Ashley Vergis

Structured operative reporting: a randomized trial using dictation templates to improve operative reporting

BACKGROUND Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. METHODS Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. RESULTS There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02). CONCLUSIONS The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.

MIS training in Canada: a national survey of general surgery residents

BackgroundGeneral surgery trainees’ perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level.MethodsTwo hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training.ResultsTwo hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department’s responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present.ConclusionsThere exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed.

Validation of the quality of ultrasound imaging and competence (QUICk) score as an objective assessment tool for the FAST examination.

BACKGROUND The Focused Assessment with Sonography for Trauma (FAST) examination has become a valuable tool in trauma resuscitation. Despite the widespread use of FAST training among traumatologists, no evidence-based guidelines exist to support optimal training requirements or to provide quantitative objective assessments of imaging capabilities. Both Task-Specific Checklist (TSC) and Global Rating Scale (GRS) have been validated as objective skill assessment tools; we developed both types of scoring checklist and assessed them for construct validity with the FAST examination. METHODS Two scoring checklists, collectively termed the Quality of Ultrasound Imaging and Competence (QUICk) Score, were developed and subjected to a modified Delphi consensus process. Two cohorts of 12 novice and 12 expert sonographers performed the FAST examination and were evaluated by two experts according to the QUICk model. Total scores as well as anatomic subsets were compared via comparison of means, and logistic regression modeling was used to determine sensitivity and specificity. RESULTS Experts achieved significantly higher total scores than novices on both scoring systems (17.2 vs. 11.1 of 24, p < 0.01 TSC, 29.8 vs. 18.4 of 40, p < 0.01 GRS). Sensitivity (85.7% TSC, 92.9% GRS) and specificity (75.0% TSC, 91.7% GRS) as well as area under the receiver operating characteristic curve (89.9% TSC, 97.6% GRS) were consistent with a highly discriminant tool. CONCLUSION The QUICk Score is the first validated objective tool for assessment of the quality of FAST examination imaging. Use of this tool may be instrumental in developing an evidence-based minimum-performance standard and for assessing quality-improvement modifications in FAST examination training.

Validation of hand motion analysis as an objective assessment tool for the Focused Assessment with Sonography for Trauma examination.

BACKGROUND Point-of-care ultrasonography is a standard part of trauma assessments, but there are no objective tools to assess proficiency and ensure high-quality examinations. Hand motion analysis (HMA) has been validated as a measure of surgical skill but has not previously been applied to ultrasonography. HMA was assessed for construct validity in Focused Assessment with Sonography for Trauma (FAST) performance. METHODS Two cohorts of 12 expert and 12 novice ultrasonographers performed a FAST examination on a healthy volunteer. Hand motions were recorded with the trakSTAR 3D electromagnetic motion-tracking device (Ascension Technology) and analyzed using our custom-designed Motion Analysis and Recording System (MARS) software. Data were recorded at 240 Hz. Outcomes included time of examination, number of movements, and path length. RESULTS Time of examination was not different between cohorts (expert, 345.9 seconds; novice, 475.7 seconds; p = 0.12). Total path length of travel was shorter, and the number of discreet movements was less in the expert cohort for the left-hand (18.52 m vs. 28.01 m, p = 0.03, and 109.5 vs. 193.9, p = 0.027, respectively) and the right-hand performance (14.25 m vs. 32.09 m, p < 0.01, and 153.5 vs. 258.5, p = 0.03, respectively) versus the novice cohort. Both total path length traveled and total number of discreet movements were associated with expertise level in logistic regression modeling with areas under the receiver operating characteristic curves of 0.8269 and 0.8205, respectively. CONCLUSION This is the first study in the medical literature showing HMA as an objective, valid measure of FAST imaging performance. These objective, automated metrics can function as an adjunct measure to assess FAST performance as well as follow progress of and provide feedback to learners to improve future performances. LEVEL OF EVIDENCE A “diagnostic criteria”–style test where the “diagnosis” is a determination of competence in a care provider, level II.

