Emmeline Nugent

Personality factors and medical training: a review of the literature

Medical Education 2011: 45: 132–140

The impact of aptitude on the learning curve for laparoscopic suturing

BACKGROUND Within surgery, several specialties demand advanced technical skills, specifically in the minimally invasive environment. METHODS Two groups of 10 medical students were recruited on the basis of their aptitude (visual-spatial ability, depth perception, and psychomotor ability). All subjects were tested consecutively using the ProMIS III simulator until they reached proficiency performing laparoscopic suturing. Simulator metrics, critical error scores, observed structured assessment of technical skills scores, and Fundamentals of Laparoscopic Surgery scores were recorded. RESULTS Group A (high aptitude) achieved proficiency after a mean of 7 attempts (range, 4-10). In group B (low aptitude), 30% achieved proficiency after a mean of 14 attempts (range, 10-16). In group B, 40% demonstrated improvement but did not attain proficiency, and 30% failed to progress. CONCLUSIONS Distinct learning curves for laparoscopic suturing can be mapped on the basis of fundamental ability. High aptitude is directly related to earlier completion of the learning curve. A proportion of subjects with low aptitude are unable to reach proficiency despite repeated attempts.

Skills transfer after proficiency-based simulation training in superficial femoral artery angioplasty.

Introduction The purpose of this study was to explore whether basic endovascular skills acquired using proficiency-based simulation training in superficial femoral artery (SFA) angioplasty translate to real-world performance. Methods Five international experts were invited to evaluate a preliminary 28-item rating scale for SFA angioplasty using a modified Delphi study. To test the procedural scale, 4 experts and 11 final-year medical students then performed 2 SFA angioplasties each on the vascular intervention simulation trainer simulator. Thereafter, 10 general surgical residents (novices) received didactic training in SFA angioplasty. Trainees were then randomized with 5 trainees receiving further training on the vascular intervention simulation trainer simulator up to proficiency level. All 10 trainees then performed 1 SFA angioplasty on a patient within 5 days of training. The trainees’ performance was assessed by 1 attending consultant blinded to the trainees’ training status, using the developed procedural scale and a global rating scale. Results Four items were eliminated from the procedural scale after the Delphi study. There were significant differences in the procedural scale scores between the experts and the students in the first trial [mean (SD), 94.25 (2.22) vs. 74.90 (8.79), P = 0.001] and the second trial [95.25 (0.50) vs. 76.82 (9.44), P < 0.001]. Simulation-trained trainees scored higher than the controls on the procedural scale [86.8 (5.4) vs. 67.6 (6), P = 0.001] and the global rating scale [37.2 (4.1) vs. 24.4 (5.3), P = 0.003]. Conclusions Basic endovascular skills acquired using proficiency-based simulation training in SFA angioplasty do translate to real-world performance.

Rectal cancer surgery: volume-outcome analysis.

PurposeThere is strong evidence supporting the importance of the volume–outcome relationship with respect to lung and pancreatic cancers. This relationship for rectal cancer surgery however remains unclear. We review the currently available literature to assess the evidence base for volume outcome in relation to rectal cancer surgery.MethodsWe analysed the Medline “PubMed” online database using the keyword search parameters of “rectal cancer”, “hospital volume or caseload”, “surgeon volume or caseload”, “outcomes”, “mortality”, “approach”, “local recurrence” and “morbidity” for the time period 1997–2009. Five hundred twenty-six generic articles were identified. Articles that were not specific for, or separately identified, rectal cancer surgery in their individual analysis were excluded. Eighteen articles remained for review. We assessed short-term morbidity and long-term outcomes such as sphincter preservation, mortality and local recurrence rates.ResultsConsiderable variance was noted in the definition of high volume and low volume. Postoperative length of stay was lower and sphincter-preserving surgery was more commonly performed in high-volume hospitals and by high-volume surgeons. Surgeon specialisation was an important factor influencing sphincter preservation, survival and local recurrence rates. Volume was found to have no negative relationship with mortality and a positive one with local recurrence. Interestingly, there was no association found between hospital or surgeon caseload and postoperative morbidity.ConclusionThere is a paucity of evidence in the literature regarding the volume–outcome relationship with regard to rectal cancer surgery. High-volume institutions yielded shorter lengths of stay. However, the key finding was that high-volume surgeons that specialised in colorectal surgery yielded objectively improved outcomes for patients with rectal cancer.

Factors influencing microsurgical skill acquisition during a dedicated training course

Proficient microsurgical skills are considered essential in plastic and reconstructive surgery. Specialized courses offer trainees opportunity to improve their technical skills. Trainee aptitude may play an important role in the ability of a trainee to acquire proficient skills as individuals have differing fundamental abilities. We delivered an intensive 5‐day microsurgical training course. We objectively assessed the impact of the course on microsurgical skill acquisition and whether aptitudes as assessed with psychometric tests were related to surgical performance.

