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

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

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

Purpose 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.

Background As new technology is developed and scientific evidence demonstrates strategies to improve the quality of care, it is essential that surgeons keep current with their skills. Rural surgeons need efficient and targeted continuing medical education that matches their broader scope of practice. Developing such a program begins with an assessment of the learning needs of the rural surgeon. The aim of this study was to assess the learning needs considered most important to surgeons practicing in rural areas. Study Design A needs assessment questionnaire was administered to surgeons practicing in rural areas. An additional gap analysis questionnaire was administered to registrants of a skills course for rural surgeons. Results Seventy-one needs assessment questionnaires were completed. The self-reported procedures most commonly performed included laparoscopic cholecystectomy (n = 44), hernia repair (n = 42), endoscopy (n = 43), breast surgery (n = 23), appendectomy (n = 20), and colon resection (n = 18). Respondents indicated that they would most like to learn more skills related to laparoscopic colon resection (n = 16), laparoscopic antireflux procedures (n = 6), laparoscopic common bile duct exploration/ERCP (n = 5), colonoscopy/advanced techniques and esophagogastroscopy (n = 4), and breast surgery (n = 4). Ultrasound, hand surgery, and leadership and communication were additional topics rated as useful by the respondents. Skills course participants indicated varying levels of experience and confidence with breast ultrasound, ultrasound for central line insertion, hand injury, and facial soft tissue injury. Conclusions Our results demonstrated that surgeons practicing in rural areas have a strong interest in acquiring additional skills in a variety of general and subspecialty surgical procedures. The information obtained in this study may be used to guide curriculum development of further postgraduate skills courses targeted to rural surgeons.

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 primary goal of a residency program is to prepare trainees for unsupervised care. Duty hour restrictions imposed throughout the prior decade require that residents work significantly fewer hours. Moreover, various stakeholders (e.g. the hospital, mentors, other residents, educators, and patients) require them to prioritize very different activities, often conflicting with their learning goals. Surgical residents' learning goals include providing continuity throughout a patient's pre-, peri-, and post-operative care as well as achieving sufficient surgical experience levels in various procedure types and participating in various formal educational activities, among other things. To complicate matters, senior residents often compete with other residents for surgical experience. This paper features experiments using an optimization model and a real dataset. The experiments test the viability of achieving the above goals at a major academic center using existing models of delivering medical education and training to surgical residents. It develops a detailed multi-objective, two-stage stochastic optimization model with anticipatory capabilities solved over a rolling time horizon. A novel feature of the models is the incorporation of learning curve theory in the objection function. Using a deterministic version of the model, we identify bounds on the achievement of learning goals under existing training paradigms. The computational results highlight the structural problems in the current surgical resident educational system. These results further corroborate earlier findings and suggest an educational system redesign is necessary for surgical medical residents.

Objectives In line with a recent report entitled Effective Use of Educational Technology in Medical Education from the Association of American Medical Colleges Institute for Improving Medical Education (AAMC-IME), this study examined whether revising a medical lecture based on evidence-based principles of multimedia design would lead to improved long-term transfer and retention in Year 3 medical students. A previous study yielded positive effects on an immediate retention test, but did not investigate long-term effects. Methods In a pre-test/post-test control design, a cohort of 37 Year 3 medical students at a private, midwestern medical school received a bullet point-based PowerPoint™ lecture on shock developed by the instructor as part of their core curriculum (the traditional condition group). Another cohort of 43 similar medical students received a lecture covering identical content using slides redesigned according to Mayer’s evidence-based principles of multimedia design (the modified condition group). Results Findings showed that the modified condition group significantly outscored the traditional condition group on delayed tests of transfer given 1 week (d = 0.83) and 4 weeks (d = 1.17) after instruction, and on delayed tests of retention given 1 week (d = 0.83) and 4 weeks (d = 0.79) after instruction. The modified condition group also significantly outperformed the traditional condition group on immediate tests of retention (d = 1.49) and transfer (d = 0.76). Conclusions This study provides the first evidence that applying multimedia design principles to an actual medical lecture has significant effects on measures of learner understanding (i.e. long-term transfer and long-term retention). This work reinforces the need to apply the science of learning and instruction in medical education.

