Developing expertise in surgery

Evaluating Learning Curves in Virtual Reality Cortical Mastoidectomy Training Across Expertise Levels

HYPOTHESIS

Virtual reality (VR) simulation has been established as an effective method of supplementing traditional surgical training. Learning curves can analyze skill acquisition over time in VR settings. Although previous studies explored learning curves of mastoidectomy performances on single specimen, this study analyzed learning curves on anatomically different virtual temporal bones across three expertise levels (novice, intermediate, and expert).

METHODS

Thirty participants were divided into three groups: 10 medical students (novice), 10 ear, nose and throat (ENT) registrars (intermediate), and 10 senior ear surgeons (expert). They performed mastoidectomy on eight anatomically different temporal bones on the University of Melbourne Temporal Bone Surgery Simulator. A blinded senior ENT surgeon assessed the final products of the dissections using the Melbourne Mastoidectomy Scale (MMS). Learning curves of MMS scores, number of strokes, average force, drilling time, and total time were compared between groups using Friedman tests. Within-group analyses were conducted with Wilcoxon signed-rank tests.

RESULTS

All performance metrics showed significant differences across all groups. Only comparison between intermediate and expert groups for average force was not significant. Within-group analyses showed significant differences in expert group for total and drilling time, intermediate group for average force, and novice group for total time. Individual learning curves of intermediate group demonstrated varied learning behavior.

CONCLUSIONS

Trainee performance was not seen to reach the level of experts after eight repetitions on anatomically different specimens. Enhancing training with individualized feedback and increased repetitions may optimize skills acquisition.

Artificial Intelligence-Generated Social Media Content Creation and Management Strategies for Plastic Surgeons

BACKGROUND

Social media platforms have come to represent integral components of the professional marketing and advertising strategy for plastic surgeons. Effective and consistent content development, however, remains technically demanding and time consuming, prompting most to employ, at non-negligible costs, social media marketing specialists for content planning and development.

OBJECTIVES

In the present study, we aimed to investigate the ability of presently available artificial intelligence (AI) models to assist plastic surgeons in their social media content development and sharing plans.

METHODS

An AI large language model was prompted on the study's objectives through a series of standardized user interactions. Social media platforms of interest, on which the AI model was prompted, included Instagram, TikTok, and X (formerly Twitter).

RESULTS

A 1-year, entirely AI-generated social media plan, comprising a total of 1091 posts for the 3 aforementioned social media platforms, is presented. Themes of the AI-generated content proposed for each platform were classified in 6 categories, including patient-related, practice-related, educational, "uplifting," interactive, and promotional posts. Overall, 91 publicly recognized holidays and observant and awareness days were incorporated into the content calendars. The AI model demonstrated an ability to differentiate between the distinct formats of each of the 3 social media platforms investigated, generating unique ideas for each, and providing detailed content development and posting instructions, scripts, and post captions, leveraging features specific to each platform.

CONCLUSIONS

By providing detailed and actionable social media content creation and posting plans to plastic surgeons, presently available AI models can be readily leveraged to assist in and significantly alleviate the burden associated with social media account management, content generation, and potentially patient conversion.

Technical, Non-Technical, or Both? A Scoping Review of Skills in Simulation-Based Surgical Training

OBJECTIVE

Technical and non-technical skills are traditionally investigated separately in simulation-based surgical training (SBST). Recent literature has indicated an interrelation of these skills, but a clear relationship is yet to be established. This scoping review aimed to identify published literature on the use of both technical and non-technical learning objectives in SBST and investigate how the entities are related. Additionally, this scoping study reviewed the literature with the aim of mapping how publications on technical and non-technical skills within SBST have changed over time.

DESIGN

We conducted a scoping review using the 5 step framework by Arksey and O'Malley and reported our results according to the PRISMA guidelines for scoping reviews. Four databases, PubMed, Web of Science, Embase and Cochrane Library, were systematically searched for empirical studies on SBST. Studies within surgical training addressing both technical and non-technical learning objectives and presenting primary data were included for further analysis.

RESULTS

Our scoping review identified 3144 articles on SBST published between 1981 and 2021. During our analysis, an emphasis on technical skills training in published literature was identified. However, recent years have seen an immense increase of publications within either technical or non-technical skills. A similar trend is seen in publications addressing both technical and non-technical. In total, 106 publications addressed both technical and non-technical learning objectives and were included for further analysis. Only 45 of the included articles addressed the relationship between technical and non-technical skills. These articles mainly focused on the effect of non-technical skills on technical skills.

