Optimizing resident operative self-confidence through competency-based surgical education modules: are we there yet?

The Making of Confident Surgeons: Why and How?

Low self-confidence in surgical residents can be associated with poor self-efficacy and perceptions of sub-optimal preparedness for practice at graduation. The influence of social and biologic determinants of confidence deserves further study. Through a randomized controlled trial of procedure-specific didactic and low fidelity simulation training for vaginal surgery, we showed positive correlations between self-confidence and objective performance in the real operating room for three different surgical procedures and through validated scales. This demonstrates an accurate ability of novice surgeons to self-monitor in a high-stakes environment. Our trial results (described in full elsewhere), combined with our multiple one-on-one teaching interactions with surgical trainees through the trial, incentivized us to evaluate self-confidence in view of optimizing it through directed training and feedback. The current opinion piece summarizes our main findings for surgical educators and emphasizes their role engaging with trainees at extremes of confidence.

What are the learning objectives in surgical training - a systematic literature review of the surgical competence framework

OBJECTIVE

To map the landscape of contemporary surgical education through a competence framework by conducting a systematic literature review on learning outcomes of surgical education and the instructional methods applied to attain the outcomes.

BACKGROUND

Surgical education has seen a paradigm shift towards competence-based training. However, a gap remains in the literature regarding the specific components of competency taught and the instructional methods employed to achieve these outcomes. This paper aims to bridge this gap by conducting a systematic review on the learning outcomes of surgical education within a competence framework and the instructional methods applied. The primary outcome measure was to elucidate the components of competency emphasized by modern surgical curricula. The secondary outcome measure was to discern the instructional methods proven effective in achieving these competencies.

METHODS

A search was conducted across PubMed, Medline, ProQuest Eric, and Cochrane databases, adhering to PRISMA guidelines, limited to 2017-2021. Keywords included terms related to surgical education and training. Inclusion criteria mandated original empirical studies that described learning outcomes and methods, and targeted both medical students and surgical residents.

RESULTS

Out of 42 studies involving 2097 participants, most concentrated on technical skills within competency-based training, with a lesser emphasis on non-technical competencies. The effect on clinical outcomes was infrequently explored.

CONCLUSION

The shift towards competency in surgical training is evident. However, further studies on its ramifications on clinical outcomes are needed. The transition from technical to clinical competence and the creation of validated assessments are crucial for establishing a foundation for lifelong surgical learning.

Summative Evaluation of Vaginal Surgery Skills: Setting A Pass-Fail Score

INTRODUCTION AND HYPOTHESIS

We developed a summative assessment tool to evaluate competent performance on three procedure-specific low fidelity simulation models for vaginal surgery. Our purpose was to determine a pass-fail score for each model.

METHODS

We enrolled participants (2011-2023, three Canadian academic centers) and grouped them according to operative competency in vaginal procedures. Novice operators were medical students recruited through targeted advertisement to clerkship level medical students. Proficient operators consisted of gynecology residents from the intervention arm of a randomized controlled trial, trained to competence in the use of the models; urogynecology fellows and attending gynecologic surgeons recruited through departmental rounds. All participants were asked to perform the three procedures on the models, were videotaped, and their performance assessed by evaluators familiar with the procedure and the scoring system, blinded to operator identity. A total performance score (range 0-400) assessed timing and errors. Basic skill deductions were set a priori. We calculated sensitivity and specificity scores and obtained an optimal cutoff based on Youden's J statistic.

RESULTS

For anterior repair, we rated 46 novice and 16 proficient videos. The pass-fail score was 170/400. For posterior repair, we rated 54 novice and 14 proficient videos. The pass-fail score was 140/400. For vaginal hysterectomy, we rated 47 novice and 12 proficient videos. The pass-fail score was 180/400. Scores of proficient operators were significantly better than those of novice participants (p < 0.001 for all).

CONCLUSIONS

A pass-fail score can distinguish between novice and proficient operators and can be used for summative assessment of surgical skill.