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.

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

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.

OBJECTIVE Because continuity of care (CC) is a necessary component of resident education, this analysis was done to understand what keeps CC between residents and patients low and how it can be most effectively improved. BACKGROUND Many authors lament low CC between residents and patients, especially in the era of duty hour regulations. Some have tried lengthening rotations, some have tried increasing clinic attendance, and some have argued for various training models. Little detailed analysis has been done to identify root causes of low CC or ways to improve it. METHODS Two months of charts were reviewed to estimate baseline CC on a vascular surgery rotation. Probability theory and engineering simulations were used to determine whether CC can be enhanced by (a) lengthening rotations, (b) altering observed logistical patterns, (c) using a "resident return" model where residents are able to see patients postoperatively even if moved to a different rotation, or (d) employing an apprenticeship model. RESULTS Baseline analysis showed residents had 0% CC given 131 opportunities to do so. Probability analysis and the simulation outcomes suggest that rotation length plays a minor role in achieving CC. Logistical changes showed some improvement in CC, but not as much as using an apprenticeship rotation model. CONCLUSIONS The limitations placed on CC by rotation duration are real, but lengthening the rotation does not meaningfully resolve the gap between acceptable CC levels and actual levels. Although CC can be enhanced with longer rotations if coupled with the use of the resident return model, the greater barrier to CC is the logistical patterns such as where residents spend time, how cases are assigned, and the lack of an alert system to inform residents about returning postoperative patients. The apprenticeship model enables residents to achieve CC closer to that of the faculty.

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.

Medical Education 2011: 45: 818–826 Context The Association of American Medical Colleges’ Institute for Improving Medical Education’s report entitled ‘Effective Use of Educational Technology’ called on researchers to study the effectiveness of multimedia design principles. These principles were empirically shown to result in superior learning when used with college students in laboratory studies, but have not been studied with undergraduate medical students as participants. Methods A pre-test/post-test control group design was used, in which the traditional-learning group received a lecture on shock using traditionally designed slides and the modified-design group received the same lecture using slides modified in accord with Mayer’s principles of multimedia design. Participants included Year 3 medical students at a private, midwestern medical school progressing through their surgery clerkship during the academic year 2009–2010. The medical school divides students into four groups; each group attends the surgery clerkship during one of the four quarters of the academic year. Students in the second and third quarters served as the modified-design group (n = 91) and students in the fourth-quarter clerkship served as the traditional-design group (n = 39). Results Both student cohorts had similar levels of pre-lecture knowledge. Both groups showed significant improvements in retention (p

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.

Background Composite score validity depends on its reliability, content, and comparison with other outcomes measures. This study examined all three aspects of a composite score used in a third-year surgery clerkship. Method Composite score reliability was calculated using stratified alpha; several other reasonable composite combinations were tested. Correlation coefficients between clerkship composite scores and grades were calculated with other achievement measures. Two consecutive years were studied (N = 162, N = 159). Results The clerkship composite score reliability was .76 (Year 1) and .81 (Year 2). Positive correlations (P ≤ .05) were found between composite scores and other clerkships' test scores and the United States Medical Licensing Examination Step 2 Clinical Knowledge examination. Positive correlations (P ≤ .05) were found between surgery clerkship grades and other clerkship grades. Conclusions This study documents the reliability of a composite score and provides evidence for its validity in a surgery clerkship.

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.

This project sought to study the effectiveness of a curriculum to enhance the intraoperative clinical judgment and procedural skill of surgical residents.A multiinstitutional, prospective, randomized study was performed. A cognitive task analysis of laparoscopic cholecystectomy (LC) was conducted on which instructional activities and measurement instruments were designed. Residents were randomly assigned to a control or intervention group. Subjects took written pre- and posttests examining procedure-related judgment and knowledge. The intervention group participated in a three-session curriculum emphasizing LC critical decisions and error prevention. All subjects were evaluated performing the procedure on a cadaveric model. Scores from written and practical exams were compared using independent-sample and paired Student t tests.Written examination scores increased for both groups. The intervention group scored significantly higher (P.05) on the written posttest than the control group. There were no differences between groups on the practical examination. Reliability coefficients for the written examination ranged from .65 to .75. Reliability coefficients for the oral exam, technical skill, and error items on the porcine practical exam were .83, .90, and .53.The curriculum resulted in enhanced performance on a written exam designed to assess intraoperative judgment, but no differences in technical skills, showing important implications for future skills lab curriculum formats.

