Competency-Based Medical Education for Plastic Surgery: Where Do We Begin?

Interprogram Differences in Core General, Core Plastic, and Plastic Surgery-Adjacent Training

BACKGROUND

Plastic surgery training continues to evolve with integrated residents spending more time in plastic versus general surgery. Herein, we provide an updated description of interprogram differences in core general, core plastic, and plastic surgery-adjacent training curricula.

METHODS

We obtained rotation schedules from US plastic surgery residency websites or program coordinators for AY2021-2022. Rotation months were recorded and categorized into Core General Surgery, Core Plastic Surgery, and Plastic Surgery-Adjacent. Rotations were compared to American Board of Plastic Surgery (ABPS) and Accreditation Council for Graduate Medical Education (ACGME) standards. Data were analyzed using descriptive statistics (SPSS, IBM Corp., v27.0, Armonk, NY).

RESULTS

Of 84 programs, we obtained schedules for 63 (75%). Most offered 2 years of Core General Surgery followed by 4 years of Core Plastic Surgery training (n = 32, 50.8%). From postgraduate years 1-6, programs offered median 52 months [interquartile range (IQR): 47.5, 55] of Core Plastic Surgery, 12 months (IQR: 9, 14) of Core General Surgery, and 8 months (IQR: 6, 10) of Plastic Surgery-Adjacent rotations. Six (9.5%) programs' schedules included rotations specifically addressing all ABPS competency requirements; 1 (1.6%) included rotations addressing all ACGME Core General Surgery competency requirements. Departmental status was not associated with differences in training time.

CONCLUSIONS

Our results demonstrate that in AY2021-2022, integrated plastic surgery training programs offered 6 months less Core General Surgery, 3 months less Plastic Surgery-Adjacent, and 9 months more Core Plastic Surgery Rotations than in 2012. Very few program schedules include named rotations that specifically addressed all ABPS or ACGME competency requirements.

Evaluating Plastic Surgery Resident Satisfaction Globally: Predictors and Recommendations for Training Enhancement

BACKGROUND

Measures of quality in resident training in plastic and reconstructive surgery (PRS) programs are scarce and often methodologically inconsistent. Our research provides insights from current PRS trainees globally, mapping their training inputs, expected outputs, and recommendations for program improvements.

METHODS

A global online survey was conducted among PRS residents across 70 countries to gauge their satisfaction with residency training, capturing training inputs such as the number of surgeries attended and seminars they participated in. We also extracted residents' proposed recommendations for program improvement. We investigated the explanatory role of training inputs, demographics, hospital characteristics, and country income on resident satisfaction and graduate competence.

RESULTS

The analysis incorporated data from 518 PRS residents. On average, residents attended 9.8 surgeries and 1.3 seminars per week. Simultaneously, there was a positive correlation between the perceived level of professional competency and training inputs, particularly seminars attended (p - value = 0.001). Male residents tended to report higher satisfaction (p - value = 0.045) with their training (67%) compared with their female counterparts (58%), while those with family responsibilities also demonstrated slightly higher satisfaction levels.

CONCLUSIONS

Our analysis expands the evidence base regarding a "global hunger" for more comprehensive seminar-based and hands-on surgical training. Resident recommendations on program improvement reveal the need to address gaps, particularly in aesthetic surgery training. The development of healthcare business models that allow for aesthetic procedures in training institutions is crucial in the promotion of aesthetic surgery training during residency. Policymakers, program directors, and stakeholders across the world can leverage these findings to formulate policies addressing the weaknesses of training programs.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dear Program Directors: There Are Numerous Entrustable Professional Activities on a Burns Rotation!

Background: Burn care has long been an integral part of the scope of plastic surgery, but the time allocated to exposure for plastic surgery residents is under threat due to the range of sub-specialities competing for their time. As part of the Competence by Design approach to plastic surgical training, residents are provided with a list of 52 "Entrustable professional activities' (EPA's) to ensure that core skills and knowledge are acquired. Methods: This survey, distributed via email using a link to Survey MonkeyTM, sought to determine which EPA's were available for completion by plastic surgeons in training during the burn rotation at a major academic burn centre in Canada. Via investigator consensus, 26 of the 52 EPA's were included for assessment; the remaining 26 were not regarded as relevant to the burn centre rotation and therefore better acquired elsewhere. Results: Thirty two residents who underwent a burn rotation between 1 January 2015 and 31 December 2021 completed the anonymous survey. Seventeen of the 26 EPA's evaluated were judged by more than 75% of respondents as being readily amenable to completion during the burn rotation. Most of these EPA's relate to the comprehensive care of patients with acute burn injuries, the management of an in-patient plastic surgery service, and associated quality improvement processes. Residents who completed rotations less than three months in duration had less opportunity to complete a further 8 EPA's in comparison to those who had longer rotations, especially with respect to the care of patients undergoing complex wound care and burn reconstruction. Conclusions: In addition to threatening seamless service delivery at burn centres, reduced resident exposure to the burn rotation may compromise the delivery of burn care in the community. The results of this survey refute any argument that the burn service is a "low yield" rotation from an EPA acquisition perspective.

Models and materials for teaching auricular framework carving: A systematic review

INTRODUCTION

The process of carving an auricular framework is technically challenging and unique to the patient. As such, there is a need for a robust and reliable training model for practicing and planning ear reconstruction. The aim of this study is to assess the best models and methods available to practice the carving of an auricular framework.

METHODS

A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines using MEDLINE, Embase, and Cochrane databases. Terms such as "ear", "reconstruction" and "teaching" were searched.

RESULTS

A total of 354 articles were identified, and 13 studies met the inclusion criteria. Vegetables, animal tissue, synthetic materials, as well as more advanced methods such as 3D-printed moulds, were analysed. The similarity of these materials to human costal cartilage was investigated to determine the best or most suitable ones for the purpose. The methods used in the studies were also analysed. Due to heterogeneity of the studies, it was not possible to conduct a quantitative analysis.

CONCLUSION

This review identifies that for the junior surgeons at the skill acquisition phase of their training in auricular framework carving repetition using firstly a cheap synthetic material would be most useful, followed by animal cartilage or 3D printing using silicone. These materials bear the most resemblance to human costal cartilage, and by repeating the carvings, proficiency will improve. Those surgeons with an established ear reconstruction practise, wishing to undertake immediate pre-operatively simulation could benefit from cross-sectional imaging and 3D printing of a patient's non-affected ear to ensure a good match.

