Factors affecting operative autonomy and performance during otolaryngology training: A multicenter trial

Operative competency and autonomy achieved by senior vascular surgery integrated residents and fellows

OBJECTIVE

Integrated vascular surgery residency and traditional fellowship training paradigms offer two unique pathways to independent vascular surgery practice and board eligibility. Although operative case requirements are equivalent in each, it is unknown whether operative competence achieved by graduates is comparable between paradigms. We sought to examine operative performance and autonomy achieved between vascular integrated residents (VIRs) and vascular surgery fellows (VSFs) in their final year of training.

METHODS

Operative assessments were collected between 2018 and 2022 from a national cohort of vascular surgery training programs using the Society for Improving Medical Professional Learning (SIMPL) OR assessment application. Statistical analysis of intraoperative autonomy, performance, and case complexity was stratified by training paradigm. Generalized linear mixed models were conducted to compare assessments of autonomy and performance between VIRs and VSFs in their graduating year, controlling for case complexity and procedure type (open or endovascular). To account for the statistical dependency within the nested data, the random effects of trainee, faculty, program, and procedure were included. Separate analyses were conducted for faculty assessments and trainee self-assessments. Data were analyzed using R software.

RESULTS

Twenty-five training programs (n = 12 residency; n = 13 fellowship) collected 4927 assessments (n = 2232 assessments by faculty; n = 2695 self-assessments by trainees) from 106 trainees and 94 faculty. There were no differences in faculty assessments or trainee self-assessments of operative performance (faculty: B = 0.06; P = .56; trainee: B = -0.15; P = .19) or autonomy (faculty: B = 0.06; P = .61; trainee: B = 0.03; P = .83) between VIRs and VSFs during the final year of training, even when corrected for case complexity and procedure type. Using the model, the predicted performance and autonomy ratings for VIRs and VSFs were estimated across postgraduate year and various case complexities for open and endovascular procedures, respectively.

CONCLUSIONS

During the final year of vascular surgery training, VIR and VSF trainees achieve similar operative performance and autonomy for both endovascular and open procedures. Despite inherent differences in the training paradigms, equivalent operative competence and autonomy are achieved by graduation, suggesting similar preparedness for independent practice.

The Gender Disparity in Operative Opportunities for Trainee Surgeons: A Review

INTRODUCTION

Assessing gender disparity in surgical trainees' operative opportunities and experience quantifies implicit gender bias and reflects a summation of many smaller biased interactions within the operating room environment. Highlighting gender disparity in surgery informs a platform for advocacy.

METHODS

A systematic literature search was performed using Medline, Web of Science, OpenMD and Science Direct consistent with the Preferred Reporting Items for Systematic Reviews and Metanalysis guidelines. A Boolean search strategy was used to identify articles relevant to gender in operative surgery. Only English language studies that assessed the gender of surgical trainees with regards to operative cases for total and/or autonomously performed case numbers were included.

RESULTS

Fifteen papers assessing the influence of gender on operative opportunities for trainee surgeons were identified. A discrepancy between the operative experiences of men and women trainee surgeons was found. Of eight studies assessing gender differences in total case numbers, four reported women undertaking fewer total cases than men; a similar trend was demonstrated in two studies that failed to reach statistical significance. Eight of eleven studies examining surgical autonomy reported more surgical autonomy afforded to men trainee surgeons than women.

CONCLUSIONS

A gendered bias in the operative opportunities afforded to trainee surgeons is suggested in the literature, reflecting implicit bias that underlies surgical culture worldwide. Although surgical specialties continue to have vast gender inequity, we fail to leverage talent and the benefits of diverse skills and experience, to the detriment of ourselves and our patients. Quantifying this issue will inform change.

Quality of Office-based Procedure Training During Laryngology Fellowship

OBJECTIVES

The primary objective was to assess the perspectives of recent laryngology fellowship graduates on office-based procedure training, with a secondary objective to compare this with previous research on perspectives of fellowship directors.

METHODS

Recent laryngology fellowship graduates were surveyed via an online survey platform regarding post-fellowship practice and various aspects of office-based procedure training, including perceived competence, mentorship, and barriers.

RESULTS

There were 51 respondents. Seventy-six percent of respondents felt they "definitely" received adequate office procedure training. Number of procedures as primary surgeon was significantly associated with perception of adequate training (OR 1.54, 95% CI: 1.08-2.19, p = 0.018) and high post-fellowship office procedure volume (OR 1.56, 95% CI: 1.02-2.39, p = 0.040). Fellows reported a lower percentage of procedures as primary surgeons compared with program directors (46.8% vs. 61.9%, p = 0.028). Fellows and directors agreed that informal debriefs were more commonly employed than more structured training elements such as checklists and simulators. Of nine office procedures, laryngeal electromyography, KTP laser, and transnasal esophagoscopy had the greatest decreases in practice after training.

CONCLUSION

Although most recent laryngology fellowship graduates endorse adequate office-based procedure training, a range of individual experiences exists, and office procedure volume, both overall and across individual procedures, may decrease after fellowship. Fellows performing office procedures as primary surgeons may be linked to perceived quality of training and post-fellowship volume.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1802-1806, 2024.

Evaluation Tools for Assessing Autonomy of Surgical Residents in the Operating Room and Factors Influencing Access to Autonomy: A Systematic Literature Review

BACKGROUND

Surgical residents in France lack a clear pedagogical framework for achieving autonomy in the operating room. The progressive acquisition of surgical autonomy is a determining factor in the confidence of operators for their future independent practice. Currently, there is no autonomy scale commonly used in Europe. The objective of this study is to identify existing tools for quantifying the autonomy of residents and the factors that influence it.

MATERIALS AND METHODS

We conducted a qualitative systematic review following the recommendations of the Systematic Review Without Meta-Analysis (SWiM) guidelines. Publications were extracted from the MEDLINE (PubMed), EMBASE, and PSYCINFO databases. All publications without date restrictions up to July 2022 were identified.

RESULTS

Among the 231 identified publications, 21 met the inclusion criteria. Seventeen publications used a graded autonomy assessment tool by the student and/or the teacher, while 4 used evaluations by an observing third party. We found 8 different autonomy scales, with the Zwisch Scale representing 57.1% of the cases. Factors influencing autonomy were diverse, including the work context, experience, and gender of the resident and their teacher.

DISCUSSION

We found heterogeneity in the tools used to "measure" the autonomy of a resident in the operating room. The SIMPL tool or the Zwisch Scale appear to be the most frequently used tools. The relationship between autonomy, performance, confidence, and knowledge may require multidimensional tools that encompass various areas of competence, but this could make their daily application more challenging. The factors influencing autonomy are numerous; and understanding them would improve teaching in the operating room. There is a significant lack of data on surgical autonomy in France, as well as a lack of evaluation in the field of gynecology-obstetrics worldwide.

Bias in Surgical Residency Evaluations: A Scoping Review

OBJECTIVE

Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States.

DESIGN

A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively.

SETTING/PARTICIPANTS

English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included.

RESULTS

The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery.

CONCLUSIONS

Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback

BACKGROUND

Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy.

METHODS

Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141).

RESULTS

Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p < .001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p = .009) and attendings (69% vs. 32%, p < .01).

CONCLUSIONS

Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations.