1
|
Wang TN, Woelfel IA, Huang E, Pieper H, Meara MP, Chen X(P. Behind the pattern: General surgery residsent autonomy in robotic surgery. Heliyon 2024; 10:e31691. [PMID: 38841510 PMCID: PMC11152925 DOI: 10.1016/j.heliyon.2024.e31691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 05/12/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024] Open
Abstract
Objective Robotic surgery is increasingly utilized and common in general surgery training programs. This study sought to better understand the factors that influence resident operative autonomy in robotic surgery. We hypothesized that resident seniority, surgeon work experience, surgeon robotic-assisted surgery (RAS) case volume, and procedure type influence general surgery residents' opportunities for autonomy in RAS as measured by percentage of resident individual console time (ICT). Methods General surgery resident ICT data for robotic cholecystectomy (RC), inguinal hernia (RIH), and ventral hernia (RVH) operations performed on the dual-console Da Vinci surgical robotic system between July 2019 and June 2021 were extracted. Cases with postgraduate year (PGY) 2-5 residents participating as a console surgeon were included. A sequential explanatory mixed-methods approach was undertaken to explore the ICT results and we conducted secondary qualitative interviews with surgeons. Descriptive statistics and thematic analysis were applied. Results Resident ICT data from 420 robotic cases (IH 200, RC 121, and VH 99) performed by 20 junior residents (PGY2-3), 18 senior residents (PGY4-5), and 9 attending surgeons were extracted. The average ICT per case was 26.8 % for junior residents and 42.4 % for senior residents. Compared to early-career surgeons, surgeons with over 10 years' work experience gave less ICT to junior (18.2 % vs. 32.0 %) and senior residents (33.9 % vs. 56.6 %) respectively. Surgeons' RAS case volume had no correlation with resident ICT (r = 0.003, p = 0.0003). On average, residents had the most ICT in RC (45.8 %), followed by RIH (36.7 %) and RVH (28.6 %). Interviews with surgeons revealed two potential reasons for these resident ICT patterns: 1) Surgeon assessment of resident training year/experience influenced decisions to grant ICT; 2) Surgeons' perceived operative time pressure inversely affected resident ICT. Conclusions This study suggests resident ICT/autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, but not related to surgeon RAS case volume. Design and implementation of an effective robotic training program must consider the external pressures at conflict with increased resident operative autonomy and seek to mitigate them.
Collapse
Affiliation(s)
- Theresa N. Wang
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Ingrid A. Woelfel
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Emily Huang
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Heidi Pieper
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | - Michael P. Meara
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA
| | | |
Collapse
|
2
|
Geoffrion R, Koenig NA, Cundiff GW, Flood C, Hyakutake MT, Schulz J, Brennand EA, Lee T, Singer J, Todd NJ. Procedure-specific simulation for vaginal surgery training: A randomized controlled trial. Acta Obstet Gynecol Scand 2024; 103:1165-1174. [PMID: 38382912 PMCID: PMC11103140 DOI: 10.1111/aogs.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. MATERIAL AND METHODS We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). CLINICALTRIALS gov: Registration no. NCT05887570. RESULTS We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. CONCLUSIONS Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.
Collapse
Affiliation(s)
- Roxana Geoffrion
- Division of Gynecologic Specialties, Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Nicole A. Koenig
- Division of Gynecologic Specialties, Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Geoffrey W. Cundiff
- Division of Gynecologic Specialties, Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Catherine Flood
- Division of Urogynecology, Department of Obstetrics and GynecologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Momoe T. Hyakutake
- Division of Urogynecology, Department of Obstetrics and GynecologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Jane Schulz
- Division of Urogynecology, Department of Obstetrics and GynecologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Erin A. Brennand
- Division of Urogynecology, Department of Obstetrics and GynecologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Terry Lee
- Centre for Advancing Health OutcomesVancouverBritish ColumbiaCanada
| | - Joel Singer
- Centre for Advancing Health OutcomesVancouverBritish ColumbiaCanada
| | - Nicole J. Todd
- Division of Gynecologic Specialties, Department of Obstetrics and GynecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| |
Collapse
|
3
|
Keuning MC, Lambert B, Nieboer P, Huiskes M, Diemers AD. Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review. JOURNAL OF SURGICAL EDUCATION 2024; 81:93-105. [PMID: 37838573 DOI: 10.1016/j.jsurg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/24/2022] [Accepted: 09/11/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed. BACKGROUND Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence. METHODS A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included. RESULTS Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role. CONCLUSIONS This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.
