56.18 Analysis of Instructional Behaviors in Robotic Surgery

Posted on January 18, 2018

S. N. Chu1, C. A. Green2, H. Chern2, P. O’Sullivan2,3  1University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA 2University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 3University Of California – San Francisco,Department Of Medicine,San Francisco, CA, USA

Introduction:  Surgical robotics has rapidly emerged in minimally invasive surgery with adoption and expansion into many surgical disciplines. Surgical educators are pressed to integrate robotic training during residency to adequately equip surgical trainees. However, they lack insight about appropriate operative instruction with robotics. We conducted a wet lab using live tissue and robotic technology to observe the instructional behaviors of attendings teaching residents in a robotic environment.

Methods:  At the beginning of the 2017 academic year, senior surgical residents at the University of California, San Francisco completed a four-hour session receiving hands-on experience manipulating live porcine tissue using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale CA). Residents first worked through a series of tissue manipulation drills and then completed a variety of surgical procedures (cholecystectomy, ventral hernia repair, sigmoid colectomy). Instructors, one-on-one, guided residents with the stipulation that they could not touch the operative console. Chen has developed a taxonomy of operating room teaching behaviors for open and laparoscopic surgery. We developed a structured observational form using these teaching behaviors and three independent observers documented instructional behaviors in real time. Through content analysis, researchers summarized the types and frequencies of these behaviors.

Results: Six instructors taught six residents. Instructors represented surgical specialties of colorectal, thoracic, bariatric and general surgery. Four faculty had 2-8 years of robotic experience and two teaching residents had less than a year of experience. Instructors predominantly and consistently used three distinct teaching behaviors, comprising over 75% of all behaviors used to instruct residents. The three behaviors were: verbal direction or re-direction, explaining thought process or decision and complimenting. Instructors employed this subset and frequency of behaviors regardless of specialty area or level of experience. Additionally, instructors displayed higher frequency of active versus passive teaching methodologies (i.e. proactive questioning).

Conclusion: Instructors consistently used a distinct set of teaching behaviors to guide their robotic surgical teaching that varied significantly from those seen in open and laparoscopic cases. Given the constraints of the individual robotic console, which consequently requires instruction from the periphery, experienced surgeons cannot employ many common instructional techniques such as directly pointing out anatomical structures with fingers or instruments or indirectly with a camera, which constitute two of the most highly used instructional behaviors in an open or laparoscopic setting. Further qualitative analysis of successful robotic teaching methodologies will provide guidance for instructional methods and evidence-based curriculum for teaching in this new environment.

56.16 Early Autonomy May Contribute to an Increase in General Surgical Workforce

Posted on January 18, 2018

M. P. Taylor1, M. A. Quinn1, J. Burns1  1East Tennessee State University College Of Medicine,Department Of Surgery,Johnson City, TENNESSEE, USA

Introduction:  Nationally, 85% of general surgery graduates pursue fellowships reducing the incoming general surgical workforce. The Association of American Medical Colleges predicts a shortage of 41,000 general surgeons by 2025. In recent studies, lack of confidence appears to be a major factor contributing to resident decision to pursue fellowship.  We evaluated the level of confidence, level of autonomy, and decision to pursue fellowship at a hybrid academic/community program that historically produces 70% general surgeons.

Methods:  An anonymous survey was sent to current residents and attending surgeons at our institution. Participants responded to questions on their experiences of resident autonomy and level of confidence in technical skills using Likert scales along with simple polar questions. Descriptive statistics were calculated.

Results: There were 28 residents (90%) and 15 attending surgeons (54%) that responded. Most attendings (64%) reported during their third year of residency they began performing the majority (more than 75%) of their major cases as surgeon junior (>50% of the case performed independently) while current residents (55%) reported they were performing the majority of their major cases as a second year resident. Attendings reported that upon graduation from residency, they felt fairly comfortable performing major cases independently (64%) and none (0%) reported feeling very comfortable. Most current residents (90%) reported upon graduation they will feel very confident (45%) or fairly confident (45%) performing major cases independently. No residents reported they would not feel confident (0%).  33% of our current chief residents and only 34% of the total general surgery residents at this institution plan to pursue fellowships. 67% of responding surgeon faculty were fellowship trained. 

Conclusion: Our study showed that our residents appear to have earlier levels of autonomy and greater levels of confidence than that experienced by our practicing surgeons when they were residents. Though we were not able to determine if this difference was statistically significant it would be worthwhile to further investigate and determine if this finding is due to chance, varying confidence levels, or type of training module implemented at our institution.  Our unique program continues to graduate the majority of our surgical residents into successful general surgery practice and variables contributing to this success merit further investigation.

 

56.15 Surgical Education for the Millennial Generation: Transforming ABSITE Learning in the 21st Century

Posted on January 18, 2018

N. Leigh1, M. Passeri1, G. Kim1  1St. Luke’s Roosevelt Hospital Center,Surgery,New York, NY, USA

Introduction: Millennial surgeons have unique traits which can be targeted with novel educational techniques. A “flipped classroom” model of education, consisting of self-directed learning with an interactive resident-run educational conference, was instituted to supplement traditional lecture-based teaching methods. We hypothesized that tailoring education to millenial learners would improve American Board of Surgery In-Training Examination (ABSITE) scores.

Methods: A single center prospective study was conducted at Mt. Sinai St. Luke’s-Roosevelt Hospital, New York. All residents enrolled in the Mt. Sinai St. Luke’s-Roosevelt Accreditation Council for Graduate Medical Education (AGCME)-accredited General Surgery Residency Program during academic years 2015-17 (n=28) were included. A weekly conference, termed General Surgery Club, tailored specifically towards the characteristics of millennial learners and run entirely by residents, was introduced to the existing curriculum in 2015. Membership was voluntary. Self-directed reading was encouraged. Sessions were moderated by resident volunteers. Post-session summary guides were written by residents and left open for collaborative updates on our cloud system. ABSITE percentile scores from 2015 were compared to 2016 and 2017, before and after the introduction of General Surgery Club.

