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General surgery education has continued to evolve regarding test preparation, simulation, and skill acquisition. The "Resident as Educator" (RAE) model has been proposed and enacted by programs as a viable education model for general surgery education. This study examines the current education structures in general surgery residency programs in the United States and how many programs have adopted the RAE model or aspects of the model.A 20-question survey regarding education structure was distributed to all program directors in October 2021. Questions focused on the involvement of residents in leading education sessions, creating the weekly education schedule, program feedback to residents on teaching, and recognition for distinguished resident educators.A total of 156 programs responded to the survey. The response rate was 60%. 76.4% of the respondents have a combination of resident and faculty-led didactic sessions, 8.5% have an RAE model, and 15% have faculty-led education sessions. In terms of concerns regarding resident-led didactics-24.4% of respondents stated that their main concern would be the quality of education provided, and 20.4% referenced low resident satisfaction levels with resident-led education. There were no differences among the groups regarding the American Board of Surgery board passage rates.Most residency programs have adopted a model in which residents have significant involvement in creating and maintaining the education calendar and leading formal education sessions. However, only 8.5% have a purely resident-led educational curriculum among the responding programs. More studies are needed to assess how to implement a resident as educator model successfully.

Surgical education requires proficiency with multiple types of learning to create capable surgeons. This article reviews a conceptual framework of learning that starts with the biological basis of learning and how neural networks encode memory. We then focus on how information can be absorbed, organized, and recalled, discussing concepts such as cognitive load, knowledge retrieval, and adult learning. Influences on memory and learning such as stress, sleep, and unconscious bias are explored. This overview of the biological and psychological aspects to learning provides a foundation for the articles to follow.

Introduction The United States Medical Licensing Examination (USMLE) was designed as a universal assessment tool for states to determine physician’s medical licensure's candidacy. Recent changes in the USMLE exam have changed the way future surgical residency candidate applications will be reviewed. The survey aimed to assess the effect of changes in USMLE exams—USMLE Step 1 pass/fail, complete dissolution of USMLE clinical skills exam, and the role of holistic review in future surgical residency candidacy selection. Methods An anonymous online survey was created and distributed to general surgery program directors and coordinators across the USA. The survey aimed to assess attitudes toward changes to USMLE exams and the potential changes with a holistic review of candidate applications. Results The response rate was 63.7%. Most program directors and coordinators disagree with changing USMLE Step 1 to a pass/fail scoring system. The majority felt that contacts, the medical school's name, and performance in clinical electives and sub-internships would hold more significance. They also believe that a holistic review of application will decrease socioeconomic discrepancies and promote a more diverse and inclusive resident cohort. Conclusion Step 2 clinical knowledge (CK) will gain more importance in future residency matches because of the change in the scoring system of Step 1. The medical school's name, personal contacts, and clinical performance in rotations will hold more significance.

Background Physical distancing required by coronavirus disease 2019 (COVID-19) has limited traditional in-person resident education. We present our novel online curriculum for incorporation into traditional surgical educational programs. Methods The online curriculum utilized weekly sub-specialty themed faculty and resident created lectures, ABSITE practice questions, and weekly sub-specialty synchronized readings. Attendance, resident and faculty surveys, and completed ABSITE practice questions evaluated for curriculum success. Curriculum was adapted as COVID-19 clinical restructuring ended. Results 77% and 80% of clinical residents attended faculty lectures and resident led topic discussions as compared to 66% and 48% attending traditional in-person grand rounds and SCORE curriculum (both p > 0.05). 71.9% of residents and 16.6% of faculty reported improved resident participation while none reported decreased levels of participation (p, Highlights • Online educational platforms are useful and effective tools for the acquisition and application of knowledge. • Successful knowledge acquisition requires multimodal approach. • Resident driven educational sessions can empower residents to take change of their education. • Online educational platforms can facilitate sharing of knowledge across large distances.

Introduction COVID-19 emerged as a global pandemic in 2020 and has affected millions of lives. Surgical training has also been significantly affected by this pandemic, but the exact effect remains unknown. We sought to perform a national survey of general surgery residents in the United States to assess the effect of COVID-19 on surgical resident training, education, and burnout. Methods An anonymous online survey was created and distributed to general surgery residents across the United States. The survey aimed to assess changes to surgical residents’ clinical schedules, operative volume, and educational curricula as a result of the COVID-19 pandemic. Additionally, we sought to assess the impact of COVID-19 on resident burnout. Results One thousand one hundred and two general surgery residents completed the survey. Residents reported a significant decline in the number of cases performed during the pandemic. Educational curricula were largely shifted toward online didactics. The majority of residents reported spending more time on educational didactics than before the pandemic. The majority of residents feared contracting COVID-19 or transmitting it to their family during the pandemic. Conclusions COVID-19 has had significant impact on surgical training and education. One positive consequence of the pandemic is increased educational didactics. Online didactics should continue to be a part of surgical education in the post-COVID-19 era. Steps need to be taken to ensure that graduating surgical residents are adequately prepared for fellowship and independent practice despite the significantly decreased case volumes during this pandemic. Surgery training programs should focus on providing nontechnical clinical training and professional development during this time.

OBJECTIVE There is currently little known about acute care surgery (ACS) education in US medical schools. The purpose of this paper was to systematically review the state of the literature describing ACS training at the medical school level and introduce an ACS education model provided to medical students at our institution. DESIGN We conducted a comprehensive literature review using the PubMed database to identify all articles related to ACS (trauma surgery, emergency general surgery, and surgical critical care) and undergraduate medical education. PARTICIPANTS A total of 376 articles were captured with our search strategy. The articles were reviewed for eligibility by 2 separate reviewers. RESULTS We identified 3 relevant articles for our literature review. All studies were performed at level 1 trauma centers. The duration of ACS rotations ranges from 1 to 4 weeks with variable night call schedules. While several curricular changes have improved student perceptions on ACS education, none of the studies have thoroughly evaluated the impact on students’ readiness or career choices for their postgraduate training. CONCLUSIONS The current lack of information on ACS education in medical school has left us with a need to better understand this area in order to improve students’ experience and exposure to the specialty. Future efforts should be placed on addressing current issues in ACS education and evaluating its impact on career choice of medical students.

