Diana Curran

Low-hanging fruit: A clementine as a simulation model for advanced laparoscopy

Introduction Low-cost, high-fidelity models for training in advanced laparoscopic surgery techniques are not currently available. The objective of this study was to evaluate a model and assessment protocol for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making. Methods Novice to expert laparoscopists (n = 41) were asked to remove the peel of a clementine in as few pieces as possible, separate and remove all albedo from and between all fruit segments, and return the clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision making included deciding when unacceptable segment damage would result by removing difficult-to-extract albedo, analogous to treating lesions or metastases through other methods, rather than risking damage to vital anatomic structures. Faculty assessed deidentified video-recorded performances. Data analyses included analysis of variance with Bonferroni post hoc. Results A single-performance construct (operative ability) with 2 scoring dimensions (surgical skills and clinical judgment) was confirmed through factor analysis. There were significant performance differences between all experience levels (F2,41 = 59.175, P < 0.000). There were no statistical time differences between the groups. Conclusions Validation of this low-cost, easily facilitated model for developing advanced laparoscopic surgical skills may support the preparation of residents and fellows and provide a platform for skill acquisition, assessment, and basic critical thinking for performing laparoscopic tasks.

Preparing medical students for obstetrics and gynecology milestone level one: a description of a pilot curriculum

Background The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident. Purpose We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies. Methods The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks. Results Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey. Conclusions This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGMEs Next Accreditation System.Background The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident. Purpose We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies. Methods The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks. Results Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey. Conclusions This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGMEs Next Accreditation System.

Universal Cystoscopy After Benign Hysterectomy: Examining the Effects of an Institutional Policy.

OBJECTIVE: To evaluate the association between a universal cystoscopy policy at the time of benign hysterectomy and the detection of urologic injuries. METHODS: This is a retrospective cohort study at a tertiary care academic center where a policy of universal cystoscopy at the time of benign hysterectomy was instituted on October 1, 2008. Benign hysterectomies performed from March 3, 2006, to September 25, 2013, were included and dichotomized into preuniversal and postuniversal cystoscopy groups. Medical records were reviewed for baseline and perioperative characteristics, cystoscopy use, and urologic injuries related to hysterectomy. Urologic injuries were identified by using a search engine and a departmental quality improvement database. RESULTS: Two thousand nine hundred eighteen hysterectomies were identified during the study time period, 96 of which were excluded for indications of abdominopelvic cancers and peripartum indications. Therefore, 973 women were in the preuniversal cystoscopy group and 1,849 were in the postuniversal cystoscopy group. Thirty-six percent (347/973, 95% confidence interval [CI] 32.8–38.8%) and 86.1% (1,592/1,849, 95% CI 84.5–87.7%) of patients underwent cystoscopy prepolicy and postpolicy, respectively. The urologic injury rates were 2.6% (25/973, 95% CI 1.6–3.6%) and 1.8% (34/1,849, 95% CI 1.2–2.5%) in the prepolicy and postpolicy groups, respectively. Delayed urologic injuries decreased significantly (0.7% [7/973], 95% CI 0.3–1.2% compared with 0.1% [2/1,849], 95% CI 0.0–0.3%). Of the nine patients with delayed injuries, four had normal intraoperative cystoscopy findings and five had no cystoscopy performed. CONCLUSION: The practice of universal cystoscopy at the time of hysterectomy for benign indications is associated with decreased delayed postoperative urologic complications.

Validity: what does it mean for competency-based assessment in obstetrics and gynecology?

Validity refers to an evidence-based claim about the trustworthiness of decisions made from context-specific performance data. Validity requirements for competency-based assessments in obstetrics and gynecology have not been defined in the literature. We explain why validity is intrinsic to any discussion about competency assessment and provide a model for obstetrics and gynecology programs to use in determining the essential validity evidence for various forms of assessments. The implications of decisions made from assessment results influence the requisite level and precision of validity evidence. Although validity evidence is essential, it is also flexibly tied to the implications of decisions made from assessment results and not all assessments require the same degree of validity. We propose a model for considering validity, and build a discussion around specific assessment examples targeting progressive levels of expertise along the training continuum.

Transcervical tubal cannulation: a comparison of two techniques *

Transcervical tubal cannulation using tactile guidance has a similar rate of successful cannulation compared with that with US guidance (78% versus 73%) but takes less time to perform (2.3 +/- 1.8 minutes versus 8.7 +/- 6.2 minutes, mean +/- SD) and is associated with less pain and bleeding. This appears to be because of the design of the Labotect tubal cannulation set that uses a special speculum and tenaculum to straighten the uterus before insertion of the guide cannula and a less traumatic ball-tipped guide catheter.

