Residents' perception of skill decay during dedicated research time

Skill decay in surgeons deployed on military operations: a systematic review

INTRODUCTION

Decay of surgical skills due to paucity of opportunity to operate is a potential threat to patients being cared for by the Defence Medical Services while on operational deployment. Our aim was to review the literature regarding skill decay in the trained surgeon in order to understand how it may affect clinical performance and patient outcomes. We also wished to survey the likely causes of such decay and possible means of mitigation.

METHODS

A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study bias assessment was also undertaken. Content summaries for the papers included study design and methodology, participant level of experience, measures and magnitude of effect, duration of no practice, and study limitations.

RESULTS

Five papers met the selection criteria. There were insufficient quantitative data on the impact of surgical skill decay on patient outcome, surgeon performance or mitigation strategies, and a meaningful quantitative synthesis could not be undertaken.

CONCLUSIONS

This systematic review of the literature found very little specific evidence confirming or refuting surgical skill decay in trained surgeons, with measurement of decay hampered by the lack of an accepted methodology. Studying this in the deployed setting may offer a firmer evidence base from which to generate policy. Potential mitigation strategies are discussed. PROSPERO registration number ID260846.

Utilization Large Animal Research as an Adjunct for Surgical Education Increases Perceived Resident Confidence

Surgical education has evolved over time to incorporate supplemental modalities of training beyond the operating room. Even with the utility of simulation software and didactic education, there is still a need to provide surgical residents with experience in live tissue dissection and tissue handling while maintaining patient safety. In our program, after two clinical years, residents participate in a year of translational research which uses porcine models for complex open abdominal procedures. During the porcine surgeries, our residents are guided by the supervising attending to perform key portions of the procedure typically reserved for those more senior trainees. We found in a survey that research residents after two clinical years found this experience with large animal surgeries helped them better navigate anatomic structures and would recommend this to future trainees. We believe this dual-purpose research-training model provides a valuable resource that can be adapted to other programs.

Surgical Rehabilitation for Research Residents: A Pilot Program to Offset Surgical Skill Decay

OBJECTIVE

Select general surgery residents in the surgeon-scientist pipeline dedicate time away from clinical residency to conduct research. However, these research residents (RR) are vulnerable to operative skill decay. The aim of this study is to assess the feasibility of implementation and impact of an organized intervention designed to combat skill decay experienced by RR.

DESIGN

RR were enrolled in a pilot Surgical Rehabilitation Program (SRP). The SRP is comprised of 12 cadaver-based simulation sessions and supplemented with Fundamentals of Laparoscopic Surgery-based simulation workouts. The RR were integrated with the clinical residents (CR) during the cadaver sessions and were subsequently performance tested, surveyed, and interviewed.

SETTING

One academic general surgery residency program graduating 8 chief residents yearly in New York.

PARTICIPANTS

General surgery CR and residents on dedicated research years.

RESULTS

Data were collected for all local RR (n = 8) and 77% (n = 37) of CR. Local RR conducted research within the same health system that sponsors the residency. RR experienced gaps in training ranging from 2 to 4 years. All RR were permitted to moonlight on surgical services, however performed 0 operations and only 0.88 procedures on average per shift. Although RR performed similarly to level-matched CR on basic laparoscopic tasks, they required significantly more time on laparoscopic suturing-based skills than CR (p < 0.001). RR had significantly lower confidence levels precadaver sessions but gained confidence postcadaver sessions (p < 0.05), whereas CR confidence was unchanged. Regarding the SRP, qualitative interviews revealed major themes emphasizing the integration of RR, exposure to CR and faculty, technical skill development, maintenance of surgical know-how, and improved confidence for RR.

CONCLUSIONS

The implementation of such structured interventions, like our SRP, aimed at supporting RR over gap years is essential to help residents maintain skills and confidence needed to achieve their goals of becoming surgeon scientists.

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland

BACKGROUND

Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience.

