How long does it take to train a surgeon?

Online training module for micro suturing incorporating motor imagery and mental practice: a design and development research study

INTRODUCTION

There have been reduced opportunities for surgical skill acquisition due to the COVID-19 pandemic and the regulated training hours. Despite these challenges, self-regulated learning allows trainees to learn continuously, and one form of this is through mental practice and motor imagery. The study aimed to design and develop an online basic micro suturing training module for skill acquisition for self-regulated learning using a low-fidelity rubber glove model.

METHODS

This study utilized a design and developmental research framework and Mayer's multimedia theory guidelines. The primary author created an online instructional module on micro suturing based on the ADDIE instructional design model. This module was then evaluated in a pilot study comparing the new training model to traditional methods of learning using an experimental design.

RESULTS

This study describes the use of Design and Development Research to create a new model for surgical skill training and a tool for producing instructional materials and learning products for online learning. The product was evaluated using an experimental design and showed a significant effect on the quality of motor skill outcome and the richness of motor imagery using the resource developed in the research.

CONCLUSION

This study describes the methodological approach of a design and developmental framework to create an online training module for micro suturing which has significant utility in hand surgery.

Complications after breast reconstruction with alloplastic material in breast cancer patients submitted or not to post mastectomy radiotherapy

Background and purpose

Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material.

Materials and methods

Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications.

Results

251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications.

Conclusions

The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.

Educational value of surgical telementoring

Educating surgeons is a time‐consuming process. In addition to theoretical knowledge, the practical tasks of surgical procedures must be mastered. Translation of such knowledge from mentor to mentee may be efficiently done by surgical telementoring (ST). This is a review on surgical telementoring. Recent technological advances have made this tool in surgical education more available and applicable but future applications of ST have to be wisely guided by high‐quality trials.

Is It Safe to Let Trainees Operate on High Risk Cardiac Surgery Cases?

Increasing complexity in cardiac operations has raised the discussion on trainee autonomy and the number of cases required to achieve competency. This study compares outcomes among cases done by trainees vs consultants for high risk patients. 696 (trainee=158 vs consultant=438) major high risk cardiac operations (Euroscore >10) were reviewed at a single center. Observations were propensity matched to consultant or trainee based on several baseline characteristics. Euroscore was: Trainee; 12.3 ± 1.6 versus Consultant; 12.8 ± 2.2, p=.036. Multivariable analysis did not identify trainee as a risk factor for worse in-hospital mortality (OR; 0.95, CI; 0.4-2.2, p=.914) or composite outcome of length of stay >30 days, deep sternal infection, new hemodialysis, new stroke or transient ischemic attack, in-hospital death or reoperation (OR; 0.64, CI; 0.39-1.03, p=.069). NYHA class, diabetes and emergency/salvage surgery were predictors of worse composite outcome. After propensity matching (130 pairs), there was no difference in reoperation rates (3.1% versus 4.6%, p=.727), inhospital death (5.4% versus 7.7%, p=.607) or composite outcome (20.8% versus 29.2%, p=.152). There was no statistical difference in cross clamp times (Trainee; 74.0 ± 32.7 min vs Consultant; 82.6 ± 51.1, p=.229) and bypass times (Trainee; 116.3 ± 52.8 min versus Consultant 135.3 ± 72.6 min, p=.055). The length of stay was similar (18.2 ± 13.2 days versus 19.9 ± 15.6 days, p=.302). It is possible for trainees to perform high risk cardiac surgery without compromising the quality of patient care.

Surgical Boot Camps Increases Confidence for Residents Transitioning to Senior Responsibilities

OBJECTIVE

Surgical boot camps enhance the confidence of medical students and surgical interns. The impact of boot camps on the confidence of post-graduate year (PGY) 2 residents is unknown. We hypothesized that a postinternship boot camp would improve the confidence of PGY-2 residents in managing their newfound responsibilities. We also hypothesized that the effect of a tailored high-impact boot camp would persist over time.

DESIGN

A 2-hour boot camp at our simulation center was implemented for PGY-2 residents in 2016 and 2017. Confidence in handling boot camp scenarios was measured on a 1 to 5 Likert scale before and after the boot camp. Three-month follow-up was assessed in the 2017 cohort.

PARTICIPANTS

Thirty-one PGY-2 residents (n = 16 in 2016, n = 15 in 2017) completed the boot camp.

RESULTS

Residents reported increased confidence in placing central lines (p < 0.001), placing chest tubes (p = 0.01), managing emergency airways (p < 0.001), running a code (p = 0.03), and fulfilling the role of in-house senior resident (p < 0.001). Three-month follow-up in 2017 (n = 10) demonstrated no difference in confidence compared to postboot camp results.

CONCLUSIONS

Boot camps can durably improve confidence in skills expected of PGY-2 residents assuming in-house senior resident responsibilities.

