Journal of Surgical Education - Articles in Press

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

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.

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

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.

Implications of Current Resident Work-Hour Guidelines on the Future Practice of Surgery in Canada - Corrected Proof

2012-02-06

Objective: Work-hour restrictions have had a profound impact on surgical training. However, little is known of how work-hour restrictions may affect the future practice patterns of current surgical residents. The purpose of this study is to compare the anticipated career practice patterns of surgical residents who are training within an environment of work-hour restrictions with the current practice of faculty surgeons. Design: An electronic survey was sent to all surgery residents and faculty at 2 Canadian university-affiliated medical centers. The survey consisted of questions regarding expected (residents) or current (faculty) practice patterns. Results: A total of 149 residents and 125 faculty members completed the survey (50.3% and 52.3% response rates, respectively). A greater proportion of males were in the faculty cohort than in the resident group (77.6% vs 62.4%, p = 0.0003). More faculty than residents believed that work-hour restrictions have a negative impact on both residency education (40.8% vs 20.8%, p = 0.008) and preparation for a surgical career (56.8% vs 19.5%, p < 0.0001). Compared with current faculty, residents plan to take less call (p < 0.0003), work fewer days of the week (p < 0.0001), are more likely to limit their duty hours on postcall days (p = 0.009), and take parental leave (p = 0.02) once in practice. Male and female residents differed somewhat in their responses in that more female residents plan to limit their postcall duty hours (55.4% vs 36.5%, p = 0.009) and to take a parental leave (51.8% vs 16.1%, p < 0.0001) compared with their male resident colleagues. Conclusions: Current surgical residents expect to adopt components of resident work-hour guidelines into their surgical practices after completing their residency. These practice patterns will have surgical workforce implications and might require larger surgical groups and reconsideration of resource allocation.

Basic Laparoscopic Training Using the Simbionix LAP Mentor: Setting the Standards in the Novice Group - Corrected Proof

2012-02-06

Background: Virtual reality devices are becoming the backbone for laparoscopic training in surgery. However, without knowledge of the achievable metrics of basic training within the trainee group, these simulators cannot be used effectively. Currently, no validated task metrics of the performance of larger trainee groups are available. Study design: From April 2004 to December 2009, we collated an extensive prospective database using the Simbionix LAP Mentor (Simbionix USA, Cleveland, Ohio) for basic laparoscopic training of novice surgeons. This database was used to determine benchmarks for basic skill exercises and procedural tasks that combine stimulus to improve and feasibility with acceptance of the training program and the goal to train for safe surgery. Results: In all, 18,996 task performances of 286 novice trainees were analyzed. For the basic skill exercises, the total time for correct execution ranged between 45 seconds for basic skill 3 (eye-hand coordination) and 269 seconds for basic skill 9 (object placement). For the procedural tasks, the total time for correct execution ranged between 68 seconds for procedural task 1 (clipping and cutting) and 256 seconds for procedural task 3 (dissection). The total time to task completion depended mainly on right instrument path length with high correlation to left instrument path length. Learning curve analyses of the 4 procedural tasks demonstrated performance plateaus after 10–15 repetitions. Most complications occurred during the initial repetitions of the respective task. The best quartile of performances was chosen as peer group benchmark because it provides sufficient stimulus for improvement without discouraging trainees, thus enhancing adherence to the training program. The benchmark for safety and accuracy parameters was set at a predefined level of 95% correct execution. Conclusions: As experience with virtual reality (VR) training is growing, curricula must be based on benchmarks for efficient training derived from large trainee groups to optimize use of the still costly simulators. Safety parameters should be included in trainee assessment. We share a set of metrics that take into account both performance and feasibility for basic laparoscopic training of surgical novices using the Simbionix LAP Mentor.

A New Training Model for Adult Circumcision - Corrected Proof

Mohamed Ismat Abdulmajed, Matthew Thomas, Iqbal S. Shergill — 2012-01-27

Background: Adult circumcision is an extremely common surgical operation. As such, we developed a simple model to teach junior doctors the various techniques of circumcision in a safe, reliable, and realistic manner. Materials and Methods: A commonly available simulated model penis (Pharmabotics, Limited, Winchester, United Kingdom) is used, which is then covered with a 30-mm diameter, 400-mm long, double-layered simulated bowel (Limbs & Things, Bristol, United Kingdom). The 2 layers of the prepuce are simulated by folding the simulated bowel on itself. The model has been officially adopted in the UroEmerge hands-on practical skills course—approved by the Royal College of Surgeons in the United Kingdom, and all participants were asked to provide feedback about their experience on a scale from 1 to 10 (1 = extremely unsatisfied and 10 = excellent). Results: The model has been used successfully to demonstrate, teach, and practice adult circumcision as well as other penile procedures with rating by trainees ranged from 7 to 10 (median: 9), and 9 of 12 trainees commented on the model using expressions such as “life like,” “excellent idea,” or “extremely beneficial.” Conclusions: The model is particularly useful as it is life like, realistic, easy to set up, and can be used to repeatedly demonstrate circumcision, as well as other surgical procedures, such as dorsal slit and paraphimosis reduction.