METHODS

Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student's unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance.

RESULTS

Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P =  < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience.

CONCLUSIONS

SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.

A Survey of the Impact of the COVID-19 Crisis on Skill Decay Among Surgery and Anesthesia Residents

OBJECTIVE

The SARS-CoV-2 (COVID-19) pandemic has profoundly impacted healthcare delivery and strained medical training. This study explores resident and faculty perceptions regarding the impact of the COVID-19 crisis on technical skill decay of surgical and anesthesia residents. We hypothesized that many residents perceived that their technical abilities diminished due to a short period of interruption in their training.

DESIGN

An IRB-exempt, web-based cross-sectional survey distributed to residents and faculty SETTING: Two large academic tertiary medical centers, North Shore University Hospital and Long Island Jewish Medical Center, of the Northwell Health System in New York.

PARTICIPANTS

General surgery, anesthesiology, plastic surgery, cardiothoracic surgery, orthopedic surgery, oral maxillofacial surgery, urology, podiatry residents and faculty.

RESULTS

All residents reported a significant impact on their training. Residents (82%) and faculty (94%) reported a significant reduction in case volumes due to the COVID-19 pandemic (p < 0.05). 64% of residents reported a reduction in technical skills, and 75% of faculty perceived a decrease in resident technical skills. Residents were concerned about fulfilling ACGME case requirements, however faculty were more optimistic that residents would achieve level-appropriate proficiency by the conclusion of their training. Both residents and faculty felt that resident critical care skills improved as a result of redeployment to COVID-19 intensive care units (66% and 94%). Additionally, residents reported increased confidence in their ability to care for critically ill patients and positive impact on professional competencies.

CONCLUSIONS

Effects of the COVID-19 pandemic on residency training are multi-dimensional. The majority of surgical and anesthesia residents perceived that their technical ability diminished as a result of skill decay, whereas other skillsets improved. Longitudinal surveillance of trainees is warranted to evaluate the effect of reduced operative volume and redeployment on professional competency.

Impact of Research Training on Performance in General Surgery Residency

INTRODUCTION

It is common for North American surgical trainees to interrupt clinical training to complete 2 or more years of research training. The impact of this practice on surgical aptitudes is unknown. The University of Toronto has large general surgery and surgeon scientist training programs. We compared the examination scores of general surgery residents in continuous clinical training with those of residents whose training was interrupted by research.

METHODS

We collected anonymized scores obtained at written and oral annual in-training examinations by general surgery residents at the University of Toronto from 2011 to 2016, inclusive. The written exam assessed knowledge, while the oral exam assessed judgment. Residents were dichotomized into continuous versus non-continuous clinical training streams. We compared performance prior to, during, and following divergence for research training both within and between the 2 groups.

RESULTS

At the junior resident level, future enrollment in research training was associated with higher examination performance (P_written = .003). Annual scores plateaued during research training, while scores of residents who continued in continuous clinical training improved year over year (P_written = .009). Non-continuous stream resident exam scores remained stagnant after 1 year then improved in the second year after return to clinical training (P_written = .00007). Scores obtained in the final year of residency training did not significantly differ between residents who underwent continuous versus non-continuous clinical training. Results from written and oral exams trended concordantly.

CONCLUSIONS

We demonstrate that interruption of clinical training for 2 or more years of research is associated with a stagnation of performance on annual in-training examinations assessing both knowledge and judgment. This phenomenon is followed by an eventual catching-up after at least 2 years return to full-time clinical training. This may inform residency program curriculum design.