Gaps in plastic surgery training: A comparative literature review of assessment tools in plastic surgery and general surgery

Assessment tools for grading technical and nontechnical skills, such as operative technique and professionalism, are well established in general surgery. Less is known regarding the application of these tools in plastic surgery training. This study is a comparative review of the most prevalent assessment tools and rubrics utilized in general and plastic surgery. Two parallel systematic reviews of the literature utilizing PubMed and Cochrane were conducted for articles published between 1990 and 2022. Searches used Boolean operators specific to assessment tools in general and plastic surgery. Fourteen studies met the inclusion criteria for general surgery assessment tools, and 21 studies were included for plastic surgery assessment tools. Seven studies (50%) evaluated technical skills in general surgery, whereas 15 studies (71%) assessed technical skills in plastic surgery with commonality found in the evaluation of principles, such as tissue and instrument handling and operative flow. Task-specific evaluation tools were described for both general and plastic surgeries. Five studies evaluated nontechnical skills, such as communication and leadership in general surgery, whereas no plastic surgery studies solely examined nontechnical assessment tools. Our literature review demonstrates that standardized skill assessments in plastic surgery are lacking compared with those available in general surgery. Plastic surgery programs should consider implementing competency-based assessment tools in surgical coaching and training for technical and nontechnical skills. More research is necessary in plastic surgery to optimize the evaluation of nontechnical skills.

Evaluating Gaps in Otolaryngology Training: An In-Depth Needs Assessment in Saudi Arabia

BACKGROUND

The landscape of otolaryngology training in Saudi Arabia is undergoing transformation due to the expansion of medical colleges and increased overseas medical scholarships. However, concerns persist regarding the satisfaction and adequacy of surgical education. This study aims to assess gaps in otolaryngology training through an in-depth needs assessment.

METHODS

A cross-sectional study was conducted among 85 otolaryngology-head and neck surgery residency graduates in Saudi Arabia between 2019 and 2021. Participants completed a validated questionnaire assessing deficiencies, importance, and competence in different subspecialty areas. Data were analyzed using descriptive statistics, median comparisons, and Kruskal-Wallis tests.

RESULTS

Participants identified deficiencies in training across domains, with significant variations in specific subspecialties among different regions. Dissatisfaction with clinical discussions, research training, access to simulation labs, and training in emerging subspecialties was evident.

CONCLUSION

The study highlights challenges within otolaryngology training, emphasizing the need for continuous evaluation and adaptation to ensure high-quality and comprehensive training. Addressing these gaps is essential to produce well-rounded otolaryngologists capable of meeting the evolving demands of modern healthcare.

Making Headway in Surgical Education at Home and Abroad: Use of an Inexpensive Three-Dimensional Learning Model to Improve Plastic Surgery Resident Confidence in Mohs Defect Assessment and Closure Planning

BACKGROUND

The development of simulation, particularly low-cost models, has become a focus of interest within plastic surgery education. Current simulators for Mohs reconstruction are either expensive or not reusable. The authors hypothesize that using a Styrofoam head model during an interactive teaching session will positively affect plastic surgery trainee comfort in designing Mohs reconstructive options.

METHODS

A cohort of integrated plastic surgery residents at a single institution performed a preactivity questionnaire to obtain baseline comfort in defect assessment and design for five Mohs defects. They subsequently underwent an interactive learning session and were instructed to design flaps on life-size Styrofoam heads with feedback from the senior author (M.L.B.). A postactivity questionnaire was completed to assess improvement in comfort in defect assessment and flap design. Three attending surgeons then compared trainee designs with the senior author's design to assess accuracy. All surveys were based on a five-point Likert scale.

RESULTS

When analyzing all defects, average postactivity scores increased by 0.63 (SD, ±0.24) ( P = 0.008). Junior residents ( n = 8) had a greater increase in average score responses [mean, 1.07 (0.5 to 1.75)] compared with senior residents ( n = 9) [mean, 0.27 (0 to 1)] ( P < 0.001). When assessed by senior-level surgeons, senior residents had significantly greater accuracy in design for each defect ( P < 0.05) except cheek advancement flap ( P = 0.08).

CONCLUSION

Participation in an interactive educational activity using a Styrofoam head model demonstrated significant improvements in trainee assessment and design of reconstructive options for Mohs defects.

Bias in Surgical Residency Evaluations: A Scoping Review

OBJECTIVE

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

DESIGN

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

SETTING/PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Defining Cognitive Competencies for Breast Augmentation Surgery

BACKGROUND

Breast augmentation is the most performed aesthetic procedure in the United States yet one that surgical trainees have limited exposure to. This creates a lack of confidence in performing this key procedure among graduates. It is imperative to develop novel curricula and objective measures to standardize acquiring competency.

OBJECTIVE

This qualitative study establishes various cognitive competencies and pitfalls in augmentation mammoplasty.

METHODS

Using a priori established task analysis, literary sources and operative observations, a total of 20 cognitive vignettes were developed to conduct cognitive task analyses (CTA) for breast augmentation through semistructured interviews of experts. Interviews were itemized, and verbal data were recorded, transcribed verbatim, and thematically analyzed by reviewers.

RESULTS

Eight experts were interviewed (median age 39 years, 87.5% males, with a median of 7 years in practice). A conceptual framework for breast augmentation was developed and divided into 5 operative stages containing 208 competencies and 41 pitfalls. Pitfalls were mapped to deficits in shared decision making, proper informed consent, prospective hemostasis, and awareness of anatomical landmarks and markings.

CONCLUSIONS

This work provided an inclusive framework of cognitive competencies in breast augmentation surgery to facilitate their assessment. This model guides the analysis of other procedures to transfer cognitive competencies to learners. In a transition toward competency-based education, this provides a primer to assessments that include all aspects of a surgeon's skill set.

Competency-Based Education: Will This be the New Training Paradigm in Plastic Surgery?

The Accreditation Council for Graduate Medical Education created the "Next Accreditation System" in 2013 requiring residents to meet educational milestones based on core competencies over the course of their training. The 6 core competencies include patient care and technical skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Since the traditional time-based model requires a predetermined length of training irrespective of learning style, pace, or activity, a competency-based model is appealing because it refocuses education on deliberate and relevant skills acquisition and retention. Plastic surgery has been slowly transitioning to competency-based education (CBE), thereby permitting residents to learn at their own pace to master each competency. We performed a nonsystematic literature review of the efficacy of CBE and implementation efforts, particularly within plastic surgery. The literature revealed perceived barriers to implementation, as well as the nuts and bolts of implementation. We highlighted possible solutions and training tools with practical applications in plastic surgery. Success of CBE in plastic surgery requires instituting a transparent process that involves continuously piloting multiple assessment tools and a discussion of related costs. CBE may be particularly appealing for trainees focused on further training in craniofacial or pediatric plastic surgery after completion of an integrated or independent training program in plastic surgery to allow them to focus on their career interests once competence is achieved in the core skills required of a plastic surgeon.

