Surgeons and cognitive processes

Development of a continuously perfused ex vivo kidney training model for laparoscopic partial nephrectomy: validity and efficiency

BACKGROUND

Suture hemostasis is essential for laparoscopic partial nephrectomy (LPN). This study aimed to develop, validate, and test the efficacy of a continuously perfused training model (CPTM) in LPN with high-level simulated bleeding.

MATERIALS AND METHODS

The CPTM was constructed using fresh porcine kidneys with renal arteries continuously perfused with red-dyed liquid gelatin. Twenty-nine participants with expert, intermediate, or novice laparoscopic experience levels were recruited. The expert and intermediate participants evaluated the CPTM, and the novice participants were randomly assigned to one of two groups to complete training on a CPTM or dry box training model (DBTM). Messick's framework criteria were utilized to assess the validity and training efficacy of the model. The data were analyzed using the Mann-Whitney U , Kruskal-Wallis, and Friedman tests. A value of P< 0.05 was considered statistically significant.

RESULTS

Positive comments were provided by all experts and intermediates for the Content . The Relationships with other variables demonstrated significant differences among novices, intermediates, and experts in all metrics ( P< 0.05). The Consequences showed that the CPTM helped novices acquire LPN skills. The training efficacy was significantly better than that of the DBTM ( P< 0.05). There were no significant differences between the final performances of the novices and the initial performances of the experts ( P >0.05). Synthesizing all metrics, the LPN skills learned using CPTMs were significantly improved in the 12th round of training.

CONCLUSION

The CPTM offered a high-level simulation of bleeding with realistic tissue texture for acquiring LPN skills. Training of no fewer than 12 rounds is recommended for a novice's LPN training on the CPTM.

Defining Cognitive Competencies for Breast Augmentation Surgery

BACKGROUND

Breast augmentation is the most performed aesthetic procedure in the United States yet one that surgical trainees have limited exposure to. This creates a lack of confidence in performing this key procedure among graduates. It is imperative to develop novel curricula and objective measures to standardize acquiring competency.

OBJECTIVE

This qualitative study establishes various cognitive competencies and pitfalls in augmentation mammoplasty.

METHODS

Using a priori established task analysis, literary sources and operative observations, a total of 20 cognitive vignettes were developed to conduct cognitive task analyses (CTA) for breast augmentation through semistructured interviews of experts. Interviews were itemized, and verbal data were recorded, transcribed verbatim, and thematically analyzed by reviewers.

RESULTS

Eight experts were interviewed (median age 39 years, 87.5% males, with a median of 7 years in practice). A conceptual framework for breast augmentation was developed and divided into 5 operative stages containing 208 competencies and 41 pitfalls. Pitfalls were mapped to deficits in shared decision making, proper informed consent, prospective hemostasis, and awareness of anatomical landmarks and markings.

CONCLUSIONS

This work provided an inclusive framework of cognitive competencies in breast augmentation surgery to facilitate their assessment. This model guides the analysis of other procedures to transfer cognitive competencies to learners. In a transition toward competency-based education, this provides a primer to assessments that include all aspects of a surgeon's skill set.

Learning and teaching stage 4 clinical decision making: progression from novice to expert

BACKGROUND

This paper describes the development of learning from novice to expert in Stage 4: Clinical Decision Making (CDM) in surgery: Postoperative reflection and review. It also outlines some or the assessment and teaching approaches suitable to facilitate that transition in skill level.

METHODS

This paper is drawn from a much broader study of learning and teaching CDM, that used qualitative methodology based on Constructivist and Grounded Theory. Data was collected in individual interviews and focus groups. Using thematic analysis the data were analysed to identify key ideas. All participants worked in the Department of Surgery at one large regional hospital in Victoria.

RESULTS

For each stage there is a sequence of learning beginning from relying on external resources, gradually developing internal resources to guide and direct the learner's CDM. Those internal resources built through experience include multisensory and kinaesthetic memories that expand to facilitate the ability to cope with complexity.

DISCUSSION

Armed with the mind-map and rubric table included in this paper it should be possible for any senior clinician or teacher to diagnose their trainees' progression in Stage 4 CDM. This will enable them to tailor their teaching to best match the capabilities of the trainee and to enable to be more effectively targeted.

CONCLUSION

CDM can be taught and both trainees and senior clinicians can benefit from understanding the processes involved.

Frailty is Associated With Poor Outcomes Following Emergency Laparotomy: What’s Next?

Background and objective

The Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. We sought to evaluate the association between preoperative CFS scores and outcomes following emergency laparotomy in a dense, rural, and healthcare-deprived region of the UK inhabited by a multi-comorbid population.

Methods

We retrospectively reviewed regional National Emergency Laparotomy Audit (NELA) data across United Lincolnshire Hospitals NHS trust to identify all patients aged 65 years and above who underwent emergency laparotomy between December 2018 and March 2021. We also conducted a comprehensive multi-database literature search of Medline, Embase, and Cochrane to synthesise contemporaneous topical evidence.

Results

A total of 191 patients were assessed using the CFS before they underwent emergency laparotomy. Among 90 (47.1%) individuals categorised as vulnerable or frail (CFS score ≥4), there was no significant difference in age, gender, or length of stay related to the procedure compared with fit patients. However, vulnerable and frail patients were significantly more likely to die (84.8% vs. 39.2%, p<0.0001). Regression analysis identified a vulnerable or frail score to be a significant predictor of 30-day all-cause mortality (OR: 9.327; 95% CI: 3.101-28.054; p<0.0001). A total of six relevant papers were identified in the literature, all indicating a significant association between mortality as well as prolonged length and stay with clinical vulnerability and frailty.

Conclusions

The CFS is a practical and effective tool for assessing preoperative vulnerability and frailty among patients undergoing emergency laparotomy and can be used to predict mortality and morbidity after surgery.

Teaching and Assessing Cognitive Competencies in Aesthetic and Plastic Surgery

BACKGROUND

Cognition, part of surgical competence, employs forward planning, error prevention, and orchestrating technical skills. Thus, an understanding of mental processes used by experts throughout patient care is essential to teaching such competencies. This study aims to analyze and compare mental models of two distinct procedures in plastic surgery, breast augmentation and flexor tendon repair, to develop a framework to define cognitive competencies in plastic surgery aided by a review of the literature.