Background Humanitarian surgeons face many ethical challenges. Despite increasing resident participation during humanitarian activities, minimal literature exists describing premission ethics training. Methods A systematic literature review was conducted to identify publications on humanitarian surgery. A 3-tiered review was performed assessing for ethical conflicts and guidelines. A Humanitarian Ethics Curriculum (HEC) was developed based on these findings and administered to residents prior to a humanitarian mission. Postmission essays were assigned to describe an ethical dilemma they encountered. The HEC's value was evaluated by identifying the ACGME core competencies represented in the essays. Results 49 eligible publications were identified. Several areas of consensus were found. Controversies identified included: trainee involvement, surgical innovation, and operating on patients with dismal prognosis. All residents stated that the HEC was vital. 61% of ethical dilemmas involved surgical patients. Core competencies emphasized included systems-based practice, patient care, professionalism, interpersonal/communication skills, and medical knowledge. Conclusions There is consensus regarding ethical principles that surgeons should follow during humanitarian activities. However, areas of controversy persist. Premission HEC should be administered to residents participating in humanitarian missions.

To establish expert consensus regarding the domains and topics for senior surgery residents (PGY-4) to make critical decisions and assume senior-level responsibilities, and to develop the formative American College of Surgeons Senior Resident Readiness Assessment (ACS SRRA) Program.The American College of Surgeons (ACS) education leadership team conducted a focus group with surgical experts to identify the content for an assessment tool to evaluate senior residents' readiness for their increased levels of responsibility. After the focus group, national experts were recruited to develop consensus on the topics through three rounds of surveys using Delphi methodology. The Delphi participants rated topics using Likert-type scales and their comments were incorporated into subsequent rounds. Consensus was defined as ≥ 80% agreement with internal-consistency reliability (Cronbach's alpha) ≥ 0.8. In a stepwise fashion, topics that did not achieve consensus for inclusion were removed from subsequent survey rounds.The surveys were administered via an online questionnaire.Twelve program directors and assistant program directors made up the focus group. The 39 Delphi participants represented seven different surgical subspecialties and were from diverse practice settings. The median length of experience in general surgery resident education was 20 years (IQR 14.3-30.0) with 64% of the experts being either current or past general surgery residency program directors.The response rate was 100% and Cronbach's alpha was ≥ 0.9 for each round. The Delphi participants contributed a large number of comments. Of the 201 topics that were evaluated initially, 120 topics in 25 core clinical areas were included to create the final domains of ACS SRRA.National consensus on the domain of the ACS SRRA has been achieved via the modified Delphi method among expert surgeon educators. ACS SRRA will identify clinical topics and areas in which each senior resident needs improvement and provide data to residents and residency programs to develop individualized learning plans. This would help in preparing the senior residents to assume their responsibilities and support their readiness for future fellowship training or surgical practice.

Background There is little known about medical student education in acute care surgery (ACS)—how much and what type of exposure students receive in the specialty. The aim of this study was to investigate the current status of ACS education provided to students in U.S. medical schools. Materials and methods We created an online survey tool covering the surgical clerkship and ACS curriculum and distributed this survey to the official email list of the Association for Surgical Education Committee on Clerkship Directors. Results A total of 57 of 294 (19.4%) responses were received. All respondents reported that at least some of their major teaching hospitals are affiliated with an ACS service and have a level 1 or 2 trauma center. Although almost two-thirds (61.8%) of respondents believe that medical students should have formal ACS education in the form of a clinical rotation, an ACS rotation is mandatory at only 16.4% of programs and is optional at 69.1% of programs as part of the surgical clerkship curriculum. The duration of ACS rotations ranges from 1 to 6 wk, and half of programs require students to take overnight call (most often 1-2 nights/wk). The most common pathologies that students see on ACS include appendicitis, biliary disease and cholecystitis, intestinal obstruction, and trauma. Conclusions Medical students across the nation have varying exposure to ACS during their clinical training. With the continued growth of the ACS specialty, further study is warranted to examine the impact of undergraduate ACS education on student career planning.

The changing climate of surgical education has led to a renewed interest in the process of learning. Research from the fields of cognitive and educational psychology, neuroscience, sociology, and behavioral economics have clear implications for the teaching and learning of psychomotor skills. This article summarizes how key learning theories impact the field of surgical education and proposes practical tips, supported by the science of learning, that can be applied to optimize resident and fellow education.

IntroductionRecent changes in surgical education have had an impact on our congenital training programmes. The mandate of the 8-hour workweek, a rapidly expanding knowledge base, and a host of other mandates has had an impact on the readiness of the fellows who are entering congenital programmes. To understand these issues completely, we interviewed the top congenital experts in the United States of America. The purpose of this paper is to share their insight and offer suggestions to address these challenges.MethodsWe used a qualitative thematic analysis approach and performed phone interviews with the top five congenital experts in the United States of America.ResultsExperts unanimously felt that duty-hour restrictions have negatively affected congenital training programmes in the following ways: current fellows do not seem as conditioned as fellows in the past, patient handoffs are not consistent with excellent performance, the mentor–mentee relationship has been affected by duty-hour restrictions, and fellows may be less prepared for real-world practice. Three positive themes emerged in response to duty-hour restrictions: fellows appear to be doing less menial task work, fellows are now better rested for learning, and we are attracting more individuals into the speciality. Experts agreed that congenital fellowships should be increased to 2 years. There was support for both the traditional and integrated residency pathways.DiscussionWe are in a new era of education and must work together to overcome the challenges that have arisen in recent years.