Classical but Not Rap Music Significantly Improves Transferability and Long-Term Acquisition of Laparoscopic Suturing Skills: A Randomized Controlled Trial

INTRODUCTION

 Acoustic distractions have been shown to increase the level of stress and workload in the operating room (OR). Noise significantly reduces surgical performance, but experienced surgeons are able to reduce the acoustic perception of their surroundings to maintain a high level of performance in complex surgical tasks. However, music has been shown to improve learning and performance of complex motor skills. The aim of this study was to evaluate the influence of music on transferability and long-term acquisition of laparoscopic suturing skills.

MATERIALS AND METHODS

 To evaluate the effects of music on training, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes-prior and post 3 hours of hands-on training. To examine long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 6 months post initial training, as a follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed.

RESULTS

 Twenty-four students were included in the study; after simple randomization, 16 were trained while exposed to music (eight to Bach and eight to Bushido) and eight with traditional methods. Seven were lost due to follow-up. Both groups had comparable baseline characteristics and significantly improved after training, in all parameters assessed in this study. Subjects that trained with classical music were superior in terms of speed (p = 0.006), knot quality (p = 0.014), and procedural performance (p = 0.034) compared with controls.

CONCLUSION

 Music during acquisition of complex motor skills, like laparoscopic suturing and knot tying, is superior to traditional training. Especially music considered nondisturbing significantly improved speed, knot quality, and performance. Thus, incorporation of pleasant music into surgical skills training and the OR should be considered.

The Effect of Global Surgery Fellowship for Tertiary Hospital Professionals from Myanmar: Current Issues and Future Challenges

OBJECTIVE

As the surgical burden of diseases grows higher than ever, the development of skilled surgeons and surgery teams is of fundamental importance. However, there is scarce evidence of the effectiveness of surgical training programs. Our study aims to evaluate the effectiveness of a global surgery fellowship program.

DESIGN

In 2018, Myanmar subspecialty surgeons were trained for a 3-month in tertiary hospital of Korea. We evaluated the reactions, learning, and transfer of the 11 trainees using Kirkpatrick's Evaluation Model.

SETTING

Myanmar and Korean tertiary hospital.

PARTICIPANTS

Eleven participants of fellowship from Myanmar.

RESULTS

Participants' overall reaction scores were 4.45 ± 0.52 out of 5.00. Regarding overall competency, the trainees assessed themselves as at an "advanced beginner level" (3.63 ± 1.38 out of 10.00) at the beginning and at a "competent level" (5.40 ± 1.70 out of 10.00) after the training (p for difference = 0.014). The trainees stated that their transfer in clinical practice was between "quite applicable" and "I am very sure that I can do this" (3.39 ± 0.61 out of 4.00). Their transfer in education was second, ranked around "quite applicable" (3.21 ± 0.77 out of 4.00), and their transfer in research was last and ranked "applicable, but just a little" (2.81 ± 0.67 out of 4.00). However, in our online survey, native and foreign trainers had mixed opinions about the transfer of training and were not entirely confident in the trainees' competency. Trainees felt that there were multifactorial challenges for transfer and cited infrastructure, facilities, human resources, perioperative care, and financing.

CONCLUSIONS

Surgical trainees reported high-level satisfaction and increased knowledge after training. However, further onsite surgical experiences are necessary for a successful transfer to the real setting. Challenges for such transfers were multifactorial, and surgical care must be systemically strengthened.

Development and decay of procedural skills in surgery: A systematic review of the effectiveness of simulation-based medical education interventions

CONTEXT

Changes to surgical training programmes in the UK has led to a reduction in theatre time for trainees, and an increasing reliance on simulation to provide procedural experience. Whilst simulation offers opportunity for repetitive practice, the effectiveness of simulation as an educational intervention for developing procedural surgical skills is unclear.

METHODS

A systematic literature review was undertaken to retrieve all studies describing simulation-based medical education (SBME) interventions for the development of procedural surgical skills using the MEDLINE, PsycINFO, CINAHL, EMBASE and PUBMED databases. Studies measuring skill retention or demonstrating transferability of skills for improving patient outcomes were included in the review.

RESULTS

SBME is superior to no training and can lead to improvement in procedural surgical skills, such that skills transfer from simulated environments into theatre. SBME results in minimal skill degradation after 2 weeks, although more significant decay results after >90 days. Many studies recruited <10 participants, used a variety of methods and were restricted to endoscopic surgical techniques. All studies did not compare interventions with non-SBME teaching methods for developing procedural surgical skills. No studies compared the curriculum design of different surgical training programmes.

CONCLUSIONS

SBME interventions are effective for developing procedural skills in surgery. SBME interventions are also effective for preventing the decay of procedural surgical skills. Although no studies demonstrate non-inferiority of SBME interventions compared to time in theatre developing skills, SBME interventions do enable the transfer of skills into theatre, and the potential for improving patient outcomes.