Collapse
Affiliation(s)
- Martine C Keuning
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands.
| | - Bart Lambert
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick Nieboer
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition Groningen, University of Groningen, Groningen, The Netherlands
| | - Agnes D Diemers
- Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
4
|
Chen XP, Harzman A, Go M, Arnold M, Ellison EC. Cumulative Sum Chart as Complement to Objective Assessment of Graduating Surgical Resident Competency: An Exploratory Study. J Am Coll Surg 2023; 237:894-901. [PMID: 37530413 DOI: 10.1097/xcs.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND Rater-based assessment and objective assessment play an important role in evaluating residents' clinical competencies. We hypothesize that a cumulative sum (CUSUM) chart of operative time is a complement to the assessment of chief general surgery residents' competencies with ACGME Milestones, aiding residency programs' determination of graduating residents' practice readiness. STUDY DESIGN We extracted ACGME Milestone evaluations of performance of operations and procedures (POP) and 3 objective metrics (operative time, case type, and case complexity) from 3 procedures (cholecystectomy, colectomy, and inguinal hernia) performed by 3 cohorts of residents (N = 15) during their PGY4-5. CUSUM charts were computed for each resident on each procedure type. A learning plateau was defined as at least 4 cases consistently locating around the centerline (target performance) at the end of a CUSUM chart with minimal deviations (range 0 to 1). RESULTS All residents reached the ACGME graduation targets for the overall POP by the end of chief year. A total of 2,446 cases were included (cholecystectomy N = 1234, colectomy N = 507, and inguinal hernia N = 705), and 3 CUSUM chart patterns emerged: skewed distribution, bimodal distribution, and peaks and valleys distribution. Analysis of CUSUM charts revealed surgery residents' development processes in the operating room towards a learning plateau vary, and only 46.7% residents reach a learning plateau in all 3 procedures upon graduation. CONCLUSIONS CUSUM charts of operative time complement the ACGME Milestones evaluations. The use of both may enable residency programs to holistically determine graduating residents' practice readiness and provide recommendations for their upcoming career/practice transition.
Collapse
|
5
|
Collings AT, Doster DL, Longtin K, Choi J, Torbeck L, Stefanidis D. Surgical Resident Perspectives on the Preferred Qualities of Effective Intraoperative Teachers: A Qualitative Analysis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:629-635. [PMID: 36598471 DOI: 10.1097/acm.0000000000005131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
PURPOSE Intraoperative teaching is a critical component of surgery residents' education. Although prior studies have investigated best practices from the viewpoint of the expert educator, the perspective of the learner has been less explored. This study examined the ideal faculty teaching behaviors that optimize intraoperative teaching from the surgical residents' perspective. METHOD Using a grounded theory method, this study explored perspectives on intraoperative faculty teaching qualities of 5 focus groups of categorical clinical general surgical residents of the same postgraduate year from June to August 2021. Focus group discussions were recorded, transcribed, and coded. Emerging themes were identified, along with their corresponding subthemes. RESULTS Thirty-nine general surgery residents participated in the focus groups. Overall, 6 themes emerged regarding resident priorities of intraoperative teaching, with 10 subthemes. Themes included the following: (1) character, with subthemes of caring, respect for resident, and self-control; (2) intraoperative skill, with subthemes of clinical and operative skill and modeling leadership in the operating room; (3) instructional approach; (4) feedback, with subthemes of content of feedback and debriefing; (5) discernment of resident needs, with subthemes of managing expectations, individualizing instruction, and autonomy; and (6) variety of teachers. CONCLUSIONS Certain tangible strategies, such as demonstrating genuine care for the learner, using clear directional words, and giving actionable feedback, were considered vital by residents. In the development of great surgical educators, the emphasis should not be on conformity to a single idealized teaching style but should celebrate and encourage diversity of personas and teaching styles within a department or program.
