Journal of Surgical Education - Articles in Press

Trends of Surgical Career Selection Among Medical Students and Graduates: A Global Perspective - Corrected Proof

Ranish Deedar-Ali-Khawaja, Sadaf Mumtaz Khan — 2010-07-26

Background: Declining trends in surgery have been well-researched in the North American region, but little is known about the international dynamics affecting this phenomenon. A comprehensive approach to this emerging issue is lacking.Objectives: Our objective in this study is to explore global trends related to medical student interest in surgical careers. We will also identify factors influencing the choice of surgery as a career and outline practical interventions to nurture interest in these fields, as described in the literature.Design: We present a focused review of worldwide trends of surgical career selection among medical students of geographically distant and diverse sociocultural backgrounds. A systematic literature search was performed using PubMed. The studies were conducted over the last fifteen years with the study populations scattered over 6 continents.Results: North American studies have shown a declining trend for medical students to select surgery as a career, but a recent recovery has been observed. However, surgery is still the popular choice of career among Middle Eastern and Far-Eastern Asian men. Sociocultural variants and personal satisfaction are likely influential factors with financial rewards being the least significant. Surgery is also popular in Nigeria despite their increased awareness of risk of HIV/AIDS associated with surgery. A decline in surgery has been observed in Australia, New Zealand, and South Africa. Medical students and graduates of Greece, Switzerland, and the UK mostly prefer nonsurgical careers. Multiple extrinsic and intrinsic factors appear to play a role for such a phenomenon. Specific interventions are now being used to create a rebound effect for such a declining trend observed in most of the regions worldwide.Conclusions: Global trends show a variation of interest in surgery as a career option throughout the 6 continents. Possible factors affecting this phenomenon are similar among geographically distant and diverse student cultures.

Left-Handedness — A Handicap for Training in Surgery? - Corrected Proof

Vahktang Tchantchaleishvili, Patrick O. Myers — 2010-07-26

Background: Left-handedness was historically considered a disability and a social stigma, and teachers would make efforts to suppress it in their students. Little data are available on the impact of left-handedness on surgical training. This report reviews available data on this subject.Methods: We did systematic electronic and manual literature searches using a predetermined strategy independently by 2 investigators, 1 left- and 1 right-handed, to identify reports on surgical training and left-handedness.Results: The review revealed 19 studies on the subject of left-handedness and surgical training. Data were heterogeneous and based mostly on surveys. Left-handedness produced anxiety in residents and their trainers. There was a lack of mentoring on laterality. Surgical instruments, both conventional and laparoscopic, are not adapted to left-handed use and require ambilaterality training from the resident. There is significant pressure to change hand laterality during training. However, left-handedness might present an advantage in operations involving situs inversus or left lower limb operations.Conclusions: Left-handedness is a challenge both for the trainee and the trainer in surgery. Early laterality-related mentoring in medical school and during surgical residency with provision of left-handed instruments might reduce the inconveniences of left-handed surgeons learning.

High-Performance Teams and the Physician Leader: An Overview - Corrected Proof

Aalap Majmudar, Anshu K. Jain, Joseph Chaudry, Richard W. Schwartz — 2010-07-26

The complexity of health care delivery within the United States continues to escalate in an exponential fashion driven by an explosion of medical technology, an ever-expanding research enterprise, and a growing emphasis on evidence-based practices. The delivery of care occurs on a continuum that spans across multiple disciplines, now requiring complex coordination of care through the use of novel clinical teams. The use of teams permeates the health care industry and has done so for many years, but confusion about the structure and role of teams in many organizations contributes to limited effectiveness and suboptimal outcomes. Teams are an essential component of graduate medical education training programs. The health care industry's relative lack of focus regarding the fundamentals of teamwork theory has contributed to ineffective team leadership at the physician level. As a follow-up to our earlier manuscripts on teamwork, this article clarifies a model of teamwork and discusses its application to high-performance teams in health care organizations. Emphasized in this discussion is the role played by the physician leader in ensuring team effectiveness. By educating health care professionals on the fundamentals of high-performance teamwork, we hope to stimulate the development of future physician leaders who use proven teamwork principles to achieve the goals of trainee education and excellent patient care.

Improving Access to Surgery in a Developing Country: Experience from a Surgical Collaboration in Sierra Leone - Corrected Proof

2010-07-09

Background: Although surgery is increasingly recognized as an essential component of primary health care, there has been little documentation of surgical programs in low- and middle-income countries. Surgeons OverSeas (SOS) is a New York-based organization with a mission to save lives in developing countries by improving surgical care. This article highlights the surgical program in Sierra Leone as a possible model to improve access to surgery.Methods: An SOS team conducted a needs assessment of surgical capacity in Sierra Leone in February 2008. Interventions were then developed and programs were implemented. A follow-up assessment was conducted in December 2009, which included interviews of key Sierra Leone hospital personnel and a review of operating room log books.Results: Based on an initial needs assessment, a program was developed that included training, salary support, and the provision of surgical supplies and equipment. Two 3-day workshops were conducted for a total of 44 health workers, salary support given to over 100 staff, and 2 containers of supplies and equipment were donated. Access to surgery, as measured by the number of major operations at Connaught Hospital, increased from 460 cases in 2007 to 768 cases in 2009.Conclusions: The SOS program in Sierra Leone highlights a method for improving access to surgery that incorporates an initial needs assessment with minimal external support and local staff collaboration. The program functions as a catalyst by providing training, salary support, and supplies. The beneficial results of the program can then be used to advocate for additional resources for surgery from policy makers. This model could be beneficial in other resource-poor countries in which improved access to surgery is desired.