Satisfaction of the Irish Trauma and Orthopaedic training programme with the Intercollegiate Surgical Curriculum Programme

BACKGROUND

Surgical training has undergone extensive changes in recent years. The Intercollegiate Surgical Curriculum Programme (ISCP) has been utilised in the UK for many years to facilitate the education and assessment of trainees. It was adopted by the Irish Trauma and Orthopaedics (T&O) training programme in July 2015. This study sought to evaluate the use satisfaction with ISCP in the Irish context.

METHODS

A total of 58 T&O trainers and trainees undertook a paper-based survey during national training days in March and April 2017.

RESULTS

Eighty-nine percent of trainees responded to the survey along with 85% of trainers. Seventy-nine percent of respondents had been using ISCP for over a year. Most aspects of ISPC were rated as average, with the induction process, online multi-source feedback (MSF) and overall user friendliness rating poorly amongst respondents. Seventeen percent felt that ISCP had a positive impact on training, while 66% felt that it did not adversely affect their training opportunities. Forty-three percent reported a negative impact on the trainer-trainee relationship with adoption of ISCP and only 24% felt that the educational feedback was improved with the new system. Forty-two percent agreed that ISCP created a more structured and supervised framework to the training scheme.

CONCLUSIONS

Our survey demonstrated significant concerns and reservations amongst the Irish users of ISCP. The demonstrable level of trainee dissatisfaction with ISCP may represent a frustration that key problems such as the regulated training content of jobs remains unaddressed while ISCP does little to improve meaningful formative feedback.

Understanding Surgical Resident and Fellow Perspectives on Their Operative Performance Feedback Needs: A Qualitative Study

OBJECTIVE

Operative performance feedback is essential for surgical training. We aimed to understand surgical trainees' views on their operative performance feedback needs and to characterize feedback to elucidate factors affecting its value from the resident perspective.

DESIGN

Using a qualitative research approach, 2 research fellows conducted semistructured, one-on-one interviews with surgical trainees. We analyzed recurring themes generated during interviews related to feedback characteristics, as well as the extent to which performance rating tools can help meet trainees' operative feedback needs.

SETTING

Departments or divisions of general or plastic surgery at 9 US academic institutions.

PARTICIPANTS

Surgical residents and clinical fellows in general or plastic surgery.

RESULTS

We conducted 30 interviews with 9 junior residents, 14 senior residents, and 7 clinical fellows. Eighteen (60%) participants were in plastic and 12 (40%) were in general surgery. Twenty-four participants (80%) reported feedback as very or extremely important during surgical training. All trainees stated that verbal, face-to-face feedback is the most valuable, especially if occurring during (92%) or immediately after (65%) cases. Of those trainees using performance rating tools (74%), most (57%) expressed positive views about them but wanted the tools to complement and not replace verbal feedback in surgical education. Trainees value feedback more if received within 1 week or the case.

CONCLUSIONS

Verbal, face-to-face feedback is very or extremely important to surgical trainees. Residents and fellows prefer to receive feedback during or immediately after a case and continue to value feedback if received within 1 week of the event. Performance rating tools can be useful for providing formative feedback and documentation but should not replace verbal, face-to-face feedback. Considering trainee views on feedback may help reduce perceived gaps in feedback demand-versus-supply in surgical training, which may be essential to overcoming current challenges in surgical education.

Core trainee boot camp, a method for improving technical and non-technical skills of novice surgical trainees. A before and after study

INTRODUCTION

The transition to surgical training can be a stressful time for trainees and is most evident during national handover periods where new graduates start and senior trainees rotate to new programmes. During this time, patient mortality can increase and Hospital efficiency reduces. This influence is compounded by the impact of working time directives. Intensive, simulation rich training programmes or "Boot Camps" have been postulated as a solution. This article highlights the development of a surgical boot camp for novice surgical trainees and the impact this can have on training.

METHOD

A novel surgical boot camp was developed for all trainees within a surgical training region including nine acute NHS trusts. Participating cohort of trainees completed pre and post course questionnaires to assess technical and non-technical skills.

RESULTS

25 trainees attended and completed the pre and post boot camp questionnaire. Significant improvements were seen with technical skills (p = 0.0429), overall non-technical skills (p < 0.001) including leadership (p = 0.022), communication (p = 0.010), situational awareness (p = 0.022), patient handover (p = 0.003), ward round skills (p = 0.005) and outpatient skill (p = 0.002). Trainees reported significantly increased ability to assess and manage a critically unwell patient (p = 0.001) and a trauma patient (p = 0.001). 96% of trainees have utilised the skills they learnt on Boot Camp and all trainees would recommend it as an induction programme.