How general pediatricians learn procedures: implications for training and practice

The Accreditation Council for Graduate Medical Education (ACGME) requires General Pediatricians (GPeds) to learn thirteen procedures during training. However, GPeds infrequently perform these procedures in practice. We sought to determine:1) how GPeds learned procedures, 2) if GPeds self-reported achieving competence in the required ACGME procedures during training, and 3) if GPeds maintained these skills into practice. We conducted this mixed methods study from 2019-2020. 51 GPeds from central Ohio and the American Board of Pediatrics General Examination Committee were recruited via email or snowball sampling and participated in semi-structured recorded phone interviews probing procedural performance during training and current practice. Participants represented varied geographic regions and clinical settings. We employed Sawyer's 'Learn, See, Practice, Prove, Do, Maintain' mastery learning pedagogical framework as a lens for thematic analysis. Participants did not demonstrate competence in all ACGME required procedures during training, nor sustain procedural skills in practice. Most participants learned procedures through a 'see one, do one' apprenticeship model. GPeds reported never being formally assessed on procedural competence during residency. All GPeds referred out at least one procedure. GPeds also believed that skill maintenance was unwarranted for procedures irrelevant to their current practice. GPeds did not sufficiently demonstrate competence in all ACGME required procedures during training, partially suggesting why they infrequently perform some procedures. Alternatively, these required procedures may not be relevant to their practice. Pediatric residency procedures education might consider using mastery learning for practice-specific procedures and surface-level methods (learning without mastery) for other skills.

What Procedures Are Important to General Pediatricians and Why?

BACKGROUND/OBJECTIVE

Pediatric residents must demonstrate competence prior to graduation in Accreditation Council for Graduate Medical Education (ACGME) required procedures. Recent literature shows general pediatricians (GPeds) infrequently perform these procedures yet believe them important to learn. The purpose of this study was to determine why GPeds believe learning procedures was important, what barriers prevent them from developing and maintaining procedural skills, and what procedures they believe should be included in training.

METHODS

Fifty-one GPeds from the American Board of Pediatrics General Examination Committee and the central Ohio region participated in 30-minute semistructured recorded phone interviews that probed their use of procedures across training and current practice. Participants represented urban, suburban, and rural geographic regions and practiced in a variety of settings. We conducted a thematic analysis of transcribed interviews.

RESULTS

GPeds believed currently required ACGME procedures were crucial to learn for 5 reasons: 1) adaptation to change in practice type or location, 2) emergency preparedness, 3) counseling patients and families, 4) distance from a tertiary care center and specialists, and 5) professional identity as a pediatrician. Numerous barriers, particularly never learning the procedures, prevented GPeds from performing procedures in practice. Recommended procedures to be taught included high- (eg, circumcision), and low-risk (eg, cerumen removal, nasopharyngeal swabs, umbilical cauterization) skills.

CONCLUSIONS

GPeds believed procedural training was important, however may never have learned certain procedures. These findings suggest that teaching methods should be adapted or customized procedural education should be implemented to ensure relevancy of skills learned for clinical practice.

Effectiveness of structured education and training in perineal wound assessment and repair for midwives and midwifery students: A review of the literature

INTRODUCTION

Perineal trauma is a commonly observed complication of childbirth, affecting more than 75% of women who have a vaginal birth. Perineal trauma is associated with significant short- and long-term comorbidities that negatively impact women's quality of life. Severe perineal trauma (SPT) rates in Australia have almost doubled in the last decade. Reasons for increased rates are not completely understood; some researchers suggest improvements in diagnosis and reporting, while others have a view that it may be due to a lack of structured and standardized education in perineal wound assessment and repair for clinicians.

METHODS

The Joanna Briggs Institute (JBI) scoping review methodology was adopted as a systemic process to identify studies that have investigated the effectiveness of perineal wound assessment and repair education and training for midwives and midwifery students.

RESULTS

Five studies met the inclusion criteria for this review, to have evaluated a type of education or training, on childbirth-related perineal wound assessment and repair that included midwives and midwifery students. A total of 1279 midwives and midwifery students volunteered to participate in all five studies. The length of the education or training implemented varied between each study from a 1-day workshop to 100 hours of education. All five studies measured the effectiveness of each program through changes in participants' confidence, knowledge and skills in perineal assessment and repair before and after an intervention using various self-assessment questionnaires.