Plastic Surgery Training During Coronavirus Disease 2019 Pandemic: A Quantitative Study on Trainees' Wellness and Education

PURPOSE

Coronavirus disease 2019 (COVID-19) pandemic has had far reaching impacts on all aspects of the healthcare system, including plastic surgery training. Due to reduction in the number of elective surgery cases and need for social distancing, plastic surgery education has shifted from the operating room to the virtual learning environment. Although these changes have been qualitatively described, the authors present a quantitative analysis of plastic surgery training changes due to the COVID-19 pandemic. Our study has identified residents' greatest impediments and inquired about suggestions for further improvements. Our goal is to help residency programs through the COVID-19 pandemic era and contribute to future guidelines when residency education encounters additional unexpected changes.

METHODS

An institutional review board approved anonymous survey using Qualtrics was forwarded on April 23, 2020 to US plastic surgery program directors to be distributed to plastic surgery residents and fellows. Questions centered on the impact of COVID-19 on residents' well-being, education and career plans results were collected for data analysis. Residents were given the option to be in a raffle to win a $50 amazon gift card. Completion of the survey was both anonymous and voluntary.

RESULTS

A total of 69 trainees responded (52 integrated residents and 17 independent fellows) from 18 states. Fifty-one percent were male and 49% were female. Fifty-six percent of trainees plan to complete a fellowship program after graduation, 31% will join private practice. Nine percent of trainees reported changes in their postgraduation plans due to the pandemic, 67% were senior trainees. Of those whose goals were affected by COVID-19 pandemic, 56% opted to pursue additional fellowship training. They described reduced operative exposure and cancelations of elective surgeries (50%), the limited availability of private practice jobs (37.5%), and financial reasons (12.5%) for their decision. Twelve percent reported being concerned about not meeting the necessary requirements to finish their residency and graduate on time. Seventy-six percent of trainees expressed concerns about the health and safety of themselves, family and loved ones. Forty-nine percent of trainees reported increased levels of stress since the onset of the pandemic. Ninety-seven percent of trainees reported having reduction in their operative time during the COVID-19 pandemic. They utilized their nonoperative time for online education modules (84%), educational readings (82%), and research (80%). Plastic surgery trainees learned about national webinars through emails from professional society (83%), co-resident/fellow (77%), program director emails (74%), and social media (22%). Webinars attended were mostly through virtual platform modalities, among which Zoom and Webex were the most preferred. Less interactions with colleagues and faculty was the biggest barrier to adopting virtual conferences. Despite this, 72% agreed that having grand rounds, didactics and journal clubs online increased attendance. Additionally, 88% of respondents expressed interests in attending professional society sponsored virtual grand rounds in the future.

CONCLUSIONS

Results from our survey demonstrated that the overwhelming majority of plastic surgery residents have had reductions in operative times and widespread curriculum changes during the COVID-19 pandemic. These recent changes have increased residents' stress levels and adversity affected their future career plans. Additionally, COVID-19 has heralded an increase in virtual conferences and learning modules. Plastic surgery trainees expressed a preference for virtual educational platforms and interest in continuing virtual didactics in the future. This may irreversibly change the landscape of future plastic surgery training.

Construct validity of the Surgical Autonomy Program for the training of neurosurgical residents

OBJECTIVE

There is no standard way in which physicians teach or evaluate surgical residents intraoperatively, and residents are proving to not be fully competent at core surgical procedures upon graduating. The Surgical Autonomy Program (SAP) is a novel educational model that combines a modified version of the Zwisch scale with Vygotsky’s social learning theory. The objective of this study was to establish preliminary validity evidence that SAP is a reliable measure of autonomy and a useful tool for tracking competency over time.

METHODS

The SAP breaks each surgical case into 4 parts, or zones of proximal development (ZPDs). Residents are evaluated on a 4-tier autonomy scale (TAGS scale) for each ZPD in every surgical case. Attendings were provided with a teaching session about SAP and identified appropriate ZPDs for surgical cases under their area of expertise. All neurosurgery residents at Duke University Hospital from July 2017 to July 2021 participated in this study. Chi-square tests and ordinal logistic regression were used for the analyses.

RESULTS

Between 2017 and 2021, there were 4885 cases logged by 27 residents. There were 30 attendings who evaluated residents using SAP. Faculty completed evaluations on 91% of cases. The ZPD of focus directly correlated with year of residency (postgraduate year) (χ2 = 1221.1, df = 15, p < 0.001). The autonomy level increased with year of residency (χ2 = 3553.5, df = 15, p < 0.001). An ordinal regression analysis showed that for every year increase in postgraduate year, the odds of operating at a higher level of independence was 2.16 times greater (95% CI 2.11–2.21, p < 0.001). The odds of residents performing with greater autonomy was lowest for the most complex portion of the case (ZPD3) (OR 0.18, 95% CI 0.17–0.20, p < 0.001). Residents have less autonomy with increased case complexity (χ2 = 160.28, df = 6, p < 0.001). Compared with average cases, residents were more likely to operate with greater autonomy on easy cases (OR 1.44, 95% CI 1.29–1.61, p < 0.001) and less likely to do so on difficult cases (OR 0.72, 95% CI 0.67–0.77, p < 0.001).

CONCLUSIONS

This study demonstrates preliminary evidence supporting the construct validity of the SAP. This tool successfully tracks resident autonomy and progress over time. The authors’ smartphone application was widely used among surgical faculty and residents, supporting integration into the perioperative workflow. Wide implementation of SAP across multiple surgical centers will aid in the movement toward a competency-based residency education system.

Teaching and Assessing Cognitive Competencies in Aesthetic and Plastic Surgery

BACKGROUND

Cognition, part of surgical competence, employs forward planning, error prevention, and orchestrating technical skills. Thus, an understanding of mental processes used by experts throughout patient care is essential to teaching such competencies. This study aims to analyze and compare mental models of two distinct procedures in plastic surgery, breast augmentation and flexor tendon repair, to develop a framework to define cognitive competencies in plastic surgery aided by a review of the literature.

METHODS

Based on data from a-priori cognitive task analyses, literary sources, and field observations of breast augmentation surgery and flexor tendon repair, task-lists were produced for each procedure. Two mental models were developed using fuzzy logic cognitive maps to visually illustrate and analyze cognitive processes employed in either procedure. A comparison of the models aided by literature was used to define the cognitive competencies employed, identify differences in the decision-making process, and provide a guiding framework for understanding cognitive competencies.