OBJECTIVE The purpose of this study was to assess the impact of a preoperative Educational Time-Out (ETO) with structured postoperative feedback on resident preoperative goal-setting and the educational experience of a clinical rotation. DESIGN A preoperative ETO was developed during which trainees and faculty jointly identified an operative goal and discussed the trainee's operative autonomy. Postoperative feedback with a smartphone application was encouraged. From November 2016 to October 2017, the intervention was piloted with 1 surgical service. Outcomes included ETO completion rate, goal setting rate, and subjects’ perception of the impact of the ETO on identification of performance deficits, trainee autonomy, and receipt of feedback. Data were analyzed using descriptive statistics. SETTING This study was performed in an institutional hospital setting. PARTICIPANTS Third-year general surgery residents and surgical faculty in the Department of Hepatobiliary Surgery and Liver Transplantation at Vanderbilt University Medical Center took part in the intervention. RESULTS Seven residents and 7 attending surgeons participated in this study. Residents performed a median of 15 procurements during an average of 6.5 weeks each on service. The ETO completion rate was 83%. Resident-reported preoperative goal setting increased after the intervention (from 36% to 78%, p = 0.015). Subjects reported a positive impact of the intervention, with high resident agreement that the ETO helped identify deficits (82% median agreement), increased autonomy (82% median agreement), and increased receipt of feedback (84% median agreement). Residents and attendings agreed that the educational experience was stronger due to the ETO (median 81% and 77%, respectively). CONCLUSIONS The ETO intervention improved rates of resident preoperative goal setting and strengthened perceived educational experiences. Resident participants also reported improvements in autonomy and rates of postoperative feedback. Broader implementation of this brief preoperative pause is an easy way to emphasize procedural education in the operating room.

Objective Practice-Based Learning and Improvement is a Core Competency for surgical residents. Self-regulated learning (SRL) skills are an important component of this competency, yet are rarely taught in surgical training. Before we can teach SRL skills to residents we must understand the attributes that are essential. The purpose of this study was to develop a framework for SRL for surgical trainees. Design This mixed-methods study design utilized a two-round modified-Delphi approach to develop consensus among experts in surgical education regarding SRL in surgical training. Round One included SRL constructs derived from educational, professional, and medical literature. Based upon quantitative data and thematic coding of comments, these constructs were adapted for applicability in the context of surgical residency and reorganized using a constant comparative approach. Revised constructs and groupings were presented to the expert panel in Round Two. Further survey rounds were not needed as all items in Round Two reached the predetermined consensus level of 70%. Setting The Delphi panel was a purposeful sample of nationally recognized experts in surgical education, including members of the Association for Surgical Education and the Association for Program Directors in Surgery. Participants Thirty-eight of 42 experts (90.5%) responded to Round One, representing 29 academic and community medical systems nationally. The response rate for Round Two was 92%, 35 of the 38 Round One participants. Results In Round One, the SRL constructs were all viewed as important with median scores ranging from 50 to 99.5, on a 100-point scale. Two hundred and ninety-one comments were coded and used to refine SRL definitions into 7 domains for Round Two, which included self-awareness, task analysis, situation awareness, strategic planning, progress evaluation, learning and performance management, and goal attainment and refinement. All Round Two items reached greater than 70% agreement, and received 51 free response comments. Several key themes emerged: clinical prioritization over learning, learner's limited control, value and reliance on external resources, low use of metacognition, and complex goal orientation. Incorporation of common themes generated a novel multi-stage framework of SRL in surgical education. Conclusions Surgical residency represents a unique learning context, in which the ideal learner is one who understands their learning environment and utilizes available resources to optimize their own learning. Experts in surgical education believe SRL skills are important in training, and a novel framework of SRL is necessary to support a learner-centered model within the demanding environment of surgical training.

BACKGROUND Computed tomographic and cadaveric studies have demonstrated needle decompression of tension pneumothorax at the fifth intercostal space (ICS), anterior axillary line (AAL) has advantages over the second ICS midclavicular line (MCL). The purpose of this study was to compare the ability of prehospital care providers to accurately decompress the chest at these two locations. METHODS Randomly selected US Navy hospital corpsmen (n = 25) underwent a standardized training session followed by timed needle decompression on unmarked fresh cadavers. A 14-gauge angiocatheter was inserted in the right and left second ICS MCL and fifth ICS AAL in a predetermined computer-generated order. Time from needle uncapping to insertion, accuracy, and ease of placement were examined. RESULTS A total of 25 corpsmen inserted 100 needles into 25 cadavers. Mean (SD) age was 25.9 (3.7) years, 72.0% were male, with 4.2 (3.2) years of experience, and 52.0% had previously deployed. A total of 60.0% had attempted decompression previously, 93.3% in a model and 6.7% in a patient. Time to decompression did not differ between the second and fifth ICS (16.8 [10.1] seconds vs. 16.9 [12.3] seconds, p = 0.438). Accuracy however was superior at the fifth ICS, with a misplacement rate of only 22.0% versus 82.0% at the second ICS (p < 0.001). The aggregate distance from the target position was also significantly greater for the second ICS (3.1 [1.7] cm vs. 1.2 [1.5] cm, p < 0.001). Insertion at the fifth ICS was rated as being easier than the second by 76.0% of providers, the same by 12.0%, and more difficult by 12.0%. CONCLUSION For prehospital care providers, the fifth ICS AAL can be localized and decompressed with a higher degree of accuracy than the traditional second ICS MCL. It is rated as easier to perform and can be done just as quickly. Based on these data, the fifth ICS AAL should be considered as an equivalent first-line position for needle decompression in patients with clinical evidence of a tension pneumothorax.