Urgent Carotid Endarterectomy for Crescendo Transient Ischemic Attacks and Stroke-In-Evolution: Abstracted Review - Corrected Proof

Joshua P. Froman, Clark A. Davis, Thomas H. Cogbill — 2010-07-08

Schneider C, Johansen K, Königstein R, Metzner C, Oettinger W. World J Surg. 1999;23:1163-1167. Objective: To compare outcomes of patients who underwent emergency CEA to patients who underwent elective CEA.

Measuring Surgical Trainee Perceptions to Assess the Operating Room Educational Environment - Corrected Proof

Gouri B. Diwadkar, J. Eric Jelovsek — 2010-07-05

Objective: To determine measurable differences in the perception of learning between junior and senior residents in the operating rooms of an obstetrics and gynecology (OBGYN) residency program.Design, Setting, And Participants: Using a cross-sectional design, the Operating Room Educational Environment Measure (OREEM), a 40-item educational environment inventory, was administered to 28 OBGYN residents from 1 training program, who train at 3 hospital sites. The OREEM measures a trainee's perceptions of the teaching surgeon, learning opportunities, operating room atmosphere, and workload. The primary outcome was total OREEM scores and secondary outcomes were OREEM subscale scores, global impression of education, and internal consistency and validity of the OREEM scale. Group sample sizes of 10 and 10 achieved 80% power to detect a 10% difference between group mean OREEM scores ± 10% with a significance level of 0.05.Results: Twenty-four residents including 11 junior (postgraduate years 1 and 2) and 13 senior (postgraduate years 3 and 4) residents were included in the analysis. Total OREEM scores, learning opportunities, and workload/support subscale scores were significantly lower for junior residents compared with senior residents across all sites. Perceptions of learning at a multispecialty tertiary referral hospital were lower than the community and regional hospitals. This was secondary to complexity of cases, subspecialty fellows, and decreased opportunities to first-assist in the operating room. The OREEM demonstrated acceptable reliability and construct validity.Conclusions: There are measurable differences in perception of the operating room educational environment between junior and senior OBGYN residents using the reliable and valid Operating Room Educational Environment Measure.

Teaching First or Teaching Last: Does the Timing Matter in Simulation-Based Surgical Scenarios? - Corrected Proof

Benjamin Zendejas, David A. Cook, David R. Farley — 2010-07-05

Objective: The optimal timing of instruction in simulation-based scenarios remains unclear. We sought to determine how varying the timing of instruction, either before (teaching first) or after (teaching last) the simulation, affects knowledge outcomes of surgical trainees.Design: We conducted a pretest/posttest crossover study in which fourth-year medical students and general surgery residents (PGY 1–3) participated in 3 instructional modules, each repeated twice in consecutive weeks: endocrine surgery (sessions 1 and 2), trauma resuscitation (sessions 3 and 4), and team training (sessions 5 and 6). Each session comprised 3 cases, each involving a prescenario briefing, a simulated scenario, and a postscenario debriefing. The timing of instruction varied between sessions. For the teaching-first sequence (sessions 1, 4, and 6), participants received a lecture during each prescenario briefing. In the teaching-last sequence (sessions 2, 3, and 5), trainees received an identical lecture during the postscenario debriefings. We assessed attitudes and knowledge using a postsession survey and identical 10-question multiple-choice tests at the start (pretest) and end (posttest) of each session, respectively. The mean differences in knowledge scores between groups were analyzed with repeated-measures analysis of variance (ANOVA).Results: Forty-nine participants (11 medical students and 38 surgical residents) attended at least 1 session, providing 76 observations. Mean pretest scores were equivalent (p > 0.05). The change in scores from pretest to posttest varied between the 2 groups (p = 0.002). The mean posttest score was 8.24 (standard error [SE], 0.29) for the teaching-last group and 6.68 (SE, 0.27) for the teaching-first group (mean difference, 1.56; 95% confidence interval, 0.79–2.33). Both teaching-last and teaching-first group participants preferentially rated debriefings and scenarios, respectively, as the better learning experience.Conclusions: Participants who received instruction after simulated scenarios achieved higher mean knowledge scores than those who received instruction before simulated scenarios. Cognitive overload, stress, or activation of prior knowledge could all be involved as causal mechanisms.

Improvement in Educational Effectiveness of Morbidity and Mortality Conferences with Structured Presentation and Analysis of Complications - Corrected Proof

2010-06-14

Purpose: Although morbidity and mortality (M & M) conferences are cornerstones of surgical teaching, they are not consistent in their educational quality. The current study examines the content and process of M & M presentations by surgical residents and hypothesizes that a structured format for these presentations can improve teaching and learning.Methods: The educational effectiveness of M & M conferences was assessed through the observation of case presentations, questionnaires to residents measuring learning from presentations, and an anonymous survey of residents regarding perceptions of the effectiveness of conferences. A structured presentation format was devised to address the deficits noted from these assessments and subsequently introduced to all residents and faculty. M & M conferences were then reassessed using the 3 methods.Results: Forty M & M presentations by surgical residents were observed before the implementation of the standardized format, and 35 presentations were observed after the changes. Observation of presentations noted significant changes in residents clearly presenting causes of complications and proposing strategies for practice change. Questionnaires of residents demonstrated improved ability to specify the causes of complications after implementation of the new format (mean rating, 4.56 vs 3.11, p < 0.05) as well as to identify specific ways to avoid the complication in the future (mean, 4.31 vs 3.42, p < 0.05). Online survey results also demonstrated improved resident perception of the specificity of content covered during M & M conferences as well as in their opinions regarding the discussion process.Conclusions: A structured format for M & M presentations is a practical tool to help residents analyze complications systematically and identify steps for potential changes consistently in clinical practice. Such a format also leads to improved learning for other residents participating in these conferences. Without structured presentations, M & M conferences fail to deliver clear educational messages regarding surgical complications.