CONCLUSIONS

The implementation of a structured educational workshop on perineal wound assessment and repair improves the confidence, skills and knowledge of midwives and students.

Dual surgeon operating to improve patient safety

The COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered.

Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion.

This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.

Research productivity during orthopedic surgery residency correlates with pre-planned and protected research time: a survey of German-speaking countries

PURPOSE

The purpose of this study was to identify modifiable factors associated with research activity among residents working in orthopedic surgery and traumatology.

METHODS

Residents at 796 university-affiliated hospitals in Austria, Germany, and Switzerland were invited to participate. The online survey consisted of questions that ascertained 13 modifiable and 17 non-modifiable factors associated with the residents' current research activities. Responses of 129 residents were analyzed. Univariate linear regression was used to determine the association of individual factors with the current research activity (hours per week). The impact of significant non-modifiable factors (with unadjusted p values < 0.05) was controlled for using multivariate linear regression.

RESULTS

The univariate analysis demonstrated six non-modifiable factors that were significantly associated with the current research activity: a University hospital setting (p < 0.001), an A-level hospital setting (p = 0.024), Swiss residents (p = 0.0012), the completion of a dedicated research year (p = 0.007), female gender (p = 0.016), and the department's size (p = 0.048). Multivariate regression demonstrated that the number of protected research days per year (p < 0.029) and the percentage of protected days, that were known 1 week before (p < 0.001) or the day before (p < 0.001), were significantly associated with a higher research activity.

CONCLUSIONS

As hypothesized, more frequent and predictable protected research days were associated with higher research activity among residents in orthopedic surgery and traumatology.

LEVEL OF EVIDENCE

III.

Navigating the Postgraduate Research Fellowship: A Roadmap for Surgical Residents

BACKGROUND

To preserve the future of surgical innovation, opportunities for surgical residents to receive structured research training are paramount. The objective of this article is to help surgical residents navigate a research fellowship by overviewing key topics such as choosing an area of focus and supervisor, applying for external funding, transitioning away from clinical duties, managing intellectual property, integrating family planning, and incorporating research experience into independent career development.

MATERIALS AND METHODS

Using the framework of the University of Toronto's graduate degree-awarding Surgeon-Scientist Training Program, the authors outline key considerations, decisions, and pearls for surgical residents considering or currently enrolled in a full-time research fellowship training program.

RESULTS

Full-time research fellowships offer a unique opportunity for residents interested in an academic career. Such full-time research fellowships away from clinical duties allow surgical trainees to focus on developing key research competencies, including how to generate hypotheses, apply research methodology, gain experience presenting and publishing manuscripts, and ultimately apply these skills as independent investigators to improve patient and population health. Research fellowships may also be an opportunity to develop intellectual property or facilitate family planning. Practical tips are provided for the transition back into clinical training and how to effectively market one's research skills for career advancement.

CONCLUSIONS

The authors outline key considerations, decisions, and pearls for surgical residents considering or currently enrolled in a full-time research fellowship training program. By adhering to the principles highlighted in this article, residents will be able to successfully navigate a full-time research fellowship to optimize their intellectual development, maximize their academic productivity, and facilitate their transition into an independent investigator.

Are you surgically current? Lessons from aviation for returning to non-urgent surgery following COVID-19

The COVID-19 crisis has caused many issues across healthcare. In surgery, many operations have been cancelled with some surgeons losing their regular operating lists. During this time, technical expertise and decision making can deteriorate. In aviation after a prolonged period of absence from flying, this deficit in keeping skills and thinking up to date is known as being “out of currency” or “not current”. Although aviation and healthcare cannot be compared, numerous human factors concepts are applicable to both. In this article, we explore the likely impact of potentially prolonged absences in operating on surgical skills and psyche, and introduce the concept of a Surgical Skills Currency Barometer. We also discuss a “task-o-meter” thought experiment, and suggest practices which could be adopted to help protect surgeon workload from exceeding surgical capability when returning to operating following a period of prolonged absence.