Role Reversal Between Trainees and Surgeons: Improving Autonomy and Confidence in Surgical Residents

INTRODUCTION

There are increasing concerns regarding resident autonomy in the context of efficiency, legal ramifications, patient expectations and patient safety. However, autonomy is necessary to develop competent, independent surgeons. Therefore, educational paradigms that maximize opportunities for entrustability without sacrificing patient safety are necessary to ensure adequate training for surgeons.

METHODS

This is a prospective, qualitative study of intraoperative role reversal between surgeons and residents. Using Likert scales and binary questions, preintervention and postintervention surveys were collected, evaluating variables including intraoperative learning, decision making, communication, confidence, autonomy and opportunity for safe struggle. The Mann-Whitney U test was used to analyze results and compare responses between training years.

RESULTS

Thirty-six general surgery residents comprising post-graduate year 1, 2, 4, and 5 acted as primary surgeon in a total of 36 cases. Preoperative knowledge scores were significantly higher in more senior residents (P < 0.001), but all residents had significant improvement in knowledge scores postoperatively (P < 0.001). The knowledge improvement was quantitatively larger for junior versus senior residents. Intraoperative decision making significantly improved after the intervention for all training levels (P < 0.001). 25 intraoperative "rescues" were performed by faculty for failure to progress or unsafe conditions (23 for junior residents, 2 for senior residents). Residents indicated that this intraoperative role reversal improved preparation, confidence, autonomy, and intraoperative communication.

CONCLUSIONS

Intraoperative role reversal between residents and surgeons provides a safe opportunity for maximizing learning and increasing entrustability under direct supervision.

Self-reported confidence and perceived training needs of surgical interns at a regional hospital in Ghana: a questionnaire survey

BACKGROUND

Due to disparities in their regional distribution of the surgical specialists, those who have finished "housemanship," which is the equivalent of an internship, are serving as main surgical care providers in rural areas in Ghana. However, the quantitative volume of postgraduate surgical training experience and the level of self-reported confidence after formal training have not been investigated in detail in sub-Saharan Africa.

METHODS

The quality-assessment data of the Department of surgery at a regional hospital in Ghana was obtained from the convenience samples of house officers (HOs) who had their surgical rotation before July 2019. A self-reported questionnaire with 5-point Likert-type scale and open-ended responses regarding the 35 topics listed as learning objectives by the Medical and Dental Council of Ghana were retrospectively reviewed to investigate the volume of surgical experience, self-reported confidence, and perceived training needs.

RESULTS

Among 52 respondents, the median self-reported number of patients experienced for each condition was less than 11 cases. More than 40% of HOs reported that they had never experienced cases of liver tumor (n = 21, 40.4%), portal hypertension (n = 23, 44.2%), or cancer chemotherapy/cancer therapy (n = 26, 50.0%). The median self-confidence score was 3.69 (interquartile range, 3.04 ~ 4.08). More than 50% of HOs scored ≤2 points on the self-confidence scale of gastric cancer (n = 28, 53.8%), colorectal cancer (n = 31, 59.6%), liver tumors (n = 32, 61.5%), and cancer chemotherapy/cancer therapy (n = 38, 73.1%). The top 3 reasons for not feeling confident were the limited number of patients (n = 42, 80.8%), resources and infrastructure (n = 21, 40.4%), and amount of supervision (n = 18, 34.6%). Eighteen HOs (34.6%) rated their confidence in their surgical skills as ≤2 points. Of all respondents, 76.9% (n = 40) were satisfied with their surgical rotation and 84.6% (n = 44) perceived the surgical rotation as relevant to their future work. Improved basic surgical skills training (n = 27, 51.9%) and improved supervision (n = 18, 34.6%) were suggested as a means to improve surgical rotation.

CONCLUSIONS

Surgical rotation during housemanship (internship) should be improved in terms of cancer treatment, surgical skills, and supervision to improve the quality of training, which is closely related to the quality of surgical care in rural areas.

Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya

BACKGROUND

The education of surgical trainees is ideally designed to produce surgeons with both confidence and competence. This involves the development of autonomy in the operating room. Factors associated with autonomy and entrustment have been studied in high-resource settings. In a resource-limited context, where autonomy is solely at the discretion of faculty, and there are fewer external constraints to restrict it, we hypothesized that assessment of a trainee's performance would be dependent upon reported confidence levels of both faculty and trainees in those trainees' abilities.

MATERIALS AND METHODS

At a teaching hospital in rural Kenya, operative experience surveys were administered to eleven general surgery trainees (PGY1-5) and six faculty paired dyads immediately following operative procedures in May 2016 to elicit self-reported assessments of confidence, hesitation, and ability as measured by the Zwisch Scale. We examined factors related to learning and used dyadic structural equation models to understand factors related to the assessment of ability.

RESULTS

There were 107 paired surveys among 136 trainees and 130 faculty evaluations. Faculty scrubbed into 76 (72%) cases. In comparison to trainees, faculty were more likely to give a higher average score for confidence (4.08 versus 3.90; P value: 0.005), a lower score for hesitation (2.67 versus 2.84; P value: 0.001), and a lower score for the ability to perform the operation independently (2.73 versus 3.02; P value: 0.01). Faculty and trainee perceptions of hesitation influenced their ability scores. Trainee hesitation (OR 12.1; 1.2-127.6, P = 0.04) predicted whether trainees reported experiencing learning.

CONCLUSIONS

Between trainees and faculty at a teaching program in rural Kenya, assessment scores of confidence, hesitation, and ability differ in value but remain fairly correlated. Hesitation is predictive of ability assessment, as well as self-reported learning opportunities. Focus upon identifying when trainees hesitate to proceed with a case may yield important educational opportunities.

Survey on the surgical skills of orthopedics and traumatology residents from accredited and nonaccredited institutions in İstanbul

OBJECTIVE

To investigate whether orthopedic and traumatology residents who are undergoing training achieve competence in surgical techniques after completion of their specialization and to determine whether there are significant differences between the responses of residents from accredited and nonaccredited institutions.

METHODS

A total of 131 orthopedics and traumatology residents from nine institutions in the İstanbul province answered the questionnaire during the morning training meeting. In addition to basic demographic data, level of seniority, equipment competence, and theoretical and practical training, the residents were asked about their opinion on what type of surgeries they could perform after their specialization, considering the surgery and follow-up of the case as well as the complications occurring during this period. The residents responded to questions on 46 surgeries under the main headings of trauma, arthroscopy, arthroplasty, spine, pediatric orthopedics, hand surgery, deformity, and bone and soft tissue tumors. In addition to descriptive statistical methods, one-way analysis of variance, Tukey's multiple comparison test, and chi square test were used to evaluate the data. The significance level for the results was set at p<0.05.

RESULTS

In total, 131 orthopedics and traumatology residents answered the questionnaire. Furthermore, 53 (40.5%) specialization students were employed at accredited institutions and 78 (59.5%) at nonaccredited institutions. According to the responses, case presentations, article-writing sessions, and in-province meetings held regularly at accredited institutions showed a significant difference compared to non-accredited institutions (p<0.05), and the residents at the accredited institutions benefited significantly more from the availability of books and electronic media in gaining theoretical knowledge (p<0.05). When the responses of the residents from accredited and nonaccredited institutions regarding 46 different surgeries were compared, a significant difference was found in 17 of them (p<0.05). There was a significant difference between the averages of residents' responses on the surgical fields they have interest for (p<0.05). It was determined that the residents believed that they could mostly perform surgeries in the fields of trauma, followed by arthroplasty, deformity, arthroscopy, pediatric orthopedics, hand surgery, and spine and tumor surgery. According to their level of seniority, a significant difference was found between the averages of residents' opinions regarding their surgical skill levels (p=0.02).

CONCLUSION

We believe that it would be beneficial for the trainers to take necessary precautions to increase the skill levels of the residents of orthopedic surgery. Accreditation significantly contributes to the standardization of education as well as quality improvement. Further action should be taken to increase the number of accredited clinics.