METHODS

Based on data from a-priori cognitive task analyses, literary sources, and field observations of breast augmentation surgery and flexor tendon repair, task-lists were produced for each procedure. Two mental models were developed using fuzzy logic cognitive maps to visually illustrate and analyze cognitive processes employed in either procedure. A comparison of the models aided by literature was used to define the cognitive competencies employed, identify differences in the decision-making process, and provide a guiding framework for understanding cognitive competencies.

RESULTS

Five distinct cognitive competency domains were identified from the literature applicable to plastic surgery, namely situation awareness, decision-making, task management, leadership, and communication and teamwork. Differences in processes of decision-making employed between an elective and a trauma setting were identified. A framework to map cognitive competencies within a generic mental model in surgical care was synthesized and methods were suggested for training on such competencies.

CONCLUSION

Cognitive competencies in different settings in plastic surgery are introduced using a comparative study of two mental models of distinct procedures to guide the teaching and assessment of such competencies.

Toward Competency-Based Training: To What Extent Are We Competency-Based?

BACKGROUND

Time-based training models in plastic surgery vary in exposure, resulting in low confidence levels among graduates. The evolution of postgraduate medical education into a competency-based model to address these issues requires an understanding of interventions described in the plastic surgery literature to identify gaps and guide creation of assessments to demonstrate competence.

METHODS

A systematic search of the MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane databases from inception until December of 2017 was conducted using search terms and synonyms of educational interventions reported in plastic surgery. Full texts were retrieved following filtering and data extracted were related to intervention design and execution, involvement of competency assessment, and educational objectives and alignment to Accreditation Council for Graduate Medical Education competencies and Royal College of Physicians and Surgeons of Canada Canadian Medical Education Directives for Specialists roles. Study quality was assessed using Kirkpatrick's levels of learning evaluation, validity evidence, and the Medical Education Research Study Quality Instrument score.

RESULTS

Of the initial 4307 results, only 36 interventions met the inclusion criteria. Almost all interventions aligned to medical knowledge and patient care Accreditation Council for Graduate Medical Education competencies. One-fifth of the interventions involved no assessment of competency, whereas most displayed assessment at the level of design as opposed to outcomes. Quality assessment revealed low levels of learning evaluation and evidence of validity; the average Medical Education Research Study Quality Instrument score was 10.9 of 18.

CONCLUSION

A systematic review of educational literature in plastic surgery was conducted to assess the quality of reported educational interventions, and to help guide creating tools that ensure competency acquirement among trainees.

The influence of experience and expertise on how surgeons prepare to perform a procedure

BACKGROUND

There is a paucity of literature describing how surgeons (either novice or expert) mentally prepare to carry out a surgical procedure. This paper focuses on these processes, and is part of a larger piece of research based on the Royal Australasian College of Surgeons (RACS) Clinical Decision Making model.

METHODS

Interviews were conducted over a 3-year period with registrars, trainees, fellows and consultants in the Department of Surgery at one large regional hospital in Victoria. Analysis began from the first interview with no pre-conceived codes. Emerging themes were drawn from participants' interpretation of their experiences. Further information was obtained during discussions in theatre while patients were being prepared for surgery.

RESULTS

The findings show that the process of rehearsal changes as a surgeon gains more experience in a procedure. A 'novice' relies on external sources of information, for example textbooks and videos. After participating in a number of similar procedures their reliance gradually moves to their own sensory memories. Surgeons at all levels of experience discuss their preparations with peers, colleagues, senior clinicians, and where appropriate, with members of other disciplines.

CONCLUSION

These findings offer insight into how surgeons, at different levels of experience, prepare for a procedure. These understandings have the potential to improve the teaching and learning of this essential component of surgical practice.

Exploring the Presence of Core Skills for Surgical Practice Through Simulation

OBJECTIVE

The ability to simulate procedures in silico has transformed surgical training and practice. Today's simulators, designed for the training of a highly specialized set of procedures, also present a powerful scientific tool for understanding the neural control processes that underpin the learning and application of surgical skills. Here, we examined whether 2 simulators designed for training in 2 different surgical domains could be used to examine the extent to which fundamental sensorimotor skills transcend surgical specialty.

DESIGN, SETTING & PARTICIPANTS

We used a high-fidelity virtual reality dental simulator and a laparoscopic box simulator to record the performance of 3 different groups. The groups comprised dentists, laparoscopic surgeons, and psychologists (each group n = 19).

RESULTS

The results revealed a specialization of performance, with laparoscopic surgeons showing the highest performance on the laparoscopic box simulator, while dentists demonstrated the highest skill levels on the virtual reality dental simulator. Importantly, we also found that a transfer learning effect, with laparoscopic surgeons and dentists showing superior performance to the psychologists on both tasks.

CONCLUSIONS

There are core sensorimotor skills that cut across surgical specialty. We propose that the identification of such fundamental skills could lead to improved training provision prior to specialization.

Construct Validity and Experience of Using a Low-cost Arthroscopic Knee Surgery Simulator

OBJECTIVE

To validate an affordable and easily reproducible arthroscopic knee surgery simulator made from simple, low-cost materials by demonstrating its ability to distinguish experienced from novice arthroscopists (i.e., construct validity). Additionally, acceptance and usefulness of the simulator in medical training and education were assessed.

DESIGN

The simulator was used to perform a partial meniscectomy in both menisci. External and intra-articular images obtained during the procedures were used to assess objective visual parameters. The Arthroscopic Surgical Skill Evaluation Tool and a Likert scale addressing individual perceptions about the simulator and its applicability in medical education were also used.

SETTING

The study was conducted at Hospital de Clínicas da Universidade Federal do Paraná, a teaching hospital in southern Brazil.

PARTICIPANTS

Thirty sixth-year medical students were recruited, as well as 10 orthopedic surgeons who had knee arthroscopy expertise and were members of a sports traumatology and knee arthroscopy group.

RESULTS

There were statistically significant differences between the groups in all objective parameters. The mean time to perform the procedure was 60% higher among students compared to surgeons. Students needed 72.5% more time on average to perform triangulations and obtained an error rate approximately twice higher in the assessment of the area removed from the menisci. Regarding Arthroscopic Surgical Skill Evaluation Tool scores, statistically significant differences were found between surgeons and students in all 8 domains and in the total score. The simulator was well accepted, as over 90% of participants found it useful for education and training, believed it contributed to teaching and assessing specific surgical steps and procedures, and reported that the task was enjoyable.

