Journal of Surgical Education

Masthead

2012-05-01

Friendship

John A. Weigelt — 2012-05-01

Training periods are full of personal experiences. We review these in our minds as we train and after we finish. We all have favorite memories: some good, some bad. Regardless, these experiences help shape us into the person we identify as a surgeon and professional. Current training programs are in a state of change, some might even say confusion, but there is no doubt that how we train the surgeons of the future will be different.

A Crisis of Faith? A Review of Simulation in Teaching Team-Based, Crisis Management Skills to Surgical Trainees

2012-01-06

Background: Team-based training using crisis resource management (CRM) has gained popularity as a strategy to minimize the impact of medical error during critical events. The purpose of this review was to appraise and summarize the design, implementation, and efficacy of peer-reviewed, simulation-based CRM training programs for postgraduate trainees (residents). Methods: Two independent reviewers conducted a structured literature review, querying multiple medical and allied health databases from 1950 to May 2010 (MEDLINE, EMBASE, CINAHL, EBM, and PsycINFO). We included articles that (1) were written in English, (2) were published in peer-reviewed journals, (3) included residents, (4) contained a simulation component, and (5) included a team-based component. Peer-reviewed articles describing the implementation of CRM instruction were critically appraised using the Kirkpatrick framework for evaluating training programs. Results: Fifteen studies involving a total of 404 residents met inclusion criteria; most studies reported high resident satisfaction for CRM training. In several CRM domains, residents demonstrated significant improvements after training, which did not decay over time. With regard to design, oral feedback may be equivalent to video feedback and single-day interventions may be as efficacious as multiple-day interventions for residents. No studies demonstrated a link between simulation-based CRM training and performance during real-life critical events. Conclusions: The findings support the utility of CRM programs for residents. A high degree of satisfaction and perceived value reflect robust resident engagement. The iteration of themes from our review provides the basis for the development of best practices in curricula design. A dearth of well-designed, randomized studies preclude the quantification of impact of simulation-based training in the clinical environment.

A Simulator Model for Sacroiliac Screw Placement

John Riehl, James Widmaier — 2011-12-14

Objective: Fixation with percutaneously placed sacroiliac screws has become a well-established technique for fixation of the posterior pelvic ring in the proper clinical setting. This technique, however, carries with it the risk of iatrogenic injury to neurovascular structures with aberrant screw placement. Given the potential risks involved with this technique, a model whereby the psychomotor skills involved could be refined before entering the operating room may be of benefit. The purpose of the current study is (1) to describe a simulator model for SI screw placement that can be assembled from readily available equipment and (2) to attempt to demonstrate the construct validity of such a simulator. Design: A simulator was assembled using readily available equipment found in the hospital and at a hardware store, and the cost of set up is less than $50. Orthopedic surgeons and novice operators were then observed using the simulator and results were recorded. Setting: Tertiary referral teaching hospital. Participants: Orthopedic surgery residents, resident faculty, x-ray technicians. Results: This simulator has been found to be a safe and effective model for teaching junior residents the technique of sacroiliac (SI) screw placement. An added benefit to this module is that it helps train new C-arm technicians to learn how to obtain the necessary views for this procedure. Conclusions: This model can be a valuable component of orthopedic training programs whereby technical and psychomotor skills necessary for percutaneous SI screw placement can be developed in a controlled setting.

An Analysis of the Orthopaedic In-Training Examination Rehabilitation Section

2011-12-02

Objective: One subject tested by the Orthopaedic In-Training Examination (OITE) is rehabilitation. Our purpose was to analyze the OITE's rehabilitation section to (1) identify the rehabilitation subjects that are tested, (2) evaluate trainee performance on this section, and (3) evaluate the literature cited for this section as an aide to the trainee preparation for future OITE examinations. Design: This study included OITE examinations from 2004 through 2009. The rehabilitation sections of these examinations were analyzed for content, type of questions asked (taxonomy 1: direct recall; taxonomy 2: diagnosis; taxonomy 3: evaluation/decision making and development of a treatment plan), and literature cited. The mean score in the rehabilitation section of the OITE from 2004 to 2009 was also evaluated, and literature citations were tabulated. Setting: Orthopaedic surgery residency. Results: In the 2004-2009 OITE examinations, a total of 1619 questions were administered, of which 53 (3.3%) related to rehabilitation. The most common rehabilitation questions assessed knowledge of prosthetic/orthotics (20.8%) and neuro-orthopedics (20.8%). Other questions addressed amputation (18.9%), physical therapy treatment and outcomes (18.9%), rehabilitation terminology (9.4%), and spinal cord injury (7.7%). Most frequently, the questions evaluated the trainee's direct recall of the subject (51%), evaluation/decision making and development of a treatment plan (30.1%), and diagnosis (18.9%). The mean score in the rehabilitation section of the OITE from 2004 through 2009 was 54.1% (range, 40% to 77.8%). A total of 53 references was used. The 3 most common references were the Journal of Bone and Joint Surgery-American Volume (10), Orthopaedic Knowledge Update (volumes 7 through 9) (8), and Clinical Orthopaedics and Related Research (7). Conclusion: To our knowledge, our study is the first to analyze the rehabilitation section of the OITE. Our results will help the trainee prepare for the examination by focusing on the appropriate content and literature.