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

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.

Service versus Education, What Are We Talking About? - Corrected Proof

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.

Do Medical Students Understand Brain Death? A Survey Study - Corrected Proof

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.

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

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.

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

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.

Computer-Aided Feedback of Surgical Knot Tying Using Optical Tracking - Corrected Proof

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.

Educational Value of an Intensive and Structured Interval Practice Laparoscopic Training Course for Residents in Obstetrics and Gynecology: A Four-Year Prospective, Multi-Institutional Recruitment Study - Corrected Proof

2012-01-12

Objective: To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents. Design: Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate. Setting: International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France. Participants: 191 PGY2 or PGY3 residents from different institutions. Results: Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p < 0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p < 0.0001). Conclusions: Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

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

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.

The Center for Medical Education and Innovation at Riverside - Corrected Proof

William D. Watson, Douglas J. Knutson, Oscar Ruiz — 2011-12-30

The Center for Medical Education and Innovation (CME + I) is a state-of-the-art simulation center for the education of medical students, residents, practicing physicians, nurses, and allied health care providers. It was developed through the Department of Medical Education at Riverside Methodist Hospital using funds from the Medical Education Foundation and opened in June 2005. Since then, it has trained thousands of health care professionals.

Human Patient Simulator-Based Training … for the Olympics! - Corrected Proof

Hannah Browne, Olivia Cheetham, John Mason — 2011-12-26

As medical students studying in a busy capital city, we at Cardiff University School of Medicine are exposed to an incredibly busy emergency department (ED) at the University Hospital of Wales (UHW). It can be astonishing how so many patients are treated effectively and efficiently by a comparatively small team of multidisciplinary professionals. Therefore, Steinemann et al.'s recent article discussing teamwork training to improve early trauma care was read and discussed with great interest by members of Cardiff University Surgical Society's fortnightly journal club.

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

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.

The Production of Audiovisual Teaching Tools in Minimally Invasive Surgery - Corrected Proof

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.

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

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.

Perceived Benefits of a Transplant Surgery Experience to General Surgery Residency Training - Corrected Proof

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.

A Simulator Model for Sacroiliac Screw Placement - Corrected Proof

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.

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

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.

An Analysis of the Orthopaedic In-Training Examination Rehabilitation Section - Corrected Proof

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.

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

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.

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

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.

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

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?”

Trauma Leadership: Does Perception Drive Reality? - Corrected Proof

2011-11-16

Introduction: Leadership plays a key role in trauma team management and might affect the efficiency of patient care. Our hypothesis was that a positive relationship exists between the trauma team members' perception of leadership and the efficiency of the injured patient's initial evaluation.Methods: We conducted a prospective observational study evaluating trauma attending leadership (TAL) over 5 months at a level 1 trauma center. After the completion of patient care, trauma team members evaluated the TAL's ability using a modified Campbell Leadership Descriptor Survey tool. Scores ranged from 18 (ineffective leader) to 72 (perfect score). Clinical efficiency was measured prospectively by recording the time needed to complete an advanced trauma life support (ATLS)-directed resuscitation. Assessment times across Leadership score groups were compared using Kruskal-Wallis and Mann-Whitney tests (p < 0.05, statistically significant).Results: Seven attending physicians were included with a postfellowship experience ranging from ≤1 to 11 years. The average leadership score was 59.8 (range, 27–72). Leadership scores were divided into 3 groups post facto: low (18–45), medium (46–67), and high (68–72). The teams directed by surgeons with low scores took significantly longer than teams directed by surgeons with high scores to complete the secondary survey (14 ± 4 minutes in contrast to 11 ± 2 minutes, p < 0.009) and to transport the patient for CT evaluation (19 ± 5 minutes in contrast to 14 ± 4 minutes; p < 0.001). Attending surgeon experience also affected clinical efficiency with teams directed by less experienced surgeons taking significantly longer to complete the primary survey (p < 0.05).Conclusion: The trauma team's perception of leadership is associated positively with clinical efficiency. As such, more formal leadership training could potentially improve patient care and should be included in surgical education.