RESULTS

Five distinct cognitive competency domains were identified from the literature applicable to plastic surgery, namely situation awareness, decision-making, task management, leadership, and communication and teamwork. Differences in processes of decision-making employed between an elective and a trauma setting were identified. A framework to map cognitive competencies within a generic mental model in surgical care was synthesized and methods were suggested for training on such competencies.

CONCLUSION

Cognitive competencies in different settings in plastic surgery are introduced using a comparative study of two mental models of distinct procedures to guide the teaching and assessment of such competencies.

"Identification of Essential Assessment Criteria in Facial Botulinum Toxin Injections"

INTRODUCTION

Facial botulinum toxin injections represent the most commonly performed aesthetic non-surgical procedures by plastic surgeons; however, post-graduate programs remain devoid of objective tools to adequately assess competence in trainees. In this study, the authors employ the Delphi methodology to establish a list of essential assessment criteria in facial botulinum toxin injections.

METHODS

A list of 10 suggested criteria was generated through a literature search and in consultation with an expert plastic surgeon. A panel of content experts was selected to which an online survey was administered; skills were ranked for their relevance using a 1-10 Likert scale. Recommendations for additional skills were solicited and survey rounds were repeated until consensus was achieved. The latter was a measure of panelist reliability and assessed using Cronbach α (≥0.8); skills with a rating of 7 or above were taken to be essential.

RESULTS

The survey process was successful at achieving consensus following two rounds of survey administration. Twenty-one participants completed the first round representing a response rate of 38%. Percent agreement among the panel was 83% and Cronbach α was computed as 0.78, necessitating further rounds. The response rate in the second round was 90%; one additional skill was added; percent agreement and Cronbach α improved to 88% and 0.87, respectively.

CONCLUSION

Nine assessment criteria were identified as essential in facial botulinum toxin injections; these findings provide the groundwork necessary for the development of an objective assessment tool for the more appropriate training of marginalized aesthetic procedures in plastic surgery.

Resident Exposure to Aesthetic Surgical and Nonsurgical Procedures During Canadian Residency Program Training

North American residency programs are transitioning to competency-based medical education (CBME) to standardize training programs, and to ensure competency of residents upon graduation. At the centre of assessment in CBME are specific surgical procedures, or procedural competencies, that trainees must be able to perform. A study previously defined 31 procedural competencies for aesthetic surgery. In this transition period, understanding current educational trends in resident exposure to these aesthetic procedures is necessary. The aim of this study was to characterize aesthetic procedures performed by Canadian plastic surgery residents during training, as well as to describe resident performance confidence levels and degree of resident involvement during those procedures. Case logs were retrieved from all 10 English-language plastic surgery programs. All aesthetic procedures were identified, and coded according to previously defined core procedural competencies (CPCs) in the aesthetic domain of plastic surgery. Data extracted from each log included the procedure, training program, resident academic year, resident procedural role, and personal competence. From July 2004 to June 2014, 6113 aesthetic procedures were logged by 55 graduating residents. Breast augmentation, mastopexy, and abdominoplasty were the most commonly performed CPCs, and residents report high levels of competence and surgical role in these procedures. Facial procedures, in particular rhinoplasty, as well as nonsurgical CPCs are associated with low exposure and personal competence levels. Canadian plastic surgery residents are exposed to most of the core aesthetic procedural competencies, but the range of procedures performed is variable. With the implementation of CBME, consideration should be given to supplementation where gaps may exist in aesthetic case exposure.

Development of a 3D Motion Tracking System for the Analysis of Skills in Microsurgery

Microsurgical skills of trainee surgeons have been subjectively evaluated due to the lack of technological tools. The objective of this investigation is to present the construct validity of the mitracks3D, which is a system designed to help in the objective evaluation of microsurgery trainees. To achieve this, a stereoscopic vision system records the 3D motion of two tweezers manipulated by surgeons during microsurgery training. Using motion analysis parameters (MAPs), quantitative information about their microsurgical skills and performance is obtained. For validation, 14 participants were enrolled and divided into two groups: expert microsurgeons (3 female, 2 male) and trainee surgeons (4 female, 5 male). The 3D motion tracking was acquired while the surgeons practiced with two training models: transferring objects and suture. Twelve MAPs were used to objective assessment the skill levels of each participant. Subsequent, statistical analysis was computed to compare the scores of both groups. Validation results showed statistically significant differences in 8 of the 12 MAPs and in 10 of the 12 MAPs using the transferring and the suturing models, respectively. The capability of mitracks3D to differentiate the performance of microsurgeons by analyzing their movements was shown. The mitracks3D system was successfully validated. With this system was possible to differentiate the psychomotor microsurgical skills between the two groups of surgeons. The mitracks3D system is a suitable device for the evaluation of microsurgical skills in a variety of surgical specialties that require it during the training of their residents.

SMaRT Assessment Tool: An Innovative Approach for Objective Assessment of Flap Designs

SUMMARY

The teaching and assessment of ideal surgical markings for local flaps required for optimal aesthetic and functional outcomes remain a challenge in the present era of competency-based surgical education. The authors utilized the bilobed flap for nasal reconstruction as a proof of concept for the development of an innovative objective assessment tool based on statistical shape analysis, with a focus on providing automated, evidence-based, objective, specific, and practical feedback to the learner. The proposed tool is based on Procrustes statistical shape analysis, previously used for the assessment of facial asymmetry in plastic surgery. For performance boundary testing, a series of optimal and suboptimal designs generated in deliberate violation of the established ideals of optimal bilobed flap design were evaluated, and a four-component feedback score of Scale, Mismatch, Rotation, and Translation (SMaRT) was generated. The SMaRT assessment tool demonstrated the capacity to proportionally score a spectrum of designs (n = 36) ranging from subtle to significant variations of optimal, with excellent computational and clinically reasonable performance boundaries. In terms of shape mismatch, changes in SMaRT score also correlated with intended violations in designs away from the ideal flap design. This innovative educational approach could aid in incorporating objective feedback in simulation-based platforms in order to facilitate deliberate practice in flap design, with the potential for adoption in other fields of plastic surgery to automate assessment processes.

Toward Competency-Based Training: To What Extent Are We Competency-Based?

BACKGROUND

Time-based training models in plastic surgery vary in exposure, resulting in low confidence levels among graduates. The evolution of postgraduate medical education into a competency-based model to address these issues requires an understanding of interventions described in the plastic surgery literature to identify gaps and guide creation of assessments to demonstrate competence.

METHODS

A systematic search of the MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane databases from inception until December of 2017 was conducted using search terms and synonyms of educational interventions reported in plastic surgery. Full texts were retrieved following filtering and data extracted were related to intervention design and execution, involvement of competency assessment, and educational objectives and alignment to Accreditation Council for Graduate Medical Education competencies and Royal College of Physicians and Surgeons of Canada Canadian Medical Education Directives for Specialists roles. Study quality was assessed using Kirkpatrick's levels of learning evaluation, validity evidence, and the Medical Education Research Study Quality Instrument score.

