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Objective: To collaboratively develop a hybrid virtual curriculum for a medical school surgery clerkship within an emerging medical university in Vietnam., Design: A hybrid virtual surgery clerkship curriculum was collaboratively developed by Vietnamese and American surgeons as part of an international partnership between their respective universities. A set of 25 virtual lectures with associated materials were created and deployed in tandem with live, in-person review and skills sessions. Student quantitative and qualitative evaluation methods were developed and deployed to allow continuous iteration. A 6-month course was deployed to develop surgical faculty into effective teachers., Setting: The curriculum was deployed at VinUniversity College of Health Sciences, the youngest medical university in Vietnam. It was developed in collaboration with the University of Pennsylvania Perelman School of Medicine. Each cohort of 12 students in the surgical clerkship will participate in the curriculum., Conclusions: The development of this hybrid surgical clerkship in Vietnam leveraged local resources and expertise with those available remotely. Lessons learned are directly applicable to future collaborative curriculum development efforts at other emerging medical schools., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Our aim was to assess how ChatGPT compares to Google search in assisting medical students during their surgery clerkships., Design: We conducted a crossover study where participants were asked to complete 2 standardized assessments on different general surgery topics before and after they used either Google search or ChatGPT., Setting: The study was conducted at the Perelman School of Medicine at the University of Pennsylvania (PSOM) in Philadelphia, Pennsylvania., Participants: 19 third-year medical students participated in our study., Results: The baseline (preintervention) performance of participants on both quizzes did not differ between the Google search and ChatGPT groups (p = 0.728). Students overall performed better postintervention and the difference in test scores was statistically significant for both the Google group (p < 0.001) and the ChatGPT group (p = 0.01). The mean percent increase in test scores pre- and postintervention was higher in the Google group at 11% vs. 10% in the ChatGPT group, but this difference was not statistically significant (p = 0.87). Similarly, there was no statistically significant difference in postintervention scores on both assessments between the 2 groups (p = 0.508). Postassessment surveys revealed that all students (100%) have known about ChatGPT before, and 47% have previously used it for various purposes. On a scale of 1 to 10 with 1 being the lowest and 10 being the highest, the feasibility of ChatGPT and its usefulness in finding answers were rated as 8.4 and 6.6 on average, respectively. When asked to rate the likelihood of using ChatGPT in their surgery rotation, the answers ranged between 1 and 3 ("Unlikely" 47%), 4 to 6 ("intermediate" 26%), and 7 to 10 ("likely" 26%)., Conclusion: Our results show that even though ChatGPT was comparable to Google search in finding answers pertaining to surgery questions, many students were reluctant to use ChatGPT for learning purposes during their surgery clerkship., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Stereotypes of surgeons are pervasive and play a role in medical students' decisions about pursuing a surgical career. This study aimed to determine: (1) how medical students' perceptions of surgery and surgeons changed following exposure to surgery during clerkship rotations; and (2) if gender and racial/ethnic identification played a role in this process., Design, Setting, and Participants: In this mixed-method study, clerkship students at one U.S. medical school were asked to anonymously contribute words and phrases that they associated with surgery to an online "word cloud" at the beginning and end of their 12-week surgery clerkship. In addition, an end-of-year, anonymous survey of their perceptions was administered and analyzed using a Grounded Theory approach., Results: Of 154 students invited to complete the online survey, analysis of 24 completed surveys suggested that students believe surgical culture to be toxic, with unfriendly attitudes, strict hierarchy, and lack of work-life balance. Analysis of 678 Word Cloud responses, however, indicated that the frequency of complimentary responses increased following surgery clerkships (25% vs 36%; z = -3.26; p = 0.001), while the proportion of responses describing surgery/surgeons as male-dominated, egotistical, and scary decreased (5% vs 1%, z = 2.86, p = 0.004; 9% vs 4%, z = 2.78, p = 0.005; 3% vs 0.3%, z = 2.56, p = 0.011, respectively). The association between surgeons and being White disappeared entirely. Female students were more likely than male students to state that their perceptions did not change following exposure (40% vs 0%; z = 2.19; p = 0.029)., Conclusions: With exposure to surgery, students' preconceived notions may be positively influenced. However, students continue to hold negative perceptions, and this effect may be stratified by gender identification. Institutions should work to address these perceptions in pre-clerkship years to attract a more diverse pool of future surgeons., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the use of a professionally trained, resilience coach for surgical interns., Design: Mixed-methods study with pre- and postcoaching quantitative surveys measuring burnout and resilience factors and semistructured interviews., Setting: General, Vascular, Cardiac, Plastic, and