Becca L. Gas

Do You See What I See? How We Use Video as an Adjunct to General Surgery Resident Education

OBJECTIVE Preparation of learners for surgical operations varies by institution, surgeon staff, and the trainees themselves. Often the operative environment is overwhelming for surgical trainees and the educational experience is substandard due to inadequate preparation. We sought to develop a simple, quick, and interactive tool that might assess each individual trainees knowledge baseline before participating in minimally invasive surgery (MIS). DESIGN A 4-minute video with 5 separate muted clips from laparoscopic procedures (splenectomy, gastric band removal, cholecystectomy, adrenalectomy, and inguinal hernia repair) was created and shown to medical students (MS), general surgery residents, and staff surgeons. Participants were asked to watch the video and commentate (provide facts) on the operation, body region, instruments, anatomy, pathology, and surgical technique. Comments were scored using a 100-point grading scale (100 facts agreed upon by 8 surgical staff and trainees) with points deducted for incorrect answers. All participants were video recorded. Performance was scored by 2 separate raters. SETTING An academic medical center. PARTICIPANTS MS = 10, interns (n = 8), postgraduate year 2 residents (PGY)2s (n = 11), PGY3s (n = 10), PGY4s (n = 9), PGY5s (n = 7), and general surgery staff surgeons (n = 5). RESULTS Scores ranged from -5 to 76 total facts offered during the 4-minute video examination. MS scored the lowest (mean, range; 5, -5 to 8); interns were better (17, 4-29), followed by PGY2s (31, 21-34), PGY3s (33, 10-44), PGY4s (44, 19-47), PGY5s (48, 28-49), and staff (48, 17-76), p < 0.001. Rater concordance was 0.98-measured using a concordance correlation coefficient (95% CI: 0.96-0.99). Only 2 of 8 interns acknowledged the critical view during the laparoscopic cholecystectomy video clip vs 10 of 11 PGY2 residents (p < 0.003). Of 8 interns, 7 misperceived the spleen as the liver in the splenectomy clip vs 2 of 7 chief residents (p = 0.02). CONCLUSIONS Not surprisingly, more experienced surgeons were able to relay a larger number of laparoscopic facts during a 4-minute video clip of 5 MIS operations than inexperienced trainees. However, even tenured staff surgeons relayed very few facts on procedures they were unfamiliar with. The potential differentiating capabilities of such a quick and inexpensive effort has pushed us to generate better online learning tools (operative modules) and hands-on simulation resources for our learners. We aim to repeat this and other studies to see if our learners are better prepared for video assessment and ultimately, MIS operations.

Annual Surgeon Volume and Patient Outcomes Following Laparoscopic Totally Extraperitoneal Inguinal Hernia Repairs

PURPOSE Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. MATERIALS AND METHODS A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) (n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) (n = 3 surgeons), 15-30 repairs; and Group 3 (G3) (n = 17), <15 repairs. RESULTS In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. CONCLUSIONS Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.

Influence of Social Media on the Dissemination of a Traditional Surgical Research Article

OBJECTIVE Many institutions use social media to share research with the general public. However, the influence of social media on the dissemination of a surgical research article itself is unknown. Our objective was to determine whether a blog post highlighting the findings of a surgical research article would lead to increased dissemination of the article itself. DESIGN We prospectively followed the online page views of an article that was published online in Surgery in May 2015 and published in print in August 2015. The authors subsequently released a blog post in October 2015 to promote the research. The number of article page views from the journals website was obtained before and after the blog post, along with the page views from the blog post itself. Social media influence data were collected, including social activity in the form of mentions on social media sites, scholarly activity in online libraries, and scholarly commentary. RESULTS The articles online activity peaked in the first month after online publication (475 page views). Online activity plateaued by 4 months after publication, with 118 monthly page views, and a blog post was subsequently published. The blog post was viewed by 1566 readers, and readers spent a mean of 2.5 minutes on the page. When compared to the projected trend, the page views increased by 33% in the month after the blog post. The blog post resulted in a 9% increase in the social media influence score and a 5% absolute increase in total article page views. CONCLUSIONS Social media is an important tool for sharing surgical research. Our data suggest that social media can increase distribution of an articles message and also potentially increase dissemination of the article itself. We believe that authors should consider using social media to increase the dissemination of traditionally published articles.

