Creating the educated surgeon in the 21st century

Data-driven coaching to improve statewide outcomes in CABG: before and after interventional study

BACKGROUND

The impact of quality improvement initiatives program (QIP) on coronary artery bypass grafting surgery (CABG) remains scarce, despite improved outcomes in other surgical areas. This study aims to evaluate the impact of a package of QIP on mortality rates among patients undergoing CABG.

MATERIALS AND METHODS

This prospective cohort study utilized data from the multicenter database Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II), spanning from July 2017 to June 2019. Data from 4018 isolated CABG adult patients were collected and analyzed in three phases: before-implementation, implementation, and after-implementation of the intervention (which comprised QIP training for the hospital team). Propensity Score Matching was used to balance the groups of 2170 patients each for a comparative analysis of the following outcomes: reoperation, deep sternal wound infection/mediastinitis ≤30 days, cerebrovascular accident, acute kidney injury, ventilation time >24 h, length of stay <6 days, length of stay >14 days, morbidity and mortality, and operative mortality. A multiple regression model was constructed to predict mortality outcomes.

RESULTS

Following implementation, there was a significant reduction of operative mortality (61.7%, P =0.046), as well as deep sternal wound infection/mediastinitis ( P <0.001), sepsis ( P =0.002), ventilation time in hours ( P <0.001), prolonged ventilation time ( P =0.009), postoperative peak blood glucose ( P <0.001), total length of hospital stay ( P <0.001). Additionally, there was a greater use of arterial grafts, including internal thoracic ( P <0.001) and radial ( P =0.038), along with a higher rate of skeletonized dissection of the internal thoracic artery.

CONCLUSIONS

QIP was associated with a 61.7% reduction in operative mortality following CABG. Although not all complications exhibited a decline, the reduction in mortality suggests a possible decrease in failure to rescue during the after-implementation period.

Intraoperative Teaching and Evaluation in General Surgery

The operating room continues to be the location where surgical residents develop both technical and nontechnical skills, ultimately culminating with them being capable of safe and independent practice. The process of intraoperative instruction is, by necessity, moving from an apprentice-based model where skills are acquired somewhat randomly through repeated exposure and evaluation is done in a global gestalt fashion. Modern surgical education demands that intraoperative instruction be intentional and that evaluation provides formative and summative feedback. This chapter describes some best practice approaches to intraoperative teaching and evaluation.

On Becoming a Master Surgeon: Role Models, Mentorship, Coaching, and Apprenticeship

Cardiothoracic surgery is a high risk, high reward specialty demanding exceptional performance for desired outcomes. Whereas the demand for technical excellence, critical thinking skills, judgment, and overall experience is clear, the pathway to optimize performance improvement after training is completed is less clear. "Role modeling," "mentorship," "coaching," and "apprenticeship" are all buzz words that have flooded the proverbial air of our specialty in recent years. The goal of this article is to describe strategies, including career development relationships, continuing medical education, and professional societal involvement, that are key to continuing to improve one's craft and identify career phases when such elements are most applicable.

Verification of Proficiency in Basic Skills for PGY-1 Surgical Residents: 10-Year Update

OBJECTIVE

The American College of Surgeons and the Association of Program Directors in Surgery developed a curriculum in 2001 that involved instructional modules for 11 basic surgical skills and a standardized Verification of Proficiency (VOP) evaluation instrument. Our institution continues to employ a modified version of this curriculum and the purpose of this study was to provide a 10-year update on our VOP evaluation instrument used to assess postgraduate year 1 (PGY-1) residents on surgical skills.

DESIGN

All PGY-1 surgical residents over the past 10 years at our institution have completed the American College of Surgeons/the Association of Program Directors in Surgery-adapted basic surgical skills curriculum and VOP assessment. Retrospective analysis of VOP data for all residents was subjected to statistical analysis for internal validity and level of correlation.

SETTING

Department of Surgery at Southern Illinois University School of Medicine located in Springfield, Illinois.