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

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.

Attracting Students to Surgical Careers: Preclinical Surgical Experience - Corrected Proof

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.

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

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.

Invited Commentary for “Trauma Leadership: Does Perception Drive Reality?” - Corrected Proof

Thomas H. Cogbill — 2011-11-07

The value of trauma attending presence at trauma resuscitations has been scrutinized over the past decade with important potential consequences for patient care, trauma center verification, and in-house call status. In this issue of the Journal of Surgical Education, Sakran et al. at the Hospital of the University of Pennsylvania report the effect of trauma attending leadership on the efficiency of trauma resuscitations. By using the Campbell Leadership Descriptor tool to gauge leadership ability, they found that a trauma team's perception of leadership was positively associated with shorter times to complete the secondary ATLS survey (11 vs 14 min) and to transport patients to computed tomography (CT) scan (14 vs 19 min). They also confirmed that more attending surgeon experience led to shorter times to complete the primary survey. The authors concluded that leadership training might improve patient care and should be included in surgical education.

The Surgical Skills Laboratory Residency Interview: An Enjoyable Alternative - Corrected Proof

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.

Using the Hidden Curriculum to Teach Professionalism During the Surgery Clerkship - Corrected Proof

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.

Learning Styles of First-Year Orthopedic Surgical Residents at 1 Accredited Institution - Corrected Proof

Lisa Caulley, Veronica Wadey, Risa Freeman — 2011-10-24

Background: This study represents 1 arm of a 5-year prospective study investigating the learning styles of orthopedic residents and their surgical educators.Methods: This project investigates the learning styles of the 2009-2010 year 1 orthopedic surgical residents. A cross-sectional survey using the Kolb Learning Style Inventory was completed by 13 first year orthopedic residents. Direct 1-to-1 interviews were completed with the primary investigator and each participant using the Kolb Learning Style Inventory and learning styles were determined.Results: Converging learning style was the most common among the residents (53.8%). Residents demonstrated a high tendency toward the learning skill of abstract conceptualization combined with active experimentation, and a transition from action-oriented to more reflective learning style with age and postgraduate education.Conclusions: These results may be useful in creating strategies specific to each learning style that will be offered to residents to enhance future teaching and learning.

Self-Regulated Learning Strategies Used in Surgical Clerkship and the Relationship with Clinical Achievement - Corrected Proof

Sevgi Turan, Ali Konan — 2011-10-24

Introduction: Self-regulated learning indicates students' skills in controlling their own learning. Self-regulated learning, which a context-specific process, emphasizes autonomy and control. Students gain more autonomy with respect to learning in the clinical years. Examining the self-regulated learning skills of students in this period will provide important clues about the level at which students are ready to use these skills in real-life conditions.Objectives: The self-regulated learning strategies used by medical students in surgical clerkship were investigated in this study and their relation with clinical achievement was analyzed.Methods: The study was conducted during the surgery clerkship of medical students. The participation rate was 94% (309 students). Motivated Strategies for Learning Questionnaire (MSLQ), a case-based examination, Objective Structured Clinical Examination (OSCE), and tutor evaluations for assessing achievement were used. The relationship between the Motivated Strategies for Learning Questionnaire scores of the students and clinical achievement was analyzed with multilinear regression analysis.Results: The findings showed that students use self-regulated learning skills at medium levels during their surgery clerkship. A relationship between these skills and OSCE scores and tutor evaluations was determined. OSCE scores of the students were observed to increase in conjunction with increased self-efficacy levels. However, as students' beliefs regarding control over learning increased, OSCE scores decreased. No significant relationship was defined between self-regulated learning skills and case-based examination scores.Conclusions: We observed that a greater self-efficacy for learning resulted in higher OSCE scores. Conversely, students who believe that learning is a result of their own effort had lower OSCE scores.

Operating Room Fatigue: Is Your Twentieth Surgical Knot as Strong as Your First? - Corrected Proof

Tyler M. Muffly, Luis M. Espaillat-Rijo, Alexandra M. Edwards, Amanda Horton — 2011-10-24