CONCLUSIONS

Though literature on the relationship between technical and non-technical skills remains scarce, the included studies on technical skills and non-technical skills such as mental training suggest such a relationship exists. This implies that the separation of the skill sets is not necessarily beneficial for the outcome of SBST. A shift towards seeing technical and non-technical skills as intertwined may enhance learning outcomes from SBST.

Making sense of adaptive expertise for frontline clinical educators: a scoping review of definitions and strategies

Adaptive expertise has been promoted as an emerging model of expertise in health professions education in response to the inherent complexities of patient care; however, as the concept increasingly influences the structure of professional training and practice, it creates the potential for misunderstandings of the definition and implications of adaptive expertise. To foster a common understanding of the concept, we conducted a scoping review to explore how adaptive expertise has been discussed within health professions education literature. Five databases-MedLine, PubMed, ERIC, CINAHL, and PsycINFO-were searched using the exact term "adaptive expertise", producing 212 unique articles. Fifty-eight articles met inclusion criteria. In the included articles, authors discussed the conceptual implications of adaptive expertise for health professions education, strategies for training for adaptive expertise, and research findings aimed at supporting the development of adaptive expertise or utilizing adaptive expertise as a theoretical framework. The goal of this scoping review is to establish a resource for frontline educators tasked with fostering the development of adaptive expertise in learners through education initiatives. A common understanding of adaptive expertise is essential to ensuring effective implementation in training programs.

Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review

Surgical expertise does not have a clear definition and is often culturally associated with power, authority, prestige, and case number rather than more objective proxies of excellence. Multiple models of expertise progression have been proposed including the Dreyfus model, however, they all currently require subjective evaluation of skill. Recently, efforts have been made to improve the ways in which surgical excellence is measured and expertise is defined using artificial intelligence, video recordings, and accelerometers. However, these aforementioned methods of assessment are still subjective or indirect proxies of expertise, thus uncovering the neural mechanisms that differentiate expert surgeons from trainees may enhance the objectivity of surgical expertise validation. In fact, some researchers have already suggested that their neural imaging-based expertise classification methods outperform currently used methods of surgical skill certification such as the Fundamentals of Laparoscopic Surgery (FLS) scores. Such imaging biomarkers would not only help better identify the highest performing surgeons, but could also improve residency programs by providing more objective, evidence-based feedback and developmental milestones for those in training and perhaps act as a marker of surgical potential in medical students. Despite the potential advantages of using neural imaging in the assessment of surgical expertise, this field of research remains in its infancy. This systematic review identifies studies that have applied neuromonitoring in assessing surgical skill across levels of expertise. The goals of this review are to identify (1) the strongest neural indicators of surgical expertise, (2) the limitations of the current literature on this subject, (3) the most sensible future directions for further study. We found substantial evidence that surgical expertise can be delineated by differential activation and connectivity in the prefrontal cortex (PFC) across multiple task and neuroimaging modalities. Specifically, novices tend to have greater PFC activation than experts under standard conditions in bimanual and decision-making tasks. However, under high temporal demand tasks, experts had increased PFC activation whereas novices had decreased PFC activation. Common limitations uncovered in this review were that task difficulty was often insufficient to delineate between residents and attending. Moreover, attending level involvement was also low in multiple studies which may also have contributed to this issue. Most studies did not analyze the ability of their neuromonitoring findings to accurately classify subjects by level of expertise. Finally, the predominance of fNIRS as the neuromonitoring modality limits our ability to uncover the neural correlates of surgical expertise in non-cortical brain regions. Future studies should first strive to address these limitations. In the longer term, longitudinal within-subjects design over the course of a residency or even a career will also advance the field. Although logistically arduous, such studies would likely be most beneficial in demonstrating effects of increasing surgical expertise on regional brain activation and inter-region connectivity.

Remediation for surgical trainees: recommendations from a narrative review

BACKGROUND

Remediation involves formalized support for surgical trainees with significant underperformance to return to expected standards. There is a need to understand current evidence of remediation for surgical trainees to inform practice and justify investment of resources.

METHODS

Following the principles of a systematic review, we conducted a narrative analysis to make recommendations for remediation of underperforming surgical trainees.