Results: There was an improvement in members’ ABSITE percentile scores from 2015 to 2017 after the introduction of General Surgery Club. Members, when compared with non-members, achieved better overall scores in 2016 (66% vs. 60%) and 2017 (69% vs. 42%). They demonstrated continued improvement with an overall percentile increase of 19% compared with a 16% decrease in non-members. 83% of members compared with 44% of non-members had 1 or more improving scores.

Conclusion: The addition of a resident-run conference tailored to millennial learners, was associated with a significant and consistent improvement in ABSITE scores over a 3 year period.

56.14 Journal Club in US Plastic Surgery Training Programs: Are We Doing It Right?

Posted on January 18, 2018

A. Nayyar2, M. C. Roughton1, L. K. Kalliainen1  1University Of North Carolina At Chapel Hill,Plastic And Reconstructive Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Lineberger Comprehensive Cancer Center,Chapel Hill, NC, USA

Introduction:
Journal club (JC) is a recognized evidence-based teaching method for trainees in medical education. Journal clubs help residents learn critical appraisal skills by reviewing literature objectively with an emphasis on the validity of the evidence. To our knowledge, the format and overall goals of JC in plastic surgery (PS) training programs remain undefined in existing literature. Our study attempts to elucidate how PS residency programs across the US implement JC in training.

Methods:
We distributed a 25-question survey by email to all 92 PS program directors (PDs) within the American Council of Academic Plastic Surgeons (ACAPS). The PDs were requested to forward the survey to residents to incorporate their views and experience. The survey was redistributed two and four weeks after the initial attempt. The questions pertained to the structure and perceptions about the role of JC in training. All responses were recorded and analyzed anonymously

Results:
We received responses from 30 PDs (32.6%), 18 attending faculty and 37 residents. Ninety-four percent of the respondents are affiliated to a program with regular JC. Most JCs meet monthly (72%), in the evening after the work day (75%), are organized by an attending faculty (43%) or the chief resident (32%), are associated with meals (65%) paid for by the department/faculty (53%), discuss >4 articles/session (71%) and employ 'Plastic and Reconstructive Surgery (PRS)' journal as a resource (94%). The curriculum for most JCs varied with each academic year (92%) driven by current literature (61%), faculty preference (14%), and resident feedback (12%). Inservice exam scores did not play a role in articles discussed. Most JCs are mandatory for residents (96%) and voluntary for attending faculty (64%) with average attendance being 90% for residents and 45% for attendings. Most respondents ranked “keeping abreast with current literature” as the primary goal (59%) followed by “teaching critical appraisal skills” (31%) (Figure1). Most programs (70%) did not have dedicated study/research time for residents and the average time available for resident education was 2-3 hours/week (53%).

Conclusion:
The structure of JC is relatively consistent across programs. Time for resident education (including JC) accounts for <5% time of the 80-hour work week. Our study highlights some issues that may be helpful to maximize the use of this time to improve overall resident education.
 

56.12 Design and Implementation of Surgical Resident Simulation Curriculum via Novel Myotomy Model

Posted on January 18, 2018

B. P. Blackwood1, B. R. Veenstra1, A. Wojtowicz1, S. Pillai1, J. M. Velasco1  1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction:  Initially, simulation in surgical education merely focused on technical skills. Recently, the application of deliberate practice theory and individualized adult learning has been shown to be relevant in obtaining higher levels of performance, leading to skill acquisition and professional expert development. Our objective was to design, develop, and implement a novel syllabus to educate residents in the operative management of achalasia and pyloric stenosis.

Methods:  Kern six-step approach was used to identify objectives, target learner needs and develop individualized learning opportunities. A syllabus, based on Kolb learning theory, was created which included both web based cognitive material and individual reflective assessment. We built an inanimate model replicating upper abdominal and chest structures with mesh and silicone based materials. A fresh, 2.5cm in diameter raw sausage, cored out to a 3mm layer was inserted in either the esophagus or the pylorus, representing the muscular layer. Finally an inflated balloon was placed within the core of the sausage.  A senior pediatric surgeon, four general surgeons, and two thoracic surgeons reviewed, tested, and revised the model via an open myotomy simulation. We then evaluated fifteen senior surgery residents.

Results: The cost for construction and assembly of the base model was $289.53. The senior faculty felt that the model provided a reliable and realistic simulation of the key steps required to perform an open myotomy. Residents agreed that this was a high fidelity and realistic model for the practice of performing a myotomy. Furthermore, surgical residents felt inclusion of web based cognitive material followed by individualized assessment on a simulation model facilitated progressive surgical mastery. 

Conclusion: Despite changes in surgical education leading to time constraints, surgical residents are still expected to perform advanced surgical procedures. Our model provides a low cost, reproducible, and realistic simulation for residents, easily adaptable to laparoscopy. Furthermore, it allowed us to successfully implement a novel curriculum to address performance of a myotomy as part of the operative management of achalasia and pyloric stenosis. This curriculum lends itself to individualized learning by applying deliberate practice principles in the acquisition of surgical skills in a stepwise fashion, to facilitate advancement to expert state. 

 

56.13 Incongruity in Graduating Surgery Residents' Experience with Breast Operations

Posted on January 18, 2018

L. A. Linker1, S. F. Markowiak2, S. A. Toraby2, M. Adair2, S. M. Pannell2, M. M. Nazzal2  1University Of Toledo,College Of Medicine,Toledo, OH, USA 2University Of Toledo,Department Of Surgery,Toledo, OH, USA

Introduction:  General surgeons perform 90% of breast cases in the US. In 2003, the ACGME implemented 80-hour work week restrictions. As a result, training programs have moved away from subspecialty exposure, including breast, in favor of more alimentary and laparoscopic cases. To address this, beginning with the 2017-18 academic year, graduating residents will be required to log 40 breast-specific cases, including 5 mastectomies and 5 axillary cases. We analyzed general surgery residents’ exposure to breast surgery in order to find whether training is adequate for transition into practice and meets new ACGME requirements.

Methods:  We retrospectively reviewed ACGME logs of graduating general surgery residents for the academic years 1999-00 to 2015-16 in the defined category of “breast.” Individual procedures were analyzed using the total surgeon cases and standard deviation (STD).