Collapse
Affiliation(s)
- Amelia T Collings
- A.T. Collings is a surgery resident, Department of Surgery, University of Louisville, Louisville, Kentucky. At the beginning of this work, the author was a surgical education research fellow, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dominique L Doster
- D.L. Doster is a surgical education research fellow, Indiana University School of Medicine, Indianapolis, Indiana
| | - Krista Longtin
- K. Longtin is associate professor of communication studies, Indiana University School of Liberal Arts at Indiana University-Purdue University Indianapolisassistant dean of faculty affairs and professional development, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jennifer Choi
- J. Choi is associate professor of clinical surgery and program director for general surgery residency, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laura Torbeck
- L. Torbeck is professor of surgery and vice chair of professional development, Department of Surgeryassistant dean for faculty affairs and professional development, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dimitrios Stefanidis
- D. Stefanidis is professor of surgery and vice chair of education, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
6
|
Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room. Ann Surg 2022; 275:e264-e270. [PMID: 32224741 DOI: 10.1097/sla.0000000000003887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy. BACKGROUND Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome. METHODS In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents. RESULTS In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9). CONCLUSIONS This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.
Collapse
Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition, University of Groningen, Groningen, The Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Research and Innovation in Medical Education, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
7
|
Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. Fingerprints of Teaching Interactions: Capturing and Quantifying How Supervisor Regulate Autonomy of Residents in the Operating Room. JOURNAL OF SURGICAL EDUCATION 2021; 78:1197-1208. [PMID: 33358759 DOI: 10.1016/j.jsurg.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/13/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Supervisors and residents agree that entrusted autonomy is central to learning in the Operating Room (OR), but supervisors and residents hold different opinions about entrustment: residents regularly experience that they receive insufficient autonomy while supervisors feel their guiding is not appreciated as teaching. These opinions are commonly grounded on general experiences and perceptions, instead of real-time supervisors' regulatory behaviors as procedures unfold. To close that gap, we captured and analyzed when and to what level supervisors award or restrain autonomy during procedures. Furthermore, we constructed fingerprints, an instrument to visualize entrustment of autonomy by supervisors in the OR that allows us to reflect on regulation of autonomy and discuss teaching interactions. DESIGN All interactions between supervisors and residents were captured by video and transcribed. Subsequently a multistage analysis was performed: (1) the procedure was broken down into 10 steps, (2) for each step, type and frequency of strategies by supervisors to regulate autonomy were scored, (3) the scores for each step were plotted into fingerprints, and (4) fingerprints were analyzed and compared. SETTING University Medical Centre Groningen (the Netherlands). PARTICIPANTS Six different supervisor-resident dyads. RESULTS No fingerprint was alike: timing, frequency, and type of strategy that supervisors used to regulate autonomy varied within and between procedures. Comparing fingerprints revealed that supervisors B and D displayed more overall control over their program-year 5 residents than supervisors C and E over their program-year 4 residents. Furthermore, each supervisor restrained autonomy during steps 4 to 6 but with different intensities. CONCLUSIONS Fingerprints show a high definition view on the unique dynamics of real-time autonomy regulation in the OR. One fingerprint functions as a snapshot and serves a purpose in one-off teaching and learning. Multiple snapshots of one resident quantify autonomy development over time, while multiple snapshots of supervisors may capture best teaching practices to feed train-the-trainer programs.
Collapse
Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, the Netherlands.
| | - Mike Huiskes
- Center for Language and Cognition, University of Groningen, Groningen, the Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, the Netherlands
| | - Martin Stevens
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Debbie A D C Jaarsma
- Center for Research & Innovation in Medical Education, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
8
|
Brady AK, Town JA, Robins L, Bowen J. Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice. Chest 2021; 160:1799-1807. [PMID: 34126057 DOI: 10.1016/j.chest.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? STUDY DESIGN AND METHODS This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.
Collapse
Affiliation(s)
- Anna K Brady
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR.
| | - James A Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Lynne Robins
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA
| | - Judith Bowen
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| |
Collapse
|
9
|
Foster MJ, O'Hara NN, Weir TB, Aneizi A, Henn RF, Packer JD, Hasan SA, Slobogean GP, Gilotra MN. Difference in Resident Versus Attending Perspective of Competency and Autonomy During Arthroscopic Rotator Cuff Repairs. JB JS Open Access 2021; 6:JBJSOA-D-20-00014. [PMID: 33748637 PMCID: PMC7963494 DOI: 10.2106/jbjs.oa.20.00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A noted deficiency in orthopaedic resident education is a lack of intraoperative autonomy; however, no studies exist evaluating this issue. The purpose of this study was to determine whether there is a difference between resident and attending perception of resident competency and autonomy during arthroscopic rotator cuff repairs and whether increased perceived competency leads to more autonomy.