Objective Assessment of General Surgery Residents Followed by Remediation

OBJECTIVE Surgical training programs often lack objective assessment strategies. Complicated scheduling characteristics frequently make it difficult for surgical residents to undergo formal assessment; actually having the time and opportunity to remediate poor performance is an even greater problem. We developed a novel methodology of assessment for residents and created an efficient remediation system using a combination of simulation, online learning, and self-assessment options. DESIGN Postgraduate year (PGY) 2 to 5 general surgery (GS) residents were tested in a 5 station, objective structured clinical examination style event called the Surgical X-Games. Stations were 15 minutes in length and tested both surgical knowledge and technical skills. Stations were scored on a scale of 1 to 5 (1 = Fail, 2 = Mediocre, 3 = Pass, 4 = Good, and 5 = Stellar). Station scores ≤ 2 were considered subpar and required remediation to a score ≥ 4. Five remediation sessions allowed residents the opportunity to practice the stations with staff surgeons. Videos of each skill or test of knowledge with clear instructions on how to perform at a stellar level were offered. Trainees also had the opportunity to checkout take-home task trainers to practice specific skills. Residents requiring remediation were then tested again in-person or sent in self-made videos of their performance. SETTING Academic medical center. PARTICIPANTS PGY2, 3, 4, and 5 GS residents at Mayo Clinic in Rochester, MN. RESULTS A total of, 35 residents participated in the Surgical X-Games in the spring of 2015. Among all, 31 (89%) had scores that were deemed subpar on at least 1 station. Overall, 18 (58%) residents attempted remediation. All 18 (100%) achieved a score ≥ 4 on the respective stations during a makeup attempt. Overall X-Games scores and those of PGY2s, 3s, and 4s were higher after remediation (p < 0.05). No PGY5s attempted remediation. CONCLUSIONS Despite difficulties with training logistics and busy resident schedules, it is feasible to objectively assess most GS trainees and offer opportunities to remediate if performance is poor. Our multifaceted remediation methodology allowed 18 residents to achieve good or stellar performance on each station after deliberate practice. Enticing chief residents to participate in remediation efforts in the spring of their final year of training remains a work in progress.

Mental and physical workloads in a competitive laparoscopic skills training environment: A pilot study

Surgical trainees undergo demanding training to achieve high surgical task proficiency. Abounding clinical and educational responsibilities mandate efficient and effective training. This research measured resident workload during laparoscopic skills training to identify excessive workload and how workload impacted task performance. Twenty-eight surgical trainees performed a standardized surgical training task and completed a workload questionnaire while observers measured physiological stress, posture risk assessment, and task performance. Participants self-reported mental demands, physical demands, temporal demands, performance, effort, and frustration. Effort (12±4) and frustration (12±5) were the highest subscales while physical demand (8±4) was the lowest. All participants were observed performing the task in at-risk postures, with 21% exhibiting risk levels requiring immediate intervention. Physical demand was associated with posture risk assessment scores (p<0.05). Mental demand was positively (R2=0.20, p<0.05) and frustration was negatively (R2=0.18, p<0.05) associated with skin conductance range. A point increase in physical demand was associated with a six second increase in performance time (β=6.0, p=0.01). These results support the fact that human factors and ergonomic tools can be used to relate surgical skills performance with workload, stress, and posture risks.

Mindfulness Meditation and Interprofessional Cardiopulmonary Resuscitation: A Mixed-Methods Pilot Study

ABSTRACT Problem: Mindfulness training includes mindfulness meditation, which has been shown to improve both attention and self-awareness. Medical providers in the intensive care unit often deal with difficult situations with strong emotions, life-and-death decisions, and both interpersonal and interprofessional conflicts. The effect of mindfulness meditation training on healthcare providers during acute care tasks such as cardiopulmonary resuscitation remains unknown. Mindfulness meditation has the potential to improve provider well-being and reduce stress in individuals involved in resuscitation teams, which could then translate into better team communication and delivery of care under stress. A better understanding of this process could lead to more effective training approaches, improved team performance, and better patient outcomes. Intervention: All participants were instructed to use a mindfulness meditation device (Muse™ headband) at home for 7 min twice a day or 14 min daily over the 4-week training period. This device uses brainwave sensors to monitor active versus relaxing brain activity and provides real-time feedback. Context: We conducted a single-group pretest–posttest convergent mixed-methods study. We enrolled 24 healthcare providers, comprising 4 interprofessional code teams, including physicians, nurses, respiratory therapists, and pharmacists. Each team participated in a simulation session immediately before and after the mindfulness training period. Each session consisted of two simulated cardiopulmonary arrest scenarios. Both quantitative and qualitative outcomes were assessed. Outcome: The median proportion of participants who used the device as prescribed was 85%. Emotional balance, as measured by the critical positivity ratio, improved significantly from pretraining to posttraining (p = .02). Qualitative findings showed that mindfulness meditation changed how participants responded to work-related stress, including stress in real-code situations. Participants described the value of time for self-guided practice with feedback from the device, which then helped them develop individual approaches to meditation not reliant on the technology. Time measures during the simulated scenarios improved, specifically, time to epinephrine in Scenario 1 (p = .03) and time to defibrillation in Scenario 2 (p = .02), improved. In addition, team performance, such as teamwork (p = .04), task management (p = .01), and overall performance (p = .04), improved significantly after mindfulness meditation training. Physiologic stress (skin conductance) improved but did not reach statistical significance (p = .11). Lessons Learned: Mindfulness meditation practice may improve individual well-being and team function in high-stress clinical environments. Our results may represent a foundation to design larger confirmatory studies.