CONCLUSIONS

The arthroscopic knee surgery simulator was largely accepted and had good applicability in objective measurement of surgical skills, distinguishing medical students from orthopedic surgeons and thus demonstrating construct validity.

Frontal theta brain activity varies as a function of surgical experience and task error

OBJECTIVE

Investigations into surgical expertise have almost exclusively focused on overt behavioral characteristics with little consideration of the underlying neural processes. Recent advances in neuroimaging technologies, for example, wireless, wearable scalp-recorded electroencephalography (EEG), allow an insight into the neural processes governing performance. We used scalp-recorded EEG to examine whether surgical expertise and task performance could be differentiated according to an oscillatory brain activity signal known as frontal theta-a putative biomarker for cognitive control processes.

DESIGN SETTING AND PARTICIPANTS

Behavioral and EEG data were acquired from dental surgery trainees with 1 year (n=25) and 4 years of experience (n=20) while they performed low and high difficulty drilling tasks on a virtual reality surgical simulator. EEG power in the 4-7 Hz range in frontal electrodes (indexing frontal theta) was examined as a function of experience, task difficulty and error rate.

RESULTS

Frontal theta power was greater for novices relative to experts (p=0.001), but did not vary according to task difficulty (p=0.15) and there was no Experience × Difficulty interaction (p=0.87). Brain-behavior correlations revealed a significant negative relationship between frontal theta and error in the experienced group for the difficult task (r=-0.594, p=0.0058), but no such relationship emerged for novices.

CONCLUSION

We find frontal theta power differentiates between surgical experiences but correlates only with error rates for experienced surgeons while performing difficult tasks. These results provide a novel perspective on the relationship between expertise and surgical performance.

Surgical Competencies Required in Newly Commencing Colorectal Surgeons: an Educational and Training Spectrum

PURPOSE

Surgical training models have changed from master-apprentice to competency-based training. We aimed to determine the relative importance and peak periods of acquiring these competencies in newly commencing colorectal surgeons.

METHODS

A mailed questionnaire to all current Colorectal Surgical Society of Australia and New Zealand (CSSANZ) members was conducted between October and December 2016 assessing the relative importance of each competency and the period or activity of learning or training contributing most to achieving that competency.

RESULTS

The response rate was 43% (90/208) with 87% (n = 75) agreed or strongly agreed to the relevance and applicability of the nine RACS competencies. Competencies varied in perceived importance (strongly agreed: judgment-clinical decision-making (JU) 63%, collaboration/teamwork (CT) 53%, technical expertise (TE) 47%, communication (CO) 44%, medical expertise (ME) 34%, scholarship/teaching (ST) 33%, professionalism (PR) 33%/ethics (ET) 24%, health advocacy (HA) 18%, management (MX) 13%/leadership (LE) 17%), and the peak period for acquiring them (registrar: CO 39%, ST 30%; fellow: TE 62%, CT 44%, ME 40%, JU 38%; consultant: MX/LE 52%, HA 48%, PR/ET 33%).

CONCLUSION

Surgical competencies for colorectal surgeons are accumulated and acquired at varying degrees and periods across a spectrum of continuing registrar, fellow, and consultant education and training. These findings serve as a baseline for further refinement of current and continuing educational and training programs.

An Analysis of the Decision-Making Process After “Decision not to Operate” in Acutely Unwell, High-Risk General Surgery Patients

Objectives:

The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken.

Background:

A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof.

Methods:

We retrospectively evaluated “decisions not to operate” over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth–Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality.

Results:

Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score ( P < .001) and a poorer functional status ( P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively).

Conclusions:

Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.

Surgery Hurts: Characterizing the Experience of Pain in Surgical Patients as Witnessed by Medical Students

BACKGROUND

The patient experience around surgical care is poorly characterized. Medical students have a unique position on the surgical team, which allows them to observe patient experiences that may otherwise be overlooked. The objective of this study was to characterize surgical patients' experience with pain as witnessed by medical students.

STUDY DESIGN

At the end of an 8-week surgical clerkship, we asked all third-year medical students to write a reflective essay describing one surgical patient in pain. We collected 341 essays over a 4-year period and used qualitative content analysis to explore the students' reports of pain experienced by surgical patients.

RESULTS

When asked to tell a story about a surgical patient in pain, medical students report vivid descriptions of physical agony, emotional distress, and patient regret. For example, "Throughout the procedure our patient cried out and writhed in agony from the searing pain in his chest," and "The patient was practically shedding tears, complaining of pain, as [we] changed her dressing." The students' accounts reveal wide-ranging physical and emotional suffering among surgical patients, including alterations in self-image and feelings of vulnerability. Pain and suffering were intensified when patients felt they had lost control, in settings of uncertain prognosis and with unexpected outcomes.

CONCLUSIONS

Students' descriptions of the surgical patient's experience are disturbingly graphic. They expose suffering ranging from generalized discomfort to anguish and excruciating pain. These data suggest that surgical patients have substantial unmet needs with respect to symptom management and emotional support that, if better addressed, could improve the patient experience.

Traits and characteristics of highly successful medical leaders

Background

Medicine attracts a broad range of personality traits but the inner thoughts of its leaders have rarely been studied. The BMJ has been asking perceived leaders in the field a set of structured questions on a weekly basis. Those responses have proved insightful into the characteristic traits of high profile doctors.

Methods

We analysed the responses of each medically qualified doctor interviewed weekly by BMJ Confidential following the use of a set of structured questions about their likes and dislikes. These structured questions allowed us to cross analyse responses.

Results

From 2013 to 2017, 134 medically qualified doctors were identified by the BMJ to be suitable for inclusion in their weekly BMJ Confidential series. These individuals were selected because they were deemed by the BMJ to be leaders in their clinical, medico-political or academic fields. Of the cohort, 91% were white and 69% male. Clinical mistakes by these individuals were not uncommon (28%) over the course of their careers. Conceit and arrogance were despised most (16%) whereas politics was of interest but not political correctness. The founder of the NHS Aneurin Bevan was identified as the best Secretary of State for Health while the worst was Andrew Lansley (26%) followed by the former health secretary Jeremy Hunt.

Conclusion

Medicine attracts a broad range of personalities, but the characteristics of its perceived leaders seem less diverse.