Objective: This study aimed to determine the tensile strength in a series of 20 consecutively tied knots. Knot tying is a universally used technique in surgical procedures, and as such, knot integrity and security are essential.Study design: Twenty was the number of knots chosen as this is the average number of knots required for a vaginal hysterectomy. We used 0-0 gauge, nonexpired, polyglactin 910 to tie 20 knots in succession with less than 20 seconds rest between knots. The knots were tied without a surgeon's knot and 4 additional square knots (1 = 1 = 1 = 1 = 1). The knots were tied by 2 obstetrician/gynecologists investigators over the period of 2 weeks to minimize fatigue. The sutures were then soaked in 0.9% sodium chloride for 60 seconds and subsequently transferred to a Chatillon LTCM-100 tensiometer (Ametek, Largo, Florida) where the tails were cut to 3 mm length. The force required to break the knots was recorded. To detect a difference over time while maintaining power of 80% with a type I error rate of 5%, a minimum of 17 series of knots were needed (thus, 340 total knots after tying 20 knots per series). To buffer against unanticipated variability in the tensile strengths over time, we rounded the number of knot series up to 20, so a total of 400 knots were tied.Results: A total of 800 knots were tied. All the sutures broke at the knot and 36% untied. For analyses, the data for each series of knots were collapsed into quarters (ie, knots 1–5, 6–10, 11–15, and 16–20). A repeated-measures analysis of variance found that there were no statistically significant differences between the four quartiles (p = 0.87). A paired samples t-test comparing the first knots in each series with the last knots in each series showed no difference (p = 0.99). Similarly, a paired samples t-test comparing the first 10 knots to the last 10 knots showed no difference over time (p = 0.8). To determine whether there was a change in likelihood of knots coming untied, as more knots were tied, Cochran's Q was used to look across the entire series of 20 knots. This analysis of proportions coming untied revealed no differences over time (p = 0.61). To compare across quarters, a Friedman test was used and similarly showed no change over time (p = 0.92). The different investigators were controlled for in the analysis as a covariate, which turned out to be statistically significant, p = 0.003.Conclusions: Under laboratory conditions, the order of knots tied does not change the tensile strength of the material. This would infer that fatigue does not influence the tensile strength for a series of 20 knots; however, additional studies with a larger number of knots series may be warranted.

Mastery Learning Simulation-Based Curriculum for Laparoscopic TEP Inguinal Hernia Repair - Corrected Proof

2011-10-20

Background: The laparoscopic totally extraperitoneal (TEP) inguinal herniorrhaphy requires 250 repairs to master. Simulation training could potentially accelerate this process. We describe the development, evaluation and implementation of a TEP mastery learning curriculum.Design: We developed a 2-stage curriculum comprising online knowledge modules and skills practice on a simulator (the Guildford-MATTU TEP trainer; Limbs & Things, Ltd, Bristol, UK). Learners demonstrated mastery at each stage before advancing. The knowledge endpoint was a multiple-choice test. The skills endpoint was procedure time, as established by timing 5 experienced staff surgeons. Participants were proctored individually, receiving personalized feedback after each attempt until mastery time was achieved. The times to perform a simulated repair, number of attempts, and training time to reach mastery were compared between groups.Results: The mastery time was established at 2 minutes. Nine medical students, 36 general surgery residents (PGY 1-5), and 3 surgery fellows participated as learners. All learners achieved the knowledge and skills mastery endpoints. For the skill endpoint, participants required a median of 69 minutes (range, 13-193 minutes) and 16 simulated repairs (range, 7-27 repairs). The mean number of attempts and total training time to reach mastery varied by group (p < 0.001); more experienced residents required fewer attempts and less time to reach mastery.Conclusions: When training with a mastery learning-type simulation-based curriculum, surgical trainees can achieve the technical skill required to perform key portions of the TEP repair under artificial conditions with a performance similar to that of an expert, and are ready to move to the next phase of training in the operating room.

Man Is Fashioned, Not Born: The Contributions of George J. Heuer to Surgical Education - Corrected Proof

Julian Guitron, Walter H. Merrill — 2011-10-20

George Heuer undertook his medical education and residency training in surgery at Johns Hopkins. He then joined the surgical faculty under Halsted. He became Chair of Surgery at the University of Cincinnati in 1922, where he developed the second formal surgical training program modeled on Halsted's principles. Subsequently, he became Chair of Surgery at Cornell where he founded another surgical residency. His training programs stressed broad and thorough experience, and he championed increasing resident responsibility and independence. The demonstrated efficacy of his surgical residencies assisted greatly in the formation of subsequent resident training programs across this country.