Results: For breast reconstruction, cases increased from a mean of 2 per graduating chief in 1999-00 to 5 cases in 2015-16. Mean STD was high at 7.2 cases, indicating heterogeneity in resident experience. Sentinel lymph node biopsy increased to a mean of 8 ± 7 cases per chief from 2001-02 to 2006-07, but has since decreased to 3.9 ± 5 cases in 2015-16. Mean STD over the 15-year period is 6.13 cases, again, illustrating heterogeneity. Excisional and stereotactic breast biopsy cases decreased over a 17-year period, from a mean of 37.6 cases per chief in 1999-00 to 15 cases in 2015-16. Mean STD over this time period is 19.9 cases.

Mastectomy trends varied greatly. Beginning in 2009-10, lumpectomy exposure doubled from a mean of 10.4 cases per chief to 20.2 cases in 2015-16. Radical mastectomies didn’t vary, but modified radical mastectomies decreased. Simple mastectomies increased from a mean of 6 cases in 1999-00 to 10.8 in 15-16. The increase in lumpectomies and simple mastectomies resulted in an increase for total mastectomy cases from 2009-10 to 2015-16.

Conclusion: The combination of duty hour restrictions, breast conserving therapy, earlier diagnosis, and less time devoted to subspecialty areas in residency training has led to fewer complex breast cases for graduates. This led the ACGME to institute a defined breast category and increase the required cases for graduation. Our analysis indicates there is a subset of previous graduates who would not have met this higher standard. We propose the creation of a certificate program for residents who have achieved significant operative and educational exposure in the area of breast surgery to identify them as more prepared for practice in this area. Additional research should be done to determine where operative and clinical competency minimums for graduating chiefs truly lie.
 

56.10 Saving the World — One Medical Student at a Time!

Posted on January 18, 2018

A. V. Jambhekar1, C. Kwock1, S. Patrucco Reyes1, V. Nwaokocha1, M. Zenilman1, J. Rucinski1  1New York Presbyterian Brooklyn Methodist Hospital,Surgery,Brooklyn, NY, USA

Introduction:  While studies have examined the barriers to global health projects within developing countries and general surgery residencies, few have suggested how to enhance awareness and participation. Our objective was to determine if actual participation in a project to donate surgical supplies to a 3rd world country results in improved knowledge of global health issues. 
 

Methods:  Project Warm Heart, whose goal was to collect unused surgical supplies for donation to a local non-government organization in Malawi, began on November 15, 2016. Residents and medical students were randomly divided into two groups: the participant group (n = 19) and the control group (n = 19). Both groups were pre- and post tested about global public health issues. Data is expressed as Mean +/- SD; statistical analysis was conducted using Student’s t-test and Chi square analysis.  

Results: On February 7, 2017, total of $12,996.70 in supplies was collected, organized, and shipped to Malawi. The control group and participant groups had similar prior involvement in global health (42% vs. 47%; p = 0.76). 74% of the participant group felt that global health should be a part of their curriculum compared to 95% of the control group (p = 0.08).  Both groups had similar prior knowledge of health issues in Africa but the participant group knowledge was significantly enhanced through project development (*p <0.00001). 

Conclusion: The development of a project to donate surgical supplies internationally allows students and residents to impact change while increasing their knowledge of global health issues. 

 

56.11 The Application of Data Science Principles to Competency-Based Medical Education

Posted on January 18, 2018

N. S. Hoang1, J. Lau1  1Stanford University,Department Of General Surgery,Palo Alto, CA, USA

Introduction:
Competency-based medical education (CBME) is seeing widespread implementation as medical education moves away from the Halstedian master-apprenticeship model (MAM). Despite the recent incorporation of milestones and entrustable professional activities (EPAs) into CBME frameworks, major challenges like reductionism and the loss of authenticity have remained fixed. It has been argued that concretely defining all aspects of a qualified physician is an impossible task and there is concern that reducing higher-order competencies can lead to the overfitting of data. If curricula become ‘overfit’ to existing data, essential qualities required of a modern day physician will not be targeted for development. Data science principles involve adapting numbers to meet real-world needs and can provide insight into the development of curricula and assessment tools to advance the implementation of CBME.

Methods:
A thought experiment was conducted using competencies as data points along a coordinate plane, with each data point representing one aspect of a competent physician. A complex polynomial representing CBME curricula was formulated to perfectly capture each competency. New data points were added which represent the qualitative aspects of competency that are remiss from atomized constructions of competency typically seen in checklists. The complex polynomial was ‘overfit’ to existing data and failed to predict the new data points. Data science principles were applied to consider how to prevent overfitting in the context of CBME curricula and assessment tools. 

Results:
Curricular developments to prevent overfitting include retaining subjectivity in competency definitions (e.g. time is not completely de-valued as contributing to competence) and considering non-competency domains (e.g. cultural competency and stewardship). Mixed-methods assessment with multiple assessors in differing contexts was suggested to be frequent and embedded within the curriculum to encourage self-reflection. To prevent overfitting, the authors propose a multi-faceted assessment program involving the triangulation of methods, such that qualitative assessment tools can enrich impressions formed by quantitative tools and uncover divergent dimensions of behavior not captured by either tool alone. Dedicated faculty assessors, physician coaches, and assessment data summary techniques are described as a compromise to the current form of CBME that has alienated some educators with checklists, jargon, and demands for uncompensated assessor training for faculty.  

Conclusion:
Data science principles can be effectively applied to competency definitions to address major challenges of CBME and to facilitate the development of curricula and assessment tools. Mixed-methods assessment provides a solution to the criticisms lodged against CBME and, if properly incorporated, can advance the implementation of CBME. 
 