RESULTS

Of the initial 4307 results, only 36 interventions met the inclusion criteria. Almost all interventions aligned to medical knowledge and patient care Accreditation Council for Graduate Medical Education competencies. One-fifth of the interventions involved no assessment of competency, whereas most displayed assessment at the level of design as opposed to outcomes. Quality assessment revealed low levels of learning evaluation and evidence of validity; the average Medical Education Research Study Quality Instrument score was 10.9 of 18.

CONCLUSION

A systematic review of educational literature in plastic surgery was conducted to assess the quality of reported educational interventions, and to help guide creating tools that ensure competency acquirement among trainees.

Heterogeneity in urology teaching curricula among Canadian urology residency programs

INTRODUCTION

Postgraduate education is transitioning to a competency-based curriculum in an effort to standardize the quality of graduating trainees. The learning experiences and opportunities in each institution are likely variable, as no standard exists regarding the teaching curriculum offered through residency. The objective of this study is to examine the various teaching curricula among different Canadian urology residency programs and to identify which teaching modalities are prioritized by program directors.

METHODS

A 10-question anonymous survey was sent electronically to program directors at all 12 urology residency programs across Canada. Questions were designed to quantify the time allotted for teaching and to assess the various teaching session types prioritized by programs to ensure the successful training of their graduates. We assessed each program's perceived value of written exams, oral exams, didactic teaching session, and simulation sessions. Responses were assessed using a Likert-scale and a ranking format. Descriptive statistics were performed.

RESULTS

Overall survey response rate from residency program directors was 75% (9/12). Sixty-seven percent of programs designated one day of teaching per week, whereas 33% split resident teaching over two days. Review of chapters directly from Campbell-Walsh Urology textbook were deemed the most valuable teaching session. Practice oral exams were also prioritized, whereas most programs felt that simulation labs contributed the least to residency education. All programs included review of the core urology textbook in their weekly teaching, while only 67% of programs included faculty-led didactic sessions and case presentations. Forty-four percent of programs included resident-led didactic sessions. Practice oral exams and simulation labs were the least commonly included teaching modalities.

CONCLUSIONS

Although most program directors prioritize the review of chapters in the core urology textbook, we found significant heterogeneity in the teaching sessions prioritized and offered in current urology residency curricula. As we move to standardize the quality of graduating trainees, understanding the impact of variable educational opportunities on residency training may become increasingly important.

The Role of Resident-Run Clinics for Aesthetic Surgery Training in the Context of Competency-based Plastic Surgery Education

Resident-run clinics (RRCs) have been suggested as a clinical teaching tool to improve resident exposure in aesthetic plastic surgery education. In exchange for reduced cost aesthetic services, RRCs offer trainees the opportunity to assess, plan, execute, and follow surgical procedures in an independent yet supervised manner. With the transition into a competency-based medical education model involving a switch away from a time-based into a milestones-based model, the role of RRCs, within the context of the evolving plastic surgery curriculum has yet to be determined. To that end, the present study summarizes current models of aesthetic surgery training and assesses RRCs as an adjunct to aesthetics education within the framework of competency-based medical education. Explored themes include advantages and issues of RRCs including surgical autonomy, feasibility, exposure, learners' perception, ethics, and quality improvement. In addition, attention is focused on their role in cognitive competency acquisition and exposure to non-surgical techniques. RRCs are considered an effective educational model that provides an autonomous learning platform with reasonable patient satisfaction and safety profiles.

Role of Peer Learning in Students' Skill Acquisition and Interest in Plastic Surgery

Supplemental Digital Content is available in the text.

Although the number of plastic surgery residency positions increased over the past decade, interest among Canadian medical students experienced the opposite trajectory. The aim of this study was to assess the effect of a low intensity, basic surgical skills workshop on medical students’ confidence and interest in surgery in general, and plastic surgery in particular.

Theories of learning and teaching methods used in postgraduate education in the health sciences: a scoping review

OBJECTIVE

The objective of this scoping review was to determine the theories of learning and methods used in teaching in postgraduate education in the health sciences. The longer-term objective was to use the information gathered to design a workshop for teachers of postgraduate students.

INTRODUCTION

Whilst undergraduate teaching in the health sciences has received considerable attention in the literature in terms of methods used, innovative ideas and outcomes, the same cannot be said of postgraduate education. A considerable amount of postgraduate teaching takes place in the workplace and often in the form of informal teaching. The increasing complexity of health problems calls for innovative teaching.

INCLUSION CRITERIA

Papers included in this review were those that considered postgraduate education in the health science disciplines, including but not limited to medicine, nursing, occupational therapy, physiotherapy, pharmacy and dentistry, and that described theories of learning and/or teaching methods used in teaching.

METHODS

Five databases were searched for the period 2001 through 2016. PubMed yielded the most records (3142). No relevant papers were identified through hand searching of the references of the included papers. A data extraction table was developed and used to extract relevant information from included papers.

RESULTS

Sixty-one papers were included in the review. Most of the included papers were from the USA, with 17 published in 2015. Descriptive study designs were the most frequently identified study design. Most of the papers were from the medical disciplines. Twenty-seven papers did not refer to a teaching and learning theory, a further group referred to a theory but often towards the end of the paper, and seven papers had as their focus the importance of theories in medical education. The theories named were of a wide variety. Likewise, a wide range of teaching methods were identified.

CONCLUSIONS

It is clear that a range of theories and teaching methods are used in postgraduate health science education, with educators feeling the need to explore more innovative methods.

AMIA Board White Paper: AMIA 2017 core competencies for applied health informatics education at the master's degree level

This White Paper presents the foundational domains with examples of key aspects of competencies (knowledge, skills, and attitudes) that are intended for curriculum development and accreditation quality assessment for graduate (master's level) education in applied health informatics. Through a deliberative process, the AMIA Accreditation Committee refined the work of a task force of the Health Informatics Accreditation Council, establishing 10 foundational domains with accompanying example statements of knowledge, skills, and attitudes that are components of competencies by which graduates from applied health informatics programs can be assessed for competence at the time of graduation. The AMIA Accreditation Committee developed the domains for application across all the subdisciplines represented by AMIA, ranging from translational bioinformatics to clinical and public health informatics, spanning the spectrum from molecular to population levels of health and biomedicine. This document will be periodically updated, as part of the responsibility of the AMIA Accreditation Committee, through continued study, education, and surveys of market trends.

