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.

Objectives The American Board of Surgery has mandated intraoperative assessment of general surgery residents, yet the time required to train faculty to accurately and reliably complete operating room performance evaluation forms is unknown. Outside of surgical education, frame-of-reference (FOR) training has been shown to be an effective training modality to teach raters the specific performance indicators associated with each point on a rating scale. Little is known, however, about what form and duration of FOR training is needed to accomplish reliable ratings among surgical faculty. Design Two groups of surgical faculty separately underwent either an accelerated 1-hour ( n = 10) or immersive four-hour ( n = 34) FOR faculty development program. Both programs included a formal presentation and a facilitated discussion of sample behaviors for each point on the Zwisch operating room performance rating scale (see DaRosa et al. 8 ). The immersive group additionally participated in a small group exercise that included additional practice. After training, both groups were tested using 10 video clips of trainees at various levels. Responses were scored against expert consensus ratings. The 2-sided Mann-Whitney U test was used to compare between group means. Setting and Participants All trainees were faculty members in the Department of Surgery of a large midwestern private medical school. Results Faculty undergoing the 1-hour FOR training program did not have a statistically different mean correct response rate on the video test when compared with those undergoing the 4-hour training program (88% vs 80%; p=0.07). Conclusions One-hour FOR training sessions are likely sufficient to train surgical faculty to reliably use a simple evaluation instrument for the assessment of intraoperative performance. Additional research is needed to determine how these results generalize to different assessment instruments.

The operating room (OR) remains primarily a master/apprenticeship-based learning environment for surgical residents. Changes in surgical education and health care systems challenge faculty to efficiently and effectively graduate residents truly competent in operations classified by the Surgical Council on Resident Education as "common essential" and "uncommon essential." Program directors are charged with employing resident evaluation systems that yield useful data, yet feasible enough to fit into a busy surgical faculty member's workflow. This paper proposes a simple model for teaching and assessing residents in the operating room to guide faculty and resident interaction in the OR, and designating a resident's earned level of autonomy for a given procedure. The system as proposed is supported by theories associated with motor skill acquisition and learning.

Background Research suggests a benefit from a skills curriculum emphasizing error prevention, identification, and management. Our purpose was to identify common errors committed by trainees during simulated thoracoscopic lobectomy for use in developing an error-based curriculum. Methods Twenty-one residents (postgraduate years 1 to 8) performed a thoracoscopic left upper lobectomy on a previously validated simulator. Videos of the procedure were reviewed in a blinded fashion using a checklist listing 66 possible cognitive and technical errors. Results Of the 21 residents, 15 (71%) self-reported completing the anatomic lobectomy; however, only 7 (33%) had actually divided all of the necessary structures correctly. While dissecting the superior pulmonary vein, 16 residents (76%) made at least one error. The most common (n = 13, 62%) was dissecting individual branches rather than the entire vein. On the bronchus, 14 (67%) made at least one error. Again, the most common (n = 9, 43%) was dissecting branches. During these tasks, cognitive errors were more common than technical errors. While dissecting arterial branches, 18 residents (86%) made at least one error. Technical and cognitive errors occurred with equal frequency during arterial dissection. The most common arterial error was excess tension on the vessel (n = 10, 48%). Conclusions Curriculum developers should identify skill-specific technical and judgment errors to verify the scope of errors typically committed. For a thoracoscopic lobectomy curriculum, emphasis should be placed on correct identification of anatomic landmarks during dissection of the vein and airway and on proper tissue handling technique during arterial dissection.

The growing appreciation of the need to adopt an evidence-based approach to teaching and assessment has led to a demand for faculty who are well versed in best practices in education. Surgeons with interest and expertise in instruction, curriculum development, educational research, and evaluation can have an important impact on the educational mission of a department of surgery. The increased fervor for accountability in education together with the challenges imposed by accreditation agencies and hospitals has made educational leadership responsibilities more time consuming and complex. In response to this, an increasing number of department chairs created Vice Chair for Education positions to support clerkship and program directors and ensure the department's education mission statement is fulfilled.

