid review of three biomedical databases was conducted to identify relevant literature published up until 9 April 2018. There were no limits placed on publication date or publication type. Two authors were responsible for study selection and data extraction using a priori inclusion criteria and extraction templates. Study details and key findings were reported narratively and in tables. RESULTS: A total of nine publications, reporting outcomes for eight study groups, were identified as eligible for inclusion in this rapid review. Of these eight, six were observational studies, one was a longitudinal study and one was a randomized controlled trial. Practice visits were considered useful in identifying areas of improvement in professional practice; however, the rate at which these improvements were elicited varied greatly between the included studies. Overall, both hosts and visitors gained insight from the practice visit process and in general their experiences were positive. CONCLUSIONS: Based on the evidence provided by the included studies, recommendations for an effective practice visit can be made. Importantly, the poor quality and age of the literature from which these recommendations are based should be considered.

Characteristics of participants who withdraw from surgical simulation-based educational research.

Introduction: The problems associated with recruitment and retention of patients in clinical trials have been widely addressed in literature; however, similar problems associated with healthcare workers are rarely reported. The aim of this paper is to outline the factors that can impede a participant's successful participation in a research project and to analyse the characteristics of participants that withdrew. Methods: The Laparoscopic Simulation Skills Program (LSSP) was a prospective randomised cohort study investigating the efficacy of self-directed learning for basic laparoscopic skills acquisition. Two hundred and seven medical students, junior doctors, as well as surgical and gynaecology trainees were enrolled between June 2015 and November 2016. Results: Fifty-six (27%) participants failed to attend the final assessment. Of these, 43 participants (77%) responded to the follow-up survey and/or phone contact regarding non-attendance. Most participants failed to attend due to lack of free time/conflicting clinical duties and university requirements. Participants who did not attend the final assessment and did not provide further responses were less motivated by a career in surgery, surgical simulation and perceived less benefits of laparoscopic simulation. The 43 participants who answered the survey and/or phone contact provided similar responses to the participants who completed the study requirements and had more intrinsic motivators to enrol. Conclusions: Clinical duties and other educational commitments are the biggest barriers to participation in simulation based-education research.

Morbidity and mortality meetings: gold, silver or bronze?

BACKGROUND: Morbidity and mortality (M&M) meetings contribute to surgical education and improvements in patient care through the review of surgical outcomes; however, they often lack defined structure, objectives and resource support. The aim of this study was to investigate the factors that impact the effective conduct of M&M meetings. METHODS: We conducted a rapid systematic literature review. Three biomedical databases (PubMed, the Cochrane Library and the University of York Centre for Reviews and Dissemination), clinical practice guideline clearinghouses and grey literature sources were searched from May 2009 to September 2016. Studies that evaluated the function of a hospital-based M&M process were included. Two independent reviewers conducted study selection and data extraction. Study details and key findings were reported narratively. RESULTS: Nineteen studies identified enablers, and seven identified barriers, to the effective conduct of M&M meetings. Enabling factors for effective M&M meetings included a structured meeting format, a structured case identification and presentation, and a systems focus. Absence of key personnel from meetings, lack of education regarding the meeting process, poor perceptions of the process, logistical issues and heterogeneity in case evaluation were identified as barriers to effective M&M meetings. CONCLUSION: Taking steps to standardize and incorporate the enabling factors into M&M meetings will ensure that the valuable time spent reviewing M&M is used effectively to improve patient care.

Systematic Review of Voluntary Participation in Simulation-Based Laparoscopic Skills Training: Motivators and Barriers for Surgical Trainee Attendance.

OBJECTIVE: To examine and report on evidence relating to surgical trainees' voluntary participation in simulation-based laparoscopic skills training. Specifically, the underlying motivators, enablers, and barriers faced by surgical trainees with regard to attending training sessions on a regular basis. DESIGN: A systematic search of the literature (PubMed; CINAHL; EMBASE; Cochrane Collaboration) was conducted between May and July 2015. Studies were included on whether they reported on surgical trainee attendance at voluntary, simulation-based laparoscopic skills training sessions, in addition to qualitative data regarding participant's perceived barriers and motivators influencing their decision to attend such training. Factors affecting a trainee's motivation were categorized as either intrinsic (internal) or extrinsic (external). RESULTS: Two randomised control trials and 7 case series' met our inclusion criteria. Included studies were small and generally poor quality. Overall, voluntary simulation-based laparoscopic skills training was not well attended. Intrinsic motivators included clearly defined personal performance goals and relevance to clinical practice. Extrinsic motivators included clinical responsibilities and available free time, simulator location close to clinical training, and setting obligatory assessments or mandated training sessions. The effect of each of these factors was variable, and largely dependent on the individual trainee. The greatest reported barrier to attending voluntary training was the lack of available free time. CONCLUSION: Although data quality is limited, it can be seen that providing unrestricted access to simulator equipment is not effective in motivating surgical trainees to voluntarily participate in simulation-based laparoscopic skills training. To successfully encourage participation, consideration needs to be given to the factors influencing motivation to attend training. Further research, including better designed randomised control trials and large-scale surveys, is required to provide more definitive answers to the degree in which various incentives influence trainees' motivations and actual attendance rates.