56.08 Creation and Assessment of an Operative Trauma Training Course in a Low Resource Setting in Uganda

Posted on January 18, 2018

M. P. DeWane1, M. Cheung1, G. Kurigamba2, R. N. Kabuye2, J. Mabweijano2, M. Galukande2, D. E. Ozgediz1, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Makerere University,Department Of Surgery,Kampala, KAMPALA, Uganda

Introduction: Trauma is the leading cause of death in low-income countries, outpacing HIV, malaria and TB combined. Exacerbating the problem is a lack of formalized context-specific operative trauma training. We surveyed needs and beliefs regarding collaborative training with high-income country groups and assessed the need for operative training. We then utilized these results to develop an Operative Trauma Course (OTR) and evaluate its impact on trainees. 

Methods: Fourteen 2nd year residents of the Makerere University School of Medicine at Mulago Hospital in Kampala, Uganda participated in the anonymous needs assessment and inaugural course. Training was held over three days and consisted of didactics, practicals, and cadaveric dissection for a total of 20 hours of instruction. Major themes included initial assessment, emergent airway management, and ultrasound use in trauma.  Based on the local needs assessment, cadaveric didactics focused on penetrating neck, thoracic, and abdominal trauma. Pretests and posttests were administered and trainees completed a validated course review. Study authors were blinded to participant performance and review.

Results: The needs survey was administered to 12 of 14 residents (86%) while all 14 completed the course. All agreed that international training was important to their career. The preferred setting of training differed: 64% would prefer to travel internationally to train while the remaining preferred to have outside faculty rotate at their home institution. None were able to identify internationally sponsored trauma courses currently operating in Uganda. A majority (93%) of participants reported that operative trauma training is lacking and additional training opportunities would be highly useful. Regarding course completion, all participants felt course goals were clear and that class time was used effectively. Participants stated that the quality of the course was excellent and that it increased their knowledge and motivation to learn operative trauma techniques. A total of 13 participants completed the pre- and post-tests. Pretest score average was 56% (range 49%-71%), and increased by 24% following course completion in the posttest (80%, range 69%-89%). The difference in mean performance was statistically significant (P<0.001).

Conclusion: This study outlines the development of the first international operative trauma course hosted in Uganda. Ugandan trainees reported that international training was important and that trauma operative skills were most urgently needed to improve in their practice.  Participants approved of the course as measured by validated course review and demonstrated significant improvement in their knowledge of trauma. Future studies will include an intensive point of care ultrasound extension and further development of trauma curricula is indicated to reduce the high toll of trauma in low resource settings.

 

56.09 Complex General Surgical Oncology Training Milestones: How Much Do We Really Understand?

Posted on January 18, 2018

O. S. Eng1, R. A. Nelson1, V. Sun1, L. L. Lai1, K. A. Melstrom1  1City Of Hope National Medical Center,Duarte, CA, USA

Introduction:
The Accreditation Council for Graduate Medical Education (ACGME) implemented the Milestones Project in 2013 to provide specialty-specific objectives in evaluation of trainee performance. We hypothesized that CGSO milestones would be better understood with an educational session. We sought to assess the understanding of Complex General Surgical Oncology (CGSO) Fellowship milestones among trainees and faculty.

Methods:
Two surveys were conducted among trainees and faculty members which entailed matching learning objectives with CGSO-specific milestones, one before and one after an interactive educational session. Learning objectives and milestone wording were taken verbatim from ACGME report worksheets.

Results:
Ten trainees and eleven faculty members participated in the study. While the majority of participants had experience with ACGME Milestones previously, <30% reported having received a formal explanation of the milestones. Overall, trainees and faculty were able to correctly identify learning objectives with CGSO milestones 47% and 53% of the time, respectively, before the educational session and 50% and 51%, respectively, after the session. After the educational session, trainees and faculty changed 14% and 13% of answers, respectively, from incorrect to correct.  However, the trainees and faculty also changed 11% and 15% of answers, respectively, from correct to incorrect.

Conclusion:
Better baseline understanding of ACGME Milestones among trainees and faculty is needed. A one-time educational session is not sufficient in affecting the understanding of ACGME Milestones since understanding of individual milestones did not improve after the educational session. Development of strategies for improving our understanding is important, given that the foundation of the ACGME curricula is based on specialty-specific milestones.
 

56.06 Practice-based Learning & Improvement: Assessment of a Core ACGME Competency

Posted on January 18, 2018

M. Narayan1, R. A. Edwards2  1Weill Cornell Medical College,The Division Of Trauma, Burns, Critical And Acute Care Surgery,New York, NY, USA 2MGH Institute Of Health Professions,Center For Interprofessional Studies And Innovation,Boston, MA, USA

Introduction:
There is concern that graduating chief residents lack skills in important non-technical areas. The non-technical skills aspects of the ACGME 6 core competencies have not been broadly evaluated. We examined the literature on assessment of one, Practice-Based Learning and Improvement (PBLI), to identify assessments being utilized by residency programs to meet this competency.

Methods:
A literature review was conducted using PubMed and Google Scholar to identify publications about the ACGME PBLI competency or any PBLI sub-competency. These were then sorted into 1 of 3 categories: Intervention Studies, Survey/Needs Assessment, or Reviews and identified specialty, year of study, journal type, type of assessment, and which sub-competencies were addressed primarily/secondarily. Intervention studies were assessed using the Kirkpatrick model to evaluate type of intervention effectiveness. 

Results:
66 publications were identified: 34 Interventions, 15 Survey/Needs Assessments, and 17 Reviews, including commentaries. Internal Medicine (N=21, 31.3%) and Surgery (N=20, 29.9%) had the most. Publications occurred 1998-2017, with 69.7% in 2007-2014.  Of the 16.7% in the Journal of Surgical Education (JSE), only 3 were intervention studies and 7 were reviews. 52.9% of Intervention studies were published in other Education journals compared to 8.8% in JSE. JSE published more review/commentary publications (41.2%) compared to other journals. A majority of intervention studies assessed the PBLI sub-competency on quality improvement (QI) as the primary objective. The sub-competencies associated with self-awareness including identifying strengths, deficiencies, and limits in one’s knowledge and expertise, setting learning and improvement goals, and identifying and performing appropriate learning activities were the most commonly assessed secondary objectives. Only 3 of 34 Intervention studies used qualitative methods. The most commonly used quantitative study designs were pre- and post-assessments (66.7%) followed by post-assessments only (18.2%). Only two studies (6.1%) used an OSCE as the sole method of assessment. 91.2% of intervention studies focused on Kirkpatrick’s Level 2 (knowledge/skills) while 64.5% included Level 1 (satisfaction). 6 studies (17.6%) focused on Level 3 (observed behaviors). If self-reported behavior is included, then 41.2% of studies included a behavior component. Only 2 studies focused on Level 4 (health outcomes). 