Background The Accreditation Council for Graduate Medical Education (ACGME) duty-hour requirements prompted program directors to rethink the organizational structure of their residency programs. Many surgical educators have expressed concerns that duty-hour restrictions would negatively affect quality of resident education. This article summarizes evaluation research results collected to study the impact of our reengineered residency program designed to preserve important educational activities while meeting duty-hour accreditation requirements. Study Design The traditional residency structure was redesigned to include a mixture of apprenticeship, small team, and night-float models. Impact evaluation data were collected using operative case logs, standardized test scores, quality assurance data, resident perception surveys, a faculty survey, and process evaluation measures. Results PGY1s and PGY2s enjoyed a substantial increase in operative cases. Operative cases increased overall and no resident has failed to meet ACGME volume or distribution requirements. American Board of Surgery In-Training Examination performance improved for PGY1s and PGY2s. Patient outcomes measures, including monthly mortality and number of and charges for admissions, showed no changes. Anonymously completed rotation evaluation forms showed stable or improved resident perceptions of case load, continuity, operating room teaching, appropriate level of faculty involvement and supervision, encouragement to attend conferences, and general assessment of the learning environment. A quality-of-life survey completed by residents before and after implementation of the new program structure showed substantial improvements. Faculty surveys showed perceived increases in work hours and job dissatisfaction. New physician assistant and nurse positions directly attributed to duty-hour restrictions amounted to about 0.2 full-time equivalent per resident. Conclusions Duty-hour restrictions produce new challenges and might require additional resources but need not cause a deterioration of surgical residents' educational experience.

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.

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

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.

OBJECTIVE: Resident education in women’s health is required but is often underemphasized. Our aim was to identify women’s health topics with the most relevance to our graduates’ practices and to determine how well they were prepared to address women’s health issues.

Background: Residency programs are required to teach and evaluate trainees in the area of professionalism and medical ethics. Prior to developing a curriculum in this area, residents and fellows were surveyed to assess learning needs. Description: A case-based survey was developed based on published curricula. Residents and fellows were asked to describe their comfort level in 11 clinical scenarios on a Likert-type scale ranging from 1 (not at all comfortable) to 10 (extremely comfortable). Evaluation: 151 surveys were returned for an overall response rate of 73%. Comfort levels ranged from a low of 3.1 to a high of 8.5 on the 10-point scale. Despite additional years of clinical training, fellows only reported an increased comfort level in 1 case. Conclusion: Learning needs exist in residents and fellows in the area of medical ethics. Use of a needs assessment was instrumental in planning and designing an ethics curriculum.

In her hospital room, Betty Jones was assessed by what seemed like an endless stream of doctors and nurses. At 40 years of age, the last thing she expected was to end up in a hospital. With three young children at home and an active business, she could hardly afford to spend time lying around doing nothing, but her gallbladder was getting to be a nuisance, and the pain was slowing her down. She had no choice but to have it taken out. The experienced surgeon at the large teaching hospital assured her that it was a common procedure for which they used state-of-the-art equipment; she should recover quickly and be home soon. She was intent on getting through this and back to her normal life as quickly as possible. She felt bad about sending away that medical student or intern or resident or whatever he was who wanted to ask questions and examine her. Why did she have to go through the whole story again when the surgeon already knew it? All she wanted was to have the operation and get out of this place. Students would only slow that down. She had watched “ER” and heard the stories at the office; there was no way she was going to play the guinea pig. She was adamant that she receive only the highest quality of care. She made a note to remind the surgeon that she did not want any residents operating on her. The last few decades have seen a shift in the physician–patient relationship from one based on paternalism to one emphasizing patient autonomy. This has more recently been accompanied by the “information age,” which has allowed increased accessibility of medical knowledge for the lay public. The consequence has been a greater scrutiny on the practices of the medical community, including their education systems. In a survey conducted by Cowles and colleagues on 200 surgical inpatients, 90% wished to contribute to resident education, yet a third of the patients did not want residents involved in their operation, and most of the remainder would allow the resident to perform only small parts of the procedure. It is possible that in the future, demands such as those placed by Mrs Jones will be more commonplace. Intuitively, it is reasonable to assume that residents will make more mistakes than fully licensed physicians will. The so-called July Phenomenon, when new physicians in training (interns) first start work in the hospital, is thought to herald increases in complication rates, but studies that address this issue have not demonstrated a positive relationship between housestaff inexperience and adverse events on the wards. The same is true in the operating room. In analyzing 234 eye operations done either by senior residents with supervision or by licensed surgeons, investigators could find no significant difference in either complication rates or operative outcomes. These findings can likely be explained by two factors. First, the enculturation of physician trainees stresses the importance of vigilance such that caution is always exercised. Second, these trainees are under the watchful eye of those more experienced than they are. As Stoeckle and colleagues point out