RESULTS

From a review of 55 articles on remediation of trainees in medical and surgical sub-specialities, we have identified system and process level recommendations. Remediation is reported as long-term, complex and resource-intensive. Establishing a defined and standardized remediation framework enables co-ordination of multi-modal interventions. System level recommendations aim to consolidate protocols via developing better assessment, intervention and re-evaluation modalities whilst also strengthening support to supervisors conducting the remediation. Process level recommendations should be tailored for the specific needs of each trainee, aiming to be proactive with interventions within a programmatic framework. Regular reassessment is required, and long-term follow-up shows that remediation efforts are often successful.

CONCLUSION

While remediation within a programmatic framework is complex, it is often a successful approach to return surgical trainees to their expected standard. Future directions involve applying learning theories, encouraging research methods and to develop integrated collaborate protocols and support to synergize efforts.

Identifying technical skills and clinical procedures in surgery for a simulation-based curriculum: a national general needs assessment

BACKGROUND

The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery.

METHODS

A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study.

RESULTS

Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list.

CONCLUSION

Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

Exploring the use of high and low demand simulation for human performance assessment during multiorgan retrieval with the joint scrub practitioner

Introduction

The National Organ Retrieval Service (NORS) 2015 review recommended a Joint Scrub Practitioner for abdominal and cardiac teams during combined organ retrieval. To evaluate the feasibility of this role, and to understand the functional implications, this study explores the use of simulation and provides a novel and comprehensive approach to assess individual and team performance in simulated multiorgan retrievals.

Methods

Two high-fidelity simulations were conducted in an operating theatre with porcine organs, en bloc, placed in a mannequin. For donation after brainstem death (DBD) simulation, an anaesthetic machine provided simulated physiological output. Retrievals following donation after circulatory death (DCD) began with rapid arrival in theatre of the mannequin. Cardiothoracic (lead surgeon) and abdominal (lead and assistant surgeons; joint scrub practitioner, n=9) teams combined for the retrievals. Data collected before, during and after simulations used self-report and expert observers to assess: attitudinal expectations, mental readiness, mental effort, non-technical skills, teamwork, task workload and social validation perceptions.

Results

Attitudinal changes regarding feasibility of a joint scrub practitioner for DBD and DCD are displayed in the main body. There were no significant differences in mental readiness prior to simulations nor in mental effort indicated afterwards; however, variance was noted between simulations for individual team members. Non-technical skills were slightly lower in DCD than in DBD. Global ratings of teamwork were significantly (p<0.05) lower in DCD than in DBD. Measures of attitude indicated less support for the proposed joint scrub practitioner role for DCD than for DBD.

Discussion

The paper posits that the joint scrub practitioner role in DCD multiorgan retrieval may bring serious and unanticipated challenges. Further work to determine the feasibility of the NORS recommendation is required. Measures of team performance and individual psychological response can inform organ retrieval feasibility considerations nationally and internationally.

Embodied aspects of learning to be a surgeon

Embodied learning is an educational concept that has been applied to various aspects of education, but only touched on in medical education, largely in relation to the teaching and learning of anatomy. Thus far, the medical literature has not addressed embodied learning as it specifically relates to learning to operate and be a surgeon. This paper will discuss relevant principles of embodied learning/cognition, ways it is important both for learning to function as a surgeon and for learning to perform technical aspects of surgery, and finally will discuss implications for surgical education. In particular, it will address ways in which embodied learning can and should be incorporated into educational activities specific to surgery.

[Airway management in preclinical emergency anesthesia with respect to specialty and education]

BACKGROUND AND OBJECTIVE

Difficult airway management is a key skill in preclinical emergency medicine. A lower rate of subjective difficult airways and an increased success rate of endotracheal intubation have been reported for highly trained emergency physicians. The aim of this study was therefore to analyze the effect for different specialists and the individual state of training in the German emergency medical system.

MATERIAL AND METHODS

In a retrospective register analysis of 6024 preclinical anesthesia procedures, the frequencies of airway devices, neuromuscular blocking agents, capnography and difficult airways were analyzed with respect to specialization and status of training. Additionally, low, medium and highly experienced emergency physicians in airway management were summarized by specialization and status of training according to the Dreyfus model of skill acquisition and compared.