PARTICIPANTS

All PGY-1 surgical residents (per year: 4 general surgery, 3 orthopedic surgery, 2 plastic surgery, 2 urology, 2 ENT, 1 vascular surgery, and 1 neurosurgery) over the past 10 years.

RESULTS

One hundred and thirty five residents underwent VOP evaluation over 10 years; 92 (68%) failed at least 1 module and 40 (30%) failed at least 2 modules. Residents who failed to demonstrate proficiency were mandated to complete remediation and retested until their scores were considered proficient. Performance on checklist items showed moderate internal consistency (⍺ ≥ 0.50) on 9 of 11 modules. Poor internal consistency (⍺ < 0.30) was noted for overall proficiency across all modules. Combined performance on checklist items and economy of time and motion demonstrated significant positive correlation (p < 0.05) with overall proficiency in every module.

CONCLUSIONS

The VOP instrument offers an internally valid means of assessing distinct basic skills of PGY-1 residents at basic surgical skills. The instrument provides critical formative and summative feedback on surgical skill performance to trainees.

Good surgeon: A search for meaning

The art and philosophy of surgery are not as often discussed as scientific discoveries and technological advances in the modern era of surgery. Although these are difficult to teach and pass on to the next generations of surgeons they are no less important for training good surgeons and maintaining their high standards. The authors of this review and opinion article tried to define what being a good surgeon really means and to look into the subject by analysing the essential conditions for being a good surgeon and the qualities that such a specialist should possess. In addition to a strong theoretic knowledge and practical skills and among the several described professional and personal characteristics, a good surgeon is expected to have common sense. It enables a surgeon to make a sound practical judgment independent of specialized medical knowledge and training. The possible ways of developing and/or enhancing common sense during surgical training and subsequent practice require separate analysis.

The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?

A well-designed learning curve is essential for the acquisition of laparoscopic skills: but, are there risk factors that can derail the surgical method? From a review of the current literature on the learning curve in laparoscopic surgery, we identified learning curve components in video laparoscopic cholecystectomy; we suggest a learning curve model that can be applied to assess the progress of general surgical residents as they learn and master the stages of video laparoscopic cholecystectomy regardless of type of patient.

Electronic databases were interrogated to better define the terms “surgeon”, “specialized surgeon”, and “specialist surgeon”; we surveyed the literature on surgical residency programs outside Italy to identify learning curve components, influential factors, the importance of tutoring, and the role of reference centers in residency education in surgery. From the definition of acceptable error, self-efficacy, and error classification, we devised a learning curve model that may be applied to training surgical residents in video laparoscopic cholecystectomy.

Based on the criteria culled from the literature, the three surgeon categories (general, specialized, and specialist) are distinguished by years of experience, case volume, and error rate; the patients were distinguished for years and characteristics. The training model was constructed as a series of key learning steps in video laparoscopic cholecystectomy. Potential errors were identified and the difficulty of each step was graded using operation-specific characteristics. On completion of each procedure, error checklist scores on procedure-specific performance are tallied to track the learning curve and obtain performance indices of measurement that chart the trainee’s progress.

Conclusions. The concept of the learning curve in general surgery is disputed. The use of learning steps may enable the resident surgical trainee to acquire video laparoscopic cholecystectomy skills proportional to the instructor’s ability, the trainee’s own skills, and the safety of the surgical environment. There were no patient characteristics that can derail the methods. With this training scheme, resident trainees may be provided the opportunity to develop their intrinsic capabilities without the loss of basic technical skills.

In Your Own Words: Toward a More Perfect Union of Patient Care and Education

Communication with patients and their families is a challenge for busy trainees. It is essential, however, that these trainees learn effective communication skills to create rapport with their patients, to add to their own satisfaction in caring for these patients and to use these conversations to constantly reassess their plans for treating their patients. Reflecting on the plans for and the outcomes of the care of their patients will also significantly enhance the educational value of the participation of trainees in this patient care, while simultaneously improving the care of both their current and their future patients. Finally, gaining facility in elaborating on their plans for and the delivery of patient care will help trainees become more articulate and thoughtful practitioners.