Urologic Surgery residencies at a tertiary academic center., Participants: Categorical and preliminary interns (N = 25) participated in a year-long, 8-session resilience coaching program for the academic year 2018 to 2019., Results: Program participants included 17 (68%) men and 8 (32%) women. The precoaching survey administered to interns before the start of the program identified 60% at risk of burnout as measured by the Abbreviated Maslach Burnout Inventory. The mean (standard deviation) Brief Resilience Scale score was 3.8 (0.8), with a trend toward a higher score (greater resilience) among men compared to women (4.1 [0.7] vs 3.4 [1.0], p = 0.10). Following the completion of the coaching program, the mean (standard deviation) Brief Resilience Scale score increased significantly from 3.8 [0.8] to 4.2 [0.7] p = 0.002). There were no changes in other parameters measuring burnout, satisfaction with life, or positive/negative affect. In semistructured interviews (N = 16/25 participants), most interns believed the coaching experience provided useful skills, but expressed concern about the durability of a 1-year intervention. Additionally, leadership-driven wellness at work, including optimizing team dynamics and purpose-driven engagement, were emphasized., Conclusions: About 60% of new interns at our institution were at risk of burnout. The coaching program was viewed positively and was effective in improving resilience. While this intervention was a useful first step, it should be incorporated into a longitudinal wellness program for the duration of surgical training., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The ability to use electronic medical records (EMR) is an essential skill for surgical residents. However, frustration and anxiety surrounding EMR tasks may detract from clinical performance. We created a series of brief, 1-3 minutes "how to" videos demonstrating 7 key perioperative EMR tasks: booking OR cases, placing preprocedure orders, ordering negative-pressure wound dressing supplies, updating day-of-surgery history and physical notes, writing brief operative notes, discharging patients from the postanesthesia care unit, and checking vital signs. Additionally, we used "Cutting Insights"-a locally developed responsive mobile application for surgical trainee education-as a platform for providing interns with easy access to these videos. We hypothesized that exposure to these videos would lead to increased resident efficiency and confidence in performing essential perioperative tasks, ultimately leading to improved clinical performance., Methods: Eleven surgery interns participated in this initiative. Before watching the "how to" videos, each intern was timed performing the aforementioned 7 key perioperative EMR tasks. They also underwent a simulated perioperative emergency requiring the performance of 3 of these EMR tasks in conjunction with 5 other required interventions (including notifying the chief resident, the anesthesia team, and the OR coordinator; and ordering fluid boluses, appropriate laboratories, and blood products). These simulations were scored on a scale from 0 to 8. The interns were then directed to watch the videos. Two days later, their times for performing the 7 tasks and their scores for a similar perioperative emergency simulation were once again recorded. Before and after watching the videos, participants were surveyed to assess their confidence in performing each EMR task using a 5-point Likert scale. We also elicited their opinions of the videos and web-based mobile application using a 5-point scale. Statistical analyses to assess for statistical significance (p ≤ 0.05) were conducted using paired t-test for parametric variables and a Wilcoxon matched-pair test for nonparametric variables., Setting: Hospital of the University of Pennsylvania, Philadelphia, PA (a quaternary teaching hospital within the University of Pennsylvania Health System)., Participants: Eleven out of 15 interns (12 entered and 11 completed the study) from our categorical and preliminary general surgery residency programs during the 2016 academic year., Results: Before exposure to the brief "how to" videos, 6 of 11 interns were unable to complete all 7 EMR tasks; after exposure, all 11 interns were able to complete all 7 EMR tasks. Moreover, interns' times for each task improved following exposure. Interns self-reported improved confidence in booking an OR case (4 ± 0.9 vs. 4.7 ± 0.6, p = 0.05), ordering negative-pressure wound therapy supplies (3.1 ± 1.6 vs. 4.5 ± 0.7, p < 0.05), writing a brief operative note (3.7 ± 1.2 vs. 4.6 ± 0.7, p = 0.05), discharging patients from the postanesthesia care unit (3.3 ± 1.0 vs. 4.4 ± 0.8, p < 0.05), checking vital signs (2.5 ± 1.4 vs. 4.5 ± 0.8, p ≤ 0.01), and performing necessary EMR tasks during an emergency situation (2.4 ± 0.8 vs. 4.6 ± 0.7, p ≤ 0.0001). Participants also demonstrated a significant improvement in average clinical score on the emergency simulations (5.2 ± 1.7 vs. 6.6 ± 0.9, p < 0.05). Interns' opinions of the videos and the mobile phone application were favorable., Conclusions: In our group of 11 surgery interns, exposure to a series of short "how to" videos led to increased confidence and shortened times in performing 7 essential EMR tasks. Additionally, during a simulated perioperative emergency, EMR tasks were performed significantly faster. Clinical performance also improved significantly following exposure to the videos. This just-in-time educational intervention could improve workflow efficiency and clinical performance, both of which may ultimately enhance perioperative patient safety., (Copyright © 2017. Published by Elsevier Inc.)