RESULTS

The incidence of subjective difficult airway situations was 10% for anesthesiological emergency physicians compared to 15-20% for other disciplines. The latter used supraglottic airway devices more often (7-9% vs. 4%) and video laryngoscopes less often (3% vs. 5%) compared to anesthesiological emergency physicians. The discipline-related state of training was inhomogeneous and revealed a reduced rate of supraglottic airway devices for internal specialists with further training (10% vs. 2%). Anesthetists specialized in intensive care medicine used capnography less frequently compared to other anesthetists (79% vs. 72%). With higher levels of experience in airway management, the frequency of endotracheal intubation (86% vs. 94%), neuromuscular blocking agents (59% vs. 73%) and video laryngoscopy (3% vs. 6%) increased and the incidence of subjective difficult airway situations (16% vs. 10%) decreased.

CONCLUSION

The level of training in airway management especially for non-anesthetists is inhomogeneous. The recently published German S1 guidelines for prehospital airway management recommend education and training as well as the primary use of the video laryngoscope with Macintosh blade. The implementation could lower the incidence of subjective difficult airways.

Evaluation of the clinical effectiveness of a work-based mentoring programme to develop clinical reasoning on patient outcome: A stepped wedge cluster randomised controlled trial

BACKGROUND

Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of clinical mentoring on postgraduate physiotherapists have been explored, but its impact on patient outcomes is unknown. The objective of this trial was to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes.

METHODS

In a stepped-wedge cluster RCT in the musculoskeletal physiotherapy outpatient departments of a large NHS organisation, 16 physiotherapists were randomised by cluster to receive the intervention-150 hours of mentored clinical practice-at one of 3 time periods; control was usual training. 441 patients submitted outcome measures: Patient-Specific Functional Scale (PSFS) (primary outcome measure), EQ-5D-5L, patient activation and patient satisfaction (secondary outcome measures). A further secondary outcome measure of physiotherapist performance was collected by an independent assessor observing the physiotherapists practice.

RESULTS

80.0% of intervention patients achieved clinically significant PSFS scores compared with 63.8% of control patients. Binary logistic regression analysis modelling for time, cluster and patient characteristics showed strong statistical evidence for this difference (p = 0.023; odds ratio 4.24, 95%CI 1.22, 14.79). Physiotherapist performance scores improved from a mean of 47.8% (SD 3.60) pre-intervention to a mean of 56.0% (SD 4.24) (p<0.001). There was no statistical evidence for differences between groups on other secondary outcomes.

CONCLUSION

This is the first study that we aware of that provides patient outcomes measurement of an established educational intervention in physiotherapy, providing evidence that this type of intervention positively impacts patient outcomes and physiotherapist performance. This provides a basis for further research in education across other healthcare disciplines and outcome measures.

Relationships Between Expertise, Crew Familiarity and Surgical Workflow Disruptions: An Observational Study

BACKGROUND

Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD.

METHODS

We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity.

RESULTS

9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN.

CONCLUSIONS

The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

Identification and development of talent in surgery

Purpose

Education of the surgeon and development of surgical expertise have been debated for centuries. Today, research in surgical education applies terms and methods from other performance domains such as sport and music. However, there still seems to be a lack of consensus as to how talent may be brought into the discourse about surgical education. Especially, when it comes to identifying and developing trainees who in the future will perform better than the average surgeon.

Design/methodology/approach

This five-step scoping study aims to map existing literature about talent identification, talent development and development of expertise in the domains of surgery, sport and music in the period of 1985-2014.

Findings

A total of 242 studies, divided in the four domains of surgery (69 studies), sport (115 studies), music (34 studies) and cross-disciplinary studies (24 studies) published in the period 1985-2014 were included.

Originality/value

Informed by the performance domains of sports and music and their inclusion of a holistic, ecological approach to research, this study suggests that research in surgical education may benefit from broadening its view on talent by including psychosocial variables and environmental, demographic and structural influencers when considering how surgical talent may be identified and developed.

How Surgeons Conceptualize Talent: A Qualitative Study Using Sport Science as a Lens

OBJECTIVES

Debates prevail regarding the definition of surgical talent, and how individuals with the potential to become talented surgeons can be identified and developed. However, over the past 30 years, talent has been studied extensively in other domains. The objectives of this study is to explore notions of talent in surgery and sport in order to investigate if the field of surgical education can benefit from expanding its view on talented performances. Therefore, this study aims to use the sport literature as a lens when exploring how surgeons conceptualize and define talent.

DESIGN

Semi-structured interviews were conducted with a sample of 11 consultant surgeons from multiple specialties. We used constructivist grounded theory principles to explore talent in surgery. Ongoing data analysis refined the theoretical framework and iteratively informed data collection. Themes were identified iteratively using constant comparison.