The making of a surgeon: 10,000 hours?

There have been many changes in the "making of a surgeon". Some of the key aspects that have altered residency/fellow training include work hour restrictions; a decrease in autonomy; and the explosion in knowledge, the change in technology, and the movement of complex cases away from General Surgery. There are a number of opportunities for enhancing current surgical training which include the following: 1) returning to reasonable work hour limits; 2) improving the efficiency of resident/fellow training by promoting early development of operative skills and starting down the path toward competency-based education; 3) increasing autonomy in the General and Pediatric Surgery residencies by developing and implementing structured processes for graded autonomy, further promoting the teaching assistant role, and even incorporating time as an attending into the period of training; and 4) developing a paradigm of uniform core surgery training followed by additional qualifications and training in both General Surgery and the surgical specialties.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Achievement in surgical residency: are objective measures of performance associated with awards received in final years of training?

OBJECTIVE

For the past 15 years at our institution's general surgery residency program, 3 of the senior residents have been chosen to be awarded either (1) Best Resident in Research, (2) Best Resident in Teaching, or (3) Best Resident Overall. Considering that these awards serve as data representing outstanding performance as surgical residents, the objective of this study was to determine the association between receiving one of these awards and objective measures of performance.

METHODS

Individual files were reviewed for the 103 residents who graduated from our institution's general surgery program from 1994 to 2010. These data were studied as a whole, and then divided into an award-winning group and a non-award winning group and subsequently compared across several objective parameters, including The United States Medical Licensing Examination (USMLE) scores, American Board of Surgery In-Training Examination (ABSITE) scores, first-time American Board of Surgery Certifying and Qualifying Examination pass rates, Alpha Omega Alpha membership status, and number of research years, using a logistic regression model.

RESULTS

Overall, 103 residents completed their general surgery residency training at our institution from 1994 to 2010, and of these residents, 16 (16%) received the Best Resident in Research award, 15 (16%) received the Best Resident in Teaching award, and 17 (17%) received the Best Resident Overall award in their final years of training. Compared with those who did not receive an award, a hypothesis-based one-tailed test revealed that award winners had a significantly lower median USMLE Step 1 scores (p = 0.04) and marginally lower median USMLE Step 2 scores (p = 0.05). Alpha Omega Alpha membership status, median ABSITE percent correct overall, first-time American Board of Surgery examination pass rates, and number of research years during residency were not significantly different between the 2 groups.

CONCLUSION

Many factors contribute to success during general surgery residency. Our study showed that higher USMLE and ABSITE scores were not associated with receiving top awards in final years of training at one institution over 15 years.

Surgery, Surgeon, and Measurement of Value and Quality of Surgeons’ Work

Surgery has undergone a significant change and development entering the 21st century. The changes and development have been technology driven, both in therapy and diagnosis. There have been significant changes in the health-care systems as well universally. The changes have created a significant challenge both for the profession and the surgeon. The surgeon should be prepared for further developments and innovations and adapt himself or herself to survive practicing surgery and conserving the humanistic approach of medicine and professionalism including respect to professional values. The profession needs to prepare itself for the future to train good surgeons accordingly for better community health.

Learning curves in expert and non-expert laparoscopic surgeons for robotic suturing with the da Vinci(®) Surgical System

We investigated learning curves for robotic suturing of expert and non-expert laparoscopic surgeons to explore the length of time required to reach an acceptable plateau of technical skills. Laparoscopic suturing skills were evaluated in a training box with conventional laparoscopic instrumentation in phase 1. In phase 2, robotic suturing skills were evaluated during a training program on non-surviving animals by analyzing time required for five intracorporal stitches on the small bowel. Learning curves were plotted. A significant difference in technical skills between the expert and non-expert surgeons was demonstrated in phase 1 and at the beginning of phase 2. Both surgeons reached a learning-curve plateau exhibiting similar robotic suturing skills at the end of 90 min of training. Skills were subsequently retained equally by both surgeons. Short duration of training was sufficient for the non-expert laparoscopic surgeon to match the robotic suturing performance of the expert laparoscopic surgeon.