An Epiduroscopy Simulator Based on a Serious Game for Spatial Cognitive Training (EpiduroSIM): User-Centered Design Approach

Background

Performing high-level surgeries with endoscopy is challenging, and hence, an efficient surgical training method or system is required. Serious game–based simulators can provide a trainee-centered educational environment unlike traditional teacher-centered education environments since serious games provide a high level of interaction (feedback that induces learning).

Objective

This study aimed to propose an epiduroscopy simulator, EpiduroSIM, based on a serious game for spatial cognitive training.

Methods

EpiduroSIM was designed based on a serious game. For spatial cognitive training, the virtual environment of EpiduroSIM was modeled based on a cognitive map.

Results

EpiduroSIM was developed considering user accessibility to provide various functions. The experiment for the validation of EpiduroSIM focused on psychological fidelity and repetitive training effects. The experiments were conducted by dividing 16 specialists into 2 groups of 8 surgeons. The group was divided into beginner and expert based on their epiduroscopy experience. The psychological fidelity of EpiduroSIM was confirmed through the training results of the expert group rather than the beginner group. In addition, the repetitive training effect of EpiduroSIM was confirmed by improving the training results in the beginner group.

Conclusions

EpiduroSIM may be useful for training beginner surgeons in epiduroscopy.

Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial

IMPORTANCE

Mindfulness meditation training has been shown to be feasible in surgical trainees, but affective, cognitive, and performance benefits seen in other high-stress populations have yet to be evaluated.

OBJECTIVE

To explore potential benefits to stress, cognition, and performance in postgraduate year 1 (PGY-1) surgery residents receiving modified mindfulness-based stress reduction (modMBSR).

DESIGN, SETTING, AND PARTICIPANTS

This follow-up study is an analysis of the Mindful Surgeon pilot randomized clinical trial of modMBSR (n = 12) vs an active control (n = 9), evaluated at baseline (T1), postintervention (T2), and 1 year (T3), took place at an academic medical center residency training program among PGY-1 surgery residents. Data were collected between June 2016 and June 2017 and analyzed from June 2017 to December 2017.

INTERVENTIONS

Weekly 2-hour modMBSR classes and 20 minutes of daily home practice during an 8-week period vs an active control (different content, same structure).

MAIN OUTCOMES AND MEASURES

Preliminary evidence of efficacy was explored, primarily focusing on perceived stress and executive function and secondarily on burnout, depression, motor skill performance, and changes in blood oxygen level-dependent functional neuroimaging during an emotion regulation task. Group mean scores were calculated at T1, T2, and T3 and in linear mixed-effects multivariate analysis. Effect size for analysis of covariance is presented as partial η2 with the following cutoff points: small, less than 0.06; medium, 0.06 to 0.14; large, greater than 0.14.

RESULTS

Postgraduate year 1 surgery residents (N = 21; 8 [38%] women) were randomized to a modMBSR arm (n = 12) or an active control arm (n = 9). Linear mixed-effects modeling revealed differences at T2 and T3 in perceived stress (mean [SD] difference at T2: modMBSR, 1.42 [5.74]; control, 3.44 [6.71]; η2 = 0.07; mean [SD] difference at T3: modMBSR, 1.00 [4.18]; control, 1.33 [4.69]; η2 = 0.09) and in mindfulness (mean [SD] difference at T2: modMBSR, 3.08 [3.63]; control, 1.56 [4.28]; η2 = 0.13; mean [SD] difference at T3: modMBSR, 2.17 [3.66]; control, -0.11 [6.19]; η2 = 0.15). Burnout at T2 (mean [SD] difference: modMBSR, 4.50 [9.08]; control, 3.44 [6.71]; η2 = 0.01) and T3 (mean [SD] difference: modMBSR, 5.50 [9.96]; control, 5.56 [9.69]; η2 = 0.01) showed similar increase in both groups. Working memory increased more at T2 in the modMBSR arm (mean [SD] difference, 0.35 [0.60]) than in the control arm (mean [SD] difference, 0.21 [0.74]; η2 = 0.02) and at T3 (modMBSR, 0.68 [0.69]; control, 0.26 [0.58]; η2 = 0.20). Cognitive control decreased more in the control arm at T2 (mean [SD] difference at T2: modMBSR, 0.15 [0.40]; control, -0.07 [0.32]; η2 = 0.13) and at T3 (mean [SD] difference: modMBSR, 0.07 [0.59]; control, -0.26 [0.53]; η2 = 0.16). Mean (SD) circle-cutting time improved more at T2 in the modMBSR arm (-24.08 [63.00] seconds) than in the control arm (-4.22 [112.94] seconds; η2 = 0.23) and at T3 in the modMBSR arm (-4.83 [77.94] seconds) than in the control arm (11.67 [145.17] seconds; η2 = 0.13). Blood oxygen level-dependent functional neuroimaging during an emotional regulation task showed unique postintervention activity in the modMBSR arm in areas associated with executive function control (dorsolateral prefrontal cortex) and self-awareness (precuneus).

CONCLUSIONS AND RELEVANCE

In this pilot randomized clinical trial, modMBSR in PGY-1 surgery residents showed potential benefits to well-being and executive function, suggesting a powerful role for mindfulness-based cognitive training to support resident well-being and performance, as mandated by the Accreditation Council for Graduate Medical Education.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03141190.

What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance

OBJECTIVE

To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance.

BACKGROUND

Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety.

METHODS

Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items.

RESULTS

A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals.

CONCLUSIONS

This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

Surgeon Perception of Risk and Benefit in the Decision to Operate

OBJECTIVE

To determine how surgeons' perceptions of treatment risks and benefits influence their decisions to operate.

BACKGROUND

Little is known about what makes one surgeon choose to operate on a patient and another chooses not to operate.

METHODS

Using an online study, we presented a national sample of surgeons (N = 767) with four detailed clinical vignettes (mesenteric ischemia, gastrointestinal bleed, bowel obstruction, appendicitis) where the best treatment option was uncertain and asked them to: (1) judge the risks (probability of serious complications) and benefits (probability of recovery) for operative and nonoperative management and (2) decide whether or not they would recommend an operation.