CONCLUSION

Surgical Boot Camps offer a timely chance to develop technical and non-technical skills whilst enhancing a trainee's confidence and knowledge and reduce the patient safety impact of the handover period.

Beliefs and values about intra-operative teaching and learning: a case study of surgical teachers and trainees

Surgeons require advanced psychomotor skills, critical decision-making and teamwork skills. Much of surgical skills training involve progressive trainee participation in supervised operations where case variability, operating team interaction and environment affect learning, while surgical teachers face the key challenge of ensuring patient safety. Using a theoretical framework of situated learning including cognitive apprenticeship, we explored teachers' and trainees' beliefs and values about intra-operative training and reasons for any differences. A qualitative case study method was used where five teacher-trainee pairs participating in an observed teaching operation were separately interviewed about the same operation. Thematic analysis of transcribed interviews and observations was performed with iterative refinement and a reflexive approach was adopted throughout the study. We found that in all cases, teachers and trainees had shared recognition of learning about technical skills whereas they differed in three cases regarding non-technical skills such as surgical reasoning and team management. Factors contributing to teacher and trainee satisfaction with the process were successful trainee completion of operation without need for surgeon take-over, a positive learning environment and learning new things. Teaching-learning behaviours observed and discussed were modeling, coaching and scaffolding, while exploration, reflection and articulation were less common. Our study reveals differing teacher and trainee perspectives of some aspects of intra-operative training and surfaces new reasons other than amount of feedback and autonomy given. Factors contributing to different perspectives include teacher and trainee abilities, values and situational influences. Targeted teaching-learning strategies could enhance intra-operative learning.

Does warming up improve surgical outcome in total hip arthroplasty?

PURPOSE

Warming up prior to surgery has been shown to enhance surgeons' performance during laparoscopic procedures. It is unknown whether or not warming up prior to total hip arthroplasty (THA) will have a similar effect on surgical outcome.

METHODS

We retrospectively evaluated the effect of warming up on the intraoperative outcome of 82 patients who underwent a primary THA with identical implants. The patients were divided equally into two groups. Group 1 (first case of the day) served as "warm-up procedure," while Group 2 (second case of the day) was the "post-warm-up procedure."

RESULTS

We found no statistically significant difference when we compared cup abduction and anteversion angles, femoral offset, postoperative LLD, stem alignment, hip center of rotation and femoral stem canal fill between the two groups (p > 0.05).

CONCLUSION

Warming up prior to performing surgery does not make a difference for primary THA when performed by an experienced surgeon. However, these results may not reflect its effect on procedures that require fine motor skills or done by an orthopedic trainee or less experienced surgeons.

Simulated ventriculostomy training with conventional neuronavigational equipment used clinically in the operating room: prospective validation study

OBJECTIVES

Simulation is gaining increasing interest as a method of delivering high-quality, time-effective, and safe training to neurosurgical residents. However, most current simulators are purpose-built for simulation, being relatively expensive and inaccessible to many residents. The purpose of this study was to provide the first comprehensive validity assessment of ventriculostomy performance metrics from the Medtronic StealthStation S7 Surgical Navigation System, a neuronavigational tool widely used in the clinical setting, as a training tool for simulated ventriculostomy while concomitantly reporting on stress measures.

DESIGN

A prospective study where participants performed 6 simulated ventriculostomy attempts on a model head with StealthStation-coregistered imaging. The performance measures included distance of the ventricular catheter tip to the foramen of Monro and presence of the catheter tip in the ventricle. Data on objective and self-reported stress and workload measures were also collected.

SETTING

The operating rooms of the National Hospital for Neurology and Neurosurgery, Queen Square, London.

PARTICIPANTS

A total of 31 individuals with varying levels of prior ventriculostomy experience, varying in seniority from medical student to senior resident.

RESULTS

Performance at simulated ventriculostomy improved significantly over subsequent attempts, irrespective of previous ventriculostomy experience. Performance improved whether or not the StealthStation display monitor was used for real-time visual feedback, but performance was optimal when it was. Further, performance was inversely correlated with both objective and self-reported measures of stress (traditionally referred to as concurrent validity). Stress and workload measures were well-correlated with each other, and they also correlated with technical performance.

CONCLUSIONS

These initial data support the use of the StealthStation as a training tool for simulated ventriculostomy, providing a safe environment for repeated practice with immediate feedback. Although the potential implications are profound for neurosurgical education and training, further research following this proof-of-concept study is required on a larger scale for full validation and proof that training translates into improved long-term simulated and patient outcomes.

The impact of a surgical boot camp on early acquisition of technical and nontechnical skills by novice surgical trainees

BACKGROUND

Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program.

METHODS

New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills.

RESULTS

The scores for knowledge (53.8% vs 68.4%, P < .01), technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P < .01), and confidence levels improved significantly during boot camp. Skills improvements were still present a year later.