Can Virtual Reality Be Used to Track Skills Decay During the Research Years?

BACKGROUND

Time away from surgical practice can lead to skills decay. Research residents are thought to be prone to skills decay, given their limited experience and reduced exposure to clinical activities during their research training years. This study takes a cross-sectional approach to assess differences in residents' skills at the beginning and end of their research years using virtual reality. We hypothesized that research residents will have measurable decay in psychomotor skills when evaluated using virtual reality.

METHODS

Surgical residents (n = 28) were divided into two groups; the first group was just beginning their research time (clinical residents: n = 19) and the second group (research residents: n = 9) had just finished at least 2 y of research. All participants were asked to perform a target-tracking task using a haptic device, and their performance was compared using Welch's t-test.

RESULTS

Research residents showed a higher level of "tracking error" (1.69 ± 0.44 cm versus 1.40 ± 0.19 cm; P = 0.04) and a similar level of "path length" (62.5 ± 10.5 cm versus 62.1 ± 5.2 cm; P = 0.92) when compared with clinical residents.

CONCLUSIONS

The increased "tracking error" among residents at the end of their research time suggests fine psychomotor skills decay in residents who spend time away from clinical duties during laboratory time. This decay demonstrates the need for research residents to regularly participate in clinical activities, simulation, or assessments to minimize and monitor skills decay while away from clinical practice. Additional longitudinal studies may help better map learning and decay curves for residents who spend time away from clinical practice.

Decay of Competence with Extended Research Absences During Residency Training: A Scoping Review

A significant number of residents in postgraduate training programs pursue dedicated research training. Currently, no formal curricula exist to transition residents back into clinical roles following dedicated research leave. This scoping review aims to determine what literature exists on the challenges faced by trainees who interrupt their clinical training for extended periods of time for research leave. The Pubmed and Medline databases were searched for all study designs related to postgraduate trainees taking academic or research leave. A three-step selection process including title, abstract and full-article review was employed to identify articles that mentioned decay of knowledge, skill or competence. A narrative review of the literature was generated to present key themes identified within the studies. The search yielded 174 articles of which five investigated resident skill decay during research leave. The five studies included for analysis were cohort studies that used general surgery residents’ self-perception and faculty members’ perception of residents’ skill decay as a measure. Residents and faculty perceived decay of residents’ technical skills, leadership skills and knowledge following dedicated research leave. The greatest decay perceived was in technical skills, specifically with more complex tasks and longer periods of non-use. This review identified that residents and faculty perceive a decay of resident skills following dedicated research training. To provide the necessary support to limit this potential decay, as well as to assist in the transition back into clinical training, the needs of and challenges faced by research residents and postgraduate programs must be better understood.

Factors Affecting the Development of Confidence Among Surgical Trainees

OBJECTIVE

The objective of this study was to explore and better characterize the factors affecting confidence during surgical training.

DESIGN

This was a qualitative research study in which we conducted semistructured interviews with surgical residents to explore factors affecting their confidence.

SETTING

This study was conducted at the University of Alberta Hospital, a tertiary care center located in Edmonton, Alberta, Canada.

PARTICIPANTS

Residents from the University of Alberta General Surgery residency program were invited to participate from each postgraduate year (PGY) 2, 3, and 4 for a total of 7 participants (3 PGY-2, 3 PGY-3, and 1 PGY-4; 3 male, and 4 female). We excluded residents who had completed or were currently enrolled in dedicated research years.

RESULTS

Resident confidence was found to be influenced by internal and external factors operating before, during, and after a particular surgical task. Internal factors incorporated personal experiences (including operative experience), personal expectations, self-perception, and individual skill development. External factors involved feedback, patient outcomes, relationships with staff, and working within a supportive environment. Interestingly, residents discussed external social factors more than case volume, technical skills, or underlying knowledge. Residents did not feel that their personal lives (e.g. marital status or having children) directly affected their surgical confidence. Regardless of the factor itself, positive experiences helped build and maintain confidence by providing feelings of reassurance, encouragement, comfort, and acceptance.