Learning Surgical Communication, Leadership and Teamwork Through Simulation - Corrected Proof

2011-10-10

BACKGROUND: In Australia and New Zealand, surgical trainees are expected to develop competencies across 9 domains. Although structured training is provided in several domains, there is little or no formal program for professionalism, communication, collaboration, and management and leadership. The Australian federal Department of Health and Aging funded a pilot course in simulation-based education to address these competencies for surgical trainees. This article describes the course and evaluation.Methods: Course development: Content and methods drew on best-evidence for teaching and learning these competencies from other disciplines. Course evaluation: Participants completed surveys using rating scales and free text comments to identify aspects of the course that worked well and those that needed improvement.Results: Eleven of 12 participants completed evaluation forms immediately after the course. Participants reported largely meeting learning objectives and valuing the educational methods. High levels of realism in simulations contributed to the ease with which participants immersed themselves in scenarios.Conclusions: This study demonstrates that a course designed to teach competencies in communication, teamwork, leadership, and the encompassing professionalism to surgical trainees is feasible. Although participants valued the content and methods, they identified areas for development. Limitations of the evaluation are highlighted, and further areas for research are identified.

Current Approaches to Journal Club by General Surgery Programs Within the Southwestern Surgical Congress - Corrected Proof

Vanessa Shifflette, Chris Mitchell, Alicia Mangram, Ernest Dunn — 2011-10-10

Background: Journal club (JC) is a well-recognized education tool for many postgraduate medical education programs. Journal club helps residents learn critical analytic skills and keep up to date with current medical practices. To our knowledge, there is minimal evidence in the current literature detailing modern JC practices of general surgery training programs. Our study attempts to define how general surgery residency programs are implementing JC in their training process.Method: We distributed by mail a 14-question survey to general surgery program directors within the Southwestern Surgical Congress. These surveys were redistributed 1 month after the initial attempt. The responses were collected and analyzed. Survey questions aimed to define JC practice characteristics, such as where JC is held, when JC is held, who directs JC, what journals are used, the perceived importance of JC, and average attendance.Results: The surveys were sent to 32 program directors (PDs), which included 26 university and 6 community-based programs. We received responses from 26 (81%) PDs. Ninety-two percent of the programs have a consistent journal club (JC). Most JCs meet monthly (64%) or weekly (16%). The meeting places ranged from conference rooms (60%), faculty homes (20%), restaurants (8%), or in the hospital (12%). The meeting times were divided between morning (29%), midday (29%), and evening (42%). Most JCs lasted between 1 and 2 hours (88%), reviewed 1-4 articles (88%), and are attended by more than 60% of residents routinely (75%). Half of the programs (50%) had 3-4 faculty members present during discussion; 29% of the programs had only 1-2 faculty present. The articles were selected from more than 10 different journals. Seventy-five percent of the programs used the American Journal of Surgery and Annals of Surgery to find articles; only 13% of the programs used evidence-based reviews in surgery. PDs believe JC is very beneficial (42%), moderately beneficial (42%), or only fairly beneficial (16%). According to PDs, JC is most beneficial because it improves clinical knowledge (88%), initiates additional reading (62%), and improves American Board of Surgery In-Training Examination (ABSITE) scores (15%).Conclusion: Journal club has historically been an integral part of general surgery training. Our research indicates that journal club is still used widely as a beneficial educational resource and helps meet core competency requirements.

Academic Time at a Level 1 Trauma Center: No Resident, No Problem? - Corrected Proof

2011-10-10

Background: Globally, the compliance of resident work-hour restrictions has no impact on trauma outcome. However, the effect of protected education time (PET), during which residents are unavailable to respond to trauma patients, has not been studied. We hypothesized that PET has no impact on the outcome of trauma patients.Methods: We conducted a retrospective review of relevant patients at an academic level I trauma center. During PET, a trauma attending and advanced practice providers (APPs) responded to trauma activations. PGY1, 3, and 4 residents were also available at all other times. The outcome of new trauma patient activations during Thursday morning 3-hours resident PET was compared with same time period on other weekdays (non-PET) using a univariate and multivariate analysis.Results: From January 2005 to April 2010, a total of 5968 trauma patients were entered in the registry. Of these, 178 patients (2.98%) were included for study (37 PET and 141 non-PET). The mean injury severity score (ISS) was 16.2. Although no significant difference were identified in mortality, complications, or length of stay (LOS), we do see that length of emergency department stay (ED-LOS) tends to be longer during PET, although not significantly (314 vs 381 minutes, p = 0.74). On the multiple logistic regression model, PET was not a significant factor of complications, LOS, or ED-LOS.Conclusions: Few trauma activations occur during PET. New trauma activations can be staffed safely by trauma activations and APPs. However, there could be some delays in transferring patients to appropriate disposition. Additional study is required to determine the effect of PET on existing trauma inpatients.