To identify the career development needs Vice Chair for Education in Surgery Departments (VCESDs).In all, 33 VCESDs were invited to complete an online survey to identify the scope of duties, scholarly activity, job satisfaction, and career development needs.A total of 29/33 (88%) VCESDs responded. Time constraints were the most frequent impediment for MDs vs. PhDs (p0.05). Dominant faculty development needs were conducting educational research (2.0 ± 0.78 for MDs, 1.33 ± 0.76 for PhDs), developing resident selection systems (1.68 ± 0.73), and mentorship programs (1.95 ± 0.77) for MDs, and developing teach the teacher programs (1 ± 0), and program performance evaluation systems (1.33 ± 0.76) for PhDs. The skills deemed to be of greatest importance were ability to communicate effectively (1.27 ± 0.55), resolve personnel conflicts (1.32 ± 0.57), and introduce change (1.41 ± 0.59). PhDs revealed a greater need to learn strategies for dealing with disruptive faculty (1.0 ± 0 vs 2.15 ± 0.87).This information will inform the future career development of VCESDs and will assist Department Chairs who wish to recruit and retain VCESDs.

Operating room teams consist of team members with diverse training backgrounds. In addition to differences in training, each team member has unique and complex decision making paths. As such, team members may function in the same environment largely unaware of their team members' perspectives. The goal of our work was to use a theory-based approach to better understand the complexity of knowledge-based intra-operative decision making. Cognitive task analysis methods were used to extract the knowledge, thought processes, goal structures and critical decisions that provide the foundation for surgical task performance. A triangulated and iterative approach is presented.

The Northwestern Center for Advanced Surgical Education (N-CASE) is an academic training center committed to comprehensive skills learning for a variety of medical and surgical disciplines at Northwestern University affiliated hospital systems (McGaw axis— http://www.feinberg.northwestern.edu/clinical-services/ mcgaw.html). In addition to being a center that promotes excellence in technical skills acquisition and clinical competency, N-CASE has become a nucleus for research in surgical education and advances in minimally invasive surgery techniques. Moreover, N-CASE strives in fostering collaborative efforts among medical disciplines that utilize technical skills and nonmedical disciplines that focus on technology development.