Milestones on the Plastic Surgery In-Service Training Examination

BACKGROUND

The Plastic Surgery Milestones Project was implemented in 2014 to establish standards for competency based resident education. In restructuring educational activities under the Milestones, various pedagogical tools have been revised. However, these standards have not yet been applied to the Plastic Surgery In-Service Training Examination. The purpose of this study was to determine the representation of the various components of the Plastic Surgery Milestones Project, on the In-Service Training Examination.

METHODS

All questions from the 2014 - 2018 In-Service Examinations were evaluated within the framework of the current Plastic Surgery Milestones. Using content analysis, each Examination question was mapped to a single Milestone. Descriptive analysis of Milestone subject area and Core Competency breakdown, as well as year to year trends, were performed.

RESULTS

Of the 1,150 questions analyzed, there was an unequal representation of individual Milestones (0-7.4%). Of the 36 Plastic Surgery Milestones, 10 represented more than 50% of the PSITEs while 8 Milestones had less than 1% representation. The most common subject area was Head and Neck (12.7%) and least common was Reconstruction of the Trunk and Perineum. Among Core Competencies, more than half (50.4%) tested Patient Care while Interpersonal and Communication Skills was the lowest represented, 0.2%.

CONCLUSIONS

The Plastic Surgery In-Service Examination tests a variable proportion of Milestones. Currently, the PSITE is not well integrated with competency based education in spite of a shift towards such a training model. Going forward, the PSITE may include an associated Milestone with each question in order to better incorporate Competencies into this important annual evaluation metric.

The Use of Patient-Specific Three-Dimensional Printed Surgical Models Enhances Plastic Surgery Resident Education in Craniofacial Surgery

PURPOSE

A significant challenge in surgical education is to provide a meaningful hands-on experience with the pathology the trainee will see in independent practice. Craniofacial anatomy is challenging and unfamiliar to the learner.

METHODS

Using preoperative computed tomography data, the authors produced an accurately sized, three-dimensional (3D) printed model of the congenital craniofacial anatomy of patients treated by the same attending surgeon-PGY4 resident surgeon pair over the course of a 6-month rotation. A preoperative stepwise surgical plan was written by the attending and resident, and the plan was marked on the 3D model by the attending and resident separately. The written and marked plans were measured for accuracy and time to completion. The resident surgeon's applicable milestone levels were assessed.

RESULTS

Seven congenital craniofacial anomalies met criteria for inclusion: 4 craniosynostosis cases, 2 mandibular distractions, and 1 LeFort I distraction. The number of inaccuracies of the written plan improved from 5 to 0 for sagittal synostosis and 4 to 0 for mandibular distraction. The time to complete the written plan decreased by 22% for sagittal synostosis and 45% for mandibular distraction. The number of inaccuracies of the marked plan decreased from 5 to 0 for sagittal synostosis and 2 to 0 for mandibular distraction. Time to completion of the marked plan decreased by 76% for sagittal synostosis and 50% for mandibular distraction. Milestone scores increased an average of 1.875 levels.

CONCLUSION

Three-dimensional printed craniofacial models are a positive addition to resident training and have been objectively quantified to improve the accuracy and time to completion of the surgical plan as well as progression in the plastic surgery milestones.

A systematic review and meta-analysis of trainee- versus consultant surgeon-performed elective total hip arthroplasty

Total hip arthroplasty (THA) is one of the most commonly performed orthopaedic procedures. Some concern exists that trainee-performed THA may adversely affect patient outcomes. The aim of this meta-analysis was to compare outcomes following THA performed by surgical trainees and consultant surgeons.

A systematic search was performed to identify articles comparing outcomes following trainee- versus consultant-performed THA. Outcomes assessed included rate of revision surgery, dislocation, deep infection, mean operation time, length of hospital stay and Harris Hip Score (HHS) up to one year. A meta-analysis was conducted using odds ratios (ORs) and weighted mean differences (WMDs). A subgroup analysis for supervised trainees versus consultants was also performed.

The final analysis included seven non-randomized studies of 40 810 THAs, of which 6393 (15.7%) were performed by trainees and 34 417 (84.3%) were performed by consultants. In total, 5651 (88.4%) THAs in the trainee group were performed under supervision. There was no significant difference in revision rate between the trainee and consultant groups (OR 1.09; p = 0.51). Trainees took significantly longer to perform THA compared with consultants (WMD 12.9; p < 0.01). The trainee group was associated with a lower HHS at one year compared with consultants (WMD -1.26; p < 0.01). There was no difference in rate of dislocation, deep infection or length of hospital stay between the two groups.

The present study suggests that supervised trainees can achieve similar clinical outcomes to consultant surgeons, with a slightly longer operation time. In selected patients, trainee-performed THA is safe and effective.

Cite this article: EFORT Open Rev 2019;4:44-55. DOI: 10.1302/2058-5241.4.180034.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

Assessing the Value of a Multimedia-Based Aesthetic Curriculum in Plastic Surgery Residency: A Single-Center Pilot Study

BACKGROUND

Although global demand for cosmetic surgery continues to rise, plastic surgery residents feel that current models of aesthetic training are inadequate in preparing them for future practice. Digital learning resources offer promising educational possibilities, yet there are no formal studies investigating the integration of these technologies into the aesthetic curriculum.

OBJECTIVES

Here, we review the current state of aesthetic training for plastic surgery residents and present a pilot study investigating the value of a dedicated multimedia-based aesthetic curriculum at a single, large academic program.

METHODS

Twenty plastic surgery residents participated in an 8-week curriculum consisting of weekly multimedia-based modules covering a specific aesthetic topic. Participants completed pre- and post-intervention surveys at 0 and 10 weeks, respectively. Surveys evaluated resident perspectives of the current state of aesthetic training, confidence in performing surgical and non-surgical aesthetic procedures, perceived efficacy of multimedia interventions for learning, and preferences for inclusion of such approaches in future curricula.

RESULTS

16.7% of participants planned on entering an aesthetic fellowship following residency. The mean number of months of dedicated cosmetic surgery rotations was 1.65 months. Resident confidence level in performing a particular aesthetic procedure significantly increased in 6/14 modules. More than 90% of residents were interested in incorporating the modules into residency.

CONCLUSIONS

Technology-based aesthetic training is critical for producing the finest future practitioners and leaders of this specialty. Here, we show that plastic surgery residents can benefit from a multimedia-based aesthetic curriculum, even if they do not plan on pursuing a career devoted to cosmetic surgery.

The Montreal Augmentation Mammaplasty Operation (MAMO) Simulator: An Alternative Method to Train and Assess Competence in Breast Augmentation Procedures

BACKGROUND

Surgical residents' exposure to aesthetic procedures remains limited in residency training. The development of the Montreal augmentation mammaplasty operation (MAMO) simulator aims to provide an adjunctive training method and assessment tool to complement the evolving competency-based surgical curriculum.