We collected data regarding specific aspects of perioperative surgical education within our institution's Section of Surgical Sciences as a needs assessment.Categorical general surgery residents and attending surgeons were queried regarding their perceptions of resident preoperative planning and perioperative communication.The overall response rate was 81%, with 35 resident and 54 faculty respondents. Residents reported selecting an operative learning objective a median of 50% (IQR 36-67) of the time, whereas attending surgeons perceived this to be the case a median of 26% (IQR 15-35) of the time (P 0.001). The group reported median frequencies of 20% (IQR 9-31) for preoperative discussion of learning objectives, 12% (IQR 4-27) for preoperative discussion of competence and 27% (IQR 17-55) for postoperative debriefing.This study demonstrates deficits in resident goal setting and perioperative communication within our program, which are targets for future intervention. We share these results as a potential tool for other programs.

Background Research in surgical education has seen unprecedented growth but originates from single institutions and remains uncoordinated; this study aimed to generate a list of research priorities in surgical educational topics. Methods The membership of the Association for Surgical Education was asked to submit up to 5 research questions concerned with multi-institutional collaborative surgical education research and to identify challenges faced by surgical education researchers. A modified Delphi methodology was used to create the research agenda based on these responses. Results Surgical educators responded to 3 survey rounds. Categories of submitted questions included teaching methods and curriculum development; assessment and competency; simulation; medical student preparation and selection; impact of work hour restrictions; and faculty development. Participants cited institutional culture and practice variability and lack of institutional review board coordination as common barriers to collaborative research, while identifying extensive planning, frequent communication, and availability of dedicated research coordinators as the most important facilitators. Conclusions Using a Delphi methodology, a prioritized agenda for multi-institutional surgical education research was developed that may help advance surgeon education.

Background Increasing ambient temperature to prevent intraoperative patient hypothermia remains widely advocated despite unconvincing evidence of efficacy. Heat stress is associated with decreased cognitive and psychomotor performance across multiple tasks but remains unexamined in an operative context. We assessed the impact of increased ambient temperature on laparoscopic operative performance and surgeon cognitive stress. Study design Forty-two performance measures were obtained from 21 surgery trainees participating in the counter-balanced, within-subjects study protocol. Operative performance was evaluated with adaptations of the validated, peg-transfer, and intracorporeal knot-tying tasks from the Fundamentals of Laparoscopic Surgery program. Participants trained to proficiency before enrollment. Task performance was measured at two ambient temperatures, 19 and 26°C (66 and 79°F). Participants were randomly counterbalanced to initial hot or cold exposure before crossing over to the alternate environment. Cognitive stress was measured using the validated Surgical Task Load Index (SURG-TLX). Results No differences in performance of the peg-transfer and intracorporeal knot-tying tasks were seen across ambient conditions. Assessed via use of the six bipolar scales of the SURG-TLX, we found differences in task workload between the hot and cold conditions in the areas of physical demands (hot 10 [3–12], cold 5 [2.5–9], P = .013) and distractions (hot 8 [3.5–15.5], cold 3 [1.5–5.5], P = .001). Participant perception of distraction remained greater in the hot condition on full scoring of the SURG-TLX. Conclusion Increasing ambient temperature to levels advocated for prevention of intraoperative hypothermia does not greatly decrease technical performance in short operative tasks. Surgeons, however, do report increased perceptions of distraction and physical demand. The impact of these findings on performance and outcomes during longer operative procedures remains unclear.

The landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model. The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance. Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.

Objective Workplace bullying is at the forefront of social behavior research, garnering significant media attention. Most of the medical research has addressed bullying of nurses by physicians and demonstrates that patient care and outcomes may suffer. The intent of this study was to determine if general surgery residents are bullied by nurses. Design A survey instrument previously validated (Negative Acts Questionnaire—Revised) to evaluate for workplace bullying was modified to reflect the resident-nurse relationship. After institutional review board approval, the piloted online survey was sent to general surgery program directors to forward to general surgery residents. Demographic data are presented as percentages, and for negative acts, percentages of daily, weekly, and monthly frequencies are combined. Setting Allopathic general surgery residencies in the United States. Participants General surgery residents. Results The response rate was 22.1% (n = 452). Most respondents were men (55%) and had a mean age of 29 years (standard deviation = 7). Although 27.0% of the respondents were interns, the remaining classes were equally represented (12%-18% of responses/class). The respondents were primarily from medium-sized residency programs (45%), in the Midwest (28%), training in university programs (72%), and rotating primarily in a combined private and county hospital that serves both insured and indigent patients (59%). The residents had experienced each of the 22 negative acts (11.5%-82.5%). Work-related bullying occurs more than person-related bullying and physical intimidation. Ignoring of recommendations or orders by nurses occurs on a daily, weekly, or monthly basis for 30.2% of residents (work-related bullying). The most frequent person-related bullying act is ignoring the resident when they approach or reacting in a hostile manner (18.0%), followed by ignoring or excluding the resident (17.1%). Conclusions Workplace bullying of general surgery residents by nurses is prominent. Future research is needed to determine the toll on the resident’s well-being and patient outcomes.

Background Tension pneumothorax can rapidly progress to cardiac arrest and death if not promptly recognized and appropriately treated. We sought to evaluate the effectiveness of traditional didactic slide-based lectures (SBLs) as compared with fresh tissue cadaver-based training (CBT) for placement of needle thoracostomy (NT). Methods Forty randomly selected US Navy corpsmen were recruited to participate from incoming classes of the Navy Trauma Training Center at the LAC + USC Medical Center and were then randomized to one of two NT teaching methods. The following outcomes were compared between the two study arms: (1) time required to perform the procedure, (2) correct placement of the needle, and (3) magnitude of deviation from the correct position. Results During the study period, a total of 40 corpsmen were enrolled, 20 randomized to SBL and 20 to CBT arms. When outcomes were analyzed, time required to NT placement was not different between the two arms. Examination of the location of needle placement revealed marked differences between the two study groups. Only a minority of the SBL group (35%) placed the NT correctly in the second intercostal space. In comparison, the majority of corpsmen assigned to the CBT group demonstrated accurate placement in the second intercostal space (75%). Conclusion In a CBT module, US Navy corpsmen were better trained to place NT accurately than their traditional didactic SBL counterparts. Further studies are indicated to identify the optimal components of effective simulation training for NT and other emergent interventions.