Conclusion:
Current literature on the PBLI competency has primarily focused on QI. Assessment tools have been relatively limited in their scope, primarily using pre- and post-intervention tools. Higher Kirkpatrick levels have not been assessed much. Study designs can be improved through greater use of randomization, OSCEs, 360-degree evaluations and simulation. Much more work is needed to analyze how the PBLI sub-competencies can best be assessed to assure residents are meeting the prescribed ACGME competencies.
 

56.07 Understanding the Use of Video in Surgical Education

Posted on January 18, 2018

J. L. Green1, P. Bittar1, V. Suresh1, A. Allori2  1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Division Of Plastic, Maxillofacial & Oral Surgery,Durham, NC, USA

Introduction: Training surgical residents in the modern age comes with many challenges. Concerns over duty hour restrictions and limited exposure to essential operations suggest that innovative solutions are needed for proper resident education. The use of surgical video has great potential to enhance training by demonstrating surgical anatomy and procedures, facilitating assessment, and improving feedback. Although there are a variety of uses for video in surgical education, there is little information about which applications of this technology are most effective. The objective of this study was to systematically review the literature for the use of video based technology in surgical residency training and provide evidence based guidelines for its effective use.

Methods: The authors conducted a systematic review of literature on surgical video in surgical residency education. A literature search was performed of PubMed, EMBASE, ERIC, and Web of Science for comparative data and descriptive information on the use of surgical video in residency education. Information regarding video characteristics and video application were gathered from each article. Articles comparing a video group to a non-video group underwent outcome analysis and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI). Video outcomes were categorized as learning (knowledge change), performance (skill change), and experience (resident perspective).

Results: Of the 1168 papers reviewed, 63 articles met inclusion criteria and provided data on surgical video characteristics and applications. The primary video type was endoscopy (27/63, 42.9%) which was captured using laparoscopy (22/63, 34.9%) or arthroscopy (11/63, 17.5%). Videos were usually viewed post-operatively (44/63, 69.8%) by an attending (31/63, 49.2%) or resident (24/63, 38.1%). Of the included articles, 19 articles compared a video to a non-video group and therefore underwent outcome analysis and quality assessment. When compared to a non-video group, video was associated with improved resident learning (6/6, 100%), performance (13/16, 81.3%), and experience (7/7, 100%).

Conclusion: This review of literature illustrates the utility of video based technology as a tool for surgical education. Video based technology serves as a readily accessible platform for real-time feedback, out-of-OR training, and basic didactics. This review of comparative studies shows that the use of video technology not only has positive impacts on resident learning and performance but also provides trainees with a positive learning experience. In regards to video guidelines, the information from this systematic review suggests that resident video review and supplementing video with other educational tools is beneficial to surgical education. 

 

56.05 Belize It: Development of an International Surgery Rotation

Posted on January 18, 2018

J. F. Vance1, N. Rao1, B. Burns1, D. Walters1  1East Tennessee State University – Quillen College Of Medicine,Department Of Surgery,Johnson City, TN, USA

Introduction:
While many surgeons choose to use their skills in under-resourced settings, there had been few formal opportunities to cultivate volunteerism within general surgery residency training until recently. Since 2011, when the American Board of Surgery (ABS) and Accreditation Council for Graduate Medical Education (ACGME) released guidelines for international surgical rotations (ISRs) there has been an explosion of interest in the developing field of global surgery.  Many institutions, such as our own, have developed ISRs.  We will discuss necessary components for cultivation of an international surgical rotation, briefly discuss benefits and challenges of such a program and discuss our clinical experience in Belize.

Methods:
International surgery rotations have defined guidelines and requirements.  ACGME mandates having a sponsoring institution and letter of agreement.  Many factors are important selecting a site for an ISR: community resources and needs, safety, educational materials, food and lodging.  Rotations must be optional for trainees and a minimum of two weeks in length.  They are restricted to post-graduate years two through four.  Perhaps one of the most time consuming steps is to acquire the medical license for the US faculty surgeon.  It goes without saying that this person must be dedicated to initiating and sustaining partnerships.  In addition, programs must provide the resident’s salary, travel, health and evacuation insurance.  Paramount to development of ISRs are strong department backing and donor support.  In the years we have worked in Belize we have gathered some basic data to detail types of clinical encounters, disease states treated as well as procedures and surgeries performed.

Results:
In just over two years our department has provided global surgery training to six residents in as any months.  We have provided medical and surgical consults and trained a local surgeon in laparoscopy.  Four different faculty mentors have shared their time and expertise in general, trauma, and vascular surgery.  While providing general surgical coverage at the facility we assist local surgeons with obstetric, orthopedic and urologic cases.  Approximately 75% of cases logged by residents comprise a mixture of general surgery while the other fourth is a mixture of urology, OG/GYN, and Orthopedics. 

Conclusion:
Global surgery as a field is expanding rapidly. ISRs are a growing interest among applicants and residents.  There are as many as 25 such ACGME-approved programs. The partnership between LLL Hospital and ETSU is one of many possible models for international engagement and surgical education. As we gather more data and clinical experience, ETSU is developing cross-department collaborative partnerships with the hospital to expand opportunities for students and to provide other needed services. We hope that this serves as an example to other programs who wish to serve and provide surgical care around the globe.

56.04 Improving Teamwork in the Trauma Bay

Posted on January 18, 2018

A. DeLoach1, C. Coogan1, C. R. Thrush1, M. K. Kimbrough1  1University Of Arkansas For Medical Sciences,Trauma And Critical Care Surgery,Little Rock, AR, USA

Introduction: Teamwork is crucial for efficacious trauma resuscitation.  Communication failure between team members can lead to negative patient outcomes, but communication can be improved through trauma briefings and team training.  Though teamwork training has shown to improve performance, far less research has examined the differing perspectives among providers during trauma resuscitations.  This study was designed to assess different responder’s perceptions about roles, responsibilities, and communication during trauma activations. 