Attitudes and Practices of Surgery Residency Program Directors Toward the Use of Social Networking Profiles to Select Residency Candidates: A Nationwide Survey Analysis

Pauline H. Go, Zachary Klaassen, Ronald S. Chamberlain — 2012-01-16

Objective: To determine whether residency program directors (PDs) of general surgery and surgical subspecialties review social networking (SN) websites during resident selection. Design: A 16-question survey was distributed via e-mail (Survey Monkey, Palo Alto, California) to 641 PDs of general surgery and surgical subspecialty residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Setting: Institutions with ACGME-accredited general surgery and surgical subspecialty residency programs. Participants: PDs of ACGME-accredited general surgery and surgical subspecialty residency programs. Results: Two hundred fifty (39%) PDs completed the survey. Seventeen percent (n = 43) of respondents reported visiting SN websites to gain more information about an applicant during the selection process, leading 14 PDs (33.3%) to rank an applicant lower after a review of their SN profile. PDs who use SN websites currently are likely to continue (69%), whereas those who do not use SN currently might do so in the future (yes 5.4%, undecided 44.6%). Conclusions: Online profiles displayed on SN websites provide surgery PDs with an additional avenue with which to evaluate highly competitive residency applicants. Applicants should be aware of the expansion of social media into the professional arena and the increasing use of these tools by PDs. SN profiles should reflect the professional standards to which physicians are held while highlighting an applicant's strengths and academic achievements.

Attracting Students to Surgical Careers: Preclinical Surgical Experience

2011-11-14

Objectives: Along with a decline in interest in general surgery among United States medical school graduates, reports indicate a decrease in the amount of time students are spending on their surgical clerkship. In an effort to offer early exposure to general surgery as well as to equip students with the basic surgical skills that will enhance their third-year clerkship experience, we developed a preclinical surgical experience. Students were surveyed to determine whether the surgical selective changed student level of comfort with basic surgical skills. Study Design: Surveys were administered, preexperience and postexperience to the medical students enrolled in the surgery selective. The students were asked to rate their comfort level with 12 unique surgical skills. Comfort with the task was evaluated using a 10-point Likert scale. Analyses were conducted to evaluate the impact of the surgical experience on student comfort levels with the surgical skills. Results: The self-reported comfort levels of students increased significantly after the experience in all 12 areas. The greatest change in comfort level (greater than or equal to mean difference of 4) occurred in the surgical technique categories: knot tying (mean difference: 4.9, p < 0.0001), suturing (mean difference: 4.85, p < 0.0001), correctly making an incision (mean difference: 4.95, p < 0.0001), using a needle driver (mean difference: 5.35, p < 0.0001), holding pickups (mean difference: 4.6, p < 0.0001), use of laparoscopic instruments (mean difference: 4.8, p < 0.0001), and use of surgical simulators (mean difference: 6.0, p < 0.0001). Conclusions: Our preclinical surgical experience serves as a model of an effective modality providing early exposure to general surgery. The experience provides trainees with basic surgical skills well before they begin their third-year clerkships.

Computer-Aided Feedback of Surgical Knot Tying Using Optical Tracking

Robert Anthony Watson — 2012-01-16

Background: Quantifying the information content of hand motion during surgical knot tying using information theory based entropy measures enables the comparison of different groups: novice and expert. We hypothesized that complexity would differ between the 2 groups and predicted based on motor learning models that complexity/information would reduce with increased expertise. Methods: Six degrees of freedom hand-motion data during surgical knot tying were acquired using an infrared optical hand tracking device. Multiple data samples were obtained from 2 groups: novice (third-year medical students) and expert (attending surgeons). After preprocessing each knot tying data sample into a binary symbolic time series, 3 nonlinear complexity measures were calculated: Lempel Ziv complexity, Shannon entropy, and Renyi entropy. The Shannon and Renyi entropies were calculated using a word length of 6. A Student t test was used to test whether the 2 groups were from the same population when using these entropy measures, applying a p value of 0.05 to reject the null hypothesis. Results: The expert surgeons were found to have less complex patterns of motion compared with the novice group. This finding was statistically significant using Lempel Ziv complexity (p = 0.004), Shannon entropy (p = 0.006), and Renyi entropy with q = 2 (p = 0.006). Using Renyi entropy with q = 0.5, the 2 groups were not significantly different (p = 0.26). Conclusions: The ability to separate novice from expert populations during surgical knot tying using information theory entropy measures could form the basis of a low-cost educational tool to provide feedback and to assess skill acquisition using low-fidelity bench models.

Do International Rotations Make Surgical Residents More Resource-Efficient? A Preliminary Study

2011-12-22

Objective: Interest in international surgery among general surgery residents in the United States has been shown in several publications. Several general surgery residency programs have reported their experiences with international surgery rotations (ISRs). Learning to use limited resources more efficiently is often cited as a benefit of such rotations. We hypothesized that general surgery residents become more resource efficient after they have completed an ISR. Study Design: Laboratory, radiologic, and diagnostic studies ordered on 2900 patients by 21 general surgery residents over 65 months at a single institution were analyzed retrospectively. The patient populations they wrote orders on were assessed for similarity in age, gender, and diagnoses. The outcomes in those patient populations were assessed by duration of stay and in-hospital mortality. Six (29%) of these residents (ISR residents) completed a 1-month ISR during their third year of residency. Their orders were compared with their classmates who did not participate in an ISR (NISR residents). The results were compared between the 2 cohorts from both before and after their international rotations. An analysis focused on comparing the changes from pre-ISR to post-ISR. A survey was also sent after objective data were collected to all residents and alumni involved in the study to assess their subjective perception of changes in their resource efficiency and to characterize their ISRs. Results: Patient populations were similar in terms of demographics and diagnoses. ISR residents generated an average of $122 less in orders per patient per month after their ISR compared with before. NISR residents generated an average of $338 more in orders per patient per month after the ISRs compared with before (p = 0.04). Pre-ISR order charges were statistically similar. Similar results were observed when radiologic/diagnostic study orders were analyzed independently. Differences in outcomes were statistically insignificant. The survey revealed that most of the ISR residents perceived that their attitude toward ordering tests and laboratories was influenced greatly by their ISR, and all the ISR residents perceived that they became more resource efficient than their peers after their ISRs. Conclusion: These preliminary findings seem to indicate increased resource efficiency among general surgery residents who completed an ISR. However, the sample size of residents was small, and we could not establish conclusively a causal relationship to their ISRs. A more extensive study is needed if reliable conclusions are to be drawn regarding the effect of ISRs on the resource efficiency of residents.