Assessing Trainee Impact on Operative Time for Common General Surgical Procedures in ACS-NSQIP - Corrected Proof

2011-10-03

Objective: To examine the effect of surgical trainee involvement on operative time for common surgical procedures. Laparoscopic appendectomy, laparoscopic cholecystectomy, and open inguinal hernia repair comprise 17.7% of the total cases sampled in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. These cases are commonly performed by residents at varying levels of surgical training.Study design: A cross-sectional study was performed using American College of Surgeons National Surgical Quality Improvement Program data from 2005 through 2008 selecting patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, and open inguinal hernia repair. The primary outcome was operative time and predictive variables were resident involvement and training level. Linear regression analysis was used to compare operative times between cases performed by an attending alone and those assisted by junior (postgraduate year 1-2) or senior (postgraduate year 3-5) trainees, adjusting for patient and operative factors.Results: A total of 115,535 surgical cases were included, with 65,364 (59%) performed with junior or senior surgical residents. Resident participation was associated with higher operative times with no significant differences between the junior and senior cohorts; this effect persisted after controlling for potential confounding factors. Operative time increased by 16.6 minutes (95% confidence interval, 16.2-17.0) for junior residents and also by 16.6 minutes (95% confidence interval, 16.2-16.9) for senior residents.Conclusions: Surgical trainees' participation in common surgical procedures is associated with an increase in total operative time, with no difference between trainee seniority levels. This finding may be significant in assessing the impact of residency training programs on hospital efficiency.

The Effect of Problem-Based Learning With Cooperative-Learning Strategies in Surgery Clerkships - Corrected Proof

Sevgi Turan, Ali Konan, Yusuf Alper Kılıç,, Şevkat Bahar Özvarış, İskender Sayek — 2011-09-26

Background: Cooperative learning is used often as part of the problem-based learning (PBL) process. But PBL does not demand that students work together until all individuals master the material or share the rewards for their work together.Objective: A cooperative learning and assessment structure was introduced in a PBL course in 10-week surgery clerkship, and the difference was evaluated between this method and conventional PBL in an acute abdominal pain module.Methods: An experimental design was used.Results: No significant differences in achievement were found between the study and control group. Both the study and control group students who scored low on the pretest made the greatest gains at the end of the education. Students in the cooperative learning group felt that cooperation helped them learn, it was fun to study and expressed satisfaction, but they complained about the amount of time the groups had to work together, difficulties of group work, and noise during the sessions.Conclusions: This study evaluated the impact of a cooperative learning technique (student team learning [STL]) in PBL and found no differences. The study confirms that a relationship exists between allocated study time and achievement, and student's satisfaction about using this technique.

An ERAS-Based Survey Evaluating Demographics, United States Medical Licensing Examination Performance, and Research Experience Between American Medical Graduates and United States Citizen International Medical Graduates: Is the Bar Higher on the Continent? - Corrected Proof

Pauline H. Go, Zachary Klaassen, Ronald S. Chamberlain — 2011-09-26

Objective: To provide an assessment and comparison of the demographics, medical school academic performance, United States Medical Licensing Examination (USMLE) performance, and research experience between American Medical Graduate (AMG) and United States International Medical Graduate (USIMG) candidates who applied for and successfully matched into categorical general surgery residency programs.Design: Data were obtained through the Electronic Residency Application Service (ERAS) and a post-match survey distributed to all applicants.Setting: . The study was conducted at a community-based, university-affiliated hospital.Participants: All United States citizen graduates of allopathic American medical schools or international medical schools, who were applying for a general surgery residency position at our institution.Results: A total of 854 candidates applied, including 143 AMGs and 223 USIMGs. Seventy-two AMGs (50.3%) and 41 USIMGs (18.4%) were invited to interview (p < 0.0001). Mean USMLE step 1 scores were higher among USIMG applicants overall (USIMG: 212.1 ± 14.9 vs AMG: 206.9 ± 15.5; p < 0.0005) and among those invited to interview (USIMG: 227.8 ± 16.2 vs AMG: 215.5 ± 16.2; p < 0.0001). Seventy percent of AMGs matched into a categorical surgery residency compared with 31.6% of USIMGs (p < 0.001). Compared with AMGs, USIMGs applied to more programs (USIMG: 90.3 ± 42.8 vs AMG: 52.1 ± 26.4; p < 0.002), were offered fewer interviews (USIMG: 9.0 ± 6.9 vs AMG: 20.9 ± 13.7; p < 0.0001), and subsequently ranked fewer programs (USIMG: 7.5 ± 4.5 vs AMG: 12.5 ± 6.1; p < 0.0008).Conclusions: USIMGs require higher USMLE scores than their AMG counterparts to be considered for categorical general surgery residency positions. However, excellence on the USMLE neither ensures an invitation to interview nor categorical match success. A well-rounded application in conjunction with a practical application strategy is critical for USIMGs to achieve success in attaining a general surgery residency position.