CONCLUSION

The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees.

Surgical training is undermined by inadequate provision of laparoscopic surgical simulators

In parallel with the introduction of working time regulations that have led to changes in working patterns, surgical trainees are taking longer to achieve operative competencies and logging fewer surgical cases. 1–3 The existing style of surgical training appears to provide insufficient operative exposure in limited working hours.

Is the National Registration website (Australian Health Practitioner Regulation Agency) effective in tracking Australian medical graduates' rural work?

OBJECTIVE

This study compared rural location identified through the National Registration (AHPRA) registry with location obtained through labour-intensive personal contact.

DESIGN

Longitudinal cohort study with two methods to identify the work locations of medical graduates from The Rural Clinical School of Western Australia (RCSWA).

PARTICIPANTS

Consenting alumni from the University of Western Australia and the University of Notre Dame Fremantle participating in RCSWA between 2002 and 2009 inclusive and available to contact in 2011.

MAIN OUTCOME MEASURE

Percentage location matches between two contact methods.

RESULTS

There was 80% agreement for principal suburb, 92% agreement for principal city and 94% agreement for principal state between RCSWA personal contact and the AHPRA registry. AHPRA identified nearly two times as many graduate locations. However, there was only 31% agreement for a rural placement location (of any length). In more detail, for year-long rural placement, personal contact was 88% concordant with AHPRA; work six months or more were less concordant (44% agreement); work less than six months were not concordant (4% agreement).

CONCLUSIONS

AHPRA data matched RCSWA alumni data only for graduates in full-time rural work. Since medical alumni spend up to 10 years in pre-vocational and vocational training, which includes many rural options, personal contact was able to pick up the myriad of rural choices, whereas the AHPRA database was not sensitive enough to identify them. Until graduates have stably finished training, the optimal method to identify rural work is through personal contact but statistical correction for missing data needs to be considered.

The use of simulation in neurosurgical education and training

Object

There is increasing evidence that simulation provides high-quality, time-effective training in an era of resident duty-hour restrictions. Simulation may also permit trainees to acquire key skills in a safe environment, important in a specialty such as neurosurgery, where technical error can result in devastating consequences. The authors systematically reviewed the application of simulation within neurosurgical training and explored the state of the art in simulation within this specialty. To their knowledge this is the first systematic review published on this topic to date.

Methods

The authors searched the Ovid MEDLINE, Embase, and PsycINFO databases and identified 4101 articles; 195 abstracts were screened by 2 authors for inclusion. The authors reviewed data on study population, study design and setting, outcome measures, key findings, and limitations.

Results

Twenty-eight articles formed the basis of this systematic review. Several different simulators are at the neurosurgeon's disposal, including those for ventriculostomy, neuroendoscopic procedures, and spinal surgery, with evidence for improved performance in a range of procedures. Feedback from participants has generally been favorable. However, study quality was found to be poor overall, with many studies hampered by nonrandomized design, presenting normal rather than abnormal anatomy, lack of control groups and long-term follow-up, poor study reporting, lack of evidence of improved simulator performance translating into clinical benefit, and poor reliability and validity evidence. The mean Medical Education Research Study Quality Instrument score of included studies was 9.21 ± 1.95 (± SD) out of a possible score of 18.

Conclusions

The authors demonstrate qualitative and quantitative benefits of a range of neurosurgical simulators but find significant shortfalls in methodology and design. Future studies should seek to improve study design and reporting, and provide long-term follow-up data on simulated and ideally patient outcomes.

The emerging role of national academies in surgical training: an inspiring environment for increasing the quality of health care in breast cancer management

Medical education, both graduate and postgraduate, is given at medical schools and affiliated teaching hospitals. The training at these institutions is necessary and valuable. In each field of the medical profession, the relevant science is being developed and changed constantly. Training of medical staff and auxilliary professionals must be adaptable to changes in the field. Also, the development of standards for the diagnosis and treatment of diseases is important. Independent institutions, called academies, serve an extremely useful task in the continuing further training that needs to be adjusted according to individual needs. Academies are independent and free from bureaucracies. Standardized records are uniform and comparable at these institutions. Both patients and medical staff receive training from these institutions. In this way, a high standard is provided in medicine, error rates are decreased and patient satisfaction is increased. Breast cancer, the most common tumor in women, is a serious cause of morbidity and mortality. The European Institute of Oncology (EIO) in Milan, Italy and the European Academy of Senology in Duesseldorf, Germany play important roles in establishing the standards of breast care. They provide substantial training for physicians to achieve high quality in breast cancer management. SENATURK (Senoloji Akademisi, Turkish Academy of Senology) was established in 2010 in Istanbul, Turkey. Both national and international scientists and physicians including eminent senologists are currently faculty members of this young organization. SENATURK collaborates with other institutions in Europe. Its missions include developing training programs for each level of the profession, as well as developing data recording systems and electronic learning tools for breast cancer prevention, diagnosis, treatment, rehabilitation and palliation. Briefly, SENATURK plays a significant role as the opinion leader on every aspect of health care related to conditions and diseases of the breast.