Do Medical Students Understand Brain Death? A Survey Study

2012-01-19

Background: A lack of understanding of brain death has been demonstrated among physicians, and may stem from knowledge deficits at the medical school level. The authors sought to evaluate current understanding of brain death and knowledge gaps among U.S. medical students at a single center. Methods: Using a validated “Understanding Brain Death” survey tool, the authors surveyed the student body at an accredited four year medical school. A score of 5/5 on this scale indicated an expert level of understanding. The investigators identified areas of knowledge gaps, and compared brain death expertise throughout the curriculum progression. Results: The overall response rate was 69% (212 of 306 students). Mean scores were 3.1, 3.9, 4.1, and 4.0 (out of 5) among first through fourth year classes respectively. Understanding of brain death differed across the medical school classes (p <0.0001). 33% (N=70) of all students attained scores of 5 indicating an expert level of understanding brain death. By class; 18% of first year students demonstrated expert levels of understanding, compared to 31% of second year students, 48% of third year students, and 39% of fourth year students. Conclusions: The level of understanding of brain death is low among the student body in a four year accredited U.S. medical school. This knowledge gap persists among graduating students as most do not attain an expert understanding of brain death. A more comprehensive brain death curriculum should be implemented in order to adequately equip physicians with this fundamental knowledge.

Educational Value of Morbidity and Mortality (M&M) Conferences: Are Minor Complications Important?

Marie K. Thomas, Robert J. McDonald, Eugene F. Foley, Sharon M. Weber — 2012-01-16

Background: Often, minor complications are not reported in morbidity and mortality (M&M) conference because they are considered insignificant to patient outcome. As part of an effort to improve the quality of the M&M conference, we sought to integrate a specific, focused intervention to improve the reporting of minor complications and to evaluate the perception of its educational value. Materials and Methods: To provide evidence-based training in recognizing, treating, and preventing minor complications, a presentation strategy was created. Surgical faculty identified 20 complications as minor complications. Each month, a junior resident was assigned to give a 10-minute presentation, assessing 1 of the 20 minor complications in depth during the M&M conference. To assess the impact of the intervention, we surveyed residents and faculty about the educational value of M&M conferences before and after implementation. Results: Before introducing minor complication presentations into the M&M conference, only 58% of respondents indicated that minor complications should be reported at the conference. After the changes were implemented in minor complication reporting, 95% of respondents said that minor complications should be reported (p < 0.01). Eighty-nine percent of respondents found the minor complication presentations to be educationally beneficial. In addition, postsurvey respondents were also more likely than presurvey respondents to identify that a purpose of an M&M conference was to improve patient care (29% vs 71%, p < 0.05). Conclusions: A formal, evidence-based presentation of minor complications can increase both the faculty and residents' perception of the importance of reporting minor complications at an M&M conference. Focused minor complication reporting should be incorporated into M&M curriculum.

Gaming Used as an Informal Instructional Technique: Effects on Learner Knowledge and Satisfaction

Travis P. Webb, Deborah Simpson, Steven Denson, Edmund Duthie — 2011-11-16

Background: Jeopardy!, Concentration, quiz bowls, and other gaming formats have been incorporated into health sciences classroom and online education. However, there is limited information about the impact of these strategies on learner engagement and outcomes. To address this gap, we hypothesized that gaming would lead to a significant increase in retained short- and long-term medical knowledge with high learner session satisfaction. Methods: Using the Jeopardy! game show model as a primary instructional technique to teach geriatrics, 8 PGY2 General Surgery residents were divided into 2 teams and competed to provide the “question” to each stated “answer” during 5 protected block curriculum units (1-h/U). A surgical faculty facilitator acted as the game host and provided feedback and brief elaboration of quiz answers/questions as necessary. Each quiz session contained two 25-question rounds. Paper-based pretests and posttests contained questions related to all core curriculum unit topics with 5 geriatric gaming questions per test. Residents completed the pretests 3 days before the session and a delayed posttest of geriatric topics on average 9.2 weeks (range, 5-12 weeks) after the instructional session. The cumulative average percent correct was compared between pretests and posttests using the Student t test. The residents completed session evaluation forms using Likert scale ratings after each gaming session and each protected curriculum block to assess educational value. Results: A total of 25 identical geriatric preunit and delayed postunit questions were administered across the instructional sessions. The combined pretest average score across all 8 residents was 51.5% for geriatric topics compared with 59.5% (p = 0.12) for all other unit topics. Delayed posttest geriatric scores demonstrated a statistically significant increase in retained medical knowledge with an average of 82.6% (p = 0.02). The difference between delayed posttest geriatric scores and posttest scores of all other unit topics was not significant. Residents reported a high level of satisfaction with the gaming sessions: The average session content rating was 4.9 compared with the overall block content rating of 4.6 (scale, 1-5, 5 = Outstanding). Conclusions: The quiz type and competitive gaming sessions can be used as a primary instructional technique leading to significant improvements in delayed posttests of medical knowledge and high resident satisfaction of educational value. Knowledge gains seem to be sustained based on the intervals between the interventions and recorded gains.