What are the demographic predictors in laparoscopic simulator performance?

BACKGROUND: Simulation is playing an increasingly important role in surgical education. There are a number of laparoscopic simulators of which the design and tasks vary considerably. It is unknown if any particular type may result in better outcomes for a specific population. This study assesses the predictors of acquisition of basic surgical skills on two different laparoscopic simulators. METHODS: Participants (n = 370) were randomized to be trained and assessed using either a fundamentals of laparoscopic surgery (FLS) or a LapSim (Surgical Science, Goteborg, Sweden) simulator. The number of attempts required to reach proficiency on individual tasks and on each simulator was recorded and compared with demographic data and surgical experience. RESULT: Skills acquisition on both simulators was positively affected by surgical experience. Gender was an influential factor on the LapSim with men reaching proficiency sooner than women. The effect of gaming had no clear influence on the participants' scores; however, for those who reported more than 1 h/week gaming, it had a positive influence on skills acquisition on the FLS and a negative influence on the LapSim. Playing a musical instrument had no impact. Practising non-surgical tasks requiring manual dexterity and handedness were not an influential factor in total proficient scores, but had a significant impact on individual task scores on the FLS simulator. CONCLUSIONS: The rate of skills acquisition on each simulator and individual tasks are influenced by different demographic characteristics of the participants. This has implications for surgical education as it may inform the selection of the most suitable laparoscopic simulators for specific populations of trainees.

Effect of fatigue on laparoscopic skills: a comparative historical cohort study.

BACKGROUND: Fatigue has been shown to have a negative impact on surgical performance. However, there is a lack of research investigating its effect on laparoscopy, particularly in Australia. This study investigated whether fatigue associated with a surgeon's usual workday led to a measurable drop off in laparoscopic surgical skills as assessed on a laparoscopic simulator. METHODS: A comparative study involving two cohorts was undertaken: a study group whose data were collected prospectively was compared to a historical control group. Participants were required to reach a predetermined level of proficiency in each laparoscopic task on either a FLS or LapSim simulator. The participants in the study cohort were re-tested approximately 1 month after completing 10 h of work. The participants in the historical non-fatigued group were re-tested approximately 1 month after reaching proficiency. Comparisons between cohorts were made using a 'decrease in score per day elapsed' value to account for the natural attrition in skills over time and the variability in testing times within and between the two cohorts. RESULTS: The decrease in overall score per day elapsed for fatigued participants was significantly greater than for historical non-fatigued participants, irrespective of the simulator type. Fatigue had a greater impact on certain laparoscopic skills, including peg transfer and knot tying. Participants who self-reported higher level of fatigue demonstrated significantly better skills than those who self-reported lower levels. CONCLUSION: Overall laparoscopic skill proficiency was reduced in the fatigued participants compared to the historical non-fatigued participants, with certain laparoscopic skills more affected than others.

Laparoscopic skills acquisition: a study of simulation and traditional training.

BACKGROUND: Training in basic laparoscopic skills can be undertaken using traditional methods, where trainees are educated by experienced surgeons through a process of graduated responsibility or by simulation-based training. This study aimed to assess whether simulation trained individuals reach the same level of proficiency in basic laparoscopic skills as traditional trained participants when assessed in a simulated environment. METHODS: A prospective study was undertaken. Participants were allocated to one of two cohorts according to surgical experience. Participants from the inexperienced cohort were randomized to receive training in basic laparoscopic skills on either a box trainer or a virtual reality simulator. They were then assessed on the simulator on which they did not receive training. Participants from the experienced cohort, considered to have received traditional training in basic laparoscopic skills, did not receive simulation training and were randomized to either the box trainer or virtual reality simulator for skills assessment. The assessment scores from different cohorts on either simulator were then compared. RESULTS: A total of 138 participants completed the assessment session, 101 in the inexperienced simulation-trained cohort and 37 on the experienced traditionally trained cohort. There was no statistically significant difference between the training outcomes of simulation and traditionally trained participants, irrespective of the simulator type used. CONCLUSIONS: The results demonstrated that participants trained on either a box trainer or virtual reality simulator achieved a level of basic laparoscopic skills assessed in a simulated environment that was not significantly different from participants who had been traditionally trained in basic laparoscopic skills.