RESULTS

Across all clinical vignettes, surgeons varied markedly in both their assessments of the risks and benefits of operative and nonoperative management (narrowest range 4%-100% for all four predictions across vignettes) and in their decisions to operate (49%-85%). Surgeons were less likely to operate as their perceptions of operative risk increased [absolute difference (AD) = -29.6% from 1.0 standard deviation below to 1.0 standard deviation above mean (95% confidence interval, CI: -31.6, -23.8)] and their perceptions of nonoperative benefit increased [AD = -32.6% (95% CI: -32.8,--28.9)]. Surgeons were more likely to operate as their perceptions of operative benefit increased [AD = 18.7% (95% CI: 12.6, 21.5)] and their perceptions of nonoperative risk increased [AD = 32.7% (95% CI: 28.7, 34.0)]. Differences in risk/benefit perceptions explained 39% of the observed variation in decisions to operate across the four vignettes.

CONCLUSIONS

Given the same clinical scenarios, surgeons' perceptions of treatment risks and benefits vary and are highly predictive of their decisions to operate.

Surgical Supervisor Feedback Affects Performance: A Blinded Randomized Study

While performing a simple task of following: a suture while closing a surgical wound in a simulated environment, we hypothesized that negative reinforcement results in increased procedural errors, longer operating time and poorer trainee satisfaction. We aimed to measure the effect on participant performance and the perception of the instructor, following positive or negative supervisor feedback during the task. A blinded randomized study was conducted assessing positive and negative supervisor feedback styles on participant performance in a simulated operation room. Students performed the task twice, with a reflection in between the repeated task. We found that the change in procedure time between the two tasks was adversely affected by feedback style. Participants receiving negative feedback sought cues to improve. From this study, it was found that negative supervisor feedback has the potential to adversely affect elements of performance. Despite this, participants receiving negative feedback express a willingness to improve their performance by seeking cues from the supervisor.

An Instrumented Glove to Assess Manual Dexterity in Simulation-Based Neurosurgical Education

The traditional neurosurgical apprenticeship scheme includes the assessment of trainee’s manual skills carried out by experienced surgeons. However, the introduction of surgical simulation technology presents a new paradigm where residents can refine surgical techniques on a simulator before putting them into practice in real patients. Unfortunately, in this new scheme, an experienced surgeon will not always be available to evaluate trainee’s performance. For this reason, it is necessary to develop automatic mechanisms to estimate metrics for assessing manual dexterity in a quantitative way. Authors have proposed some hardware-software approaches to evaluate manual dexterity on surgical simulators. This paper presents IGlove, a wearable device that uses inertial sensors embedded on an elastic glove to capture hand movements. Metrics to assess manual dexterity are estimated from sensors signals using data processing and information analysis algorithms. It has been designed to be used with a neurosurgical simulator called Daubara NS Trainer, but can be easily adapted to another benchtop- and manikin-based medical simulators. The system was tested with a sample of 14 volunteers who performed a test that was designed to simultaneously evaluate their fine motor skills and the IGlove’s functionalities. Metrics obtained by each of the participants are presented as results in this work; it is also shown how these metrics are used to automatically evaluate the level of manual dexterity of each volunteer.

Validation of a Novel Cognitive Simulator for Orbital Floor Reconstruction

PURPOSE

The increasing focus on patient safety in current medical practice has promoted the development of surgical simulation technology in the form of virtual reality (VR) training designed largely to improve technical skills and less so for nontechnical aspects of surgery such as decision making and material knowledge. The present study investigated the validity of a novel cognitive VR simulator called Touch Surgery for a core maxillofacial surgical procedure: orbital floor reconstruction (OFR).

MATERIALS AND METHODS

A cross-sectional study was carried out on 2 groups of participants with different experience levels. Novice graduate dental students and expert surgeons were recruited from a local dental school and academic residency programs, respectively. All participants completed the OFR module on Touch Surgery. The primary outcome variable was simulator performance score. Post-module questionnaires rating specific aspects of the simulation experience were completed by the 2 groups and served as the secondary outcome variables. The age and gender of participants were considered additional predictor variables. From these data, conclusions were made regarding 3 types of validity (face, content, and construct) for the Touch Surgery simulator. Dependent-samples t tests were used to explore the consistency in simulation performance scores across phases 1 and 2 by experience level. Two multivariate ordinary least-squares regression models were fit to estimate the relation between experience and phase 1 and 2 scores.

RESULTS

Thirty-nine novices and 10 experts who were naïve to Touch Surgery were recruited for the study. Experts outperformed novices on phases 1 and 2 of the OFR module (P < .001), which provided the measurement of construct validation. Responses to the questionnaire items used to assess face validity were favorable from the 2 groups. Positive questionnaire responses also were recorded from experts alone on items assessing the content validity for the module. Participant age and gender were not relevant predictors of performance scores.

CONCLUSION

Construct, content, and face validities were observed for the OFR module on a novel cognitive simulator, Touch Surgery. Therefore, OFR simulation on the smart device platform could serve as a useful cognitive training and assessment tool in maxillofacial surgery residency programs.

Cognitive training: How can it be adapted for surgical education?

BACKGROUND

There is a need for new approaches to surgical training in order to cope with the increasing time pressures, ethical constraints, and legal limitations being placed on trainees. One of the most interesting of these new approaches is "cognitive training" or the use of psychological processes to enhance performance of skilled behaviour. Its ability to effectively improve motor skills in sport has raised the question as to whether it could also be used to improve surgical performance. The aim of this review is to provide an overview of the current evidence on the use of cognitive training within surgery, and evaluate the potential role it can play in surgical education.

METHODS

Scientific database searches were conducted to identify studies that investigated the use of cognitive training in surgery. The key studies were selected and grouped according to the type of cognitive training they examined.

RESULTS

Available research demonstrated that cognitive training interventions resulted in greater performance benefits when compared to control training. In particular, cognitive training was found to improve surgical motor skills, as well as a number of non-technical outcomes. Unfortunately, key limitations restricting the generalizability of these findings include small sample size and conceptual issues arising from differing definitions of the term 'cognitive training'.

CONCLUSIONS

When used appropriately, cognitive training can be a highly effective supplementary training tool in the development of technical skills in surgery. Although further studies are needed to refine our understanding, cognitive training should certainly play an important role in future surgical education.

Different Goals, Different Pathways: The Role of Metacognition and Task Engagement in Surgical Skill Acquisition

BACKGROUND

The purpose of this study is to understand why learning goals and performance goals may produce different outcomes in surgical skills training for novices, with specific attention to metacognition and task engagement.

METHODS

Third-year medical students were randomized to a performance or learning-goal condition during a knot tying and suturing training program. Performance was assessed by blinded videotaped review. Demographics, goal orientation, and metacognition were captured with pre- and posttraining questionnaires.