High-Fidelity, Low-Cost, Automated Method to Assess Laparoscopic Skills Objectively

2012-05-01

Background: We sought to define the extent to which a motion analysis-based assessment system constructed with simple equipment could measure technical skill objectively and quantitatively. Methods: An “off-the-shelf” digital video system was used to capture the hand and instrument movement of surgical trainees (beginner level = PGY-1, intermediate level = PGY-3, and advanced level = PGY-5/fellows) while they performed a peg transfer exercise. The video data were passed through a custom computer vision algorithm that analyzed incoming pixels to measure movement smoothness objectively. Results: The beginner-level group had the poorest performance, whereas those in the advanced group generated the highest scores. Intermediate-level trainees scored significantly (p < 0.04) better than beginner trainees. Advanced-level trainees scored significantly better than intermediate-level trainees and beginner-level trainees (p < 0.04 and p < 0.03, respectively). Conclusions: A computer vision-based analysis of surgical movements provides an objective basis for technical expertise-level analysis with construct validity. The technology to capture the data is simple, low cost, and readily available, and it obviates the need for expert human assessment in this setting.

Is the Evaluation of the Personal Statement a Reliable Component of the General Surgery Residency Application?

Bobbie Ann Adair White, Mark Sadoski, Scott Thomas, Mohsen Shabahang — 2012-02-06

Background: Each year, fourth-year medical students spend considerable time writing and rewriting their personal statements. However, there is little evidence of what role the personal statement plays in deciding which applicants will be invited for an interview. Objective: To evaluate the inter-rater reliability of a surgical selection committee's ratings for both the personal statement and the application summary parts of the residency application. Design: We completed a retrospective analysis of the 2007–2008 Scott & White surgical residency application pool. From a total pool of 174 residency applications, we selected 8 (5%) applications randomly to be evaluated by 4 experienced members of the selection committee. The 4 committee members rated each personal statement on a 7-point scale, from “negative—would not invite for an interview” to “positive—will invite for an interview.” They rated respective application summaries separately on a similar 7-point scale. Committee members also listed their top three reasons for assigning their scores. Methods: Rating scores for the personal statements and the applications were analyzed for inter-rater correlation. The qualitative data (ie, reasons for the scores) were reviewed to help the investigators profile the reasons given for very positive and very negative scores. Results: For the application summaries, the correlations between each pair of raters ranged from 0.79 to 0.94 with an overall average of 0.88. For the personal statements, inter-rater correlations ranged from −0.83 to 0.63 with an overall average of −0.09. Conclusion: These results demonstrate that the personal statements lacked objective criteria for evaluation.

Is There a Digital Generation Gap for E-Learning in Plastic Surgery?

Roger J.G. Stevens, Neil M. Hamilton — 2011-12-19

Background: Some authors have claimed that those plastic surgeons born between 1965 and 1979 (generation X, or Gen-X) are more technologically able than those born between 1946 and 1964 (Baby Boomers, or BB). Those born after 1980, which comprise generation Y (Gen-Y), might be the most technologically able and most demanding for electronic learning (e-learning) to support their education and training in plastic surgery. These differences might represent a “digital generation gap” and would have practical and financial implications for the development of e-learning. Objectives: The aim of this study was to survey plastic surgeons on their experience and preferences in e-learning in plastic surgery and to establish whether there was a difference between different generations. Design: Online survey (e-survey) of plastic surgeons within the UK and Ireland was used for this study. Methods: In all, 624 plastic surgeons were invited by e-mail to complete an e-survey anonymously for their experience of e-learning in plastic surgery, whether they would like access to e-learning and, if so, whether this should this be provided nationally, locally, or not at all. By stratifying plastic surgeons into three generations (BB, Gen-X, and Gen-Y), the responses between generations were compared using the χ2-test for linear trend. A p value < 0.05 was considered to be statistically significant. Results: Of the 624 plastic surgeons contacted, 237 plastic surgeons completed the survey (response rate, 38%), but data from 2 surgeons were excluded. For the remaining 235 plastic surgeons, no evidence was found of statistically significant linear trends between by generation and either experience, access, or provision of e-learning. Conclusions: These findings refute the claim that there are differences in the experience of e-learning of plastic surgeons by generation. Furthermore, there is no evidence that there are differences in whether there should be access to e-learning and how e-learning should be provided for different generations of plastic surgeons.

Lessons Learned from an Unusual Case of Inflammatory Breast Cancer

2012-05-01

Inflammatory breast cancer (IBC) is a rare breast malignancy that is associated with poor long-term outcomes despite aggressive surgical and chemotherapeutic interventions. We recently treated a 56-year-old woman with right-sided IBC and biopsy-proven cutaneous metastases to her back and left breast. She underwent chemotherapy, bilateral modified radical mastectomy, and radiation therapy. One year after diagnosis, she is currently disease-free based on positron-emission tomography (PET) imaging and repeat skin biopsies. To provide insight into the management of IBC, we present this interesting case with a reflection on important lessons to be learned.

Limiting PGY 1 Residents to 16 Hours of Duty: Review and Report of a Workshop

Pamela Tan, Nancy J. Hogle, Warren D. Widmann — 2011-12-14

Background: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted limits on duty hours. Residents were restricted to working 80 hours/week and limited to 24 hours of continuous patient care. Effective July 2011, an additional restriction will be instituted for PGY 1 residents limiting continuous duty to 16 hours maximum. Objective: Prospective evaluation of the impact of the upcoming work shift limitations for PGY 1 residents. Design/Setting/Participants: Review of literature and discussions among program directors, program coordinators, and residents on the effects of prior limitations of duty hours, as a point of reference, to manage the changes of duty hours for PGY 1 residents during a workshop at the Association of Program Directors in Surgery Annual Meeting. Results: Work-hour restrictions necessitate a change from the traditional 24-hour on-duty call schedule for PGY 1 residents. The benefits to patients of being treated by less tired doctors working in shifts may be offset by communication failures from poor handoffs, rendering the system prone to adverse events/near misses. With additional work-hour restrictions, it is imperative to anticipate problems and deal with them effectively. Continued reevaluation of the handoff system and efforts made to decrease the number of preventable adverse events that typically occur during periods of cross coverage should be undertaken. Labor costs to carry out these new restrictions are predictably high but can be made budget neutral if improvement in patient care leads to reduction in the costs of corrective actions. Conclusions: Residency programs have adapted to the 2003 work-hour restrictions without apparent ill effect. We must study the effects of the July 2011 requirements prospectively as the traditional frontline physicians (PGY 1 residents) will no longer be available for 24-hour duty shifts.