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.

Purpose To assess use of the combined just-in-time teaching (JiTT) and peer instruction (PI) instructional strategy in a residency program's core curriculum. Method In 2010-2011, JiTT/PI was piloted in 31 core curriculum sessions taught by 22 faculty in the Northwestern University Feinberg School of Medicine's general surgery residency program. JiTT/PI required preliminary and categorical residents (n=31) to complete Web-based study questions before weekly specialty topic sessions. Responses were examined by faculty members "just in time" to tailor session content to residents' learning needs. In the sessions, residents answered multiple-choice questions (MCQs) using clickers and engaged in PI. Participants completed surveys assessing their perceptions of JiTT/PI. Videos were coded to assess resident engagement time in JiTT/PI sessions versus prior lecture-based sessions. Responses to topic session MCQs repeated in review sessions were evaluated to study retention. Results More than 70% of resident survey respondents indicated that JiTT/PI aided in the learning of key points. At least 90% of faculty survey respondents reported positive perceptions of aspects of the JiTT/PI strategy. Resident engagement time for JiTT/PI sessions was significantly greater than for prior lecture-based sessions (z=-2.4, P=.016). Significantly more review session MCQ responses were correct for residents who had attended corresponding JiTT/PI sessions than for residents who had not (chi-square=13.7; df=1; P Conclusions JiTT/PI increased learner participation, learner retention, and the amount of learner-centered time. JiTT/PI represents an effective approach for meaningful and active learning in core curriculum sessions.

This resource is a 1-day course for incoming surgery residents to help decrease their anxiety and prepare them to their roles as surgical interns. The course is comprised of five distinct sessions with clear goals and objectives. Each session utilizes appropriate interactive techniques including direct questions, open discussions, roleplay, and simulation with structured debriefings to achieve its goals. The five sessions feature the SBAR (situation, background, assessment, recommendation) technique, answering pages, hand offs, advanced trauma life support, and a scavenger hunt. Residents described the course as important and enjoyable, and stated that it achieved its goals. The overall course rating was a 4.8 out of 5. Residents indicated that the course improved their self-confidence and understanding of their roles and duties. More residents passed the knowledge test after attending this boot camp (24% passed pretest versus 68% passed posttest).