Collapse
Affiliation(s)
- Michael J Foster
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tristan B Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
10
|
|
11
|
Mayes CG. A Grounded Theory of Intraoperative Team Members' Decision Making Regarding Surgical Attire Guideline Adherence. AORN J 2020; 112:457-469. [PMID: 33113173 DOI: 10.1002/aorn.13207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 02/24/2020] [Accepted: 03/12/2020] [Indexed: 11/07/2022]
Abstract
Surgical attire guidelines (SAGs) assist perioperative nurses with minimizing the risk of patients developing surgical site infections. However, some intraoperative team members fail to fully adhere to SAGs, which may put patients at risk. Because there is a lack of published literature on the reasons for intraoperative team members' SAG nonadherence, I undertook a grounded theory study to explore the decision making of intraoperative team members related to the AORN SAG. The resulting model identifies the factors that affect decision making regarding SAG adherence, including personal identity needs, adherence anchoring activities, SAG awareness, direction from authority figures and organizations, guideline evidence strength, and resource availability. After weighing the influence of each factor, team members decide to what extent they will adhere to the SAG. The theory also provides guidance for enhancing adherence decisions.
Collapse
|
12
|
Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya. J Surg Res 2020; 258:137-144. [PMID: 33010559 DOI: 10.1016/j.jss.2020.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/07/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023]
Abstract
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.
Collapse
|
13
|
Torbeck L, Dunnington G. Development of a peer review of operative teaching process and assessment tool. Am J Surg 2020; 221:263-269. [PMID: 32958155 DOI: 10.1016/j.amjsurg.2020.08.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/24/2020] [Accepted: 08/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND While teaching evaluation systems are common in academia, very little information is available regarding formal coaching and peer review of teaching performance in surgery. This article is a report on the development and implementation of a peer review of operative teaching program. METHODS Our process was designed using a multistep sequential model which included developing a peer review of teaching instrument that was piloted to study the efficacy and utility of the tool. RESULTS Thirty-nine peer reviews of teaching were conducted. Among the most frequent challenges that faculty identified were allowing residents to struggle/give autonomy, judging when to take over the case, communicating effectively, being patient, balancing education and patient safety, and giving feedback. CONCLUSIONS Our peer review of teaching program is systematic, feasible, and can be adopted by other surgery departments. Faculty's identified strengths and challenges have been incorporated into our faculty development curricula.
Collapse
Affiliation(s)
- Laura Torbeck
- Indiana University, 545 Barnhill Dr., 543 Emerson Hall, Indianapolis, IN, 46202, USA.
| | - Gary Dunnington
- Indiana University, 545 Barnhill Dr., 543 Emerson Hall, Indianapolis, IN, 46202, USA
| |
Collapse
|
14
|
Shin TH, Naples R, French JC, Khandelwal CM, Rose W, Alaedeen D, Dai J, Lipman J, Rosen MJ, Petro C. Effect modification of resident autonomy and seniority on perioperative outcomes in laparoscopic cholecystectomy. Surg Endosc 2020; 35:3387-3397. [PMID: 32642848 DOI: 10.1007/s00464-020-07780-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Resident operative involvement is an integral aspect of general surgery residency training. However, current data examining the effect of resident autonomy on perioperative outcomes remain limited. METHODS Patient and operator-specific data were collected from 344 adult laparoscopic cholecystectomies at a tertiary academic institution and its regional affiliates between 2018 and 2019. Multivariate modeling compared postoperative outcomes between cases completed with or without resident involvement and its effect modification by resident seniority and autonomy per Zwisch scale. Outcomes include 30-day postoperative complications, hospital readmission rate, and operative time. RESULTS Multivariate analysis revealed resident involvement in laparoscopic cholecystectomy did not significantly change odds of 30-day postoperative complications (OR 2.52, p = 0.185, 95% CI 0.64-9.92) or hospital readmission (OR 1.61, p = 0.538, 95% CI 0.36-7.23). Operative time is significantly increased compared to faculty-only cases (IRR 1.37, p < 0.001, 95% CI 1.26-1.48). While accounting for case difficulty and resident performance evaluated by SIMPL criteria, stratification by resident autonomy measured by Zwisch scale or seniority reveal no effect modification on 30-day postoperative complications, readmissions, or operative time. The effect of resident involvement on longer relative rates of operative time loses its significance in supervision-only cases (IRR 1.18, p = 0.069, 95% CI 0.99-1.41). CONCLUSION While resident involvement and autonomy are associated with significantly longer operative times in laparoscopic cholecystectomy, their lack of significant effect on postoperative outcomes argues strongly for continued resident involvement and supervised operative independence.