SETTING

The setting included 8 separate hospitals across Canada and Denmark.

PARTICIPANTS

A total of 11 consultant surgeons from 6 different surgical subspecialties (urology, orthopedic surgery, colorectal surgery, general surgery, vascular surgery, head & neck surgery) were included.

RESULTS

We identified three key elements for conceptualizing surgical talent: (1) Individual skills makes the surgical prospect "good", (2) a mixture of skills gives the surgical prospect the potential to become talented, and (3) becoming talented may rely on the fit between person and environment.

CONCLUSION

We embarked on a study aimed at understanding talent in surgery. Talent is a difficult construct to agree on. Whether in medicine or sports, debates about talent will continue to persist, as we all perceive talent differently. While we heard different opinions, three key ideas summarize our participants' discussions regarding surgical talent. These findings resonate with the holistic ecological approach from sport science and hence highlight the limits of a reductionist approach while favoring the individual-environment system as the minimal ontology for describing talented performances.

Professional expertise amongst speech-language therapists: “willing to share”

Purpose

The current healthcare environment provides several challenges to the existing roles of healthcare professionals. The value of the professional expert is also under scrutiny. The purpose of this paper is to generate a construction of professional expertise amongst practitioners in the current healthcare environment. It used the speech-language therapy community in New Zealand (NZ) as an example.

Design/methodology/approach

Speech-language therapists currently practicing in NZ completed an online survey including qualitative and quantitative components. The range of experience and work settings of participants (n=119) was representative of the workforce.

Findings

Participants clearly identified being “highly experienced” and “having in-depth knowledge” as essential elements of professional expertise. Thematic analysis generated two interconnected themes of a professional expert being a personal leader and teacher, and a highly experienced, knowledgeable and skilful practitioner. Additionally, practitioners needed to be seen to contribute to the community in order to be known as experts. Clinical practice was valued differently from research generation.

Originality/value

This study is novel in exploring a construction of professional expertise amongst practitioners in a current healthcare community. Within that community, experts could be viewed as highly effective practitioners that visibly contribute to the professional community. The study draws attention to the role of reputation and the impacts of being a clinical teacher or leader compared with pursuing a research role. This could be particularly relevant in the promotion of evidence-based practice.

"They Have to Adapt to Learn": Surgeons' Perspectives on the Role of Procedural Variation in Surgical Education

OBJECTIVE

Clinical research increasingly acknowledges the existence of significant procedural variation in surgical practice. This study explored surgeons' perspectives regarding the influence of intersurgeon procedural variation on the teaching and learning of surgical residents.

DESIGN AND SETTING

This qualitative study used a grounded theory-based analysis of observational and interview data. Observational data were collected in 3 tertiary care teaching hospitals in Ontario, Canada. Semistructured interviews explored potential procedural variations arising during the observations and prompts from an iteratively refined guide. Ongoing data analysis refined the theoretical framework and informed data collection strategies, as prescribed by the iterative nature of grounded theory research.

PARTICIPANTS

Our sample included 99 hours of observation across 45 cases with 14 surgeons. Semistructured, audio-recorded interviews (n = 14) occurred immediately following observational periods.

RESULTS

Surgeons endorsed the use of intersurgeon procedural variations to teach residents about adapting to the complexity of surgical practice and the norms of surgical culture. Surgeons suggested that residents' efforts to identify thresholds of principle and preference are crucial to professional development. Principles that emerged from the study included the following: (1) knowing what comes next, (2) choosing the right plane, (3) handling tissue appropriately, (4) recognizing the abnormal, and (5) making safe progress. Surgeons suggested that learning to follow these principles while maintaining key aspects of surgical culture, like autonomy and individuality, are important social processes in surgical education.

CONCLUSIONS

Acknowledging intersurgeon variation has important implications for curriculum development and workplace-based assessment in surgical education. Adapting to intersurgeon procedural variations may foster versatility in surgical residents. However, the existence of procedural variations and their active use in surgeons' teaching raises questions about the lack of attention to this form of complexity in current workplace-based assessment strategies. Failure to recognize the role of such variations may threaten the implementation of competency-based medical education in surgery.

Working volume: validity evidence for a motion-based metric of surgical efficiency

BACKGROUND

The aim of this study was to evaluate working volume as a potential assessment metric for open surgical tasks.