UK doctors' views on the implementation of the European Working Time Directive as applied to medical practice: a quantitative analysis

OBJECTIVES

To report on doctors' views, from all specialty backgrounds, about the European Working Time Directive (EWTD) and its impact on the National Health Service (NHS), senior doctors and junior doctors.

DESIGN

All medical school graduates from 1999 to 2000 were surveyed by post and email in 2012.

SETTING

The UK.

METHODS

Among other questions, in a multipurpose survey on medical careers and career intentions, doctors were asked to respond to three statements about the EWTD on a five-point scale (from strongly agree to strongly disagree): 'The implementation of the EWTD has benefited the NHS', 'The implementation of the EWTD has benefited senior doctors' and 'The implementation of the EWTD has benefited junior doctors'.

RESULTS

The response rate was 54.4% overall (4486/8252), 55.8% (2256/4042) of the 1999 cohort and 53% (2230/4210) of the 2000 cohort. 54.1% (2427) of all respondents were women. Only 12% (498/4136 doctors) agreed that the EWTD has benefited the NHS, 9% (377) that it has benefited senior doctors and 31% (1289) that it has benefited junior doctors. Doctors' views on EWTD differed significantly by specialty groups: 'craft' specialties such as surgery, requiring extensive experience in performing operations, were particularly critical.

CONCLUSIONS

These cohorts have experience of working in the NHS before and after the implementation of EWTD. Their lack of support for the EWTD 4 years after its implementation should be a concern. However, it is unclear whether problems rest with the current ceiling on hours worked or with the ways in which EWTD has been implemented.

Radiotherapy in implant-based immediate breast reconstruction: risk factors, surgical outcomes, and patient-reported outcome measures in a large Swedish multicenter cohort

The purpose of this large cohort study was to analyze the effects of prior and postoperative radiotherapy (RT) on surgical outcomes and patient-reported outcome measures (PROMs) in implant-based immediate breast reconstruction (IBR). All breast cancer patients (n = 725, of whom 29 had bilateral IBR) operated with implant-based IBR at four Stockholm hospitals from 2007 to 2011 were included. The median follow-up was 43 months. Three groups were compared: no RT (n = 386), prior RT (n = 64), and postoperative RT (n = 304). Outcomes were IBR failure (implant loss with or without secondary autologous reconstruction), unplanned reoperations, and PROMs, as measured by the BreastQ(®) questionnaire. IBR failure occurred in 22/386 (6 %) of non-irradiated cases, 16/64 (25 %) after prior and 45/304 (15 %) after postoperative RT (p < 0.001). Failure risk was higher after prior than postoperative RT (HR 9.28 vs. 3.08). Further risk factors were high BMI, less surgeon reconstructive experience, and postoperative infection, while the use of permanent implants lowered the risk of IBR failure. The estimated 5 years IBR failure rate was 10.4 % for non-irradiated, 28.2 % for previously and 25.2 % for postoperatively irradiated patients (p < 0.001). At least one unplanned reoperation occurred in 169/384 of non-irradiated (44 %), 42/64 (66 %) of previously, and 180/303 (59 %) of postoperatively irradiated breasts (p < 0.001). Further contributing factors were the use of one-stage expander and permanent implants, less surgeon reconstructive experience, and smoking. RT significantly impaired scores on all scales of the BreastQ(®). However, a clear majority of women in all groups would choose IBR again. Implant-based IBR remains a feasible option for women undergoing mastectomy as patient satisfaction levels are high. After prior RT, however, autologous alternatives should be considered.

Teaching and Assessing Colorectal Surgery Residents in the Age of ACGME Competencies: Pieces of the Whole

Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.

Deliberate practice, domain-specific expertise, and implications for surgical education in current climes

BACKGROUND AND OBJECTIVES

Within surgery, recent years have witnessed increasing focus on patient safety, accountability, and surgical performance. In addition to these factors, increasing subspecialisation and reductions to working hours among junior doctors most notably in the United States of America and Europe mandate the need for surgeons to develop expertise. However, surgical expertise as a concept is poorly defined. The aim of this review is to (i) define surgical expertise, (ii) discuss the literature analyzing how expertise is attained, and (iii) highlight the concept of domain-specific expertise.

METHODS

A review was performed of literature pertinent to expertise both within and external to medicine and surgery. Additional literature concerning deliberate practice, simulation, and transfer of learning was also reviewed.