Methods:  A brief survey was sent to all Emergency Medicine residents (n=24), General Surgery residents (n=27), and Emergency Department nurses (n=23) at a mid-size comprehensive academic health center.  The survey assessed perceived effectiveness during trauma activations and also allowed for free text comments in the following categories: Interpersonal Communication, Leadership, Roles/Responsibilities, Environmental Control, Documentation, and Other. 

Results: The results showed significant differences in team member perceptions in three areas: 1) noise in trauma bay negatively impacts patient care (p<0.001, Surgery<Nurses, EM<Nurses), 2) ineffective interpersonal communication by trauma team members occurring during trauma activation (p<0.05, Surgery<Nurses), and 3) confusion about the responsibilities of trauma activation participants (p<0.05 Surgery<EM).  The open response comments showed uncertainty in roles and responsibilities of trauma resuscitation participants and revealed a need for more defined roles and pre-rehearsed protocols.

Conclusion: Study results highlight the importance of differing interprofessional perceptions in order to encourage collaboration, improve communication, and ensure well-defined roles in the trauma bay.  As part of our performance improvement process of applying for and receiving Level 1 Trauma Center verification from the American College of Surgeons, the survey results helped inform multiple changes to improve trauma resuscitations.  These changes included more defined responsibilities, posted roles, and video-recording of trauma resuscitations for review in the Emergency Department and Trauma joint Morbidity and Mortality conferences.

 

56.01 Surgical Resident Participation in Daily, ABSITE Preparatory e-Quiz

Posted on January 18, 2018

C. V. Warner1, G. Havelka1, S. Naffouj1, H. Shah1, S. Thomas1, J. Sugrue1, A. Mellgren1, J. Nordenstam1  1University Of Illinois At Chicago,Chicago, IL, USA

Introduction: Weekly didactic conference is part of general surgery residency training. Previous studies report no correlation between conference attendance and American Board of Surgery In-Training Examination (ABSITE) performance. However, studies have demonstrated a structured reading program in addition to weekly ABSITE-style questions improve ABSITE scores. We piloted the implementation of a daily, electronically administered, ABSITE-style quiz and evaluated resident participation.

Methods:  General surgery residents at a single institution were given a survey to determine their study habits. Following this, for one month they received daily emails containing two ABSITE-style questions corresponding to each week’s didactic lecture. The number of quizzes taken and quiz scores were compared to 1) reported methods of studying (comprehensive resource (e.g. textbook/ SCORE) or alternative resource (e.g. review book/question bank) 2) effort in learning (attendance to weekly conference and a bi-weekly ABSITE study session and reported time spent studying) and 3) previous standardized examination performance. 

Results: 21 out of 32 (66%) general surgery residents participated in the survey. This included 17 (n=21, 81%) junior (PGY1, 2 and 3) and 4 (n=11, 36%, p=0.02) senior residents. For clinical duties, most residents (n=12, 57%) read when they encountered an unfamiliar case, but few (n=5, 24%) reported a year round reading schedule. Overall, residents read a median of 360 (range 120-600) minutes/month. 71% (n=15) primarily utilized a comprehensive resource, whereas 29% (n=6) used an alternative resource. In preparation for the ABSITE, most residents (53%, n=10) studied at least 8 weeks in advance, but few (n=4, 19%) followed a year round reading schedule. Residents read a median of 60 (range 30-480) minutes/month for the ABSITE. 69% (n=22) of residents partook of the daily quizzes (median 10 quizzes/resident; range 1-27). There was a trend suggesting a comprehensive resource to study for the ABSITE was associated with better quiz scores (p=0.079). Neither attendance to ABSITE study sessions or conferences, nor time spent studying affected quiz performance. There was no significant correlation between previous USMLE STEP 1 and STEP 2 scores. A positive correlation was noted between previous ABSITE scores and daily quiz scores (r=0.342, p=0.212), but this was not significant. Finally, there was a significant, but small, positive correlation between the number of quizzes taken and quiz score performance (r=0.156, p=0.017).  

Conclusion: This pilot study suggests most general surgery residents are willing to take a daily e-quiz to enhance learning. The use of a comprehensive study resource seems to improve results on quizzes. A long-term study is necessary to determine whether implementation of daily emailed quizzes will influence ABSITE performance or augment study habits. 

 

56.02 Is Solo Surgery the Goal of the Laparoscopic Colorectal Surgeries?

Posted on January 18, 2018

J. Yasutomi1, K. Kusashio1, M. Matsumoto1, T. Suzuki1, A. Iida1, K. Fushimi1, S. Irabu2, T. Komura2, N. Yamamoto2, N. Imamura1, R. Harano1, A. Yoshizumi1, R. Takayanagi1, N. Matsuyama1, I. Udagawa1  1Chiba Rosai Hospital,Department Of Surgery,Ichihara-city, CHIBA, Japan 2Chiba Rosai Hospital,Department Of Emergency And Intensive Care,Ichihara-city, CHIBA, Japan

Introduction : The technical qualification of the Japanese Society for Endoscopic Surgery requires the operator to lead every operative procedure with initiative throughout the operation. Since leadership and initiative of the operator is regarded as important, relatively high score is given to solo surgery.  However, in order to let young surgeons experience laparoscopic colorectal surgeries as operators, the expert support and guiding performed by the assistant should be necessary. The presenting author experienced more than 600 cases as an assistant (mentor). The aim of this study is to justify our educational system of laparoscopic surgery.

Method : ?We analyzed the current status of laparoscopic surgeries. Sigmoid colon resections (n=172) and right hemicolectomies (n=184) were performed from 2011 to 2016 in our institution, in which 87 of the former and 106 of the latter were performed  by surgeons in training. The operative data were compared. ?We also classified our laparoscopic colorectal surgeries by the achievement level of the operator. Step 0: A beginner-level surgeon, even if the mentor provides a complete operative field, it is still necessary to assist, or to be replaced by the senior scope holder.  Step 1: At the level where the operator can understand and practice the standardized procedure. Step 2: The operator is at the level of the mentor (or the certified surgeon) and leads the entire operation.