Background The SCORE curriculum defines surgical operations/procedures that residents are expected to be competent with by the end of the residency. Objective The purpose of this study was to conduct a gap analysis to determine how well the operative experience in a general surgery residency program approximates the expectations of the SCORE curriculum, especially regarding those procedures considered essential to general surgical training. Design Setting/Participants: Final ACGME resident operative experience reports of recent Northwestern University general surgery program graduates (n = 15) were compared with the specific procedures and procedure levels (ie, Essential-Common, Essential-Uncommon, Complex) defined in the SCORE curriculum. The average numbers of individual SCORE procedures and procedures per SCORE procedure level performed per resident were summarized using descriptive statistics. Results During their 5 years of training general surgery residents logged a mean of 1025.7 (SD 152.9) primary procedures per resident. We were able to match 87.1% of these ACGME logged procedures with specific procedures identified in the SCORE curriculum. On average, of the Essential-common procedures, 23 (35%) were performed >10 times and 35 (53%) were performed >five times. Conversely, the number of Essential-uncommon and Complex procedures performed >five times were 3 (5%) and 10 (7%), respectively. Several procedures identified in the SCORE curriculum were performed at very low frequency during residency training. Conclusions This experience suggests that leadership at SCORE and the ACGME need to make the curriculum and logging system compatible and that surgical residents need to be better educated with regards to case logging. Despite these issues, important differences appeared to exist between actual resident operative experiences and expectations set by the SCORE curriculum. Based on these finding we advocate that similar gap analyses be performed at other surgical residency training programs to identify discrepancies between program experience and SCORE curriculum expectations.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines a "handoff" as a contemporaneous, interactive process of passing patient-specific information from one caregiver to another for the purpose of ensuring the continuity and safety of patient care. The purpose of this study was to conduct a comprehensive investigation on the determinants of an effective handoff management system. Specifically, we sought to address the following null hypotheses: There is no difference before and after implementation of a new, low-cost, low-tech process for surgery patient handoffs in accuracy of information, completeness, clarity of exact time of patient transfer, and number of tasks appropriately handed off.Baseline description of the handoff process was mapped from 3 direct observation sessions by an efficiency operations team. A focus group with residents, nurses, hospital administrators, and surgeons was held to identify concerns with the baseline process and to identify important features of a handoff system. These data were used to create an electronic survey for residents to indicate level of agreement with importance of various features and qualities of a handoff system. Longitudinal telephone surveys were performed with residents throughout and after the development period to determine the residents' perceptions of the completeness, accuracy, clarity of handoff time, and method of information transfer, as well as the frequency with which residents were expected to perform tasks that should have been performed by outgoing residents. An online survey was sent to residents before and after the new handoff system was implemented to study perceptions of information quality, process operations, clarity of responsibility, and satisfaction with the handoff process. Perceptions were rated on operationally defined scales. All instruments underwent expert review for content validity and clarity of instructions and scale definition appropriateness. A standardized, and partially automated, handoff form was then developed. After a 2-week pilot study, telephone surveys were repeated. Data were analyzed using descriptive statistics, the Student t-test, and multivariate analysis.Compared with baseline, residents reported increased accuracy, as measured by the perceived number of inaccuracies found on sign-out sheets (p = 0.003). Completeness of the information on sign-out sheets also was improved (p = 0.015). Clarity as to the time of transfer of care from outgoing (day team) to incoming (night float) improved (p = 0.0001). The type of rotation (intensive care unit vs non-intensive care unit) did lead to an improvement (confidence interval99%). Across both shifts, the perceived number of inappropriate tasks transferred decreased significantly. Experience (months of training) and type of rotation did not affect these measures.By simplifying and standardizing the handoff instrument, we demonstrated improvements in resident perceptions of accuracy, completeness, and number of tasks transferred. This low-cost, low-tech paradigm may be useful to others.

To identify the learning needs of faculty members who are not perceived by residents as outstanding teachers in the operating room.General surgery residents electronically evaluated each faculty surgeon with whom they had significant contact upon completion of each clinical rotation between July 2005 and October 2006. Evaluation forms requested global ratings (1-5 scale ranging from poor to excellent) in 10 separate teaching-related areas, 1 of which was operating room teaching. Residents also rated faculty on 10 specific operating room teaching behaviors identified during a previous observational study.In total, 134 faculty surgeons were evaluated by 63 residents. Faculty who were evaluated by at least 5 residents (n = 99) were included in the study (mean = 21.9; range, 5-118 evaluations). The ratings of overall operating room teaching (M +/- SD: 4.46 +/- 0.52) correlated significantly (p0.001) with ratings of overall performance (r = 0.80) and each of the 10 teaching behaviors (range, r = 0.65 {confident in role as teacher and surgeon} to r = 0.85 {teaches with enthusiasm}). Stepwise multiple regression analysis (R2 = 0.76, p0.01) identified ratings of the following teaching behaviors as independently significant predictors (p0.05) of global ratings of operating room teaching: allows learners to "feel pathology" (B = 0.38), teaches with enthusiasm (B = 0.31), and remains calm and courteous (B = 0.17).Resident perceptions of operating room teaching by faculty surgeons are strongly associated with overall perceptions of the surgeon and with perceptions of specific teaching behaviors exhibited in the operating room. Regression analysis suggests that approximately 76% of the variability in resident evaluations of operating room teaching may be associated with the extent to which a surgeon demonstrates a positive attitude toward teaching, remains calm and courteous, and provides a "hands on" learning experience. Faculty development efforts aimed at operating room teaching that focus on reinforcing or modifying these behaviors may contribute to improved overall perceptions of faculty by residents.