Purpose Because of the automated nature of knowledge, experts tend to omit information when describing a task. A potential solution is cognitive task analysis (CTA). The authors investigated the percentage of knowledge experts omitted when teaching a cricothyrotomy to determine the percentage of additional knowledge gained during a CTA interview. Method Three experts were videotaped teaching a cricothyrotomy in 2010 at the University of Southern California. After transcription, they participated in CTA interviews for the same procedure. Three additional surgeons were recruited to perform a CTA for the procedure, and a "gold standard" task list was created. Transcriptions from the teaching sessions were compared with the task list to identify omitted steps (both "what" and "how" to do). Transcripts from the CTA interviews were compared against the task list to determine the percentage of knowledge articulated by each expert during the initial "free recall" (unprompted) phase of the CTA interview versus the amount of knowledge gained by using CTA elicitation techniques (prompted). Results Experts omitted an average of 71% (10/14) of clinical knowledge steps, 51% (14/27) of action steps, and 73% (3.6/5) of decision steps. For action steps, experts described "how to do it" only 13% (3.6/27) of the time. The average number of steps that were described increased from 44% (20/46) when unprompted to 66% (31/46) when prompted. Conclusions This study supports previous research that experts unintentionally omit knowledge when describing a procedure. CTA is a useful method to extract automated knowledge and augment expert knowledge recall during teaching.

Background The purposes of this study were to develop a comprehensive framework for professionalism in surgery and to determine which attributes are most valued by medical students. Methods A framework for professionalism in surgery, consisting of 11 attribute categories, was developed. All 3rd-year medical students (n = 168) participated in a focus group and completed a questionnaire regarding their perceptions about professionalism. Students' responses were transcribed verbatim, coded, and assigned attribute categories. Results Students rated respect as the most important attribute of professionalism (56%), followed by altruism (21%) and interpersonal skills (8%). Fifty-three percent of students witnessed unprofessional behavior among faculty members while on the surgical clerkship. Of these incidents, 74% were related to respect, 28% to practice improvement, and 1% to altruism. Conclusions Respect was rated as the single most important characteristic of professionalism and was the attribute with the most witnessed violations.

Purpose To create and empirically verify a taxonomy of metrics for assessing surgical technical skills, and to determine which types of metrics, skills, settings, learners, models, and instruments were most commonly reported in the technical skills assessment literature. Method In 2011-2012, the authors used a rational analysis of existing and emerging metrics to create the taxonomy, and used PubMed to conduct a systematic literature review (2001-2011) to test the taxonomy's comprehensiveness and verifiability. Using 202 articles identified from the review, the authors classified metrics according to the taxonomy and coded data concerning their context and use. Frequencies (counts, percentages) were calculated for all variables. Results The taxonomy contained 12 objective and 4 subjective categories. Of 567 metrics identified in the literature, 520 (92%) were classified using the new taxonomy. Process metrics outnumbered outcome metrics by 8:1. The most frequent metrics were "time," "manual techniques" (objective and subjective), "errors," and "procedural steps." Only one new metric, "learning curve," emerged. Assessments of basic motor skills and skills germane to laparoscopic surgery dominated the literature. Novices, beginners, and intermediate learners were the most frequent subjects, and box trainers and virtual reality simulators were the most frequent models used for assessing performance. Conclusions Metrics convey what is valued in human performance. This taxonomy provides a common nomenclature. It may help educators and researchers in procedurally oriented disciplines to use metrics more precisely and consistently. Future assessments should focus more on bedside tasks and open surgical procedures and should include more outcome metrics.

As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum.Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure.A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.90±1.02 and postdissection confidence was 4.20±0.94 (p0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps.A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD.

OBJECTIVE: To understand how teaching behaviors contribute to simulation-based learning, we used a 7-category educational framework to assess the teaching behaviors used in basic skills training. METHODS: Twenty-four first-year cardiothoracic surgery residents and 20 faculty participated in the Boot Camp vessel anastomosis sessions. A portable chest model with synthetic graft and target vessels and a tissue-based porcine model simulated coronary artery anastomosis. After each 2-hour session on days 1 and 2, residents assessed teaching behaviors of faculty using a 20-item questionnaire based on the 5-point Likert scale. After session on day 1, faculty completed a self-assessment questionnaire. At 3 months, faculty completed self-assessment questionnaires regarding teaching behaviors in simulation and clinical settings. Each questionnaire item represents 1 or more teaching categories: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," "evaluation," "feedback," and "self-directed learning." RESULTS: Generally, resident ratings indicated that faculty showed positive teaching behaviors. Faculty self-assessment ratings were all lower (P

Since 2005 there have been very few (if any) individuals trained outside of the United States in congenital surgery. Confining congenital training to only programs in the US has with it some unintended consequences. First, we need to recognize that progress is made around the world and not only in the US. Second, we decrease our opportunity to establish international peers, which leads to less opportunity for multi-institutional and multi-national studies and intellectual isolation. Third, we are in a new age of globalization. Advances in technology, E-learning platforms, transportation, Internet, and other means of telecommunication have all expedited our capabilities to transmit knowledge and have created for us a "global village." I believe that it is time for us to reorganize and extend our programs beyond our own borders. To do this, we must think about creating Exchange Programs within our congenital fellowships. International fellowships will expose our trainees to new practice environments and help to open our minds to new ways of thinking. To be successful, our current board requirements will need to reflect these changes. The programs will need oversight, coordination, time and resources. In addition, and most importantly, we must make sure that it is a good learning experience. It will not be enough to "just send fellows abroad"; the programs must be guided by specific goals and objectives that need to be continually monitored and revised as needed.