Result : ?In recent 8 years, we performed 998 colorectal surgeries including 722 laparoscopic surgeries in our institution. The average number of laparoscopic colorectal surgeries performed by surgeons in training (N=17) was 13 cases per year, and that of laparoscopic cholecystectomies was 38 cases per year. Compared to staff surgeons, we found no significant difference in operative time in sigmoid colon resections—Surgeons in Training ;170min.(SD:37, N=87) , Staff (senior) surgeons:160min.(SD:35,N=85). We could find no significant difference in blood loss either. The surgeons in training performed almost satisfying number of surgeries as operators and no severe complications were experienced.?Among 104/116 laparoscopic colorectal surgeries performed in our hospital in 2015/2016, the number of Step 0 operations were 32/30 cases, whereas Step 1 were 42/57 cases, and Step 2 were 12/11 cases.
Conclusion : Is "Solo Surgery" the Goal of the Laparoscopic Colorectal Surgeries? The answer is "No".  An ideal form of the laparoscopic colorectal surgery that we still think is almost the same as traditional open surgery, in which the operator should lead the whole operative procedures and at the same time the assistant should perform a role of harmonious movement with the operator. In order to allow surgeons in training perform laparoscopic colorectal surgeries, our educational system was seemed to be feasible and thought to be the first step for an ideal form of the operation.

56.03 Accessibility and Content of Abdominal Transplant Fellowship Program Web Sites in the United States

Posted on January 18, 2018

C. K. Cantrell1, S. L. Bergstresser1, B. L. Young2, S. H. Gray3, J. A. White3  1University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA 2Carolinas Medical Center,Department Of Orthopaedic Surgery,Charlotte, NC, USA 3University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:
Abdominal organ transplant volume in the United States is at an all-time high. However, the ideal number of transplant programs and fellowship positions is debatable. When deciding if and where to apply to abdominal transplant fellowship training programs, prospective applicants commonly utilize individual programs’ web sites to help make these determinations, in addition to numerous other factors. Consequently, accessibility and content of these web sites from one program to the next is highly variable and may contribute to difficulties in the selection of programs and navigation of the match process.  The aim of this study is to evaluate the accessibility and content of abdominal transplant surgery fellowship web sites. 

Methods:
The American Society of Transplant Surgeons (ASTS) web site provides a complete list of accredited abdominal transplant fellowship programs in the United States. A Google search was performed in a systematic fashion to determine the presence and accessibility of a program’s web site. Available web sites were evaluated on the presence of 20 content criteria, previously published in similar studies from other subspecialties.

Results:
Sixty-five programs in the United States were identified using the ASTS directory. Web sites for fifty-one (78%) fellowship programs were identified, while fourteen (22%) programs did not contain an accessible web site. Three-fourths of web sites contained 50% or less of the 20 evaluated data points, while 24% of web sites contained 5 or less criteria. The most and least included data points were program description (100%) and on-call expectations (10%), respectively. Abbreviated results are listed in Table I.

Conclusion:
The accessibility and content of a program’s web site is one major factor that can influence a potential applicant’s decision on where to pursue transplant surgery fellowship training. This study revealed that a significant percentage of programs fail to provide a functional web site. Of the fifty-one programs that did have web sites, information deemed important to prospective applicants was inadequate. Establishing web sites and improving existing web sites could influence an applicant’s decision on whether to apply to a particular program. This information could potentially enhance ideal program-fellow matches and improve the overall match rate.
 

55.19 Smartphone App Improves Communication and Teamwork in Trauma Care

Posted on January 18, 2018

A. R. Privette1, L. Roberts1, D. Wilson1, M. Kish1, B. Carter1, E. Woltz1, B. Crookes1, K. Catchpole1  1Medical University Of South Carolina,Charleston, SC, USA

Introduction:

Successful trauma care is dependent upon effective communication and rapid coordination of multiple people in highly complex fast-paced scenarios. Communication and care-coordination is improved through shared access to patient and contextual information prior to patient arrival and during the initial phase of care.  Observational and interview studies of trauma teamwork have shown that communicating information about incoming patients to the trauma team and ancillary services (anesthesia, radiology, OR and ICU personnel) is a significant problem.  In order to provide timely and accurate information to all team members, we developed a novel trauma teamwork/communication smartphone application that was designed to (i) provide patient and injury details prior to arrival in the ED (ii) allow secure communications (texts and pictures), and (iii) integrate with clinical workflow to reduce disruptive and unreliable phone calls/pages and allow more focused and efficient face-to-face communication.  Our intention was to demonstrate the feasibility and potential power of Smartphone App technology to improve communication/teamwork and decrease work flow disruptions utilizing a Human Factors derived study design.

Methods:

This was a pilot study using an interrupted time-series (before / after) design, with a 3 month pre-intervention data collection period, and a 3 month intervention period with post-intervention data collection. We explored general use statistics, usability, and performance. Observers followed 20 cases in each arm. The main outcome measures were: flow disruptions (defined as “deviations from the natural progression of an procedure”), treatment times (total time in ED, time-to-CT, time-in-CT), and teamwork scores (T-NOTECHS and team-related flow disruptions).  Ease of use and utility were assessed using the Technology Acceptance Model (TAM) survey.  We also collected metrics directly from software analytics on the number of traumas in which the app was used, the type of interactions, and types of software functionality employed (e.g. text messaging, photo messaging, voice messaging).

Results:
The app was used in 367 (87%) trauma activations during the trial period. Significant reductions were observed in the rates of the most severe flow disruptions (p=0.043). Teamwork scores improved significantly (p=0.04). A range of other positive benefits were observed. There was good agreement between SUS and TAM scales with usability rates of high or very high. Perceptions of utility varied across users, with ED staff finding it least useful, trauma staff moderately useful, and OR, ICU and consult teams the most useful.