OBJECTIVES

To perform face, content, and construct validations of the MAMO simulator for subpectoral breast augmentation procedures and assess the reliability of the assessment scales used.

METHODS

Plastic surgery staff and residents were recruited to perform a subpectoral breast augmentation on the simulator. Video recordings of their performance were blindly evaluated using the objective structured assessment of technical skills (OSATS) system consisting of the global rating scale (GRS), mammaplasty objective assessment tool (MOAT), and a surgery-specific Checklist score.

RESULTS

Fourteen plastic surgery residents and seven expert plastic surgeons were enrolled. Experts' performance was significantly higher than residents' according to each of GRS, MOAT, and Checklist scores. Mean values of residents and experts were 23.4 (2.5) vs 36.9 (3.1) (P < 0.0001) for GRS score, 30.4 (2.2) vs 40 (3.2) (P < 0.0001) for MOAT scores, and 9.7 (1.5) vs 12 (1) (P < 0.001) for Checklist scores, respectively. Face and content validations showed excellent results among parameters evaluated, with an overall mean score of 4.8 (0.3) on 5. Cronbach's alpha was 0.96 and 0.83 for GRS and MOAT scores, respectively. Intraclass correlation coefficients for interrater reliability were excellent at 0.93, 0.92, and 0.89 for the GRS, MOAT, and Checklist scores, respectively.

CONCLUSIONS

This study proves the construct simulator to be valid and the assessment scales to be reliable.

Narrowing of the surgical resident operative experience: A 27-year analysis of national ACGME case logs

BACKGROUND

Although overall operative volume has remained stable since the implementation of duty hours, more detailed analyses suggest shifts in the resident operative experience. Understanding these differences allows educators to better appreciate the impact of the current training environment on resident preparation for practice.

METHODS

National Accreditation Council for Graduate Medical Education case logs from 1990 to 2016 were reviewed. Statistical analysis was performed using analysis of variance and linear regression analysis.

RESULTS

Over the study period there was no change in total major cases. Subcategory analysis revealed an increase in skin and soft tissue, alimentary tract, abdomen, and endocrine with a concurrent decrease in breast, pediatrics, and trauma. During this time, residents completed fewer cases during their chief year, operated more during non-chief years, taught fewer operations, and assisted in minimal cases. Finally, a decrease in the variability of overall operative volume for total major cases was found as a result of 90th and 10th percentiles converging toward the median.

CONCLUSION

Although total major cases logged by residents have remained stable, the operative experience of general surgery residents has narrowed significantly. Residents are operating earlier and performing fewer teaching and first assistant cases. Surgical educators must look beyond total case numbers and be aware of these changes to ensure all residents achieve technical competency on graduation.

Undergraduate Plastic Surgery Education: A National Survey of Clerkship Directors

Background

The delivery of medical education has received increased attention in recent years due to ongoing time and financial constraints faced by medical educators. Given the recent calls to action by the Carnegie Foundation and Health Canada, an evaluation of the specialty education sector is warranted. To our knowledge, this is the first assessment of the Canadian plastic surgery undergraduate clerkship curriculum.

Method

An anonymous electronic survey was distributed to the plastic surgery clerkship directors of all Canadian medical schools (N = 17). The survey consisted of Likert scales and open-ended short answer questions. Themes included general clerkship information, exposure characteristics, teaching characteristics, resource characteristics, and challenges and barriers faced by clerkship directors.

Results

Survey response rate was 88%. All responding schools offered a clerkship rotation of varying length in time (1-4 weeks). Students had the most exposure to breast surgery (100%) and general plastic surgery (100%) and the least exposure to aesthetic surgery (40%). Sixty percent of schools indicated the use of modern educational methods. Resources available for teaching students varied. Rotations received excellent feedback from medical students (67%). More than half of respondents would like to see a universal, nationally formulated plastic surgery clerkship curriculum.

Conclusion

There is significant heterogeneity in the delivery of plastic surgery clerkship in Canada. A number of areas for improvement have been identified. We hope to establish a national plastic surgery clerkship task force to address the concerns raised here and improve the delivery of undergraduate medical education. Assessment of students based on a national curriculum may help in decision-making regarding plastic surgery program admissions by introducing an element of standardization to clerkship exposure.

Progressive Surgical Autonomy Observed in a Hand Surgery Resident Clinic Model

OBJECTIVE

Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model.

DESIGN

A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system.

SETTING

A tertiary hand surgery referral center.

RESULTS

A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks.

CONCLUSIONS

Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs.

Defining Standards in Experimental Microsurgical Training: Recommendations of the European Society for Surgical Research (ESSR) and the International Society for Experimental Microsurgery (ISEM)

Background: Expectations towards surgeons in modern surgical practice are extremely high with minimal complication rates and maximal patient safety as paramount objectives. Both of these aims are highly dependent on individual technical skills that require sustained, focused, and efficient training outside the clinical environment. At the same time, there is an increasing moral and ethical pressure to reduce the use of animals in research and training, which has fundamentally changed the practice of microsurgical training and research. Various animal models were introduced and widely used during the mid-20th century, the pioneering era of experimental microsurgery. Since then, high numbers of ex vivo training concepts and quality control measures have been proposed, all aiming to reduce the number of animals without compromising quality and outcome of training. Summary: Numerous microsurgical training courses are available worldwide, but there is no general agreement concerning the standardization of microsurgical training. The major aim of this literature review and recommendation is to give an overview of various aspects of microsurgical training. We introduce here the findings of a previous survey-based analysis of microsurgical courses within our network. Basic principles behind microsurgical training (3Rs, good laboratory practice, 3Cs), considerations around various microsurgical training models, as well as several skill assessment tools are discussed. Recommendations are formulated following intense discussions within the European Society for Surgical Research (ESSR) and the International Society for Experimental Microsurgery (ISEM), based on scientific literature as well as on several decades of experience in the field of experimental (micro)surgery and preclinical research, represented by the contributing authors. Key Messages: Although ex vivo models are crucial for the replacement and reduction of live animal use, living animals are still indispensable at every level of training which aims at more than just a basic introduction to microsurgical techniques. Modern, competency-based microsurgical training is multi-level, implementing different objective assessment tools as outcome measures. A clear consensus on fundamental principles of microsurgical training and more active international collaboration for the sake of standardization are urgently needed.

Progressive Surgical Autonomy in a Plastic Surgery Resident Clinic

Background:

Resident clinics are thought to catalyze educational milestone achievement through opportunities for progressively autonomous surgical care, but studies are lacking for general plastic surgery resident clinics (PSRCs). We demonstrate the achievement of increased surgical autonomy and continuity of care in a PSRC.