Medical Students Pursuing Surgical Fields Have No Greater Innate Motor Dexterity than Those Pursuing Nonsurgical Fields

Jason Y. Lee, David C. Kerbl, Elspeth M. McDougall, Phillip Mucksavage — 2012-05-01

Introduction: Medical students pursue different career paths based on a variety of factors. We sought to examine the impact of innate manual dexterity, both perceived and objective, on the career interests of medical students. Methods: Third-year medical students from the University of California, Irvine were recruited for this study. Subjects completed a pretest questionnaire followed by assessment of gross and fine motor dexterity using the Purdue Pegboard test. A total of 6 independent trials were performed, 3 for each hand. The scores were recorded as an integer value between 0 and 25. A statistical analysis was performed using student t tests, the Fischer exact test, or the χ2 test, where appropriate. Results: A total of 100 students completed the questionnaire while 58 completed the dexterity testing. Students interested in a surgical field (SF) were similar in handedness, gender, video game exposure, and learning style as those interested in a nonsurgical field (NSF). In the SF group, “personal skill set” was reported as the most common factor influencing career selection, and “interest in disease process/patient population” was reported most commonly by NSF students (p = 0.015). Although a perceived innate manual dexterity was higher among SF students compared with NSF students (p = 0.032), no significant objective differences were found in right hand, left hand, or combined dexterity scores. Conclusions: Perceived “personal skill set” may influence strongly a medical student's career choice. Despite greater perceived manual dexterity, students interested in an SF do not have greater objective innate manual dexterity than those interested in an NSF.

Nomogram to Predict Successful Placement in Surgical Subspecialty Fellowships Using Applicant Characteristics

2012-01-19

Purpose: The purpose of the study was to develop a model that predicts an individual applicant's probability of successful placement into a surgical subspecialty fellowship program. Methods: Candidates who applied to surgical fellowships during a 3-year period were identified in a set of databases that included the electronic application materials. Results: Of the 1281 applicants who were available for analysis, 951 applicants (74%) successfully placed into a colon and rectal surgery, thoracic surgery, vascular surgery, or pediatric surgery fellowship. The optimal final prediction model, which was based on a logistic regression, included 14 variables. This model, with a c statistic of 0.74, allowed for the determination of a useful estimate of the probability of placement for an individual candidate. Conclusions: Of the factors that are available at the time of fellowship application, 14 were used to predict accurately the proportion of applicants who will successfully gain a fellowship position.

Perceived Benefits of a Transplant Surgery Experience to General Surgery Residency Training

2011-12-14

Objectives: The benefit of a solid-organ transplant experience during general surgical training has been questioned recently. In 2008, in response to an American Board of Surgery (ABS) directive, a survey was conducted by the Association of Program Directors in Surgery (APDS) in coordination with the American Society of Transplant Surgeons (ASTS) to determine the perceived value of a transplant surgery rotation to program directors and residents. With the aim of providing additional insight, we conducted a separate study, independent of the ABS and ASTS, to ascertain resident perceptions regarding the specific skill sets that they acquire during their transplant surgery rotations and their applicability to other surgical subspecialties. Methods: A preliminary, 51-item, web-based questionnaire was completed by 69.6% of residents in nationally accredited general surgery programs who accessed the survey. The results were examined using appropriate statistical methods to determine associations between answers. Results: Although only 16.6% of participants responded that they were considering a career in transplantation, 63.4% answered that the skill sets acquired during this rotation would assist them in their surgical careers regardless of their chosen specialty. Most (65.5%) respondents answered that the techniques learned were directly applicable to other specialties, such as vascular, urologic, trauma, and hepatobiliary surgery. Free response questions indicated that the most common criticisms of this rotation were the limited amount of operative participation, lack of teaching by attendings, and lifestyle limitations. Conclusions: The results of this study indicate that surgery residents are conflicted regarding their transplant surgery experience but regard it as a beneficial addition to their training. Most respondents indicated also that these skills were transferable directly to other surgical specialties.

Practice-Based Learning and Improvement: A Two-Year Experience with the Reporting of Morbidity and Mortality Cases by General Surgery Residents

John L. Falcone, Kenneth K.W. Lee, Timothy R. Billiar, Giselle G. Hamad — 2011-11-28

Background: The Accreditation Council for Graduate Medical Education (ACGME) core competency of practice-based learning and improvement can be assessed with surgical Morbidity and Mortality Conference (MMC). We aim to describe the MMC reporting patterns of general surgery residents, describe the adverse event rate for patients and compare that with existing published rates, and describe the nature of our institutional adverse events. We hypothesize that reporting patterns and incidence rates will remain constant over time. Methods: In this retrospective cohort study, archived MMC case lists were evaluated from January 1, 2009 to December 31, 2010. The reporting patterns of the residents, the adverse event ratios, and the specific categories of adverse events were described over the academic years. χ2 and Fisher's exact tests were used to compare across academic years, using an α = 0.05. Results: There were 85 surgical MMC case lists evaluated. Services achieved a reporting rate above 80% (p < 0.001). The most consistent reporting was done by postgraduate year (PGY) 5 level chief residents for all services (p > 0.05). Out of 11,368 patients evaluated from complete MMC submissions, 289 patients had an adverse event reported (2.5%). This was lower than published reporting rates for patient adverse event rates (p < 0.001). Adverse event rates were consistent for residents at the postgraduate year 2, 4, and 5 levels for all services (p > 0.05). Over 2 years, 522 adverse events were reported for 461 patients. A majority of adverse events were from death (24.1%), hematologic and/or vascular events (16.7%), and gastrointestinal system events (16.1%). Conclusions: Surgery resident MMC reporting patterns and adverse event rates are generally stable over time. This study shows which adverse event cases are important for chief residents to report.