RESULTS

A total of 90 students participated in the training program. Trainees in the learning goals group demonstrated better performance on knot tying (4.30 ± 0.78 vs 3.86 ± 0.95; p < 0.05) and suturing (4.10 ± 0.77 vs 3.54 ± 0.73; p < 0.001). Participants in the learning goals group reported higher task engagement during both knot tying (4.32 ± 0.66 vs 3.90 ± 0.52; p < 0.001) and suturing (4.48 ± 0.42 vs 4.01 ± 0.46; p < 0.001). Additionally, the learning goals group also reported higher metacognition during both knot tying (3.88 ± 0.75 vs 3.59 ± 0.52; p < 0.05) and suturing (3.96 ± 0.75 vs 3.68 ± 0.48; p < 0.05).

CONCLUSIONS

Our findings suggest that learning goals may be optimal for trainees learning new surgical tasks because they elicit increased task engagement and metacognition among trainees.

Defining competencies for safe thyroidectomy: An international Delphi consensus

BACKGROUND

Current methods for teaching and assessing competencies that characterize expert intraoperative performance are inconsistent, subjective, and lack standardization. This mixed-methods study was designed to define and establish expert consensus on the most important competencies required to perform a thyroidectomy safely.

METHODS

Cognitive task analyses for thyroidectomy were performed with semistructured interviews of experts in thyroid surgery. Verbal data were transcribed verbatim, coded, and categorized according to themes that were synthesized into a list of items. Once qualitative data reached saturation, 26 experts were invited to complete 2-round online Delphi surveys to rank each item on a Likert scale of importance (1-7). Consensus was predefined as a Cronbach's α ≥ 0.80.

RESULTS

Sixty items were synthesized from 5 interviews and categorized into 8 sections: preparation (n = 8), incision/exposure (n = 11), general considerations (n = 4), middle thyroid vein (n = 1), superior pole (n = 5), inferior pole (n = 5), posterolateral dissection (n = 19), and closure (n = 7). Eighteen (69%) experts from 3 countries participated in the Delphi survey. Consensus was achieved after 2 voting rounds (Cronbach's α = 0.95). Greatest weighted sections included "Superior Pole Dissection" and "Posterolateral Dissection."

CONCLUSION

Consensus was achieved on defining the most important competencies for safe thyroidectomy. This blueprint serves as the basis for instructional design and objective assessment tools to evaluate performance.

Relationship between obstetricians' cognitive and affective traits and delivery outcomes among women with a prior cesarean

OBJECTIVE

We sought to investigate the relationship between obstetricians' cognitive traits and delivery outcomes among women with a prior cesarean delivery.

STUDY DESIGN

A total of 94 obstetricians completed 5 standardized psychometric scales: Reflective Coping, Proactive Coping, Multiple Stimulus Types Ambiguity Tolerance (MSTAT), Need for Cognition, and State-Trait Anxiety Inventory. Scores were analyzed by quartile. Delivery data were collected for primiparas with 1 prior low transverse cesarean delivery and a term, cephalic singleton. We used χ(2) tests and random effects logistic regression to examine the relationship between obstetricians' cognitive traits and their patients' frequency of trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC).

RESULTS

Of 1502 eligible patients, 22.6% underwent TOLAC. Women were more likely to undergo TOLAC when cared for by physicians with scores in the highest quartile of the proactive coping (33.6% vs 19.6%; P < .001), MSTAT (29.2% vs 21.0%; P = .002), and Need for Cognition (27.9% vs 21.5%; P = .02) assessments, or in the lowest quartile for anxiety assessment (28.0% vs 20.6%; P = .001). Similarly, those with high proactive coping (18.0% vs 11.3%; P = .001), high MSTAT (16.6% vs 11.8%; P = .03), and low anxiety (19.2% vs 10.4%; P < .001) had greater VBAC rates. Random effects regression analyses revealed physicians with high proactive coping remained significantly more likely to have patients undergo TOLAC (adjusted odds ratio, 1.86; 95% confidence interval, 1.10-3.14) and those with low anxiety remained significantly more likely to have patients experience VBAC (adjusted odds ratio, 2.08; 95% confidence interval, 1.28-3.37).

CONCLUSION

There is an increased likelihood of TOLAC and VBAC for women delivered by physicians with more proactive coping and less anxiety.

Ventriculostomy Simulation Using Patient-Specific Ventricular Anatomy, 3D Printing, and Hydrogel Casting

BACKGROUND

Educational simulators provide a means for students and experts to learn and refine surgical skills. Educators can leverage the strengths of medical simulators to effectively teach complex and high-risk surgical procedures, such as placement of an external ventricular drain.

OBJECTIVE

Our objective was to develop a cost-effective, patient-derived medical simulacrum for cerebral lateral ventriculostomy.

METHODS

A cost-effective, patient-derived medical simulacrum was developed for placement of an external lateral ventriculostomy. Elastomeric and gel casting techniques were used to achieve realistic brain geometry and material properties. 3D printing technology was leveraged to develop accurate cranial properties and dimensions. An economical, gravity-driven pump was developed to provide normal and abnormal ventricular pressures. A small pilot study was performed to gauge simulation efficacy using a technology acceptance model.

RESULTS

An accurate geometric representation of the brain was developed with independent lateral cerebral ventricular chambers. A gravity-driven pump pressurized the ventricular cavities to physiologic values. A qualitative study illustrated that the simulation has potential as an educational tool to train medical professionals in the ventriculostomy procedure.

CONCLUSION

The ventricular simulacrum can improve learning in a medical education environment. Rapid prototyping and multi-material casting techniques can produce patient-derived models for cost-effective and realistic surgical training scenarios.

Surgeons' and trainees' perceived self-efficacy in operating theatre non-technical skills

BACKGROUND

An important factor that may influence an individual's performance is self-efficacy, a personal judgement of capability to perform a particular task successfully. This prospective study explored newly qualified surgeons' and surgical trainees' self-efficacy in non-technical skills compared with their non-technical skills performance in simulated scenarios.

METHODS

Participants undertook surgical scenarios challenging non-technical skills in two simulation sessions 6 weeks apart. Some participants attended a non-technical skills workshop between sessions. Participants completed pretraining and post-training surveys about their perceived self-efficacy in non-technical skills, which were analysed and compared with their performance in surgical scenarios in two simulation sessions. Change in performance between sessions was compared with any change in participants' perceived self-efficacy.