Background Since 2010, the Joint Council on Thoracic Surgery Education, Inc (JCTSE) has sponsored an annual "Educate the Educators" (EtE) course. The goal is to provide United States academic cardiothoracic surgeons (CTS) the fundamentals of teaching skills, educational curriculum development, and using education for academic advancement. This report describes the course development and evaluation along with attendee's self-assessment of skills through the first 5 years of the program. Methods The content of this 2½-day course was based on needs assessment surveys of CTS and residents attending annual meetings in 2009. From 2010 to 2014, EtE was offered to all CTS at training programs approved by the Accreditation Council for Graduate Medical Education. Course content was evaluated by using end-of-course evaluation forms. A 5-point Likert scale (1 = poor, 5 = excellent) was used to obtain composite assessment mean scores for the 5 years on course variables, session presentations, and self-assessments. Results With 963 known academic CTS in the United States, 156 (16.3%) have attended, representing 70 of 72 training programs (97%), and 1 international surgeon attended. There were also 7 program coordinators. Ratings of core course contents ranged from 4.4 to 4.8, accompanied with highly complementary comments. Through self-assessment, skills and knowledge in all content areas statistically improved significantly. The effect of the course was evaluated with a follow-up survey in which responders rated the program 4.3 on the usefulness of the information for their career and 3.9 for educational productivity. Conclusions The EtE program offers an excellent opportunity for academic CTS to enhance their teaching skills, develop educational activities, and prepare for academic promotion. With its unique networking and mentorship environment, the EtE program is an important resource in the evolution of cardiothoracic surgical training in the United States.

Residents with performance problems create substantial burden on programs and institutions. Understanding the nature and quality of performance problems can help in learning to address performance problems.We sought to illuminate the effects of resident performance problems and the potential solutions for those problems from the perspectives of people with various roles in health care.We created a composite portrait from several residents who demonstrated a cluster of common performance characteristics and whose chronic or serious maladaptive behavior and response to situations created problems for themselves, for their clinical colleagues, and for faculty of their residency program. The composite was derived from in-depth interviews of program directors and review of resident records. We solicited practitioners from multiple fields to respond to the portrait by answering a series of questions about severity, prognosis, and how and whether one could reliably remediate a person with these performance characteristics. We present their perspectives in a manner borrowed from the New England Journal of Medicine's "Case Records of the Massachusetts General Hospital."We created a composite portrait of a resident whose behavior suggested he felt entitled to benefits his peers were not entitled to. Experts reflecting on his behavior varied in their opinion about the effect the resident would have on the health care system. They suggested approaches to remediation that required substantial time and effort from the faculty.Programs must balance the needs of individual residents to adjust their behaviors with the needs of the health care system and other people within it.

Background The purpose of this study was to determine the incidence and predictors of nonverifiable research publications among applicants to a trauma and surgical critical care fellowship program. Study Design All complete applications submitted to our trauma and surgical critical care fellowship program were prospectively collected for 4 application cycles (2009 to 2012). All publications listed by applicants were tabulated and underwent verification using MEDLINE and direct journal search with verification by a team of professional health sciences librarians. Demographics and academic criteria were compared between applicants with nonverifiable and verifiable publications. Results A total of 100 applicants reported 301 publications. Of those, 20 applicants (20%) listed 32 papers (11%) that could not be verified. These applicants comprised 30% of those with 1 or more peer-reviewed publications. There were no significant differences in sex (male, 55% nonverifiable vs 60% verifiable, p=0.684) or age (34.3 ± 6.6 years vs 34.2 ± 5.0 years, p=0.963). There were no differences with regard to citizenship status (foreign medical graduates, 20% nonverifiable vs 28% verifiable, p=0.495). Applicants with nonverified publications were less likely to be in the military (0% vs 14%, p=0.079), more likely to have presented their work at surgical meetings (80% vs 58%, p=0.064), and to be individuals with 3 or more peer-reviewed publications (55% vs 25%, p=0.009). Conclusions In this analysis of academic integrity, one-fifth of all applicants applying to a trauma and surgical critical care fellowship program and 30% of those with 1 or more peer-reviewed publications had nonverifiable publications listed in their curricula vitae. These applicants were less likely to be in the military, more likely to have presented their work at surgical meetings and to have 3 or more peer-reviewed publications.

Objective A paradigm shift in surgical training has led to national efforts to incorporate simulation-based learning into cardiothoracic residency programs. Our goal was to determine the feasibility of developing a cardiac surgery simulation curriculum using the formal steps of curriculum development. Methods Cardiothoracic surgery residents (n = 6) and faculty (n = 9) evaluated 54 common cardiac surgical procedures to determine their need for simulation. The highest scoring procedures were grouped into similarly themed monthly modules, each with specific learning objectives. Educational tools consisting of inanimate, animate, and cadaveric facilities and a newly created virtual operating room were used for curriculum implementation. Resident satisfaction was evaluated by way of a 5-point Likert scale. Perceived competency (scale of 1–10) and pre–/post–self-confidence (scale of 1–5) scores were collected and analyzed using cumulative mean values and a paired t -test. Results Of the 23 highest scoring procedures (mean score, ≥4.0) on the needs assessment, 21 were used for curriculum development. These procedures were categorized into 12 monthly modules. The simulation curriculum was implemented using the optimal simulation tool available. Resident satisfaction (n = 57) showed an overwhelmingly positive response (mean score, ≥4.7). The perceived competency scores highlighted the procedures residents were uncomfortable performing independently. The pre–/post–self-confidence scores increased throughout the modules, and the differences were statistically significant ( P Conclusions It is feasible to develop and implement a cardiac surgery simulation curriculum using a structured approach. High-fidelity, low-technology tools such as a fresh tissue cadaver laboratory and a virtual operating room could be important adjuncts.