Assessment of the role of aptitude in the acquisition of advanced laparoscopic surgical skill sets: results from a virtual reality-based laparoscopic colectomy training programme.

PurposeThe surgeons of the future will need to have advanced laparoscopic skills. The current challenge in surgical education is to teach these skills and to identify factors that may have a positive influence on training curriculums. The primary aim of this study was to determine if fundamental aptitude impacts on ability to perform a laparoscopic colectomy.MethodsA practical laparoscopic colectomy course was held by the National Surgical Training Centre at the Royal College of Surgeons in Ireland. The course consisted of didactics, warm-up and the performance of a laparoscopic sigmoid colectomy on thesimulator. Objective metrics such as time and motion analysis were recorded. Each candidate had their psychomotor and visual spatial aptitude assessed. The colectomy trays were assessed by blinded experts post procedure for errors.ResultsTen trainee surgeons that were novices with respect to advanced laparoscopic procedures attended the course. A significant correlation was found between psychomotor and visual spatial aptitude and performance on both the warm-up session and laparoscopic colectomy (r > 0.7, p < 0.05). Performance on the warm-up session correlated with performance of the laparoscopic colectomy (r = 0.8, p = 0.04). There was also a significant correlation between the number of tray errors and time taken to perform the laparoscopic colectomy (r = 0.83, p = 0.001).ConclusionThe results have demonstrated that there is a relationship between aptitude and ability to perform both basic laparoscopic tasks and laparoscopic colectomy on a simulator. The findings suggest that there may be a role for the consideration of an individual’s inherent baseline ability when trying to design and optimise technical teaching curricula for advanced laparoscopic procedures.

Technical Skill Set Training in Natural Orifice Transluminal Endoscopic Surgery: How Should We Approach It?

BACKGROUND The boundaries in minimally invasive techniques are continually being pushed further. Recent years have brought new and exciting changes with the advent of natural orifice transluminal endoscopic surgery. With the evolution of this field of surgery come challenges in the development of new instruments and the actual steps of the procedure. Included in these challenges is the idea of developing a proficiency-based curriculum for training. METHODS A review of the currently available literature was performed to support the points discussed. RESULTS In this article we address and discuss the issues of who, when, where, and how to teach suitable trainees in the technique of natural orifice transluminal endoscopic surgery. CONCLUSION What comes to the fore is the importance of providing safe and structured training in these techniques.

Impact of an Assistant on the Technical Skills of the Primary Operator in Superficial Femoral Artery Angioplasty

Objective: To assess the impact of an assistant on the technical skills of the operator performing superficial femoral artery (SFA) angioplasty on the vascular intervention simulation trainer (VIST) simulator. Methods: Eight experts performed 2 SFA angioplasties each on the VIST. Four experts had an assistant available. Experts’ video recordings were blindly evaluated using global and procedural rating scales. Results: Experts with assistants scored higher than the controls in the first: global rating scale (47.8 ± 0.5 vs 33.5 ± 5.1, P = .01); procedural rating scale (94.3 ± 2.2 vs 89 ± 2.5, P = .02) and the second procedure: global rating scale (47.8 ± 0.5 vs 38 ± 7, P = .03); procedural rating scale (95.3 ± 0.5 vs 89.5 ± 2.4, P = .02). Conclusions: The presence of an assistant had a positive influence on the technical skills of the operator performing SFA angioplasty on the VIST simulator.

Gastrointestinal Complications of Abdominal Aortic Aneurysms

Although the gastrointestinal complications that occur secondary to repair of an aortic abdominal aneurysm (AAA) are uncommon they are associated with a significant increase in patient morbidity and mortality and therefore they warrant discussion. The gastrointestinal complications that we plan to review in detail in this chapter are ischaemic colitis, abdominal compartment syndrome, secondary aorto-enteric fistula, chylous ascites and ileus. We are also going to briefly discuss peptic ulcer disease, acute cholecystitis and acute pancreatitis and their relationship with AAA surgery. Throughout the chapter we describe the incidence, aetiology, pathology, associated risk factors, diagnosis and management for each potential gastrointestinal complication in an evidence based manner. Over the last two decades a new technique, endovascular surgery (EVAR), has been introduced as an alternative option for the management of an abdominal aortic aneurysm. The traditional approach, open repair, has long been regarded as a durable, effective procedure that is associated with a low rate of rupture with long-term follow up. However, the evolution of endovascular surgery has promised benefits when compared to the traditional approach. The advantages of the endovascular approach include a faster recovery time post-operatively and a reduction in the morbidity and mortality rates that occur with this condition. It also allows elderly patients and patients with co-morbidities that previously would have been considered unfit for surgery to undergo aneurysm repair in a safe manner. As part of our review of gastrointestinal complications following AAA repair, in this chapter we examine the impact, if any, that endovascular surgery has had on the type and frequency of these complications since its introduction.