SEND IT: Study of E-Mail Etiquette and Notions from Doctors in Training

Sarah Resendes, Thammi Ramanan, Angela Park, Brad Petrisor, Mohit Bhandari — 2012-02-06

Objectives: Worldwide, more than 247 billion e-mails are sent each day. Little empiric evidence is available to guide how e-mail presentation style, tone, and content affect e-mail recipients and whether these factors impact opinions about the sender and the rapidity of response. In a study of physicians in training assessing a series of 100 e-mail examples, we examined the following: (1) formatting characteristics most and least endorsed, (2) impression of the sender based on the e-mail itself, and (3) factors associated with the decision to respond. We reasoned that our study would provide empiric data to support recommendations for e-mail etiquette, focusing specifically on doctors in training. Design: Cross-sectional survey study. Setting: Division of Orthopaedic Surgery at McMaster University, Hamilton, Ontario, Canada. Participants: After each e-mail, the participating surgical residents completed a series of questions focusing on their impression of the e-mail appearance, their perception of the sender, and their motivation to respond to the e-mail. Results: Thirty-two residents participated in this study. The responses indicate that the key negatively endorsed features of the e-mails included the use of colored backgrounds (84%), difficult-to-read font (83%), lack of a subject header (55%), opening salutations without recipient names (50%), or no salutation at all (42%). The senders of negatively endorsed e-mails were perceived by participants as inefficient (p = 0.03), unprofessional (p < 0.001), and irritating (p = 0.007). E-mails with overall positive endorsements were significantly more likely to have the participants perceive the e-mail senders as professional (p < 0.001), pleasant (p = 0.048), and kind (p = 0.059). The participants were 2.6-fold more likely to respond immediately when they perceived e-mails as favorable compared with disliking them (42% vs 16% of responses, respectively, p < 0.001). Conclusion: The e-mails perceived as being disliked overall are likely to result in a negative perception of the sender and delays in response time.

The Production of Audiovisual Teaching Tools in Minimally Invasive Surgery

Sarah K. Tolerton, Thomas J. Hugh, Peter H. Cosman — 2011-12-22

Objectives: Audiovisual learning resources have become valuable adjuncts to formal teaching in surgical training. This report discusses the process and challenges of preparing an audiovisual teaching tool for laparoscopic cholecystectomy. The relative value in surgical education and training, for both the creator and viewer are addressed. Design/Setting: This audiovisual teaching resource was prepared as part of the Master of Surgery program at the University of Sydney, Australia. The different methods of video production used to create operative teaching tools are discussed. Results: Collating and editing material for an audiovisual teaching resource can be a time-consuming and technically challenging process. However, quality learning resources can now be produced even with limited prior video editing experience. With minimal cost and suitable guidance to ensure clinically relevant content, most surgeons should be able to produce short, high-quality education videos of both open and minimally invasive surgery. Conclusions: Despite the challenges faced during production of audiovisual teaching tools, these resources are now relatively easy to produce using readily available software. These resources are particularly attractive to surgical trainees when real time operative footage is used. They serve as valuable adjuncts to formal teaching, particularly in the setting of minimally invasive surgery.

The Surgical Skills Laboratory Residency Interview: An Enjoyable Alternative

Travis M. Dumont, Michael A. Horgan — 2011-11-07

Purpose: The authors aimed to trial an alternative interviewing strategy by inviting residency candidates to our surgical anatomy laboratory. Interviews were coincident with surgical dissection. The authors hypothesized that residency candidates hoping to match into a surgical subspecialty might enjoy this unconventional interviewing strategy, which would mimic an operating room experience. Methods: On scheduled residency interview dates, formal, unstructured interviews were held with half of the neurosurgical faculty, and unstructured surgical skills laboratory-based interviews were held with the other half of the neurosurgical faculty. Interviews in the skills laboratory featured cases and corresponding surgical dissection guided by faculty. After the interview, the residency candidates were encouraged to complete an optional survey about their interview process. The survey results were pooled for analysis. Results: Of 28 interviewed, 19 individuals responded to the survey. The survey respondents had favorable reviews of the all aspects of the interview process. When asked to report the most enjoyable part of the interview, all respondents listed the surgical skills laboratory. The average respondent scores for importance of the surgical skills laboratory interview (9.5 ± 1.1) compared with conventional interview with faculty (9.2 ± 1.0) or residents (9.1 ± 1.0) was not significantly different (p = 0.50, analysis of variance). Conclusions: The surgical skills laboratory interviews were reviewed favorably by the survey respondents. Nearly all respondents listed the surgical skills interview as the most enjoyable part of the interview experience. The authors advocate this residency interview strategy for surgical subspecialty residencies.