Objective: The American College of Surgeons/Association of Program Directors in Surgery is a comprehensive, simulation-based curriculum for General Surgery residents which exists in 3 phases. While phases 1 and 2 deal with core skills and advanced procedures respectively, phase 3 targets team-based skills. To date, the 3rd phase of this curriculum has not seen wide scale implementation. This is a pilot study to verify the feasibility of implementing the phase 3 curriculum in the in-situ setting., Design: In our initial attempt to implement Phase 3 at our institution, we chose to perform the training in an in-situ setting within an operating room (OR) at our main hospital, despite our having a separate simulation center. By choosing the in-situ OR environment for this training we were able to minimize concerns regarding resident and faculty availability and able to successfully complete 8 separate sessions during the academic year. During 7 sessions, 2 separate scenarios were performed while a single scenario was performed in 1 session. This single session was excluded from analysis, leaving a total of 14 scenarios to evaluate. The unique scenarios included laparoscopic crisis, postoperative myocardial infarction, anaphylaxis, and postoperative hypotension. All sessions were audiovisually recorded. In order to evaluate the effect of the training, the videos were viewed by 3 independent reviewers and all surgery, anesthesia and nursing participants were rated using the NOTECHs II scale. Degree of inter-rater agreement was established. The difference between the first and second simulations on the same day was then assessed. In addition, participant opinions of the simulations were assessed through electronic surveys following the training., Setting: Tertiary Care University Hospital., Participants: We performed a total of 8 sessions, for a total of 15 scenarios. Eight surgery residents at the postgraduate year 1 (PGY1)-PGY3 level, 16 anesthesia residents at the PGY3-PGY4 level, 16 nurses and 13 ancillary staff participated., Results: From the first to the second scenario, the total team NOTECHs II score increased from 69.4 ± 1.4 to 77.3 ± 0.5 (p = 0.007). The NOTECHs II scores for each subteam also improved, from 24.2 ± 0.6 to 26.4 ± 0.5 (p = 0.007) for surgery residents, 23.7 ± 0.9 to 26.7 ± 0.4 (p = 0.03) for anesthesia, and 21.6 ± 0.3 to 24.3 ± 0.5 (p = 0.01) for nursing. The inter-rater reliability as measured by Kendall's coefficient of concordance was modest for the whole team score. Most of the participant responses were either favorable or strongly favorable., Conclusion: The in-situ OR environment is both a unique and effective setting to perform team-based training. Furthermore, training in the in-situ setting minimizes or removes many of the logistic issues involved in designing and implementing team-based training curricula for general surgery residency programs. However, we found that administrative and departmental (surgery, anesthesia, and nursing) "buy in" as well as protected faculty time for education were all necessary for in-situ training to be successful. NOTECHs II is an established scale for the evaluation of teams in this simulation setting and appears to be a valid tool based on the results of this study. However, further assessment of inter-rater reliability as well as improved training of evaluators are necessary to determine if inter-rater reliability can improve., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery., Design: 9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training., Setting: Tertiary care, university based teaching institution., Participants: A total of 9 general surgery residents at the intern level., Results: The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001)., Conclusion: Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Fibrocystic Breast Disease (FBD) or Fibrocystic change (FC) affects about 60% of women at some time during their life. Although usually benign, it is often associated with pain and tenderness (mastalgia). The synthetic steroid danazol has been shown to be effective in reducing the pain associated with FBD, but the cellular and molecular mechanisms for its action have not been elucidated. We investigated the hypothesis that danazol acts by affecting energy metabolism. Effects of danazol on Mcf10A cells homeostasis, including mechanisms of oxidative phosphorylation, cytosolic calcium signaling and oxidative stress, were assessed by high-resolution respirometry and flow cytometry. In addition to fast physiological responses the associated genomic modulations were evaluated by Affimetrix microarray analysis. The alterations of mitochondria membrane potential and respiratory activity, downregulation