RESULTS

There were 40 participants in all, 17 of whom attended the non-technical skills workshop. There was no significant difference in participants' self-efficacy regarding non-technical skills from the pretraining to the post-training survey. However, there was a tendency for participants with the highest reported self-efficacy to adjust their score downwards after training and for participants with the lowest self-efficacy to adjust their score upwards. Although there was significant improvement in non-technical skills performance from the first to second simulation sessions, a correlation between participants' self-efficacy and performance in scenarios in any of the comparisons was not found.

CONCLUSION

The results suggest that new surgeons and surgical trainees have poor insight into their non-technical skills. Although it was not possible to correlate participants' self-belief in their abilities directly with their performance in a simulation, in general they became more critical in appraisal of their abilities as a result of the intervention.

The effect of divided attention on novices and experts in laparoscopic task performance

BACKGROUND

Attention is important for the skilful execution of surgery. The surgeon's attention during surgery is divided between surgery and outside distractions. The effect of this divided attention has not been well studied previously. We aimed to compare the effect of dividing attention of novices and experts on a laparoscopic task performance.

METHODS

Following ethical approval, 25 novices and 9 expert surgeons performed a standardised peg transfer task in a laboratory setup under three randomly assigned conditions: silent as control condition and two standardised auditory distracting tasks requiring response (easy and difficult) as study conditions. Human reliability assessment was used for surgical task analysis. Primary outcome measures were correct auditory responses, task time, number of surgical errors and instrument movements. Secondary outcome measures included error rate, error probability and hand specific differences. Non-parametric statistics were used for data analysis.

RESULTS

21109 movements and 9036 total errors were analysed. Novices had increased mean task completion time (seconds) (171 ± 44SD vs. 149 ± 34, p < 0.05), number of total movements (227 ± 27 vs. 213 ± 26, p < 0.05) and number of errors (127 ± 51 vs. 96 ± 28, p < 0.05) during difficult study conditions compared to control. The correct responses to auditory stimuli were less frequent in experts (68 %) compared to novices (80 %). There was a positive correlation between error rate and error probability in novices (r (2) = 0.533, p < 0.05) but not in experts (r (2) = 0.346, p > 0.05).

CONCLUSION

Divided attention conditions in theatre environment require careful consideration during surgical training as the junior surgeons are less able to focus their attention during these conditions.

A tool for training in decision making for emergency general surgery--explicit training is possible through facilitation

BACKGROUND

Emergency general surgery is increasingly recognized as an area for improvement within the National Health Service in the United Kingdom. Our aim was to test the feasibility of a tool we developed in assessing and facilitating surgical decision making by trainees in the emergency setting.

METHODS

A decision-making tool based on common decisions in surgery was designed and incorporated prospectively into patient clerking. The 10 decisions available to surgeons were divided into 3 major headings: discharge decisions, observation decisions, and operative decisions. "Ideal decisions" were derived from the final diagnosis on discharge by 2 independent clinicians and compared with initial decisions made by surgeons. We analyzed the data with a view to validate the tool using 2 methods. Firstly, we looked at the percentage of correct decisions made by different grades of surgeon, and secondly, we analyzed the trends in deviations from ideal decisions.

RESULTS

The decision-making tool was completed for 136 emergent surgical admissions over 2 months. Interns made less "ideal" decisions compared with residents (45% vs 56%, respectively; p = 0.10, Fisher exact test) and attending surgeons (45% vs 70%, respectively; p = 0.0001). Interns made more "admit and observe or investigate" decisions compared with residents (63% vs 55%, respectively; p = 0.27) and attending surgeons (63% vs 51%, respectively; p = 0.01), who were more likely to decide to operate on or discharge patients. A repeat study over the subsequent 2-month period has shown comparable findings in proportion of ideal decisions for each grade of surgeon.

CONCLUSIONS

There are significant differences in the proportion of "ideal decisions" and types of decisions between interns and attending surgeons suggesting a learning curve and potential for using this tool in decision-making training. The tool inherently facilitates discussion over decisions made by making these explicit. Repeating the study revealed an internal consistency.

Psychological insight for surgeons

Psychology IS for surgeons!

Knowing the operative game plan: a novel tool for the assessment of surgical procedural knowledge

BACKGROUND

What is the source of inadequate performance in the operating room? Is it a lack of technical skills, poor judgment or a lack of procedural knowledge? We created a surgical procedural knowledge (SPK) assessment tool and evaluated its use.

METHODS

We interviewed medical students, residents and training program staff on SPK assessment tools developed for 3 different common general surgery procedures: inguinal hernia repair with mesh in men, laparoscopic cholecystectomy and right hemicolectomy. The tools were developed as a step-wise assessment of specific surgical procedures based on techniques described in a current surgical text. We compared novice (medical student to postgraduate year [PGY]-2) and expert group (PGY-3 to program staff) scores using the Mann-Whitney U test. We calculated the total SPK score and defined a cut-off score using receiver operating characteristic analysis.

RESULTS

In all, 5 participants in 7 different training groups (n = 35) underwent an interview. Median scores for each procedure and overall SPK scores increased with experience. The median SPK for novices was 54.9 (95% confidence interval [CI] 21.6-58.8) compared with 98.05 (95% CP 94.1-100.0) for experts (p = 0.012). The SPK cut-off score of 93.1 discriminates between novice and expert surgeons.

CONCLUSION

Surgical procedural knowledge can reliably be assessed using our SPK assessment tool. It can discriminate between novice and expert surgeons for common general surgical procedures. Future studies are planned to evaluate its use for more complex procedures.

Why surgeons can say "no": exploring "unilateral withholding"

OBJECTIVE

To explore why it is permissible for surgeons to "unilaterally withhold" surgery, whereas it is not commonplace (in the United States) to unilaterally withhold cardiopulmonary resuscitation (CPR) for clinical situations with similar degrees of uncertainty and prognosis.

DATA SOURCES

The medical literature was sampled using PubMed and Google search engines, employing a variety of search strategies to capture articles relating to medical/surgical decision-making, risk aversion, acute care surgery, and withholding life-saving therapies. These topics are used to highlight interprovider variability that affects all practitioners-not just surgeons-and to consider why we deem it permissible for surgeons to withhold surgery, whereas-in the United States, at least-it is not routinely permissible for clinicians to unilaterally withhold mechanical ventilation and CPR for cases with similar prognoses.