Collapse
Affiliation(s)
- Thomas H Shin
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. .,Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A-100, Cleveland, OH, 44195, USA.
| | - Robert Naples
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Judith C French
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Warren Rose
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Diya Alaedeen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jie Dai
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeremy Lipman
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael J Rosen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Clayton Petro
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
15
|
Park J, Ponnala S, Fichtel E, Tehranchi K, Fitzgibbons S, Parker SH, Lau N, Safford SD. Improving the Intraoperative Educational Experience: Understanding the Role of Confidence in the Resident-Attending Relationship. JOURNAL OF SURGICAL EDUCATION 2019; 76:1187-1199. [PMID: 31255644 DOI: 10.1016/j.jsurg.2019.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/02/2019] [Accepted: 02/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE With recent changes to graduate medical education, the balance between resident autonomy and need for supervision impacts the educational and training experience of residents. The objective of this study was to understand the relationship between the confidence of attendings and residents and their different perspectives of perceived educational experience and autonomy in the operating room (OR). We hypothesized that the attending's confidence in the resident would be an important factor in improving the educational experience and resident's autonomy in the OR. DESIGN Self-reported confidence-rating and operative experience surveys were administered to teams of post-graduate year (PGY 1) through PGY 5 surgical residents and attendings in two temporal sets (Early: Sept-Dec 2015, n = 20; Late: Jan-Apr 2016, n = 22). A second "end-of-year" survey was distributed to residents (n = 9, 37.5% response) and attendings (n = 10, 35% response) asking questions regarding their educational experience and operative experience during the past year. SETTING Large rural teaching hospital. PARTICIPANTS Nineteen general surgery residents (PGY 1 - 5) and 14 general surgery attendings. RESULTS Resident perception of confidence differs from junior to senior residents, and that there was discordance between resident's confidence and skill as perceived by attendings, particularly in senior residents. Results also showed that attending's confidence in residents was positively correlated with attending's perceived educational experience in the OR. Residents and attendings both indicated attending's confidence in residents as an important factor in increasing resident autonomy in the OR, thus the attending's confidence in residents could have a positive impact on resident autonomy and educational experience in the OR. CONCLUSIONS We have demonstrated a relationship between self-confidence for residents and improved confidence from attendings in residents' capabilities. Based on these findings, we would propose identifying methods to expand resident's awareness of surgical situations and develop attending's confidence in residents.
Collapse
Affiliation(s)
- Juyeon Park
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Siddarth Ponnala
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Eric Fichtel
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Kian Tehranchi
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Shimae Fitzgibbons
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Sarah Henrickson Parker
- Human Factors Research, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Nathan Lau
- Grado Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, Virgina
| | - Shawn D Safford
- Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| |
Collapse
|
16
|
Allen M, Gawad N, Park L, Raîche I. The Educational Role of Autonomy in Medical Training: A Scoping Review. J Surg Res 2019; 240:1-16. [DOI: 10.1016/j.jss.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
|
17
|
Chen XP, Sullivan AM, Smink DS, Alseidi A, Bengtson JM, Kwakye G, Dalrymple JL. Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability. Ann Surg 2019; 269:1080-1086. [PMID: 31082905 DOI: 10.1097/sla.0000000000002717] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. BACKGROUND Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. METHODS We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. RESULTS We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. CONCLUSION Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.