Background Surgical training relies heavily on the ability of expert surgeons to provide complete and accurate descriptions of a complex procedure. However, research from a variety of domains suggests that experts often omit critical information about the judgments, analysis, and decisions they make when solving a difficult problem or performing a complex task. In this study, we compared three methods for capturing surgeons’ descriptions of how to perform the procedure for inserting a femoral artery shunt (unaided free-recall, unaided free-recall with simulation, and cognitive task analysis methods) to determine which method produced more accurate and complete results. Cognitive task analysis was approximately 70% more complete and accurate than free-recall and or free-recall during a simulation of the procedure. Methods Ten expert trauma surgeons at a major urban trauma center were interviewed separately and asked to describe how to perform an emergency shunt procedure. Four surgeons provided an unaided free-recall description of the shunt procedure, five surgeons provided an unaided free-recall description of the procedure using visual aids and surgical instruments (simulation), and one (chosen randomly) was interviewed using cognitive task analysis (CTA) methods. An 11th vascular surgeon approved the final CTA protocol. Results The CTA interview with only one expert surgeon resulted in significantly greater accuracy and completeness of the descriptions compared with the unaided free-recall interviews with multiple expert surgeons. Surgeons in the unaided group omitted nearly 70% of necessary decision steps. In the free-recall group, heavy use of simulation improved surgeons’ completeness when describing the steps of the procedure. Conclusion CTA significantly increases the completeness and accuracy of surgeons’ instructional descriptions of surgical procedures. In addition, simulation during unaided free-recall interviews may improve the completeness of interview data.

Climate variability, particularly the frequency of extreme events, is likely to increase in the coming decades, with poorly understood consequences for terrestrial ecosystems. Hydroclimatic variations of the Medieval Climate Anomaly (MCA) provide a setting for studying ecological responses to recent climate variability at magnitudes and timescales comparable to expectations of coming centuries. We examined forest response to the MCA in the humid western Great Lakes region of North America, using proxy records of vegetation, fire, and hydroclimate. Multi-decadal moisture variability during the MCA was associated with a widespread, episodic decline in Fagus grandifolia (beech) populations. Spatial patterns of drought and forest changes were coherent, with beech declining only in areas where proxy-climate records indicate that severe MCA droughts occurred. The occurrence of widespread, drought-induced ecological changes in the Great Lakes region indicates that ecosystems in humid regions are vulnerable to rapid changes in drought magnitude and frequency.

Background Cognitive task analysis (CTA) methods were used for 2 surgical procedures to determine (1) the extent that experts omitted critical information, (2) the number of experts required to capture the optimalamount of information, and (3) the effectiveness of a CTA-informed curriculum. Methods Six expert physicians for both the central venous catheter placement and open cricothyrotomy were interviewed. The transcripts were coded, corrected, and aggregated as a "gold standard." The information captured for each surgeon was then analyzed against the gold standard. Results Experts omitted an average of 34% of the decisions for the central venous catheter and 77% of the decisions for the Cric. Three to 4 experts were required to capture the optimal amount of information. A significant positive effect on performance ( t [21] = 2.08, P = .050), and self-efficacy ratings ( t [18] = 2.38, P = .029) were found for the CTA-informed curriculum for cricothyrotomy. Conclusions CTA is an effective method to capture expertise in surgery and a valuable component to improve surgical training.

Objective This study explored the effects of a cognitive task analysis (CTA)-informed curriculum to increase surgical skills performance and self-efficacy beliefs for medical students and postgraduate surgical residents learning how to perform an open cricothyrotomy. Methods Third-year medical students and postgraduate year 2 and 3 surgery residents were assigned randomly to either the CTA group (n = 12) or the control group (n = 14). The CTA group learned the open cricothyrotomy procedure using the CTA curriculum. The control group received the traditional curriculum. Results The CTA group outperformed the control group significantly based on a 19-point checklist score (CTA mean score: 17.75, standard deviation [SD] = 2.34; control mean score: 15.14, SD = 2.48; p = 0.006). The CTA group also reported significantly higher self-efficacy scores based on a 140-point self-appraisal inventory (CTA mean score: 126.10, SD = 16.90; control: 110.67, SD = 16.8; p = 0.029). Conclusions The CTA curriculum was effective in increasing the performance and self-efficacy scores for postgraduate surgical residents and medical students performing an open cricothyrotomy.

Background Culture has increasingly appreciated clinical consequences on the patient-physician relationship, and governing bodies of medical education are widely expanding educational programs to train providers in culturally competent care. A recent study demonstrated the value an international surgical mission in modern surgical training, while fulfilling the mandate of educational growth through six core competencies. This report further examines the impact of international volunteerism on surgical residents, and demonstrates that such experiences are particularly suited to education in cultural competency. Methods Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed one year after their experiences. Results One hundred percent strongly agreed that participation in an international surgical mission was a quality educational experience and 94.7% deemed the experience a valuable part of their residency training. In additional to education in each of the ACGME core competencies, results demonstrate valuable training in cultural competence. Conclusions A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. A surgical mission experience should be widely available to surgery residents.