RESULTS

A remarkable repertoire of literature demonstrates that in many domains expertise: (i) is developed after 10 years of deliberate practice (defined as repeated practice in motivated individuals receiving feedback)-the '10-year rule,' and (ii) is highly domain specific.

CONCLUSIONS

Surgical expertise is domain (procedure and context) specific. If the '10-year rule' is true for surgery, restrictions on doctors' working hours will likely delay surgical expertise acquisition. Conversely, the trend to increasing subspecialisation may facilitate surgical expertise acquisition. So, too, may simulation, as long as appropriate transfer of learning to clinical practice occurs. Further work is required to better understand surgical expertise and provide solutions to accelerate expertise acquisition in surgical trainees, with the aim of improving postgraduate training programs and optimizing patient outcomes.

Basic surgical training in Ireland: the impact of operative experience, training program allocation and mentorship on trainee satisfaction

BACKGROUND

Application to the Irish basic surgical training (BST) program in Ireland has decreased progressively over the past 5 years. We hypothesised that this decline was secondary to dissatisfaction with training correlated with reduced operative experience and lack of mentorship among BSTs.

METHODS

An anonymous 15 question electronic survey was circulated to all BSTs appraising their impression of the operative experience available to them, their mentorship and their opinions of critical aspects of training.

RESULTS

Fifty trainees responded to the survey. At the commencement of training 98 % (n = 43) intended to stay in surgery, decreasing to 79 % (n = 34) during the BST. Trainees who felt they had a mentor were three times more likely to be content in surgical training (OR 3.11; 95 % CI 0.94-10.25, P = 0.06). Trainees satisfied with their allocated rotation were more likely to be content in surgical training (OR 4.5; 95 % CI 1.03-19.6, P = 0.045). Individual trainee comments revealed dissatisfaction with operative exposure.

CONCLUSION

Mentorship and satisfaction with allocated training rotation had a positive impact on trainee satisfaction and correlated with contentedness in surgical training. Operative experience is the main element that trainees report as lacking. This highlights the need for reform of the training system to improve current levels of mentorship and increase operative exposure to enhance its attractiveness to the best quality medical graduates.

Getting lost in translation? Workplace based assessments in surgical training

Workplace based assessments (WBA) are integral to the competence-based surgical training curriculum that currently exists in the UK. The GMC emphasise the value of WBA's as assessments for learning (formative), rather than as assessments of learning (summative). Current implementation of WBA's in the workplace though, is at odds with their intended use, with the formative functions often being overlooked in favour of the summative, as exemplified by the recent announcement that trainees are required to complete a minimum of 40 WBA's a year, an increase from 24. Even before this increase, trainees viewed WBA's as tick-box exercises that negatively impact upon training opportunities. As a result, the tools are commonly misused, often because both trainees and trainers lack understanding of the benefits of full engagement with the formative learning opportunities afforded by WBA's. To aid the transition in mind-set of trainees and trainers to the purpose of assessment in the workplace, the GMC propose the introduction of 'supervised learning events' and 'assessments of performance' to supersede 'WBA's'. The impact of this change and how these will be integrated into surgical training is yet to be seen, but is likely to be a step in the right direction.

Artificial intelligence framework for simulating clinical decision-making: a Markov decision process approach

OBJECTIVE

In the modern healthcare system, rapidly expanding costs/complexity, the growing myriad of treatment options, and exploding information streams that often do not effectively reach the front lines hinder the ability to choose optimal treatment decisions over time. The goal in this paper is to develop a general purpose (non-disease-specific) computational/artificial intelligence (AI) framework to address these challenges. This framework serves two potential functions: (1) a simulation environment for exploring various healthcare policies, payment methodologies, etc., and (2) the basis for clinical artificial intelligence - an AI that can "think like a doctor".

METHODS

This approach combines Markov decision processes and dynamic decision networks to learn from clinical data and develop complex plans via simulation of alternative sequential decision paths while capturing the sometimes conflicting, sometimes synergistic interactions of various components in the healthcare system. It can operate in partially observable environments (in the case of missing observations or data) by maintaining belief states about patient health status and functions as an online agent that plans and re-plans as actions are performed and new observations are obtained. This framework was evaluated using real patient data from an electronic health record.

RESULTS

The results demonstrate the feasibility of this approach; such an AI framework easily outperforms the current treatment-as-usual (TAU) case-rate/fee-for-service models of healthcare. The cost per unit of outcome change (CPUC) was $189 vs. $497 for AI vs. TAU (where lower is considered optimal) - while at the same time the AI approach could obtain a 30-35% increase in patient outcomes. Tweaking certain AI model parameters could further enhance this advantage, obtaining approximately 50% more improvement (outcome change) for roughly half the costs.

CONCLUSION

Given careful design and problem formulation, an AI simulation framework can approximate optimal decisions even in complex and uncertain environments. Future work is described that outlines potential lines of research and integration of machine learning algorithms for personalized medicine.

