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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.

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.

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.

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

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.

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.

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.

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...

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.

Testate amoebae are a group of moisture-sensitive, shell-producing protozoa that have been widely used as indicators of changes in mean water-table depth within oligotrophic peatlands. However, short-term environmental variability (i.e., sub-annual) also probably influences community composition. The objective of this study was to assess the potential influence of short-term environmental variability on the composition of testate amoeba communities in Sphagnum-dominated peatlands. Testate amoebae and environmental conditions, including hourly measurements of relative humidity within the upper centimeter of the peatland surface, were examined throughout the 2008 growing season at 72 microsites within 11 peatlands of Pennsylvania and Wisconsin, USA. Relationships among testate amoeba communities, vegetation, depth to water table, pH, and an index of short-term environmental variability (EVI), were examined using nonmetric multidimensional scaling and correlation analysis. Results suggest that EVI influences testate amoeba communities, with some taxa more abundant under highly variable conditions (e.g., Arcella discoides, Difflugia pulex, and Hyalosphenia subflava) and others more abundant when environmental conditions at the peatland surface were relatively stable (e.g., Archerella flavum and Bullinularia indica). The magnitude of environmental variability experienced at the peatland surface appears to be primarily controlled by vegetation composition and density. In particular, sites with dense Sphagnum cover had lower EVI values than sites with loose-growing Sphagnum or vegetation dominated by vascular plants and/or non-Sphagnum bryophytes. Our results suggest that more environmental information may be inferred from testate amoebae than previously recognized. Knowledge of relationships between testate amoebae and short-term environmental variability should lead to more detailed and refined environmental inferences.