CONCLUSIONS

Surgical confidence is influenced by a range of internal and external factors. Understanding these factors can help educators improve learning experiences for residents and accelerate their progress towards being confident, independent surgeons.

Dedicated Research Time During Surgery Residency Leads to a Significant Decline In Self-Assessed Clinical Aptitude and Surgical Skills

OBJECTIVE

The surgical community commonly perceives a decline in surgical and patient care skills among residents who take dedicated time away from clinical activity to engage in research. We hypothesize that residents perceive a decline in their skills because of dedicated research time.

SETTING

UC Davis Medical Center, Sacramento, CA, an institutional tertiary care center.

PARTICIPANTS

General surgery residents and graduates from UC Davis general surgery residency training program, who had completed at least 1 year of research during their training. A total of 35 people were asked to complete the survey, and 19 people submitted a completed survey.

DESIGN

Participants were invited to complete an online survey. Factors associated with the decline in skills following their research years were examined. All statistical analyses were performed with IBM SPSS Statistics software.

RESULTS

A total of 19 current or former general surgery residents responded to the survey (54% response rate). Overall, 42% described their research as "basic science." Thirteen residents (68%) dedicated 1 year to research, while the remainder spent 2 or more years. Basic science researchers were significantly more likely to report a decrease in clinical judgment (75% vs. 22%, p = 0.013) as well as a decrease in patient care skills (63% vs. 0%, p = 0.002). Residents who dedicated at least 2 years to research were more likely to perceive a decline in overall aptitude and surgical skills (100% vs. 46%, p = 0.02), and a decline in patient care skills (67% vs. 8%, p = 0.007).

CONCLUSIONS

Most residents who dedicate time for research perceive a decline in their overall clinical aptitude and surgical skills. This can have a dramatic effect on the confidence of these residents in caring for patients and leading a care team once they re-enter clinical training. Residents who engaged in 2 or more years of research were significantly more likely to perceive these problems. Further research should determine how to keep residents who are interested in academics from losing ground clinically while they are pursuing research training.

Exploring hand coordination as a measure of surgical skill

BACKGROUND

The study aim was to identify residents' coordination between dominant and nondominant hands while grasping for sutures in a laparoscopic ventral hernia repair procedure simulation. We hypothesize residents will rely on their dominant and nondominant hands unequally while grasping for suture.

METHODS

Surgical residents had 15 min to complete the mesh securing and mesh tacking steps of a laparoscopic ventral hernia repair procedure. Procedure videos were coded for manual coordination events during the active suture grasping phase. Manual coordination events were defined as: active motion of dominant, nondominant, or both hands; and bimanual or unimanual manipulation of hands. A chi-square test was used to discriminate between coordination choices.

RESULTS

Thirty-six residents (postgraduate year, 1-5) participated in the study. Residents changed manual coordination types during active suture grasping 500 times, ranging between 5 and 24 events (M = 13.9 events, standard deviation [SD] = 4.4). Bimanual coordination was used most (40%) and required the most time on average (M = 20.6 s, SD = 27.2), while unimanual nondominant coordination was used least (2.2%; M = 7.9 s, SD = 6.9). Residents relied on their dominant and nondominant hands unequally (P < 0.001). During 24% of events, residents depended on their nondominant hand (n = 120), which was predominantly used to operate the suture passer device.

CONCLUSIONS

Residents appeared to actively coordinate both dominant and nondominant hands almost half of the time to complete suture grasping. Bimanual task durations took longer than other tasks on average suggesting these tasks were characteristically longer or switching hands required a greater degree of coordination. Future work is necessary to understand how task completion time and overall performance are affected by residents' hand utilization and switching between dominant and nondominant hands in surgical tasks.