Three-step model course to teach intracorporeal laparoscopic suturing

BACKGROUND

Laparoscopy requires a set of skills such as intracorporeal stitching and knotting. The aim of this study is to present an effective specialized training course for the laparoscopic suturing technique.

MATERIALS AND METHODS

We designed a specialized 5-day training course for laparoscopic suturing skills with theoretical and practical sessions on inanimate pelvic training. The "gladiator rule" was the method used to teach intracorporeal suturing using the right and left hand from a lateral and suprapubic access. Data on sense of depth, coordination, dexterity, traction power, and posture at the beginning and at the end of the course were compiled. Three practical evaluations were performed by each course participant. Follow-up on subsequent live laparoscopic application of intracorporeal suturing was obtained.

RESULTS

We enrolled 44 consecutive trainees: 33 men and 11 women. We found a significant statistical improvement during the course in coordination (P=.001), dexterity (P=.000), traction power (P=.002), and posture (P=.003). Men were better than women in coordination (P=.002), dexterity (P=.000), and traction power (P=.014). No significant statistical difference in suturing skill was found in relation to age, gender, previous courses, surgical training (surgeon or resident), and dominant hand. Twenty-nine of 40 (72.5%) trainees after the course began to apply intracorporeal sutures in vivo.

CONCLUSIONS

The present study demonstrates the utility of a 5-day suturing course in teaching laparoscopic suturing technique. The "gladiator rule" is a useful and reproducible theory to teach intracorporeal knotting. The three-step model allows the majority of the trainees to apply laparoscopic suturing in vivo.

Successful implementation of the american college of surgeons/association of program directors in surgery surgical skills curriculum via a 4-week consecutive simulation rotation

INTRODUCTION

Increased patient awareness, duty hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgery education. Although simulation and skills laboratories are emerging as promising alternatives for skills training, their integration into graduate surgical education is inconsistent, erratic, and often on a voluntary basis. We hypothesize that, by implementing the American College of Surgeons/Association of Program Directors in Surgery Surgical Skills Curriculum in a structured, inanimate setting, we can address some of these concerns.

METHODS

Sixty junior surgery residents were assigned to the Penn Surgical Simulation and Skills Rotation. The National Surgical Skills Curriculum was implemented using multiple educational tools under faculty supervision. Pretraining and posttraining assessments of technical skills were conducted using validated instruments. Trainee and faculty feedbacks were collected using a structured feedback form.

RESULTS

Significant global performance improvement was demonstrated using Objective Structured Assessment of Technical Skills score for basic surgical skills (knot tying, wound closure, enterotomy closure, and vascular anastomosis) and Fundamentals of Laparoscopic Surgery skills, P < 0.001. Six trainees were retested on an average of 13.5 months later (range, 8-16 months) and retained more than 75% of their basic surgical skills.

DISCUSSION

The American College of Surgeons/Association of Program Directors in Surgery National Surgical Skills Curriculum can be implemented in its totality as a 4-week consecutive surgical simulation rotation in an inanimate setting, leading to global enhancement of junior surgical residents' technical skills and contributing to attainment of Accreditation Council for Graduate Medical Education core competency.

Structuralized box-trainer laparoscopic training significantly improves performance in complex virtual reality laparoscopic tasks

Introduction

In the era of flowering minimally invasive surgical techniques there is a need for new methods of teaching surgery and supervision of progress in skills and expertise. Virtual and physical box-trainers seem especially fit for this purpose, and allow for improvement of proficiency required in laparoscopic surgery.