Background Educational, medicolegal, and financial constraints have pushed surgical residency programs to find alternative methods to operating room teaching for surgical skills training. Several studies have demonstrated that the use of skills laboratories is effective and enhances performance; however, little is known about the facilities available to residents. Study Design A survey was distributed to 40 general surgery program directors who, in an earlier questionnaire, indicated that they had skills laboratory facilities at their institutions. The survey included the following sections: demographics, facilities, administrative infrastructure, curriculum, learners, and opinions/thoughts of program directors. Results Of the 34 program directors that completed the survey, 76% are from a university program. The average facility is 1400 square feet, and most skills laboratories are located in the hospital. Nearly all skills facilities have dry laboratories (90%), and the most common equipment is box trainers (90%). Average start-up costs were $450,000. Sixty-two percent of programs have a skills curriculum for residents. Responders agreed that skills laboratories have a high value and should be part of residency curricula. Conclusions The results of this survey provide a preliminary view of skills laboratories. There is variation in the size, location, and availability of simulators in skills laboratory facilities. Variations also exist in types of curricula formats, subspecialties who make use of the laboratory, and some administrative approaches. There is strong agreement among respondents that skills laboratories are a necessary and valuable component of residency education. Results also indicated concerns for recruiting faculty to teach in the skills laboratory, securing ongoing funding, and implementing a skills laboratory curriculum.

THE WORD CURRICULUM has its origins in the running and chariot tracks of Greece. It was, literally, a course. 1 As time and society have evolved, educators’ views of the meaning of curriculum have changed. Varying philosophic positions on the role of education in society and disparate assumptions about what helps people learn shaped educators’ views about curriculum and how they defined it. The purpose of this paper is to describe two popular classifications of curriculum, briefly explain the educational theory associated with each, and review their implications for teachers and learners. The test of good theory is whether it can guide practice. In reverse, good practice is based on theory. A framework for thinking about curriculum theory and practice is important in light of current efforts to redesign curriculum for surgical residency education. Various taxonomies exist for categorizing curriculum theories, theorists, and models. 1 For the

Background The purpose of the study is to describe the academic preparation, scope of duties, and scholarly activity of professional educators in surgery departments. Methods Educators with doctoral degrees employed as full-time faculty in surgery departments were surveyed to determine terms of employment, academic preparation, scope of duties, and job satisfaction. Results Twelve of 13 educators responded and participated in the study. Educators spent, on average, 22% of their time on research activities, 33% on administrative responsibilities, 13% on teaching, 13% counseling students and residents, and 7% writing grants. They spent approximately 34% of their time with surgical faculty, 19% with residents/fellows, and 14% with medical students. Educators' contributions to surgery departments included improvements in assessment and evaluation, educational conferences, recruitment, and research productivity. Conclusions Professional educators provide support needed to meet the growing demands and requirements of surgical education. Study findings may inform those interested in recruiting a professional educator to their faculty.

Students consistently identified inadequate feedback as a deficiency in our third-year clerkship.We asked students to solicit one faculty and one resident every 2 weeks for written feedback on a "feedback prescription pad." Each prescription requested four comments: two things the student did well and two things the student needs to improve. Students rated feedback using a five-point scale. A three-point categorization scheme was employed to assess the quality of feedback.Students' rating of feedback improved significantly compared with a previous time period (3.5 +/- 1.2 versus 2.6 +/- 1.2, P0.01). Interrater reliability of our categorization scheme was high (kappaor =0.75, P0.01) and demonstrated that only 10% of comments were specific enough to qualify as effective feedback.Feedback prescription pads were a simple method to facilitate feedback. Although students appreciated feedback, most feedback was inadequate. Faculty development programs to enhance student feedback should be a priority of clinical medical education.

This study was designed to evaluate the impact of changes made to our morbidity and mortality (MM) conference.A 23-item survey using corresponding Likert-type scales was created. Faculty and residents were asked to anonymously complete the surveys in June 1999. Based on this information, specific modifications were made to the conference. The same survey was administered to faculty and residents in the Fall of 2000. Analysis was performed using Student t tests.Postsurvey findings showed residents felt eight components improved significantly (P0.05). Faculty noted nonsignificant improvement in nine survey items and decline in nine items (five unchanged).Changes in content and structure made to enhance our MM conference's educational value resulted in significant improvements as perceived by the surgical residents. Interestingly, these changes had only minimal impact on faculty perceptions.