METHODS

Surgical attendings (n = 6), residents (n = 4), and medical students (n = 5) performed a suturing task on simulated connective tissue (foam), artery (rubber balloon), and friable tissue (tissue paper). Using a motion tracking system, effective working volume was calculated for each hand. Repeated measures analysis of variance assessed differences in working volume by experience level, dominant and/or nondominant hand, and tissue type.

RESULTS

Analysis revealed a linear relationship between experience and working volume. Attendings had the smallest working volume, and students had the largest (P = .01). The 3-way interaction of experience level, hand, and material type showed attendings and residents maintained a similar working volume for dominant and nondominant hands for all tasks. In contrast, medical students' nondominant hand covered larger working volumes for the balloon and tissue paper materials (P < .05).

CONCLUSIONS

This study provides validity evidence for the use of working volume as a metric for open surgical skills. Working volume may provide a means for assessing surgical efficiency and the operative learning curve.

The effect of work-based mentoring on patient outcome in musculoskeletal physiotherapy: study protocol for a randomised controlled trial

BACKGROUND

Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of postgraduate clinical mentoring on physiotherapist performance have been assessed, but the impact of this mentoring on patient outcomes remains unknown. The objective of this trial is to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes in musculoskeletal physiotherapy.

METHODS/DESIGN

A stepped wedge cluster randomised controlled trial (CRCT) has been designed to recruit a minimum of 12 senior physiotherapists who work in musculoskeletal outpatient departments of a large National Health Service (NHS) organization. Participating physiotherapists will be randomised by cluster to receive the intervention at three time periods. Patients will be blinded to whether their physiotherapist has received the intervention. The primary outcome measure will be the Patient-Specific Functional Scale; secondary outcome measures will include the EQ-5D, patient activation, patient satisfaction and physiotherapist performance. Sample size considerations used published methods describing stepped wedge designs, conventional values of 0.80 for statistical power and 0.05 for statistical significance, and pragmatic groupings of 12 participating physiotherapists in three clusters. Based on an intergroup difference of 1.0 on the PSFS with a standard deviation of 2.0, 10 patients are required to complete outcome measures per physiotherapist, at time period 1 (prior to intervention roll-out) and at each of time periods 2, 3 and 4, giving a sample size of 480 patients. To account for the potential loss to follow-up of 33%, 720 sets of patient outcomes will be collected.All physiotherapist participants will receive 150 hours of mentored clinical practice as the intervention and usual in-service training as control. Consecutive, consenting patients attending treatment by the participating physiotherapists during data collection periods will complete outcome measures at baseline, discharge and 12 months post-baseline. The lead researcher will be blinded to the allocation of the physiotherapist when analyzing outcome data; statistical analysis will involve classical linear models incorporating both an intervention effect and a random intercept term to reflect systematic differences among clusters.

TRIAL REGISTRATION

Assigned 31 July 2012: ISRCTN79599220.

The Arthroscopic Surgical Skill Evaluation Tool (ASSET)

BACKGROUND

Surgeries employing arthroscopic techniques are among the most commonly performed in orthopaedic clinical practice; however, valid and reliable methods of assessing the arthroscopic skill of orthopaedic surgeons are lacking.

HYPOTHESIS

The Arthroscopic Surgery Skill Evaluation Tool (ASSET) will demonstrate content validity, concurrent criterion-oriented validity, and reliability when used to assess the technical ability of surgeons performing diagnostic knee arthroscopic surgery on cadaveric specimens.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Content validity was determined by a group of 7 experts using the Delphi method. Intra-articular performance of a right and left diagnostic knee arthroscopic procedure was recorded for 28 residents and 2 sports medicine fellowship-trained attending surgeons. Surgeon performance was assessed by 2 blinded raters using the ASSET. Concurrent criterion-oriented validity, interrater reliability, and test-retest reliability were evaluated.

RESULTS

Content validity: The content development group identified 8 arthroscopic skill domains to evaluate using the ASSET. Concurrent criterion-oriented validity: Significant differences in the total ASSET score (P < .05) between novice, intermediate, and advanced experience groups were identified. Interrater reliability: The ASSET scores assigned by each rater were strongly correlated (r = 0.91, P < .01), and the intraclass correlation coefficient between raters for the total ASSET score was 0.90. Test-retest reliability: There was a significant correlation between ASSET scores for both procedures attempted by each surgeon (r = 0.79, P < .01).