Material and methods

The study included 34 students who completed the authors‘ laparoscopic training on physical train-boxes. Progress was monitored by accomplishment of 3 exercises: moving pellets from one place to another, excising and clipping. Analysed parameters included time needed to complete the exercise and right and left hand movement tracks. Students were asked to do assigned tasks prior to, in the middle and after the training.

Results

The duration of the course was 28 h in total. Significant shortening of the time to perform each exercise and reduction of the left hand track were achieved. The right hand track was shortened only in exercise number 1.

Conclusions

Exercises in the laboratory setting should be regarded as an important element of the process of skills acquisition by a young surgeon. Virtual reality laparoscopic training seems to be a new, interesting educational tool, and at the same time allows for reliable control and assessment of progress.

Initial laparoscopic basic skills training shortens the learning curve of laparoscopic suturing and is cost-effective

BACKGROUND

Laparoscopic suturing is an advanced skill that is difficult to acquire. Simulator-based skills curricula have been developed that have been shown to transfer to the operating room. Currently available skills curricula need to be optimized. We hypothesized that mastering basic laparoscopic skills first would shorten the learning curve of a more complex laparoscopic task and reduce resource requirements for the Fundamentals of Laparoscopic Surgery suturing curriculum.

STUDY DESIGN

Medical students (n = 20) with no previous simulator experience were enrolled in an IRB-approved protocol, pretested on the Fundamentals of Laparoscopic Surgery suturing model, and randomized into 2 groups. Group I (n = 10) trained (unsupervised) until proficiency levels were achieved on 5 basic tasks; Group II (n = 10) received no basic training. Both groups then trained (supervised) on the Fundamentals of Laparoscopic Surgery suturing model until previously reported proficiency levels were achieved. Two weeks later, they were retested to evaluate their retention scores, training parameters, instruction requirements, and cost between groups using t-test.

RESULTS

Baseline characteristics and performance were similar for both groups, and 9 of 10 subjects in each group achieved the proficiency levels. The initial performance on the simulator was better for Group I after basic skills training, and their suturing learning curve was shorter compared with Group II. In addition, Group I required less active instruction. Overall time required to finish the curriculum was similar for both groups; but the Group I training strategy cost less, with a savings of $148 per trainee.

CONCLUSIONS

Teaching novices basic laparoscopic skills before a more complex laparoscopic task produces substantial cost savings. Additional studies are needed to assess the impact of such integrated curricula on ultimate educational benefit.

Leadership curriculum in undergraduate medical education: a study of student and faculty perspectives

BACKGROUND

Leaders in medicine have called for transformative changes in healthcare to address systems challenges and improve the health of the public. The purpose of this study was to elicit the perspectives of students, faculty physicians and administrators regarding the knowledge and competencies necessary in an undergraduate leadership curriculum.

METHODS

A mixed-methods study was conducted using focus group discussions and semi-structured interviews with faculty physicians and administrative leaders, as well as a written survey of medical student leaders.

RESULTS

Twenty-two faculties participated in focus groups and interviews; 21 medical students responded to the written survey. Participants identified emotional intelligence, confidence, humility and creativity as necessary qualities of leaders; and teamwork, communication, management and quality improvement as necessary knowledge and skills. Students perceived themselves as somewhat or fully competent in communication (90%), conflict resolution (70%) and time management (65%), but reported minimal or no knowledge or competence in coding and billing (100%), writing proposals (90%), managed care (85%) and investment principles (85%). Both faculty and students believed that experiential training was the most effective for teaching leadership skills.

CONCLUSIONS

Study participants identified the necessary qualities, knowledge and skills to serve as goals for an undergraduate leadership curriculum. Future studies should address optimal methods of teaching and assessing leadership skills among medical students.