Ultrasound-Guided Breast Biopsy for Surgical Residents: Evaluation of a Phantom Model

Anjali A. Gresens, Rebecca C. Britt, Eric C. Feliberti, L.D. Britt — 2012-05-01

Background: Ultrasound is increasingly used by surgeons for evaluation of breast lesions. While surgical residents have sufficient exposure to breast surgery, many lack exposure to office-based procedures, such as ultrasound-guided breast biopsy. A phantom model was created to teach surgical residents basic breast ultrasound and biopsy skills and to evaluate the resident's response when incorporated into the curriculum. Methods: The model was created using a pork roast and 10 variably-sized pimento olives. Twenty-four surgical residents were given a brief introduction to breast ultrasound followed by up to 5 minutes to ultrasound the model and note the embedded lesions. The number and location of lesions found and the time spent per resident were recorded. Residents were then introduced to the vacuum-assisted core biopsy system and observed performing ultrasound-guided biopsies. Pre- and postsession evaluations were completed by all residents. Scatterplot regression models were used for data analysis. Results: Most residents had previous ultrasound instruction. The intermediate level residents (postgraduate year [PGY]2 and 3) found the most lesions in the shortest time, missing on average 1.125 lesions in 3:09 minutes. Time spent did not correlate with number missed or previous ultrasound experience. Over 50% of residents sampled the center of the lesion on their first biopsy attempt, with no correlation to PGY or ultrasound experience. All residents rated this experience good to excellent, and 67% believed their ultrasound skills were improved. Ninety-five percent of residents felt the model was fairly realistic and 95% would like to have more experiences like this in the curriculum. The residents surveyed thought the curriculum would be best suited to a PGY2 experience. Conclusions: The phantom breast is a realistic and valuable teaching model for breast ultrasound. Further evaluation regarding skill retention is needed.

Use of Breast Simulators Compared with Standardized Patients in Teaching the Clinical Breast Examination to Medical Students

2011-11-28

Objective: Simulators have replaced some standardized patients in medical student teaching, and their use seems to decrease anxiety related to the clinical breast examination (CBE). We compared learning the CBE on a breast palpation simulator with learning on a standardized patient with respect to skill acquisition and comfort level. Methods: At Penn State College of Medicine, the class of 2008 (historical control group, n = 113) learned the CBE on a standardized patient, whereas the class of 2009 (experimental group, n = 131) learned on the breast palpation simulator. We used measures of the process (conducting the CBE) and measures of the outcome (examination scores and detection of abnormal findings). During their third-year surgical clerkship, students in both groups completed a questionnaire reporting the number of CBEs performed and confidence in performing the CBE. The students then performed an observed examination on the simulator, and the number of positive findings detected was recorded. The mean number of positive findings was compared between groups, and an economic analysis was conducted. Results: The experimental group had a significantly higher mean examination score than the historical control. In subgroups, this difference was significant for those who reported performing 0-5 clinical examinations but for not those who had performed >6 examinations. On individual items, the experimental group scored significantly higher in examining for neck nodes, nipple retraction, skin changes, and axillary evaluation. The 2 groups did not differ significantly in the mean number of positive findings detected or in ratings of comfort level. Conclusions: Medical students who learned the CBE on breast palpation simulators performed as well or better than those who learned on standardized patients; however, a subgroup analysis revealed that the benefit was limited to students with less clinical experience.

Using the Hidden Curriculum to Teach Professionalism During the Surgery Clerkship

David A. Rogers, Margaret L. Boehler, Nicole K. Roberts, Victoria Johnson — 2011-11-04

Background: It has been shown that medical student professionalism is influenced by the hidden curriculum, although the extent to which this occurs during the surgery clerkship is unknown. Furthermore, the processes within the hidden curriculum have been used to teach professionalism to medical students, but this strategy has not been used during the surgery clerkship. The purpose of this study was to review a 2-year experience with a surgery clerkship instructional session where the hidden curriculum was used to teach professionalism to medical students. Study Design: Medical student essays were analyzed to evaluate the influence of the hidden curriculum on their ideas about professionalism and to identify specific behaviors that they regarded as professional and unprofessional. The instructional session was evaluated using the average satisfaction session ratings and through an analysis of medical student session evaluation comments. Results: Seventy-five percent of medical students reported that their ideas about professionalism changed. This change involved their general concepts about professionalism, identifying specific behaviors that they planned to adopt or avoid, or developing opinions about the professionalism of surgeons. The average satisfaction rating was consistently high throughout the study period, and the most helpful session feature was reported as the opportunity to share and discuss their observations. Conclusions: The hidden curriculum has a substantial influence on the development of professionalism of medical students during the surgery clerkship. It was possible to illuminate and use the hidden curriculum to create an instructional session devoted to professionalism for medical students on the surgery clerkship.

Video Review Using a Reliable Evaluation Metric Improves Team Function in High-Fidelity Simulated Trauma Resuscitation

2011-11-07

Objective: To demonstrate that instruction of proper team function can occur using high-fidelity simulated trauma resuscitation with video-assisted debriefing and that this process can be integrated rapidly into a standard general surgery curriculum. Design: The rater reliability of our team metric was assessed by having physicians and nonphysicians rate the same video-recorded trauma simulations at intervals in time. To assess the effectiveness of video debriefing, subjects participated in a 3-week trauma team training course that consisted of 2 video-recorded simulation sessions, each approximately 2 hours in length separated by a 90-minute debriefing session. To assess the impact of the debriefing session, video recordings of participants performing resuscitations before and after the debriefing were reviewed by a panel of blinded traumatologists and graded using our team evaluation instrument. Setting: The study took place at the high-fidelity simulation center at a large, urban academic training hospital. Participants: All 11 PGY-2 general surgery and combined general surgery and plastic surgery residents at our institution. Results: Our instrument was found to have high interrater correlation (interclass correlation coefficient [ICC], 0.926; 95% confidence interval, 0.893–0.953). Initially, residents were either unsure as to their competency to serve as team leader (70%) or felt they were not competent to serve as team leader (30%). Ninety percent of residents found the video debriefing very to extremely helpful in improving team function and clinical competency. All participants felt more competent as both team leaders and team members because of the video debriefing. The mean team function score improved significantly after video debriefing (4.39 [±0.3] vs 5.45 [±0.4] prevideo vs postvideo review, p < 0.05). Conclusions: Video review with debriefing is an effective means of teaching team competencies and improving team function in simulated trauma resuscitation. This strategy can be integrated readily into the surgical curriculum analogous to other applications of simulation technology.