CONCLUSIONS

While there are no published research studies that deal directly with this topic, knowledge, heuristics, experience, variable aversion to risk, and other features inherent in medical-surgical education likely impact decisions to offer or withhold potentially life-saving therapies of all kinds. Both surgeons and clinicians, who request surgical consultation for hospitalized patients, should consider these issues and politely pursue second opinions when there is any doubt whether forgoing surgery is in the patient's best interests. Similarly, while unilateral withholding of CPR is not commonly employed in some medical cultures, including the United States, beneficence can be facilitated through robust informed consent.

Does residency training improve cognitive competence in obstetric and gynaecologic surgery?

OBJECTIVE

To develop an operative knowledge assessment tool to evaluate the cognitive competence of trainees in obstetric and gynaecologic surgery and to determine the rate of change in competence during a five-year residency program.

METHODS

Twenty-eight participants in five training groups (PGY-1 to PGY-5) in McGill University's residency program in obstetrics and gynaecology underwent an evaluation based on surgical cognitive competence (SCC) assessment tools developed for three different obstetric and gynaecologic operations: open total abdominal hysterectomy (TAH), Caesarean section, and laparoscopic bilateral tubal sterilization (BTL). The tools were developed as checklists listing every step in each operation based on techniques described in current surgical texts. Using analysis of variance and linear regressions, statistical significance was established for procedure-specific scores and overall SCC scores. In addition, the rate of change of cognitive competence throughout the training years was calculated. Finally, using a t test, the overall SCC score was compared to a "critical steps score".

RESULTS

Critical steps scores and overall SCC scores increased with training experience at an average yearly rate of 13.36% (P < 0.001). Procedure-specific scores increased yearly, by 15.73% for TAH (P < 0.001), 8.06% for Caesarean section (P < 0.001), and 16.31% for BTL (P < 0.001). The difference between overall scores and critical steps scores was not statistically significant for the study cohort (P = 0.94).

CONCLUSION

Surgical cognitive competence among obstetrics and gynaecology residents can be reliably assessed with our evaluation tool, and it increases proportionally with residency education, reaching maximum scores during the final year of training. This type of information may be helpful in ascertaining how long a residency program should be.

Designing simulator-based training: an approach integrating cognitive task analysis and four-component instructional design

Most studies of simulator-based surgical skills training have focused on the acquisition of psychomotor skills, but surgical procedures are complex tasks requiring both psychomotor and cognitive skills. As skills training is modelled on expert performance consisting partly of unconscious automatic processes that experts are not always able to explicate, simulator developers should collaborate with educational experts and physicians in developing efficient and effective training programmes. This article presents an approach to designing simulator-based skill training comprising cognitive task analysis integrated with instructional design according to the four-component/instructional design model. This theory-driven approach is illustrated by a description of how it was used in the development of simulator-based training for the nephrostomy procedure.

The effect of distractions in the operating room during endourological procedures

Background

Professionals working in the operating room (OR) are subject to various distractions that can be detrimental to their task performance and the quality of their work. This study aimed to quantify the frequency, nature, and effect on performance of (potentially) distracting events occurring during endourological procedures and additionally explored urologists’ and residents’ perspectives on experienced ill effects due to distracting factors.

Methods

First, observational data were collected prospectively during endourological procedures in one OR of a teaching hospital. A seven-point ordinal scale was used to measure the level of observed interference with the main task of the surgical team. Second, semistructured interviews were conducted with eight urologists and seven urology residents in two hospitals to obtain their perspectives on the impact of distracting factors.

Results

Seventy-eight procedures were observed. A median of 20 distracting events occurred per procedure, which corresponds to an overall rate of one distracting event every 1.8 min. Equipment problems and procedure-related and medically irrelevant communication were the most frequently observed causes of interruptions and identified as the most distracting factors in the interviews. Occurrence of distracting factors in difficult situations requiring high levels of concentration was perceived by all interviewees as disturbing and negatively impacting performance. The majority of interviewees (13/15) thought distracting factors impacted more strongly on residents’ compared to urologists’ performance due to their different levels of experience.

Conclusion

Distracting events occur frequently in the OR. Equipment problems and communication, the latter both procedure-related and medically irrelevant, have the largest impact on the sterile team and regularly interrupt procedures. Distracting stimuli can influence performance negatively and should therefore be minimized. Further research is required to determine the direct effect of distraction on patient safety.

Design, development, and validation of a take-home simulator for fundamental laparoscopic skills: using Nintendo Wii for surgical training

Assuring quality surgical trainees within the confines of reduced work hours mandates reassessment of educational paradigms. Surgical simulators have been shown to be effective in teaching surgical residents, but their use is limited by cost and time constraints. The Nintendo Wii gaming console is inexpensive and allows natural hand movements similar to those performed in laparoscopy to guide game play. We hypothesize that surgical skills can be improved through take-home simulators adapted from affordable off-the-shelf gaming consoles. A total of 21 surgical residents participated in a prospective, controlled study. An experimental group of 14 surgical residents was assigned to play Marble Mania on the Nintendo Wii using a unique physical controller that interfaces with the WiiMote controller followed by a simulated electrocautery task. Seven residents assigned to the control group performed the electrocautery task without playing the game first. When compared with the control group, the experimental group performed the task with fewer errors and superior movement proficiency (P < 0.05). The experimental group demonstrated increased ambidexterity with improvement in proficiency of the nondominant hand over time. In conclusion, the Nintendo Wii gaming device along with Marble Mania serves as an effective take-home surgical simulator.

Development of expertise in surgical training

Surgical training is currently undergoing many changes. Moves toward an outcomes-based education based on achievement of core competencies will have a significant impact on how trainees are taught and evaluated. New strategies must therefore be sought to enhance surgical training to achieve outstanding resident education and safe patient care. An extensive body of literature is available concerning the attributes of experts and the development of expertise. It is increasingly apparent that the extent and nature of practice, as well as the practice structure, are critical to the development of complex motor skills. This article reviews the attributes of expert surgeons, as well as the role of deliberate practice, contextual interference, and distributed practice in the development of expertise. The role of simulation in surgical training is also discussed. The findings have direct relevance to surgical training and continuing medical educational courses, and these results may help in the design of future surgical training programs.