Measuring achievement goal motivation, mindsets and cognitive load: validation of three instruments’ scores

Measurement of motivation and cognitive load has potential value in health professions education. Our objective was to evaluate the validity of scores from Dwecks Implicit Theories of Intelligence Scale (ITIS), Elliots Achievement Goal Questionnaire‐Revised (AGQ‐R) and Leppinks cognitive load index (CLI).

Personalized video feedback improves suturing skills of incoming general surgery trainees

Background. The American Board of Surgery encourages graduating medical students to prepare for surgical residency before day 1. We sought to determine the impact of personalized video feedback on an advance preparation task. Methods. We conducted a nonrandomized study comparing video feedback versus no feedback. We sent incoming surgical interns a preparatory package 2 months before starting residency. Trainees video‐recorded themselves performing a subcuticular wound closure, 3 times at 3‐week intervals, and submitted these for appraisal. A staff surgeon provided personalized feedback on each video as a narrated voiceover. The voiced‐over videos were then returned to trainees. We compared performance (time and completion rate) on suturing in a multistation assessment against residents from the previous year (no‐feedback group). Results. The feedback group had a higher completion rate for the suturing assessment than the no‐feedback group (23/28 [82%] vs. 8/27 [30%], P < .0001). The feedback group also completed the suturing station at a faster rate than those without feedback (hazard ratio 4.9 [95% confidence interval (CI): 2.2,11.2), P < .0001). Global rating scores were significantly higher for the feedback group (mean difference [5‐point scale] = 0.7 [95% CI: 0.3, 1.1]). However, Objective Structured Assessment of Technical Skills scores indicated no significant difference between groups (mean difference [5‐point scale] = 0.3 [95% CI: 0.0, 0.6]). Within the feedback group, we found significant improvement from baseline to final performances (mean difference = 109 seconds [95% CI: 79, 140]). Conclusion. Personalized narrated feedback as part of a home‐based advance preparation package for incoming residents is associated with higher performance on early objective assessments.

A Comparison of Objective Assessment Data for the United States and International Medical Graduates in a General Surgery Residency

OBJECTIVE To compare objective assessment scores between international medical graduates (IMGs) and United States Medical Graduates. Scores of residents who completed a preliminary year, who later matched into a categorical position, were compared to those who matched directly into a categorical position at the Mayo Clinic, Rochester. DESIGN Postgraduate year (PGY) 1 to 5 residents participate in a biannual multistation, OSCE-style assessment event as part of our surgical training program. Assessment data were, retrospectively, reviewed and analyzed from 2008 to 2016 for PGY-1 and from 2013 to 2016 for PGY 2 to 5 categorical residents. SETTING Academic medical center. PARTICIPANTS Categorical PGY 1 to 5 General Surgery (GS) residents at Mayo Clinic Rochester, MN. RESULTS A total of 86 GS residents were identified. Twenty-one residents (1 United States Medical Graduates [USMG] and 20 IMGs) completed a preliminary GS year, before matching into a categorical position and 68 (58 USMGs and 10 IMGs) residents, who matched directly into a categorical position, were compared. Mean scores (%) for the summer and winter multistation assessments were higher for PGY-1 trainees with a preliminary year than those without (summer: 59 vs. 37, p < 0.001; winter: 69 vs. 61, p = 0.05). Summer and winter PGY-2 scores followed the same pattern (74 vs. 64, p < 0.01; 85 vs. 71, p < 0.01). For the PGY 3 to 5 assessments, differences in scores between these groups were not observed. IMGs and USMGs scored equivalently on all assessments. Overall, junior residents showed greater score improvement between tests than their senior colleagues (mean score increase: PGY 1-2 = 18 vs. PGY 3-5 = 3, p < 0.001). CONCLUSIONS Residents with a previous preliminary GS year at our institution scored higher on initial assessments compared to trainees with no prior GS training at our institution. The scoring advantage of an added preliminary year decreased as trainees progressed through residency.