Service versus Education, What Are We Talking About?

Dane E. Smith, Brent Johnson, Yonge Jones — 2012-01-19

Objective: To investigate the degree of variability in perception as related to the service versus education issue in general surgery residency education. Study Design: A survey questionnaire was designed with 15 scenarios constructed by the author to represent an array of resident experiences with differing educational and noneducational value. After appropriate Institutional Review Board (IRB) approval, the survey was administered to a variety of medical student, resident, and faculty groups. Individual and intergroup variability was assessed. Setting: Large, university-affiliated teaching hospital. Results: A total of 137 questionnaires were returned from medical students, residents, and attending physicians encompassing several medical specialties and a broad range of clinical experience. In all, 7 of 15 scenarios resulted in statistically significant different response patterns across specialties and 8 of 15 scenarios across levels of experience. Individual responses spanned nearly all possible responses for most scenarios. Conclusions: Considerable variability exists across individuals as well as groups in the interpretation of the types of experiences that represent service, education, or both in general surgery residency training. Arriving at a quantifiable balance in service versus education in general surgery resident education may never be possible given the variability in interpretation of the various activities residents perform. This must be kept in mind in both interpreting the results of the Accreditation Council for Graduate Medical Education (ACGME) survey and also when designing educational activities within a program.

Speaking From the Heart: End-of-Life Discussions in the ICU From the Surgeon's Perspective

Jon D. Simmons — 2011-11-24

As a surgeon, end-of-life discussions with my patients are often difficult for me to conduct. A recent experience has given me a new perspective regarding this difficult process. As a new surgical critical care fellow, I received a late-night call regarding a middle-aged patient with a terminal stage IV gastric cancer invading into his chest and other vital structures. The patient was admitted to the intensive care unit (ICU) for dyspnea and tachycardia. I was surprised to discover that no restrictions had been put in place regarding resuscitation; he was a “full code.” The admitting service had not discussed end-of-life issues and it became my responsibility to have this family meeting. These types of meetings are an integral part of critical care medicine. In my previous experience as a surgical attending, I led many of these meetings; to discuss a surgical complication, a poor outcome, or withdrawal of support. But in this meeting something was different, profoundly different. Previously, these meetings weighed heavily on my mind; but not this time. I pondered the question, “Does my perspective on end-of-life care depend on my role as a surgeon or consulting intensivist?”

Erratum

2012-05-01

There was an error in the March/April 2012 (69/2) issue of Journal of Surgical Education. The article on page 253, Novel Education Approach for Medical Students: Improved Retention Rates Using Interactive Medical Software Compared with Traditional Lecture-Based Format, by Anuradha Subramanian, Matthew Timberlake, Harsha Mittakanti, Michael Lara, and Mary L. Brandt, was erroneously listed as a 2011 APDS Spring Meeting article. This article will appear in the July/August issue (69/4) as an Original Article.

Journal of Surgical Education

Masthead

Contents

Friendship

A Crisis of Faith? A Review of Simulation in Teaching Team-Based, Crisis Management Skills to Surgical Trainees

A Simulator Model for Sacroiliac Screw Placement

An Analysis of the Orthopaedic In-Training Examination Rehabilitation Section

Attitudes and Practices of Surgery Residency Program Directors Toward the Use of Social Networking Profiles to Select Residency Candidates: A Nationwide Survey Analysis

Attracting Students to Surgical Careers: Preclinical Surgical Experience

Computer-Aided Feedback of Surgical Knot Tying Using Optical Tracking

Do International Rotations Make Surgical Residents More Resource-Efficient? A Preliminary Study

Do Medical Students Understand Brain Death? A Survey Study

Educational Value of Morbidity and Mortality (M&M) Conferences: Are Minor Complications Important?

Gaming Used as an Informal Instructional Technique: Effects on Learner Knowledge and Satisfaction

High-Fidelity, Low-Cost, Automated Method to Assess Laparoscopic Skills Objectively

Is the Evaluation of the Personal Statement a Reliable Component of the General Surgery Residency Application?

Is There a Digital Generation Gap for E-Learning in Plastic Surgery?

Lessons Learned from an Unusual Case of Inflammatory Breast Cancer

Limiting PGY 1 Residents to 16 Hours of Duty: Review and Report of a Workshop

Medical Students Pursuing Surgical Fields Have No Greater Innate Motor Dexterity than Those Pursuing Nonsurgical Fields

Nomogram to Predict Successful Placement in Surgical Subspecialty Fellowships Using Applicant Characteristics

Perceived Benefits of a Transplant Surgery Experience to General Surgery Residency Training

Practice-Based Learning and Improvement: A Two-Year Experience with the Reporting of Morbidity and Mortality Cases by General Surgery Residents

SEND IT: Study of E-Mail Etiquette and Notions from Doctors in Training

The Production of Audiovisual Teaching Tools in Minimally Invasive Surgery

The Surgical Skills Laboratory Residency Interview: An Enjoyable Alternative

Ultrasound-Guided Breast Biopsy for Surgical Residents: Evaluation of a Phantom Model

Use of Breast Simulators Compared with Standardized Patients in Teaching the Clinical Breast Examination to Medical Students

Using the Hidden Curriculum to Teach Professionalism During the Surgery Clerkship

Video Review Using a Reliable Evaluation Metric Improves Team Function in High-Fidelity Simulated Trauma Resuscitation

Service versus Education, What Are We Talking About?

Speaking From the Heart: End-of-Life Discussions in the ICU From the Surgeon's Perspective

Erratum