Methods:

A retrospective review of all patients seen in a PSRC from October 1, 2010, to October 1, 2015, was conducted. Our PSRC is supervised by faculty plastic surgery attendings, though primarily run by chief residents in an accredited independent plastic surgery training program. Surgical autonomy was scored on a 5-point scale based on dictated operative reports. Graduated chief residents were additionally surveyed by anonymous online survey.

Results:

Thousand one hundred forty-four patients were seen in 3,390 clinic visits. Six hundred fifty-three operations were performed by 23 total residents, including 10 graduating chiefs. Senior resident autonomy averaged 3.5/5 (SD = 1.5), 3.6/5 (SD = 1.5), to 3.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. A linear mixed model analysis demonstrated that training level had a significant impact on operative autonomy when comparing postgraduate years 6 and 8 (P = 0.026). Graduated residents’ survey responses (N = 10; 100% response rate) regarded PSRC as valuable for surgical experience (4.1/5), operative autonomy (4.4/5), medical knowledge development (4.7/5), and the practice of Accreditation Council of Graduate Medical Education core competencies (4.3/5). Preoperative or postoperative continuity of care was maintained in 93.5% of cases.

Conclusion:

The achievement of progressive surgical autonomy may be demonstrated within a PSRC model.

Rheumatology training experience across Europe: analysis of core competences

Background

The aim of this project was to analyze and compare the educational experience in rheumatology specialty training programs across European countries, with a focus on self-reported ability.

Method

An electronic survey was designed to assess the training experience in terms of self-reported ability, existence of formal education, number of patients managed and assessments performed during rheumatology training in 21 core competences including managing specific diseases, generic competences and procedures. The target population consisted of rheumatology trainees and recently certified rheumatologists across Europe. The relationship between the country of training and the self-reported ability or training methods for each competence was analyzed through linear or logistic regression, as appropriate.

Results

In total 1079 questionnaires from 41 countries were gathered. Self-reported ability was high for most competences, range 7.5–9.4 (0–10 scale) for clinical competences, 5.8–9.0 for technical procedures and 7.8–8.9 for generic competences. Competences with lower self-reported ability included managing patients with vasculitis, identifying crystals and performing an ultrasound. Between 53 and 91 % of the trainees received formal education and between 7 and 61 % of the trainees reported limited practical experience (managing ≤10 patients) in each competence. Evaluation of each competence was reported by 29–60 % of the respondents. In adjusted multivariable analysis, the country of training was associated with significant differences in self-reported ability for all individual competences.

Conclusion

Even though self-reported ability is generally high, there are significant differences amongst European countries, including differences in the learning structure and assessment of competences. This suggests that educational outcomes may also differ. Efforts to promote European harmonization in rheumatology training should be encouraged and supported.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1114-y) contains supplementary material, which is available to authorized users.

Microsurgical skill acquisition in a one-day introductory course with performance evaluation using software-assisted scoring system

BACKGROUND

Recent emphasis on microsurgical skill acquisition at an earlier stage of plastic surgery training has seen a shift toward objective competence-based assessment. Yet no objective measures of spacing or alignment exist, with few validated models that assess ability. The authors propose a novel software analysis scoring system to objectively measure spacing, alignment and the overall improvement in a 1-day, introductory course setting.

METHODS

Images of standard 4-mm latex strips that had been sutured by participants using the Microtrainer system were uploaded onto calibrated, online software. Sutures were analysed with regard to spacing, alignment and density. From these measurements, a total score was calculated, one on initial assessment at the course beginning (Score 1) and another on final assessment at the course end (Score 2), thereby facilitating measurement of the overall improvement.

RESULTS

A total of 38 microsurgical anastomoses from 19 participants ranging from postgraduate years 1-7 were analysed. Seventeen participants had no previous experience of microsurgery. The mean average Score 1 of participants was -2 (range -12 to +22) and Score 2 was 22 (range +12 to +32), thus showing a significant improvement in candidate ability throughout the course of the day (p < 0.0001).

CONCLUSIONS

Microtrainer system software analysis provides a novel, reliable, and consistent objective assessment for surgical trainees at all stages of training, without risk to patients. It has an associated cost for the initial setup, yet is timely, repeatable and can efficiently demonstrate progress in a 1-day course setting.

The Development of Assessment Tools for Plastic Surgery Competencies

BACKGROUND

Objective tools to assess procedural skills in plastic surgery residency training are currently lacking. There is an increasing need to address this deficit in order to meet today's training standards in North America.

OBJECTIVES

The purpose of this pilot study was to establish a methodology for determining the essential procedural steps for two plastic surgery procedures to assist resident training and assessment.

METHODS

Following a literature review and needs assessment of resident training, the authors purposefully selected two procedures lacking robust assessment metrics (breast augmentation and facelift) and used a consensus process to complete a list of procedural steps for each. Using an online survey, plastic surgery Program Directors, Division Chiefs, and the Royal College Specialty Training Committee members in Canada were asked to indicate whether each step was considered essential or non-essential when assessing competence among graduating plastic surgery trainees. The Delphi methodology was used to obtain consensus among the panel. Panelist reliability was measured using Cronbach's alpha.

RESULTS

A total of 17 steps for breast augmentation and 24 steps for facelift were deemed essential by consensus (Cronbach's alpha 0.87 and 0.85, respectively).

CONCLUSION

Using the aforementioned technique, the essential procedural steps for two plastic surgery procedures were determined. Further work is required to develop assessment instruments based on these steps and to gather validity evidence in support of their use in surgical education.

Changing trends in plastic surgery training

BACKGROUND

The currently available training models are being put to scrutiny in India today, both by the residents and the teachers. Plastic surgery specialty was created primarily for reconstructive purposes but the society always perceived it from a cosmetic angle, particularly in the post second world war era. As a result, there is a need to redefine the goals of plastic surgery training in the present times so that the plastic surgeon is "future ready" to meet the needs of society and the market forces.

MATERIALS AND METHODS

The author has reviewed the currently available literature on plastic surgery training from India and the western countries. An attempt has been made to study opinions from the teachers and the trainees. The modules currently available in India and abroad have been analyzed and a suggestion has been made for drafting training programs that would meet the demands of the society as well as prepare the resident both for the aesthetic and reconstructive practice.

CONCLUSIONS

The plastic surgery training needs to be more vibrant and in tune with the changing times. While maintaining its core nature, the current predominantly reconstructive modules need to incorporate the aesthetic content. The evaluation should be both knowledge and competence based. The teachers need to be educated in the various teaching methods that are more applicable to grown up residents. There is a need to find ways to attract talented people in the academic plastic surgery.