Purpose The purpose of this study was to determine the extent to which first-year surgical residents are prepared to obtain informed consent from patients. The study was designed to answer the following research questions: 1) Are first-year residents who are asked to obtain informed consent sufficiently knowledgeable about the risks, benefits, and alternatives of the procedures? 2) Can first-year residents accurately answer the questions patients may pose about these procedures? Methods First-year residents (n = 18) were asked to list the risks, benefits, and alternatives for open inguinal hernia repair, laparoscopic cholecystectomy, total thyroidectomy, esophagogastrectomy, and abdominal aortic aneurysm repair, assuming the procedures were elective on otherwise healthy individuals. Residents were also asked to answer questions that patients may pose about each of the procedures. The basic minimum risks, benefits, and alternatives to be listed and answers to the questions were validated by asking faculty representing general (n = 6) and vascular (n = 3) surgery to complete the questionnaires. Results Few residents were able to correctly list all risks, benefits, and alternatives of any of the procedures. Less than one-half of the questions that patients may ask about the procedures were correctly answered. Conclusions Even though first-year residents are commonly obtaining consent for surgical procedures, many are unable to provide patients with the correct descriptions of the risks, benefits, and alternatives. Nor were they able to correctly answer common questions. Surgical faculty must take more time to educate first-year residents on the appropriate issues in informed consent for the procedures being performed.

Background: Surgical education peer-reviewed publications have markedly increased over the last decade. The purpose of this study was to review the surgical education literature published over the last 10 years and address the following questions: What subjects in surgical education tend to be studied? What are the most to least commonly employed research designs and statistics? Has there been a change in how research data are collected? Where are these studies published? Methods: A literature search encompassing surgical education papers published between January 1988 and August 1998 was performed. Four investigators coded qualifying abstracts on journal type, subject of research, data collection methods, research design, and statistics. Each investigator was asked to code 10 articles at the start of the study to assess interrater reliability. Results: A total of 420 abstracts were evaluated. Interrater reliability yielded percent agreements ranging from 82% to 96%. Curriculum and teaching were the most frequent topics studied (40%), followed by assessment (23%) and program evaluation (18%). Most research designs used were descriptive (41%). Experimental design has progressively increased from 2% in 1988–89 to 16% in 1998. A total of 551 statistical methods were accounted for in the 420 abstracts. The most common statistical analyses used were descriptive statistics (32%). The predominant mode of data collection was through testing or direct observations (34%). Survey instruments followed closely as a popular data collection method at 27%.The majority of papers were published in peer-reviewed surgical journals (64%),followed by medical education journals (22%) and “other” journals (14%). Conclusions: An analysis of the surgical education literature demonstrates the growing emphasis on the use of educational research to explore relevant issues and problems. Descriptive research is most popular, with an increasing trend in experimental research. Publication of educational research in peer-reviewed surgical journals is becoming more popular. This study informs those interested in the surgical education research literature of current trends, and what they need to know for a more critical appraisal of this body of literature.

Introduction: This study sought to develop and evaluate a medical ethics curriculum designed specifically for surgical residents. Methods: The learning needs of surgical residents relevant to ethics were determined by using a structured literature review and synthesis strategy. We identified 5 primary areas of importance for ethics education for surgical residents: withdrawing and withholding treatment, advance directives, do-not-resuscitate orders, informed consent, and communicating bad news. Learning objectives were developed, and teaching plans were designed for four 90-minute interactive teaching episodes on the basis of adult learning principles. We surveyed residents using a published survey instrument modified for surgery to identify residents' beliefs about the usefulness of ethics training, confidence in addressing ethical issues, and factual knowledge of ethics questions. Results: Twenty surgical residents at a single institution completed the pretest and posttest close-ended surveys. Results showed that although 88% had formal ethics exposure in medical school, 93% considered ethics education at the resident level to be a “very important” or “important” topic. Residents' confidence in addressing ethical issues showed statistically significant improvement between pretest and posttest surveys for 13 of 23 items. There were no statistically significant linear relationships between postgraduate year of residency and the pretest confidence items or the number of correct responses on the pretest multiple-choice items. Conclusions: Despite the prevalence of ethics education during medical school, surgical residents welcome formal instruction on numerous ethical issues pertinent to surgical practice. A focused curriculum can be developed that has a measurable impact on residents' confidence in addressing ethical issues. (Surgery 1999;126:701-7.)

