Search

Background Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. Methods We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. Results Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74). Conclusion Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors.

This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy.The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role.Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation.A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%.US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Background Concerns exist regarding the competency of general surgery graduates with performing core general surgery procedures. Current competence assessment incorporates minimal procedural numbers requirements. Methods Based on the Zwisch scale we evaluated the level of autonomy achieved by categorical PGY1-5 general surgery residents at 14 U.S. general surgery resident training programs between September 1, 2015 and December 31, 2016. With 5 of the most commonly performed core general surgery procedures, we correlated the level of autonomy achieved by each resident with the number of procedures they had performed before the evaluation period, with the intent of identifying specific target numbers that would correlate with the achievement of meaningful autonomy for each procedure with most residents. Results Whereas a definitive target number was identified for laparoscopic appendectomy (i.e. 25), for the other 4 procedures studied (i.e. laparoscopic cholecystectomy, 52; open inguinal hernia repair, 42; ventral hernia repair, 35; and partial colectomy, 60), target numbers identified were less definitive and/or were higher than many residents will experience during their surgical residency training. Conclusions We conclude that procedural target numbers are generally not effective in predicting procedural competence and should not be used as the basis for determining residents' readiness for independent practice.

Purpose Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs. Methods Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail. Results A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents ( n = 3555 assessments) and 259 attendings ( n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures. Conclusions SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.

Correct clinical decision-making is a key competency of surgical trainees. The purpose of this study was to assess validity and effect on resident decision-making accuracy of web-based virtual patient case scenarios in general surgery training.During the 2013-2014 academic year, the use of web-based virtual patient scenarios for teaching and assessment of resident critical thinking and decision-making was assessed in 2 urban university-based residency programs. In all, 71 residents (PGY [postgraduate year] 1 = 21, PGY2 = 11, PGY3 = 14, PGY4 = 13, and PGY5 = 12) took the cases over the course of the academic year. Cases were made available to the residents online 1 week before a scheduled debriefing conference with a faculty facilitator and were completed by residents individually on their own schedule. At the completion of each case attempt, residents were given a computer-generated score and feedback. Residents were allowed to repeat the cases before the debriefing if they wished. Cases were required to be completed by 48 hours before the conference, at which time a faculty report was computer generated that measured group and individual performance and identified the frequency of errors in decision-making. This report was reviewed with the residents in the faculty debriefing, and teaching focused on the knowledge gaps identified in the reports.The mean percentage of assigned cases completed by categorical residents was 85.7%. Mean score (maximum possible = 100) on the cases increased by resident year (PGY1 = 45.3, PGY2 = 49.3, PGY3 = 53.6, PGY4 = 57.5, and PGY5 = 61.8), a 25% increase between PGY1 and PGY5 (p0.001 by analysis of variance). In all, 45 (63%) residents chose to repeat at least 1 case before the debriefing. The number of repetitions of individuals on the same case varied from a minimum of 1 to a maximum of 5. On repeated cases, mean scores rose (attempt 1 = 22.6, attempt 2 = 69.3, attempt 3 = 72.1, attempt 4 = 77.5, attempt 5 = 100, p0.0001 by analysis of variance). Paired t tests on case repetition using each resident as his-her own control showed that scores rose by 46 points between attempt 1 and attempt 2 (p0.001).(1) In a beta test of web-based scenarios that teach and assess clinical decision-making, resident scores improved by 25% from PGY 1 to PGY5 in a stepwise and statistically significant manner, suggesting that such exercises could serve as milestones for competency assessment. Additional studies are needed to acquire evidence for other forms of validity. (2) Repetition of cases after feedback led to highly significant increases in performance, suggesting that requiring repeated training to reach defined levels of competence is practical.