The impact of subspecialization on postgraduate medical education in neurosurgery

Medical subspecialization is a response to rapidly expanding technology and knowledge. Although beneficial to patient care, it poses a challenge to the current infrastructure of resident education. This article analyzes the advent of subspecialization, the current template of postgraduate neurosurgical education, the impact of subspecialization on postgraduate neurosurgical education, and, finally, suggests strategies to optimize professional education in the face of an increasingly subspecialized field.

Accreditation Council on Graduate Medical Education Technical Skills Competency Compliance: Urologic Surgical Skills

BACKGROUND

In accordance with new mandates implemented by the Accreditation Council on Graduate Medical Education, reliance on operative case logs as demonstration of residents' surgical competence will no longer be adequate. We describe the implementation of a comprehensive, year-round, mandatory skills laboratory curriculum as an integral component of our urology residency training program.

STUDY DESIGN

We developed eight laboratory practicums using primarily nonhuman models: basic endoscopy, advanced endoscopy, ureteroscopy, percutaneous renal surgery, basic laparoscopy, advanced laparoscopy, urologic use of the gastrointestinal tract, and cadaveric pelvic dissection.

RESULTS

Anonymous evaluations submitted by all training session participants indicate that acquisition of surgical skills is facilitated through participation in laboratory practicums. An incremental progression in proficiency was observed by all of the instructors and students who participated. There was a high degree of satisfaction with model fidelity and the value of technical experience gained.

CONCLUSIONS

Our urologic surgery skills laboratory curriculum is an effective means of skills acquisition and maintenance for a wide variety of urologic techniques, including complex endourologic procedures. Patient care can safely be of secondary importance with respect to trainee experience in a low-stress environment that provides an opportunity for supervised repetitive performance of essential technical skills. We describe effective models, with high fidelity-to-cost ratio, that incorporate laboratory-based surgical skills training and evaluation into urology residency programs, with the aim of Accreditation Council on Graduate Medical Education competency guideline compliance.

Thoracic Surgery Education-Past, Present, and Future

Organized thoracic surgery education began with the establishment of the first thoracic residency program at the University of Michigan in 1928. Subsequent changes and progress in thoracic education have included the development of the American Board of Thoracic Surgery, the Thoracic Surgery Residency Review Committee, the Thoracic Surgery Directors' Association, the Matching Program, the In-Training Examination, and the Joint Council on Thoracic Surgery Education. Current challenges in thoracic surgery education include (1) the declining interest in medical school and especially in surgery and cardiothoracic surgery, (2) changing demographics of medical students and residents, (3) lifestyle of surgical residents and practicing surgeons, (4) changes in societal expectation, and (5) the need for better tools to assess the outcomes of surgical education and the continued competency of practicing surgeons. Despite the recent difficulty with job availability for finishing cardiothoracic residents, there is evidence that this is temporary and that there will be an increased need in the future. Recent changes by the American Board of Thoracic Surgery, including making optional American Board of Surgery certification, new pathways for entry into the cardiothoracic surgery educational process, and the recent development of a joint training proposal (4/3) by the American Board of Surgery and American Board of Thoracic Surgery, clearly signal the need for further changes in the cardiothoracic surgery educational process so that thoracic surgery remains relevant in the future care of patients with cardiovascular disease.

A NEW APPROACH TO UROLOGY TRAINING:: A LABORATORY MODEL FOR PERCUTANEOUS NEPHROLITHOTOMY

PURPOSE

The efficacy of traditional operating room based training of urology residents is being reevaluated. The development of hands-on laboratory practicums to facilitate the acquisition of skills by surgical residents lessens learning curves and hastens familiarity with tissue and instrument handling. We describe an innovative model for simulated percutaneous renal access and nephrolithotomy.

MATERIALS AND METHODS

Porcine kidneys pre-implanted with artificial stone material were placed within intact chicken carcasses as a model for percutaneous nephrolithotomy. Urology residents were taught needle access, tract dilation and renal access sheath insertion using fluoroscopy. Training in percutaneous nephrolithotomy with the nephroscope, graspers and stone fragmentation methods followed.