Laparoscopic skills maintenance: a randomized trial of virtual reality and box trainer simulators.

OBJECTIVE: A number of simulators have been developed to teach surgical trainees the basic skills required to effectively perform laparoscopic surgery; however, consideration needs to be given to how well the skills taught by these simulators are maintained over time. This study compared the maintenance of laparoscopic skills learned using box trainer and virtual reality simulators. DESIGN: Participants were randomly allocated to be trained and assessed using either the Society of American Gastrointestinal Endoscopic Surgeons Fundamentals of Laparoscopic Surgery (FLS) simulator or the Surgical Science virtual reality simulator. Once participants achieved a predetermined level of proficiency, they were assessed 1, 3, and 6 months later. At each assessment, participants were given 2 practice attempts and assessed on their third attempt. SETTING: The study was conducted through the Simulated Surgical Skills Program that was held at the Royal Australasian College of Surgeons, Adelaide, Australia. RESULTS: Overall, 26 participants (13 per group) completed the training and all follow-up assessments. There were no significant differences between simulation-trained cohorts for age, gender, training level, and the number of surgeries previously performed, observed, or assisted. Scores for the FLS-trained participants did not significantly change over the follow-up period. Scores for LapSim-trained participants significantly deteriorated at the first 2 follow-up points (1 and 3 months) (p < 0.050), but returned to be near initial levels by the final follow-up (6 months). CONCLUSIONS: This research showed that basic laparoscopic skills learned using the FLS simulator were maintained more consistently than those learned on the LapSim simulator. However, by the final follow-up, both simulator-trained cohorts had skill levels that were not significantly different to those at proficiency after the initial training period.

Centralization and the relationship between volume and outcome in knee arthroplasty procedures.

BACKGROUND: Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals. OBJECTIVES: This review assessed the efficacy of centralization for knee arthroplasty by examining the relationship between hospital and surgeon volume and patient outcomes. DATA SOURCES AND REVIEW METHODS: The systematic review identified studies using multiple databases, including Medline and Embase. Two independent researchers ensured studies met the inclusion criteria. Morbidity, mortality, length of stay, financial outcomes and statistical rigour were examined. Correlations between volume and outcome were reported. RESULTS: Twelve primary knee arthroplasty studies examined hospital volume, which was significantly associated with decreased morbidity (five of seven studies), mortality (two of five studies) and length of stay (two of three studies). Three primary knee arthroplasty studies examined surgeon volume, which was significantly associated with decreased morbidity (two of three studies), mortality (zero of two studies) and length of stay (one of one study). Two revision knee arthroplasty studies examined hospital volume. One study examined but did not test for significance between hospital volume and patient morbidity; both studies examined volume and patient mortality reporting inconclusive results; and one study reported no significant association between volume and length of stay. None of the revision knee arthroplasty studies examined surgeon volume. CONCLUSIONS: Significant associations between increased hospital and surgeon volume and improved patient outcomes were reported. However, when these results were separated by arthroplasty type, the association appeared tenuous. Judgements regarding centralization of knee arthroplasty should be made with caution until further evidence is published.

Radical prostatectomy: a systematic review of the impact of hospital and surgeon volume on patient outcome.

BACKGROUND: To assess the impact of hospital and surgeon volume on mortality, morbidity, length of hospital stay and costs of radical prostatectomy (RP). METHODS: This systematic review identified relevant studies published between 1997 and June 2007. Inclusion of papers was established through application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. RESULTS: Compared with low volume hospitals, the included studies showed high volume hospitals demonstrated lower rates of mortality, postoperative complications and readmissions, and lower overall hospital costs. High volume surgeons similarly showed lower rates of postoperative complications and shorter length of stay compared with low volume surgeons, but no difference in mortality. CONCLUSIONS: From the literature obtained, patients undergoing RP performed by high volume providers may have better outcomes compared to low volume providers; however, any move to centralize RP must be further evaluated.

Systematic review of the impact of volume of oesophagectomy on patient outcome.

PURPOSE: This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume. METHODS: A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision. RESULTS: A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume. CONCLUSIONS: Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.