Establishing the concurrent validity of general and technique-specific skills assessments in surgical education

BACKGROUND Laparoscopic surgery entails a unique skill set, but it is unclear whether it requires a specific assessment form or whether more general assessment tools can be applied. The purpose of this study was to assess the concurrent validity of 2 previously validated assessment scales. One scale designed specifically to assess laparoscopic skills and the other to assess more general surgical skills. METHODS Postgraduate year 1-6 general surgery and urology residents (n = 33) performed a live laparoscopic cholecystectomy. Three surgeon raters scored their performance using previously validated objective structured assessment of technical skills (OSATS) and global operative assessment of laparoscopic skills rating scales. RESULTS Pearsons correlation coefficient between global operative assessment of laparoscopic skills and OSATS rating scales was .975 (P = .01). CONCLUSIONS The near total correlation between the 2 scales questions the need for separate laparoscopic assessment tools, highlighting the real strengths of OSATS, the use of which allows for more consistent nomenclature and standardized skills assessment across surgical platforms.

The Fundamentals of Laparoscopic Surgery and LapVR evaluation metrics may not correlate with operative performance in a novice cohort

Background Considerable resources have been invested in both low- and high-fidelity simulators in surgical training. The purpose of this study was to investigate if the Fundamentals of Laparoscopic Surgery (FLS, low-fidelity box trainer) and LapVR (high-fidelity virtual reality) training systems correlate with operative performance on the Global Operative Assessment of Laparoscopic Skills (GOALS) global rating scale using a porcine cholecystectomy model in a novice surgical group with minimal laparoscopic experience. Methods Fourteen postgraduate year 1 surgical residents with minimal laparoscopic experience performed tasks from the FLS program and the LapVR simulator as well as a live porcine laparoscopic cholecystectomy. Performance was evaluated using standardized FLS metrics, automatic computer evaluations, and a validated global rating scale. Results Overall, FLS score did not show an association with GOALS global rating scale score on the porcine cholecystectomy. None of the five LapVR task scores were significantly associated with GOALS score on the porcine cholecystectomy. Conclusions Neither the low-fidelity box trainer or the high-fidelity virtual simulator demonstrated significant correlation with GOALS operative scores. These findings offer caution against the use of these modalities for brief assessments of novice surgical trainees, especially for predictive or selection purposes.

The effect of blocked versus random task practice schedules on the acquisition and retention of surgical skills

BACKGROUND When learning multiple tasks, blocked or random training schedules may be used. We assessed the effects of blocked and random schedules on the acquisition and retention of laparoscopic skills. METHODS Thirty-six laparoscopic novices were randomized to practice laparoscopic tasks using blocked, random, or no additional training. Participants performed immediate post-tests, followed by retention tests 6 weeks later. Outcomes included previously validated Fundamentals of Laparoscopic Surgery (FLS) and hand-motion efficiency scores. RESULTS Both blocked and random groups had significantly higher FLS and hand-motion efficiency scores over baseline on post-tests for each task (P < .05) and higher overall FLS scores than controls on retention tests (P < .01). No difference was seen between the blocked and random groups in the amount of skill acquired or skill retained. CONCLUSIONS Both blocked and random training schedules can be considered as valid training options to allow programs and learners to tailor training to their individual needs.

Development of consensus-derived quality indicators for laparoscopic Roux-en-Y gastric bypass surgery.