RESULTS

This simple, cost-effective model closely simulates percutaneous nephrolithotomy. Anonymous evaluations submitted by training session participants revealed a high degree of satisfaction with model effectiveness in the application of percutaneous renal access and nephrolithotomy techniques.

CONCLUSIONS

Our percutaneous nephrolithotomy laboratory model is an effective means of skills acquisition for a complex endourological procedure. Patient care can safely be of secondary importance with respect to trainee experience in a low stress environment that provides an opportunity for supervised, repetitive performance of essential technical skills. We describe an effective percutaneous renal access and nephrolithotomy surgical training model of original design.

The impact of a novel resident leadership training curriculum

BACKGROUND

Today's complex health care environment coupled with the 80-hour workweek mandate has required that surgical resident team interactions evolve from a military command-and-control style to a collaborative leadership style.

METHODS

A novel educational curriculum was implemented with objectives of training the residents to have the capacity/ability to create and manage powerful teams through alignment, communication, and integrity integral tools to practicing a collaborative leadership style while working 80 hours per week. Specific strategies were as follows: (1) to focus on quality of patient care and service while receiving a high education-to-service ratio, and (2) to maximize efficiency through time management.

RESULTS

This article shows that leadership training as part of a resident curriculum can significantly increase a resident's view of leadership in the areas of alignment, communication, and integrity; tools previously shown in business models to be vital for effective and efficient teams.

CONCLUSION

This curriculum, over the course of the surgical residency, can provide residents with the necessary tools to deliver efficient quality of care while working within the 80-hour workweek mandate in a more collaborative style environment.

One surgeon's philosophy of surgical education

The concept of a philosophy of surgical education provides a vehicle for ensuring that there is a united and comprehensive approach to surgical training. This is important because none of the current approaches to higher education provides a suitable model for surgical training and it is dangerous to uncritically adopt every prevailing fashion in education.

Is it safe to train residents to perform cardiac surgery?

BACKGROUND

The impact of surgical training on patient outcomes in cardiac surgery is unknown.

METHODS

All cases performed by residents from 1998 to 2001 were compared to staff surgeon cases using prospectively collected data. Operative mortality and a composite morbidity of: reoperation for bleeding perioperative myocardial infarction, infection, stroke, or ventilation more than 24 hours were compared using multivariate analysis.

RESULTS

Four residents performed 584 cases. The cases were as follows: coronary artery bypass grafting (CABG), 366 cases; aortic valve replacement (AVR) with or without CABG (AVR +/- CABG), 86 cases; mitral valve replacement, 31 cases; mitral valve repair, 25 cases; thoracic aneurysm/dissection, 22 cases; aortic root, 20 cases; transplantations, 14 cases; and adult congenital defect repairs, 20 cases. There were 2,638 CABGs and 363 AVR +/- CABG performed by the staff during the same period. Crude operative mortality in CABG patients was 2.5% (resident) and 2.9% (staff) (p = 0.62). In multivariate analysis, resident was not associated with operative mortality odds ratio (OR) of 0.59 (p = 0.19). Resident cases had a higher incidence of the composite morbidity outcome for CABG cases (19.4% vs 13.6% for staff; p = 0.003). However, in multivariate analysis, resident was not associated with increased morbidity (OR = 1.23, p = 0.16). The AVR +/- CABG crude mortality was 3.6% (resident) and 2.8% (staff) (p = 0.69). Because of the small number of cases (n = 447), operative mortality was combined with the composite morbidity outcome for the AVR +/- CABG model. In all, 16.7% of resident cases and 19.8% of staff cases had the composite outcome or died (p = 0.51). In multivariate analysis resident was not associated with this outcome (OR = 0.74, p = 0.35).

CONCLUSIONS

In this analysis of our experience with residency training, the operative morbidity and mortality in CABG and AVR patients was similar for residents and staff. Training residents to perform cardiac surgery appears to be safe.