CONCLUSION

The ASSET appears to be a useful, valid, and reliable method for assessing surgeon performance of diagnostic knee arthroscopic surgery in cadaveric specimens. Studies are ongoing to determine its generalizability to other procedures as well as to the live operating room and other simulated environments.

Capturing intra-operative safety information using surgical wikis

BACKGROUND

Expert surgeons use a mass of intra-operative information, as well as pre- and post-operative information to complete operations safely. Trainees acquired this intra-operative knowledge at the operating table, now largely diminished by the working time directive. Wikis offer unexplored approaches to capturing and disseminating expert knowledge to further promote safer surgery for the trainee.

METHODS

Grafting an abdominal aortic aneurysm represents a potentially high-risk operation demanding extreme safety measures. Operative details, presented on a surgical wiki in the form of a script and content analysed to classify types of safety information.

RESULTS

The intra-operative part of the script contained 2,743 items of essential surgical information, comprising 21 sections, 405 steps and 2,317 items of back-up information; 155 (5.7%) of them were also specific intra-operative safety checks. Best case scenarios consisted of 1,077 items of intra-operative information, 69 of which were safety checks. Worse case and rare scenarios required a further 1,666 items of information, including 86 safety checks.

CONCLUSIONS

Wikis are relevant to surgical practice specifically as a platform for knowledge sharing and optimising the available operating time of trainees, as a very large amount of minutely detailed information essential for a safe major operation can be captured.

The Hamilton Inventory for Complex Regional Pain Syndrome: a cognitive debriefing study of the clinician-based component

STUDY DESIGN

Descriptive.

INTRODUCTION

The Hamilton Inventory for Complex Regional Pain Syndrome (HI-CRPS) is a multidisciplinary assessment tool under development.

PURPOSE OF THE STUDY

This study examined the assessment practices, beliefs and preferences of health care professionals working with CRPS to inform the content and structure of the clinician-based portion of the HI-CRPS (CB-HI-CRPS), as well as refine the user manual.

METHODS

Semi-structured cognitive interviews were conducted with health care professionals from a spectrum of disciplines working with CRPS. Assessment practices and scaling preferences for 15 assessment concepts were collected, relating directly to items on the CB-HI-CRPS. Interviews were transcribed and coded with emergent themes.

RESULTS

Participants reported using the concepts from the CB-HI-CRPS 85.2% of the time. Physicians and nurses preferred present/absent judgements, while therapists used none/mild/moderate/severe scaling. Emerging themes highlighted assessment values, beliefs about CRPS, professional roles, and knowledge translation.

CONCLUSIONS

Lack of uniformity in terminology and assessment behaviours underscores the need for clear scoring frameworks and standardized assessment instructions to improve reliability across the proposed users of the HI-CRPS.

LEVEL OF EVIDENCE

Level 4.

Expertise in prehospital endotracheal intubation by emergency medicine physicians-Comparing 'proficient performers' and 'experts'

BACKGROUND

Training requirements to perform safe prehospital endotracheal intubation (ETI) are not clearly known. This study aimed to determine differences in ETI performance between 'proficient performers' and 'experts' according to the Dreyfus & Dreyfus framework of expertise. As a model for 'proficient performers' EMS physicians with a clinical background in internal medicine were compared to EMS physicians with a background in anaesthesiology as a model for 'experts'.

METHODS

Over a one-year period all ETIs performed by the EMS physicians of our institution were prospectively evaluated. 'Proficient performers' and 'experts' were compared regarding incidence of difficult ETI, ability to predict difficult ETI, and decision for ETI.

RESULTS

Mean years of professional experience were similar between the physician groups, but the median ETI experience differed significantly with 18/year for 'proficients' and 304/year for 'experts' (p<0.001). 'Proficient performers' intubated 130 of their 2170 treated patients (6.0%), while 'experts' did so in 146 of 1809 cases (8.1%, p=0.01 for difference). The incidence of difficult ETI was 17.7% for 'proficient performers', and 8.9% for 'experts' (p<0.05). In 4 cases ETI was impossible, all managed by 'proficient performers', but all patients could be ventilated sufficiently. Unexpected difficult ETI occurred in 6.1% for 'proficient performers', and 2.0% for 'experts' (p=0.08).

CONCLUSIONS

In a prehospital setting 'expert' status was associated with a significantly lower incidence of 'difficult ETI' and a higher proportion of ETI decisions. In addition, ability to predict difficult ETI was higher, although non-significant. There was no difference in the incidence of impossible ventilation.