BACKGROUND Synoptic operative reporting is a solution to the poor quality of narrative reports. OBJECTIVE To develop operative report quality indicators (QI) for laparoscopic Roux-en-Y gastric bypass (LRYGB) to generate validated parameters by which these reports can be evaluated and improved. SETTING University hospital in Canada. METHODS A Delphi protocol was used to determine QIs for LRYGB reporting. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Participants initially submitted potential QIs. These were grouped by theme. Items were rated on 9-point Likert scales in subsequent rounds. Scores of 70% or greater were used for inclusion consensus, and 30% or less denoted exclusion. Elements scoring 30% to 70% were recirculated by runoff in subsequent rounds to generate the final list of QIs. RESULTS Four community and 4 academic bariatric surgeons were invited, representing all provinces performing LRYGB. The 4 multidisciplinary invitees included 1 minimally invasive/acute care surgeon, 1 tertiary abdominal radiologist, 1 gastroenterologist performing advanced endoscopy, and 1 general surgeon with expertise in synoptic reporting. Round 1 achieved an 83.3% (10/12) response and identified 91 potential items for consideration. Round 2 had a 100% response, and 69 items reached inclusion consensus. The third round achieved a 100% response and resulted in 75 QIs reaching final inclusion consensus. CONCLUSION This study established consensus-derived multidisciplinary QIs for LRYGB operative reports. This will allow further assessment of the quality of narrative reports and afford the development of a synoptic operative report that may ameliorate identified deficiencies.

Electronic synoptic reporting: assessing the completeness of synoptic and narrative reports for Roux-en-Y gastric bypass

BACKGROUND Operative reporting is the foundation of surgical communication. The quality indicators (QIs) contained in these reports can be used to document the performance of processes that affect patient care and may afford quality assurance with improvement in healthcare. OBJECTIVES We assessed the degree to which the electronic synoptic report (SR) documents the operative QIs compared with narrative reports (NR) for Roux-en-Y gastric bypass (RYGB). The time to report availability on patient chart was also identified as a secondary measure. SETTING Academic center, public hospital, Canada. METHODS A total of 40 prospectively collected RYGB synoptic reports and 40 case-matched historical NRs were compared against checklist QIs that were established by a national Delphi process. These checklist QIs are validated and have high interrater agreement at our institution. Time from dictation to report availability on patient chart was measured. RESULTS SR had a mean completion of 99.7% (±standard deviation [SD] 1.3%) compared with 64.0% (±SD 6.3%) for NR (t = 36.0, P<.0001). All subsections of SR were>99% complete and significantly higher than NR (P<.001). The mean time from NR dictation to report availability was 4.14 days (SD±3.17, range 0-10 d). All SRs were in the operative area after the procedure and were available immediately. CONCLUSION The RYGB synoptic report is superior to the narrative report for inclusion of accepted quality indicators and time to availability. Important elements, including process of care, demographic characteristics, and anatomic-related data, were often missing from the NR. SR is a promising method for improving documentation for RYGB.

Followership: A review of the literature in healthcare and beyond

Introduction: Research in healthcare leadership has focused on leaders. In contrast, organizational success may be more influenced by followers. Kelley described five followership styles based on two characteristics: active engagement and independent critical thinking. We examined the literature on the association between followership style and workplace outcomes. Methods: Articles from MEDLINE, CINAHL, and EMBASE were searched. Given the paucity of studies, we expanded our search to non‐healthcare databases. Two reviewers identified all studies examining followership styles and their association with job satisfaction and/or performance outcomes. Included studies were evaluated using the GRADE approach. Results: We identified one article on followership for every sixty articles on leadership in the medical literature. Fourteen observational studies on followership were included in our analysis. Outcomes ranged from the individual to the organizational level. No synthesized analysis was possible due to heterogeneity. Followership styles with greater active engagement and independent critical thinking were associated with increased job satisfaction, decreased burnout, and workplace performance metrics. Conclusions: There is a dearth of studies on followership. The literature suggests that followership characterized by greater independence is associated with positive outcomes. Given the importance of teamwork in the critical care environment, we should prioritize understanding of this important variable. HIGHLIGHTSFollowership is an important but understudied concept in healthcare leadership researchFor every one research article on followership, there are sixty articles on leadership in the medical literatureThe Kelley model describes five followership styles based on attributes of active engagement and independent critical thinkingOur review shows that followership styles with greater engagement and independence are associated with positive outcomes