Collapse
Affiliation(s)
- Xiaodong Phoenix Chen
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- The Ohio State University, Columbus, OH
| | - Amy M Sullivan
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Douglas S Smink
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Joan M Bengtson
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - John L Dalrymple
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| |
Collapse
|
18
|
Resident autonomy in the operating room: Does gender matter? Am J Surg 2019; 217:301-305. [DOI: 10.1016/j.amjsurg.2018.12.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/24/2018] [Accepted: 12/14/2018] [Indexed: 11/19/2022]
|
19
|
Chen X(P, Cochran A, Dalrymple JL. Framework for Faculty Development in Resident Autonomy and Entrustment in the Operating Room. JAMA Surg 2019; 154:5-6. [DOI: 10.1001/jamasurg.2018.3529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Amalia Cochran
- The Ohio State University, Columbus
- Web and Social Media Editor, JAMA Surgery
| | - John L. Dalrymple
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
20
|
Chen XP, Sullivan AM, Alseidi A, Kwakye G, Smink DS. Assessing Residents' Readiness for OR Autonomy: A Qualitative Descriptive Study of Expert Surgical Teachers' Best Practices. JOURNAL OF SURGICAL EDUCATION 2017; 74:e15-e21. [PMID: 28712687 DOI: 10.1016/j.jsurg.2017.06.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/26/2017] [Accepted: 06/27/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Providing resident autonomy in the operating room (OR) is one of the major challenges for surgical educators today. The purpose of this study was to explore what approaches expert surgical teachers use to assess residents' readiness for autonomy in the OR. We particularly focused on the assessments that experts make prior to conducting the surgical time-out. METHODS We conducted semistructured in-depth interviews with expert surgical teachers from March 2016 to September 2016. Purposeful sampling and snowball sampling were applied to identify and recruit expert surgical teachers from general surgery residency programs across the United States to represent a range of clinical subspecialties. All interviews were audio-recorded, deidentified, and transcribed. We applied the Framework Method of content analysis, discussed and reached final consensus on the themes. RESULTS We interviewed 15 expert teachers from 9 institutions. The majority (13/15) were Program or Associate Program Directors; 47% (7/15) primarily performed complex surgical operations (e.g., endocrine surgery). Five themes regarding how expert surgical teachers determine residents' readiness for OR autonomy before the surgical time-out emerged. These included 3 domains of evidence elicited about the resident (resident characteristics, medical knowledge, and beyond the current OR case), 1 variable relating to attending characteristics, and 1 variable composed of contextual factors. Experts obtained one or more examples of evidence, and adjusted residents' initial autonomy using factors from the attending variable and the context variable. CONCLUSIONS Expert surgical teachers' assessments of residents' readiness for OR autonomy included 5 key components. Better understanding these inputs can contribute to both faculty and resident development, enabling increased resident autonomy and preparation for independent practice.
Collapse
Affiliation(s)
- Xiaodong Phoenix Chen
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Amy M Sullivan
- Harvard Medical School, Boston, Massachusetts; Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Adnan Alseidi
- Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Gifty Kwakye
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
21
|
Hill KA, Dasari M, Littleton EB, Hamad GG. How can surgeons facilitate resident intraoperative decision-making? Am J Surg 2017; 214:583-588. [DOI: 10.1016/j.amjsurg.2017.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/26/2017] [Accepted: 06/18/2017] [Indexed: 10/19/2022]
|
22
|
Entrustment Evidence Used by Expert Gynecologic Surgical Teachers to Determine Residents' Autonomy. Obstet Gynecol 2017; 130 Suppl 1:8S-16S. [DOI: 10.1097/aog.0000000000002201] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Sutkin G, Littleton EB, Kanter SL, Cianciolo AT, Chen XP, Cope A, Koschmann T. Teaching, Learning, and Performance in the Surgical Workplace: Insights From the Examination of Intraoperative Interactions. TEACHING AND LEARNING IN MEDICINE 2017; 29:378-382. [PMID: 29020522 DOI: 10.1080/10401334.2017.1384732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.
Collapse
Affiliation(s)
- Gary Sutkin
- a Departments of Biomedical and Health Informatics and Obstetrics and Gynecology , University of Missouri-Kansas City School of Medicine , Kansas City , Missouri , USA
| | - Eliza Beth Littleton
- b Department of Medicine , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | - Steven L Kanter
- c Office of the Dean , University of Missouri-Kansas City School of Medicine , Kansas City , Missouri , USA
| | - Anna T Cianciolo
- d Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Xiaodong Phoenix Chen
- e Obstetrics Gynecology and Reproductive Biology , Brigham and Women's Hospital , Boston , Massachusetts , USA
| | - Alexandra Cope
- f Leeds Institution of Medical Education , University of Leeds , Leeds , England
| | - Timothy Koschmann
- d Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| |
Collapse
|
24
|
Timberlake MD, Mayo HG, Scott L, Weis J, Gardner AK. What Do We Know About Intraoperative Teaching? Ann Surg 2017; 266:251-259. [DOI: 10.1097/sla.0000000000002131] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
25
|
Phitayakorn R, Kelz RR, Petrusa E, Sippel RS, Sturgeon C, Patel KN, Perrier ND. Expert consensus of general surgery residents’ proficiency with common endocrine operations. Surgery 2017; 161:280-288. [DOI: 10.1016/j.surg.2016.06.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/05/2016] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
|