Implementation of an Objective Structured Clinical Exam (OSCE) into Orthopedic Surgery Residency Training - Corrected Proof

2011-09-26

Objective: While the musculoskeletal (MSK) physical examination (PE) is an essential part of a patient encounter, we believe it is an underemphasized component of orthopedic residency education and that resident PE skills may be lacking. The purpose of this investigation was to (1) assess the attitudes regarding PE teaching in orthopedic residencies today; (2) develop an MSK objective structured clinical examination (OSCE) to assess the MSK PE knowledge and skills of our orthopedic residents.Design: Prospective, uncontrolled, observational.Setting: A major Midwestern tertiary referral center and academic medical center.Participants: The orthopedic surgery residents in our program. Twenty-two of 24 completed the OSCE.Results: Surveys showed that residents agreed that although learning the PE is important, there is not enough time in clinic to actually observe and critique a resident examining a patient. For the 22 residents (postgraduate year [PGY] 2-5) who participated in the OSCE, the overall score was 66%. Scores were significantly better for the trauma scenario (78%; p < 0.05) than for the shoulder (67%), spine (64%), and knee (59%) encounters. The overall scores for each component of the OSCE were: (1) history 53%; (2) PE 60%; (3) 5-question posttest 64%; and (4) communication skills 90%.Conclusions: We have exposed a deficiency in the PE knowledge and skills of our residents. Clinic time alone may be insufficient to both teach and learn the MSK PE. The use of a MSK OSCE, while novel in orthopedics, will allow more direct observation of our residents MSK PE skills and also allow us to follow resident skills longitudinally through their training. We hope that our efforts will encourage other programs to assess their PE curriculum and perhaps prompt change.

Career Development Needs of Vice Chairs for Education in Departments of Surgery - Corrected Proof

Hilary Sanfey, Margaret Boehler, Debra DaRosa, Gary L. Dunnington — 2011-09-26

Aim: To identify the career development needs Vice Chair for Education in Surgery Departments (VCESDs).Methods: In all, 33 VCESDs were invited to complete an online survey to identify the scope of duties, scholarly activity, job satisfaction, and career development needs.Results: A total of 29/33 (88%) VCESDs responded. Time constraints were the most frequent impediment for MDs vs. PhDs (p < 0.05). Dominant faculty development needs were conducting educational research (2.0 ± 0.78 for MDs, 1.33 ± 0.76 for PhDs), developing resident selection systems (1.68 ± 0.73), and mentorship programs (1.95 ± 0.77) for MDs, and developing teach the teacher programs (1 ± 0), and program performance evaluation systems (1.33 ± 0.76) for PhDs. The skills deemed to be of greatest importance were ability to communicate effectively (1.27 ± 0.55), resolve personnel conflicts (1.32 ± 0.57), and introduce change (1.41 ± 0.59). PhDs revealed a greater need to learn strategies for dealing with disruptive faculty (1.0 ± 0 vs 2.15 ± 0.87).Conclusions: This information will inform the future career development of VCESDs and will assist Department Chairs who wish to recruit and retain VCESDs.

“Do One, Teach One”: The New Paradigm in General Surgery Residency Training - Corrected Proof

Roger J.G. Stevens, Michaela P. Davies, Lisa Hadfield-Law — 2011-09-19

We read with interest the article by Picarella and colleagues and their proposed modification of the classic paradigm used in surgical training from “see one, do one, teach one” to “do one, teach one” and would like to provide a British perspective. The “see one, do one, teach one” model of competence is based on the traditional “master-apprenticeship” model of surgical residency training devised by Halsted at Johns Hopkins Hospital in the late 19th century. Although the “master-apprenticeship” model for surgical training has been successful, it has gradually become outdated.