In 2001, the Keck School of Medicine of the University of Southern California initiated a major curriculum reform with fully integrated teaching of the basic sciences.The new curriculum integrated a set of selected clinical cases called the student practice profile (SPP). The SPP cases were designed to (a) define the core target knowledge base and essential clinical experience of all graduating students, (b) to improve the relevance of basic science teaching, and (c) to serve as the overarching organizational structure for the 4-year curriculum.Evaluation data demonstrated that implementation of the SPP project has been moderately successful and students have reported high exposure to the SPP cases and confidence in their ability to diagnose and manage problems. Improvement in teaching the basic sciences in a clinically relevant manner is suggested by a small continued improvement in USMLE scores since the SPP project was fully implemented.The SPP design represents a uniquely successful pathway to curriculum redesign.

Testate amoebae inhabiting Sphagnum peatlands are sensitive indicators of substrate-moisture content. However, ecological data from a range of peatland types is needed to assess their indicator-value in other peatland systems. We examined testate amoeba communities and species–environment relationships at 40 locations within a pocosin of North Carolina. Primary objectives were to provide baseline data on the ecology of testate amoebae in pocosins, compare communities with those of northern peatlands, and assess the potential of using testate amoebae as environmental indicators in these systems. Results indicated that pH, substrate-moisture content, and conductivity were important controls on community composition. Communities that were relatively similar and dissimilar to those of northern peatlands were encountered, and the ecology of species with respect to water-table depth was similar in both peatland types. Cross validation of transfer functions for pH and water-table depth suggests that poc...

Background: Medical school faculty members face increased clinical and academic demands, leaving less time for teaching, curriculum development, and assessment of learners. Description: The Keck School of Medicine has hired a dedicated medical student educator for each required clerkship. The medical student educator assists the clerkship director with clinical teaching, curriculum development, student and program evaluation, and administrative functions. Evaluation: The program has been well received by both students and faculty. Students believe that the medical student educators add value to their clinical experiences and support both their clinical education and personal and professional development. Preliminary data suggest that student performance has improved, and additional measures of quantitative impact are under way. Conclusions: Medical student educators have been a successful addition to the program at the Keck School of Medicine. This strategy should be considered at medical schools that are...

Objective The purpose of the current study was to determine the effectiveness of using cognitive task analysis (CTA) to develop a curriculum to teach the behavioral skills and the cognitive strategies of a percutaneous tracheostomy (PT) placement. Methods Postgraduate 2, 3, and 4 general surgery residents were randomly assigned to either the CTA group (N = 9) or the control group (N = 11). The CTA group was taught percutaneous tracheostomy placement using the CTA curriculum. The control group received the traditional curriculum. Results The CTA group performed significantly higher on the PT procedure at 1 month (CTA: 43.5 ± 3.7, control 35.2 ± 3.9, P = .001) and at 6 months post-instruction (CTA: 39.4 ± 4.2, control: 31.8 ± 5.8, P = .004). In addition, the CTA group demonstrated superior cognitive strategies than the control group (CTA: 25.4 ± 5.3, control: 19.2 ± 2.0, P = .004). Conclusions The use of CTA was effective in improving the cognitive processes and technical skills of performing a PT for surgical residents.

Background The Consortium of American College of Surgeons Accredited Education Institutes (ACS-AEIs) was created to promote patient safety through the use of simulation, develop innovative education and training, advance technologies, identify best practices, and encourage research and collaboration. Methods During the seventh annual meeting of the consortium, leaders from across the consortium who have developed institution-wide simulation centers were invited to participate in a panel to discuss their experiences and the lessons learned. Conclusion These discussions resulted in definition of 5 key areas that need to be addressed effectively to support efforts of the ACS-AEIs.

Simulation is increasingly recognized as an integral aspect of thoracic surgery education. A number of simulators have been introduced to teach component cardiothoracic skills; however, no good model exists for numerous essential skills including redo sternotomy and internal mammary artery takedown. These procedures are often relegated to thoracic surgery residents but have significant negative implications if performed incorrectly. Fresh tissue dissection is recognized as the gold standard for surgical simulation, but the lack of circulating blood volume limits surgical realism. Our aim is to describe the technique of the pressurized cadaver for use in cardiothoracic surgical procedures, focusing on internal mammary artery takedown.

Purpose. The aim of this study was to determine the effectiveness of a focused breast skills workshop for teaching clinical skills to third-year medical students. Methodology. One hundred twenty-four third-year medical students involved in the surgical core clerkship were randomly assigned to two groups. Group 1 (n = 67) participated in a 2-h focused breast skills workshop. Group 2 (n = 57) received traditional ambulatory teaching for a period of 4 h in the breast clinic. The focused workshop consisted of a series of encounters concentrating on mammogram and ultrasound interpretation, physical examination skills, lump detection, and workup of a breast mass. Both groups received a didactic core curriculum lecture from surgical faculty. All students completed a satisfaction rating scale and a subset of students completed a pre- and postencounter self-efficacy rating scale on several aspects of breast skills. Student's t test was used to compare the groups in the areas of clinical skills as evidenced by performance on the breast-specific items on the end of the clerkship Objective Structure Clinical Examination and student satisfaction as evidenced by their response on a satisfaction rating scale. ANCOVA (controlling for preencounter self-efficacy rating) was used to compare the change scores between pre- and postencounter self-efficacy ratings. Results. Students in Group 1 performed significantly higher than the students in Group 2 in the areas of clinical examination skills (t = -2.99, P < 0.05); in sensitivity (t = -5.82, P < 0.05) and specificity (t = -7.27, P < 0.05) in the examination of breast models; and with their satisfaction with the encounter (t = 10.72, P < 0.05). Students in Group 1 also demonstrated a higher level of confidence in their breast skills at the end of the clerkship than students in Group 2 (F = 6.22, P < 0.05). Conclusions. The focused breast skills workshop is more effective than the traditional ambulatory setting for teaching clinical breast examination skills. This setting also demonstrated the development of higher confidence in breast skills than the traditional ambulatory setting.