Conclusion:
Our novel trauma-specific smartphone app, designed to improve teamwork and communication, was successfully adopted and produced improvements in flow disruption and teamwork.  The use of appropriately designed smartphone technology has signficant potential for improving the safety and efficiency of trauma care delivery.

55.20 Characteristics Of Trauma Patients Who Received Palliative Care Consultation

Posted on January 18, 2018

I. Puente1,2, A. Fokin2, J. Katz1, A. Tymchak2, J. Wycech1, S. Koff2, S. Viitaniemi2, R. Teitzman2  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma,Delray Beach, FL, USA

Introduction: Palliative care has been underutilized in the trauma ICU (TICU) setting in comparison to surgical and medical ICU settings. The characterization of palliative care trauma patients has yet to be delineated. The objective of this study was to analyze the characteristics of TICU patients who received palliative care consultation (PCC) and compare that data to patients who did not receive PCC.

Methods: In this IRB approved retrospective-cohort study, 331 TICU patients who received a PCC from 12/2012 – 05/2017 (PCC group) were compared to all 7,758 trauma patients (ATP group) who did not receive a PCC and to 331 trauma patients in a matched control group (MCG) that were matched by age, gender, Injury Severity Score (ISS), and Mechanism of Injury (MOI). All patients were identified through the database of a level 1 trauma center. Analyzed variables included age, gender, race, MOI, ISS, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and traumatic brain injury (TBI) incidence.

Results: The mean age in the PCC and MCG patients were similar (81.3 in PCC vs 81.0 in MCG, p=0.81) but, the mean age in the ATP group (56.8) was significantly lower (p<0.05). There was a 3:2 male to female ratio in all groups. Among all PCC patients (N=331), there were 304 white patients (91.8%), 6 black patients (1.8%), 4 Hispanic patients (1.2%), and 17 unidentified patients (5.1%). There was an unintended match in race distribution between the MCG and PCC group (p=0.74); however, in the ATP group the race distribution was significantly different (p<0.001) with fewer white patients (73% in ATP vs 91.8% in PCC) and more black patients (12% in ATP vs 1.8% in PCC). There were similar MOI distributions in all groups (p=0.45) with the dominant MOI being falls (81.6% for PCC and 78.9% for MCG) followed by MVCs (13.0% for PCC and 17.5% for MCG). In the ATP group, while the order of prevalence of MOI was the same (48.3% falls and 25.9% MVC), the degree of prevalence was different from the PCC and MCG groups (p<0.001). The mean ISS for the PCC and MCG patients were similar (20.3 in PCC vs 19.3 in MCG, p=0.26); however, the mean ISS for the ATP group (10.2) was significantly lower than in the PCC and MCG groups (p<0.05). The mean GCS in the PCC group (11.0) was significantly lower when compared to the MCG group (12.8, p<0.001) and the ATP group (13.7, p<0.001). The mean RTS in the PCC group (6.78) was also significantly lower when compared to the MCG group (7.11, p<0.01) and the ATP group (7.44, p<0.001). The TBI incidence in the PCC group (72.8%) and MCG group (71.6%) was similar (p=0.73); however, TBI incidence was significantly lower in the ATP group (44.0%, p<0.001).

Conclusion: Trauma patients who received palliative care consultation were significantly older, predominantly white, male, more severely injured, and had a higher incidence of traumatic brain injury with a lower neurological status.

 

55.17 Frailty Score on Admission Predicts Outcomes in Elderly Trauma Patients

Posted on January 18, 2018

E. Curtis1, K. S. Romanowski2, S. Sen1, A. Hill3, C. Cocanour1  1University Of California – Davis,Department Of Surgery,Sacramento, CA, USA 2University Of Iowa,Department Of Surgery,Iowa City, IA, USA 3University Of California – Davis,Clinical Diagnostic Epidemiology,Davis, CA, USA

Introduction: Chronologic age alone does not define the frailty of a patient.  There are many measures of frailty and a single measure has not been agreed upon as defining frailty. Many measures of frailty are time-consuming and require the collection of data that is not readily available in the medical chart. This study examines whether the Canadian Study on Health and Aging Clinical Frailty Scale (CSHA CFS), a simple 7 point clinical opinion scale, can help predict elderly patients at high risk from hospital mortality and discharge to skilled nursing facilities following traumatic injury.

Methods:   Following IRB approval the charts of trauma patients >65 years old who admitted from 12/1/2011 to 12/31/2013 were examined. Data abstracted included age, mechanism of injury, Glasgow coma score, systolic blood pressure and heart rate on arrival, injury severity score, hospital mortality, length of stay, and discharge disposition. Frailty scores were assessed from admission data and calculated using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA CFS). Univariate, followed by Multivariate analysis of each of the variables listed and their effects on discharge disposition were examined.

Results: A total of 1403 patients were included in the study population. The mean age was 77.6 ± 8.6 years.  Of all the patients admitted, 1385 (98.7%) patients had blunt injuries, these included 930 (66.3%) for falls, 272 (19.3%) for motor vehicle accidents, and 51 (3.6%) were pedestrians hit by cars. The mean CSHA CFS of the entire population was 4.23 ± 1.25. CSHA CFS was significantly higher in patients with falls (4.58 ± 1.2) compared to all other mechanisms (3.52 ±1.15) (p<.00001).  Patients who fell were also significantly older (79.5±8.6 vs 73.4 ±7.4) (p<.00001). Non-survivors had significantly increased CSHA CFS (4.6 ± 1.3) compared to survivors (4.2 ± 1.2) (p<.01).  The best-fitting multivariable logistic regression for mortality included age, GCS, and CSHA CFS, which had an odds ratio of 1.52(1.37-1.69).  Cox proportional hazard models showed that a higher CSHA CFS was associated with earlier death and increased mortality.

Conclusions: Admission frailty scores allow for an improved assessment of pre-injury physiologic condition in trauma patients ≥65 years.  Poor pre-injury physiologic fitness increases the risk of mortality in trauma patients ≥65 years. CSHA CFS is a simple to obtain frailty score that can help identify elderly patients at high risk for in-hospital mortality and discharge to skilled nursing facilities following traumatic injury.

 

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