of energy metabolism transcripts result in suppression of energy homeostasis and arrest of Mcf10A cells growth. The data obtained in this study impacts the recognition of direct control of mitochondria by cellular mechanisms associated with altered energy metabolism genes governing the breast tissue susceptibility and response to medication by danazol., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To systematically review the literature surrounding operating room-based in situ training in surgery., Methods: A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible., Results: The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics., Conclusions: Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to understand the effect of a team-based surgical skills intervention on the technical and nontechnical skills of surgery residents., Design: This was a prospective cohort study with pretesting or posttesting. We designed basic tasks for the assessment and learning of nontechnical skills in the operating room (OR). A total of 15 postgraduate year 1 residents performed an open gastrojejunostomy in a simulated OR setting (pretest), followed by training in the 3 team-based tasks designed to teach communication and teamwork, followed by performance of a gastrojejunostomy in the simulated OR (posttest)., Setting: Tertiary care, university-based teaching institution., Participants: A total of 15 general surgery residents at the intern level., Results: The mean nontechnical skills for surgeons (NOTSS) score improved postteam task training (10.04 ± 0.33 vs. 12.14 ± 1.33). There was a concomitant increase in the objective structured assessment of technical skills (OSATS) score (18.56 ± 0.86 vs. 22.86 ± 0.15, p = 0.006). The percentage increases in OSATS and NOTSS score for each resident was similar (19.49 ± 4.8 % for NOTSS vs. 21.22 ± 4.92 % for OSATS, p = 0.502)., Conclusion: Nontechnical skills positively correlate with the technical performance of a surgeon. Simple, easily designed tasks can be used to improve NOTSS in the OR. These team tasks and development of curricula based on them can be used to explicitly address one of the most important components of ACGME core competencies for surgical residents, namely interpersonal skills and communication., (Copyright © 2016. Published by Elsevier Inc.)

The determinants of HIV-1-associated lymphadenopathy are poorly understood. We hypothesized that lymphocytes could be sequestered in the HIV-1+ lymph node (LN) through impairments in sphingosine-1-phosphate (S1P) responsiveness. To test this hypothesis, we developed novel assays for S1P-induced Akt phosphorylation and actin polymerization. In the HIV-1+ LN, naïve CD4 T cells and central memory CD4 and CD8 T cells had impaired Akt phosphorylation in response to S1P, whereas actin polymerization responses to S1P were impaired dramatically in all LN maturation subsets. These defects were improved with antiretroviral therapy. LN T cells expressing CD69 were unable to respond to S1P in either assay, yet impaired S1P responses were also seen in HIV-1+ LN T cells lacking CD69 expression. Microbial elements, HIV-1, and interferon α - putative drivers of HIV-1 associated immune activation all tended to increase CD69 expression and reduce T-cell responses to S1P in vitro. Impairment in T-cell egress from lymph nodes through decreased S1P responsiveness may contribute to HIV-1-associated LN enlargement and to immune dysregulation in a key organ of immune homeostasis.

A methodology for modeling the needle and soft-tissue interaction during needle insertion is presented. The approach consists of the measurement of needle and tissue motion using a dual C-arm fluoroscopy system. Our dual C-arm fluoroscopy setup allows real time 3-D extraction of the displacement of implanted fiducials in the soft tissue during needle insertion to obtain the necessary parameters for accurate modeling of needle and soft-tissue interactions. The needle and implanted markers in the tissue are tracked during the insertion and withdrawal of the needle at speeds of 1.016 mm/s, 12.7 mm/s and 25.4 mm/s. Both image and force data are utilized to determine important parameters such as the approximate cutting force, puncture force, the local effective modulus (LEM) during puncture, and the relaxation of tissue. We have also validated the LEM computed from our finite element model with arbitrary needle puncture tasks. Based on these measurements, we developed a model for needle insertion and withdrawal that can be used to generate a 1-DOF force versus position profile that can be experienced by a user operating a haptic device. This profile was implemented on a 7-DOf haptic device designed in our laboratory.