Worlds apart: training in rural South Africa

BACKGROUND

Reforms in the delivery of surgical and anaesthetic services in the UK have reduced the opportunity for trainees to acquire 'hands-on' training. These problems are seen in other European countries and in North America.

CONTEXT

Surgical and anaesthetic services within developed health care systems tend to be specialised, and are often consultant led. In rural South Africa there is a shortage of surgeons and anaesthetists to service the population, and the public health care system is vastly over-burdened. Trauma accounts for a large percentage of the surgical and anaesthetic workload.

INNOVATION

This report compares the anaesthetic and surgical training experience of two first-year registrars during a 6-month training period in rural South Africa and a 6-month training period in the UK.

IMPLICATIONS

Surgical and anaesthetic trainees from countries such as the UK can spend an out-of-programme training period in rural South Africa, thereby broadening their experience and exposure to trauma. They have the opportunity to take on a higher level of responsibility at an earlier stage of training, gaining 'hands-on' experience. Similarly, South African anaesthetic and surgical trainees can spend an out-of-programme training period in the UK, where they can learn the specialist procedures needed in their home country.

Virtual Reality Simulator

Background. The overriding importance of patient safety, the complexity of surgical techniques, and the challenges associated with teaching surgical trainees in the operating room are all factors driving the need for innovative surgical simulation technologies. Technical development. Despite these issues, widespread use of virtual reality simulation technology in surgery has not been fully implemented, largely because of the technical complexities in developing clinically relevant and useful models. This article describes the successful use of the NeuroTouch neurosurgical simulator in the resection of a left frontal meningioma. Conclusion. The widespread application of surgical simulation technology has the potential to decrease surgical risk, improve operating room efficiency, and fundamentally change surgical training.

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook

BACKGROUND

There is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.

METHODS

Retrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009.

RESULTS

104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.

CONCLUSIONS

A centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.

The Lost Opportunities for Surgical Training in the NHS

Surgery is a craft specialty based on gaining sufficient operating theatre experience. The European Working Time Directive was introduced in 1998 to protect the health and safety of employees. However, the progressive reduction in the hours available for surgical training combined with full-shift working patterns have raised fears that we will produce less experienced surgeons in the future.

Using simulation for interventional radiology training

Debate on the existence of innate skills has all but evaporated in the light of evidence that it is only the hours spent in deliberate practice that correlate with even the most elite levels of expertise. A range of simple to advanced technologies stands to address some of the many challenges to effective training of 21st century, procedural medicine. Simulation could train and assess behaviours remotely from patients, in complete safety, reducing the risks of inexperienced trainees learning critical tasks in patients while contributing to certification and revalidation. Understanding the strengths and limitations of these devices, determining and improving their effectiveness and identifying their roles, as well as those of individuals and teams, represents a cornerstone of successful adoption into the interventional radiology curriculum. This requires a simulation strategy that includes standards for simulator documentation.

The effect of stress-related factors on mental health status among resident doctors in Japan

OBJECTIVES

This study was designed to investigate how the interaction between the ability of medical residents (doctors in postgraduate training) to cope with stress and their working conditions might affect their level of job-related stress.

METHODS

A self-administered questionnaire was distributed to 549 first-year medical residents at 38 postgraduate education hospitals in Japan, 1-2 months after the start of clinical training. The questionnaires contained the 29-item Sense of Coherence (SOC) Scale, the Brief Scales for Job Stress (BSJS), the 12-item General Health Questionnaire (GHQ-12) and questions on basic conditions such as working hours. Sense of coherence is an important concept from the viewpoint of salutogenesis theory and influences stress recognition style. People with a strong SOC have a high ability to cope with stress.

RESULTS

The mean +/- standard deviation (SD) score on the SOC Scale was 134.5 +/- 20.5. All participants were classified into three groups according to their SOC Scale scores. Although the objective working conditions of the three groups were statistically similar, the group with the weakest SOC Scale score showed poorer mental health status (p < 0.05) and scored lower for 'reward from work' compared with the groups with stronger SOC scores (p < 0.05). The weaker SOC group also scored higher for 'mental workload' and 'problems in personal relationships' than the other two groups (p < 0.05). Moreover, the weak SOC group scored less for 'support from colleagues and superiors' than the strong SOC group (p < 0.05). A stepwise multiple regression analysis for GHQ-12 score was conducted (R(2) = 0.45). 'Sleep time', 'workload', 'mental workload' and 'problems in personal relationships' were positively correlated with GHQ-12 scores. 'Reward from work' was negatively correlated with GHQ-12 scores.

CONCLUSIONS

Residents' mental health was associated not only with working conditions, but also with their attitudes towards those working conditions. Enhancing residents' sense of 'reward from work' might be important in reducing their reactions to stress.