The existing methods for evaluating resident operative performance interrupt the workflow of the attending physician, are resource intensive, and are often completed well after the end of the procedure in question. These limitations lead to low faculty compliance and potential significant recall bias. In this study, we deployed a smartphone-based system, the Procedural Autonomy and Supervisions System, to facilitate assessment of resident performance according to the Zwisch scale with minimal workflow disruption. We aimed to demonstrate that this is a reliable, valid, and feasible method of measuring resident operative autonomy.Before implementation, general surgery residents and faculty underwent frame-of-reference training to the Zwisch scale. Immediately after any operation in which a resident participated, the system automatically sent a text message prompting the attending physician to rate the resident's level of operative autonomy according to the 4-level Zwisch scale. Of these procedures, 8 were videotaped and independently rated by 2 additional surgeons. The Zwisch ratings of the 3 raters were compared using an intraclass correlation coefficient. Videotaped procedures were also scored using 2 alternative operating room (OR) performance assessment instruments (Operative Performance Rating System and Ottawa Surgical Competency OR Evaluation), against which the item correlations were calculated.Between December 2012 and June 2013, 27 faculty used the smartphone system to complete 1490 operative performance assessments on 31 residents. During this period, faculty completed evaluations for 92% of all operations performed with general surgery residents. The Zwisch scores were shown to correlate with postgraduate year (PGY) levels based on sequential pairwise chi-squared tests: PGY 1 vs PGY 2 (χ(2) = 106.9, df = 3, p0.001); PGY 2 vs PGY 3 (χ(2) = 22.2, df = 3, p0.001); and PGY 3 vs PGY 4 (χ(2) = 56.4, df = 3, p0.001). Comparison of PGY 4 to PGY 5 scores were not significantly different (χ(2) = 4.5, df = 3, p = 0.21). For the 8 operations reviewed for interrater reliability, the intraclass correlation coefficient was 0.90 (95% CI: 0.72-0.98, p0.01). Correlation of Procedural Autonomy and Supervisions System ratings with both Operative Performance Rating System items (each r0.90, all p's0.01) and Ottawa Surgical Competency OR Evaluation items (each r0.86, all p's0.01) was high.The Zwisch scale can be used to make reliable and valid measurements of faculty guidance and resident autonomy. Our data also suggest that Zwisch ratings may be used to infer resident operative performance. Deployed on an automated smartphone-based system, it can be used to feasibly record evaluations for most operations performed by residents. This information can be used to council individual residents, modify programmatic curricula, and potentially inform national training guidelines.

Objective To develop operative independence with essential procedures by the end of their training, residents need graded autonomy as they progress through training. This study compares autonomy expectations, as defined by faculty and residents, with autonomy measured in the operating room. Methods Operative procedures performed by general surgery residents between November 2012 and June 2013 were each assigned an autonomy score by the operating attending physician using a previously described rating scale (Zwisch). Scores range from minimum autonomy, “show and tell,” to maximum autonomy, “supervision only.” Autonomy expectations were defined by a survey asking faculty and residents what autonomy-level residents should achieve during each year of training for each of the 10 most commonly performed procedures. Faculty expectations, resident expectations, and actual operating room autonomy data were compared using analysis of variance with post hoc analysis by Tukey honestly significant difference test. Results A total of 1467 operative cases were scored using the Zwisch scale over the period of the study. The 10 most common procedures accounted for 56.3% (827) of the cases. Resident and faculty expectations of resident operative autonomy were similar. For only laparoscopic cholecystectomy, residents expected significantly more autonomy than the faculty did during the junior years but they agreed with the faculty for the chief year. When expectations were compared with actual performance, the resident autonomy level achieved was significantly less than that expected by residents or faculty or both for all 10 procedures in at least one postgraduate level. For every procedure performed more than 5 times during the study period by postgraduate years 3 to 5 residents, autonomy was significantly less than expected. Conclusions Surgical faculty and residents had similar expectations for resident operative autonomy, yet actual resident performance failed to achieve those shared expectations for even the most common procedures. This autonomy gap provides more evidence for concerns about the preparedness of graduating residents for independent practice.

Although the practice of medicine is increasingly a multidisciplinary effort, clinical teaching of medical students is accomplished primarily within a departmental structure.The purpose of this study was to identify subject matter within the clinical curriculum that could serve as focus for multidisciplinary teaching.A questionnaire was sent to 13 clerkship directors (representing required clerkships) at a large Midwestern medical school in which they were asked to rate a list of 631 patient problems as critical (primary), important (secondary), or "nice to know," relevant to their respective clerkship objectives.All clerkship directors completed the questionnaire. There were 523 items that were considered primary, and over 90% of these items were listed as either primary or secondary in more than 1 clerkship. Twelve topics were considered primary or secondary by at least 5 clerkship directors. Four clerkship directors identified 43 patient problems, and 3 clerkship directors identified 92 topics as primary or secondary clerkship objectives.In this study, listing of patient problems across clerkships demonstrated significant overlap of the clinical curriculum, suggesting multiple opportunities for faculty collaboration in clinical education.

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.