Less than a decade ago, when a patient entered the hospital for an operation, they were prepared, operated on, and convalescing all under the same roof. Residents were exposed to patients throughout their care. Today, the large shift of inpatient health care to the outpatient setting raises concerns on how we will adequately expose residents to the full spectrum of patient care, especially in the perioperative setting. To prepare residents for these new approaches to practice, we can devise new instructional interventions and reevaluate the organizational structure of the traditional residency. This paper outlines the causes leading to shortened perioperative stays, discusses the impact on surgical residency education, and finally proposes solutions and their implementation to maintain excellence in residency education.

Background: The specific surgical knowledge and skills students learn during surgical rotations are reconsidered in light of recent changes in medical school curricula. The purpose of this study was to determine the priorities of a surgical curriculum based on input from three groups: surgical faculty (SF), primary care faculty (PCF), and community-based, practicing primary care physicians (PCP). Methods: A questionnaire was developed in which SF (n = 54), PCF (n = 85), and PCP (n = 876) were asked to rank the importance of 145 areas of knowledge and 48 areas of clinical skills on a 5-point Likert-type scale. Responses were rank ordered by the mean of importance ratings for each group. Differences among groups were evaluated using ANOVA. Results: Response rates were best for faculty (100% SF, 88% PCF, 61% PCP). All three groups considered general surgery related topics and general skills very important. Primary care physicians and PCF consistently ranked otolaryngology, ophthalmology, and orthopedic topics and skills higher than did SF. Surgery faculty ranked invasive surgical procedures higher than did PCP while PCP ranked orthopedic procedural skills more highly. Conclusions: There is significant overlap among physicians about what medical students should learn during a surgical rotation. Differences between groups centered on surgical subspecialty knowledge and clinical skills. These results provide a broad perspective about required subjects for a core surgical clerkship curriculum, which should include surgical subspecialty training.

Background: The Objective Structured Assessment of Technical Skill (OSATS) is a multistation performance-based examination that assesses the technical skills of surgery residents. This study explores the implementation issues involved in remote administration of the OSATS focusing on feasibility and the psychometric properties of the examination. Methods: An eight-station OSATS was administered to surgical residents in Los Angeles and Chicago. The University of Toronto and the local institutions shared responsibility for organization and administration of the examination. Results: There was good reliability for both the checklist (α = 0.68 for LA, 0.73 for Chicago) and global rating forms (α = 0.82 for both sites). Both iterations also showed evidence of construct validity, with a significant effect of training year for the checklist and global rating forms at both sites (analysis of variance: F = 8.66 to 19.93, P

The purpose of this study was to determine if objective performance measures from a simulated patient practical examination were related to faculty subjective assessments of surgery students' performance. Another purpose was to determine if those students performing well on a simulated patient practical examination were the same students awarded honor ratings by faculty. Faculty ratings of students (n = 72) on history taking ability, physical exam skills, problem identification, use of investigations, problem integration, patient management, and patient relations skills were correlated with objective measures on these same criteria achieved on a practical exam employing three simulated patient cases. Correlations were also calculated to study the relationship between practical exam scores and honor rating recipients. Results indicated significant relationships between faculty subjective ratings and practical exam outcomes on all practical examination skills except physical exam skills and patient management skills. Findings also indicated the performance of honor students on the practical examination was significantly better than non-honor students on two skills: history-taking and patient relations. The implications of these research findings are discussed.