The Decision to Incision Curriculum: Teaching Preoperative Skills and Achieving Level 1 Milestones

OBJECTIVE To evaluate the effectiveness of a preoperative skills curriculum, and to assess and document competence in associated Obstetrics and Gynecology Level 1 Milestones. DESIGN The Decision to Incision curriculum was developed by a team of medical educators with the goal of teaching and evaluating 5 skills pertinent to Milestone 1: Preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time-out. Competence, overall skill performance, and knowledge were assessed by evaluator rating using checklists before and after the educational intervention. Differences between preintervention and postintervention skills performance and competence were assessed using Wilcoxon rank test and Fisher exact test, respectively. SETTING Clinical Simulation Center at an academic medical center. PARTICIPANTS Overall, 29 fourth year medical students matriculating into Obstetrics and Gynecology residencies. RESULTS The proportion of participants meeting Milestone competence significantly increased in all 5 skills, with competence achieved in 95.6% (95% CI: 92.1-99.0) of posttest skills assessments. Median overall performance also significantly improved for all 5 skills, with 83.6% (95% CI: 77.3-89.9) earning scores of 4 out of 5 or greater on the posttest. For knowledge testing, the proportion of correct responses significantly increased for both topics evaluated, from 45.2% to 99.7% (p < 0.0001) for positioning and from 32.8% to 83.1% (p < 0.0001) for time-out. CONCLUSIONS The decision to incision curriculum significantly improved preoperative skills, including skills that may be required on day 1 of residency. This curriculum also facilitated achievement and documentation of competence in multiple Milestones.

Evaluation of a precise and measurable model for learning laparoscopic tissue handling.

Introduction Laparoscopic tissue handling is quite difficult to measure using virtual-reality laparoscopic simulators and box-trainer exercises, and therefore, completion time is the predominant performance measure for simulation-based laparoscopic training exercises. The purpose of this study was to evaluate the construct validity of a training and assessment model for precise laparoscopic handling of delicate tissue. Methods Participants (n = 35) completed 2 progressively challenging laparoscopic tissue translocation exercises using delicate foam pieces and templates. Deidentified performances were scored using objective measures for tissue damage, accuracy, percentage complete, and completion time. Evaluation included multiple analysis of variance with repeated measures among the 3 groups as follows: medical students, residents and faculty who perform laparoscopic surgery less than once per week, and faculty members who perform laparoscopic surgery at least once per week. Results The model demonstrated significant construct validity by discriminating performances between the types of shapes and templates and across the levels of surgical experience on all dimensions. A significant interaction effect between the level of expertise and the difficulty of the exercise revealed excellent discrimination between experienced laparoscopic surgeons and others. Discussion This low-cost model provides an alternative or adjunct platform for laparoscopic training and assessment that requires precise and measurable handling of a delicate tissue.

Evaluation of a simulation-based curriculum for implementing a new clinical protocol.

To evaluate the implementation of a new clinical protocol utilizing on‐unit simulation for team training.

Implementing New Clinical Practice Guidelines: An Ideal Use of Simulation

INTRODUCTION: The University of Michigan introduced a new clinical practice guideline detailing an urgency classification for obstetric procedures. Past guidelines had been disseminated using e-mails and electronic learning modules. We hypothesized that a simulation-based curriculum to educate members of the team would provide a meaningful experience and lead to compliance with the guidelines, in particular correct paging elements. METHODS: A simulation curriculum was implemented targeting our multidisciplinary team: faculty, residents, nurses, and allied personnel (N=72). Participants completed a web-based educational module before the simulation. Sessions involved a brief didactic review followed by 1 of 12 simulated scenarios. Debriefing followed each session focusing on team-based communication. During the 9 months while these weekly training sessions were conducted, paging records for all unplanned procedures were analyzed and compared before and after training (one-sided t test) RESULTS: Pages with a goal-entry time specified increased by 63%. The percentage of pages with an operating room entry time within 10 minutes of the stated goal time increased 50–78%. The necessary paging elements specified by untrained members compared with trained members increased from 57% to 74% for emergent pages (P<.03). The necessary paging elements increased from 79% to 84% with one training session (P=.001) and to 92.5% (P=.000) with two or three sessions. CONCLUSION: A simulation-based curriculum is effective for implementing clinical practice guidelines. The advantages of this approach are: 1) use of guidelines before implementation; 2) debriefing to increase understanding and modification before implementation; and 3) learners may err in an environment without affecting patient safety.

Improving the medical school–residency transition

In response to calls to improve the continuum between undergraduate and graduate medical education, many medical schools are creating electives designed to prepare students for residency training. There is a need for data that link improvements from these residency preparation courses to residency itself.