Educational Factors Outweigh the Importance of Lifestyle Factors for Residency Program Applicants: An International Comparative Study - Corrected Proof

Yuichi Ishida, Yoshinori Hosoya, Naohiro Sata, Yoshikazu Yasuda, Alan T. Lefor — 2011-09-07

Objective: Although studies have been conducted to identify factors that attract students to a career in surgery, the relative importance of factors that attract students to a particular training program remains unknown. Comparative data between countries may provide insights and ultimately provide guidance to program directors as they seek to attract the best applicants to their program.Design: Blinded written survey, scored 1–5 on a list of 26 factors divided into 3 categories, including educational factors, lifestyle factors, and other.Setting: Jichi Medical University, Japan and the David Geffen School of Medicine at University of California–Los Angeles.Participants: Japan residents (N = 125), Japan Medical Students (N = 68), United States Residents (N = 99), and United States Students (N = 55).Results: All 4 groups surveyed judged faculty quality among the most important factors, with educational program quality, clinical experience and perceptions of resident happiness also rated among the most important. A comparison of factors consistent with lifestyle and factors consistent with the educational program found significantly (p < 0.05) higher scores for educational factors by 3 groups surveyed.Conclusions: Resident applicants are most interested in training program factors related to the quality of the educational program and the faculty. Issues such as salary, vacation, night call, location, or benefits are considered less important. The results in Japan and the United States were remarkably similar despite major differences in the educational system and debt load at the time of graduation. Program directors should communicate the value of those factors considered important by applicants as part of the recruitment process.

Learning Basic Laparoscopic Skills: A Randomized Controlled Study Comparing Box Trainer, Virtual Reality Simulator, and Mental Training - Corrected Proof

2011-09-07

Objectives: The objectives of this study were (1) to compare different methods of learning basic laparoscopic skills using box trainer (BT), virtual reality simulator (VRS) and mental training (MT); and (2) to determine the most effective method of learning laparoscopic skills.Design: Randomized controlled trial.Setting: King's College, London.Methods: 41 medical students were included in the study. After randomization, they were divided into 5 groups. Group 1 was the control group without training; group 2 was box trained; group 3 was also box trained with an additional practice session; group 4 was VRS trained; and group 5 was solely mentally trained. The task was to cut out a circle marked on a stretchable material. All groups were assessed after 1 week on both BT and VRS. Four main parameters were assessed, namely time, precision, accuracy, and performance.Results: Time: On BT assessment, the box-trained group with additional practice group 3 was the fastest, and the mental-trained group 5 was the slowest. On VRS assessment, the time difference between group 3 and the control group 1 was statistically significant. Precision: On BT assessment, the box-trained groups 2 and 3 scored high, and mental trained were low on precision. On VRS assessment, the VRS-trained group ranked at the top, and the MT group was at the bottom on precision. Accuracy: On BT assessment, the box-trained group 3 was best and the mental-trained group was last. On VRS assessment, the VRS-trained group 4 scored high closely followed by box-trained groups 2 and 3. Performance: On BT assessment, the box-trained group 3 ranked above all the other groups, and the mental-trained group ranked last. On VRS assessment, the VRS group 4 scored best, followed closely by box-trained groups 2 and 3.Conclusions: The skills learned on box training were reproducible on both VRS and BT. However, not all the skills learned on VRS were transferable to BT. Furthermore, VRS was found to be a reliable and the most convenient method of assessment. MT alone cannot replace conventional training.

The American Board of Surgery Certifying Examination: A Retrospective Study of the Decreasing Pass Rates and Performance for First-Time Examinees - Corrected Proof

John L. Falcone, Giselle G. Hamad — 2011-08-25

Background: There has been a noticeable decrease in the pass rate for the American Board of Surgery Certifying Examination during the last 5 years. We hypothesize that this decline is statistically significant, and we wish to determine whether the pass rates had any geographic patterns of distribution.Methods: In this retrospective cohort trial, publically available electronic data sets of pass rates on the American Board of Surgery Certifying Examination were evaluated from the American Board of Surgery website. χ2 tests were used to determine whether there was any association between the pass rates and the academic year. A descriptive geographic evaluation of program-specific pass rates for first-time examinees was also performed.Results: From 2006 to 2010, there has been a 7% decrease in the pass rate for the American Board of Surgery Certifying Examination. A χ2 test shows that there is a statistically significant association with the pass percentage on the American Board of Surgery Certifying Examination and the year (p < 0.0001). Subgroup analysis demonstrated a difference in pass rate between 2006 and 2007 (p = 0.02). Geographic analysis showed the pass rates for first-time examinees were the highest in Rhode Island (100%) and the lowest in Puerto Rico (63%) from 2005 to 2010. Three of the 5 highest-performing states are on the Pacific Coast, and 4 of the 9 lowest-performing states are in the southern United States. There are differences between these 2 groups of states (p < 0.001).Conclusions: There was a significant decrease in the pass rate for the American Board of Surgery Certifying Examination from 2006 to 2010. There also were some geographic patterns relating to first-time examinee performance from 2005 to 2010.