Margaret L. Boehler

Surgeon Information Transfer and Communication: Factors Affecting Quality and Efficiency of Inpatient Care

Objective:To determine the nature of surgeon information transfer and communication (ITC) errors that lead to adverse events and near misses. To recommend strategies for minimizing or preventing these errors. Summary Background Data:Surgical hospital practice is changing from a single provider to a team-based approach. This has put a premium on effective ITC. The Information Transfer and Communication Practices (ITCP) Project is a multi-institutional effort to: 1) better understand surgeon ITCP and their patient care consequences, 2) determine what has been done to improve ITCP in other professions, and 3) recommend ways to improve these practices among surgeons. Methods:Separate, semi-structured focus group sessions were conducted with surgical residents (n = 59), general surgery attending physicians (n = 36), and surgical nurses (n = 42) at 5 medical centers. Case descriptions and general comments were classified by the nature of ITC lapses and their effects on patients and medical care. Information learned was combined with a review of ITC strategies in other professions to develop principles and guidelines for re-engineering surgeon ITCP. Results:A total of 328 case descriptions and general comments were obtained and classified. Incidents fell into 4 areas: blurred boundaries of responsibility (87 reports), decreased surgeon familiarity with patients (123 reports), diversion of surgeon attention (31 reports), and distorted or inhibited communication (67 reports). Results were subdivided into 30 contributing factors (eg, shift change, location change, number of providers). Consequences of ITC lapses included delays in patient care (77% of cases), wasted surgeon/staff time (48%), and serious adverse patient consequences (31%). Twelve principles and 5 institutional habit changes are recommended to guide ITCP re-engineering. Conclusions:Surgeon communication lapses are significant contributors to adverse patient consequences, and provider inefficiency. Re-engineering ITCP will require significant cultural changes.

An investigation of medical student reactions to feedback: a randomised controlled trial

Background  Medical educators have indicated that feedback is one of the main catalysts required for performance improvement. However, medical students appear to be persistently dissatisfied with the feedback that they receive. The purpose of this study was to evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments.

Refining the Evaluation of Operating Room Performance

PURPOSE An accurate and consistent evaluation of resident operative performance is necessary but difficult to achieve. This study continues the examination of the Southern Illinois University (SIU) operative performance rating system (OPRS) by studying additional factors that may influence reliability, accuracy, and interpretability of results. METHODS OPRS evaluations of surgical residents by faculty at SIU, from 2001 to 2008, were analyzed for the most frequently rated procedures to determine (1) the elapsed time from the procedure until completion of rating, (2) the patterns in responses of procedure-specific and global surgical skills items, and (3) whether particular evaluating surgeons differed in their stringency of ratings of resident operative performance. RESULTS In all, 566 evaluations were analyzed, which consisted of open colectomy (n = 125), open inguinal hernia (n = 103), laparoscopic cholecystectomy (n = 199), and excisional biopsy (n = 139). The number of residents evaluated per training level (PGY) ranged from 88 to 161. The median time to completion of evaluations was 11 days, 9 hours. The quickest evaluation was 18 hours after assignment. Most were completed within 4.5 to 22 days. Procedure-specific and global scale scores resulted in similar rank-ordering of performances (single-measure intraclass correlation using the consistency model = 0.88; 95% confidence interval [CI] = 0.87-0.90) and similar absolute OPRS scores (single-measure intraclass correlation using the consistency model = 0.89; 95% CI, 0.87-0.90). Evaluating surgeons differed in stringency of ratings across procedures (average difference = 1.4 points of 5 possible points). Resident performance improved with increasing PGY level for all 4 procedures. CONCLUSIONS Substantial time elapses between performance in the operating room and the completion of the evaluation. This raises the question of whether surgeons remember the nuances of the procedure well enough to rate performance accurately. The item type used for rating does not affect the absolute rating assigned or the rank ordering of the performance. Differences in stringency of evaluators indicate the need for multiple resident performance observations by multiple surgeons. These findings are the foundation for an upcoming multi-institutional trial.

Do individual attendings' post-rotation performance ratings detect residents' clinical performance deficiencies?

Purpose. To determine whether attending physicians’ post-rotation performance ratings and written comments detect surgery residents’ clinical performance deficits. Method. Residents’ performance records from 1997–2002 in the Department of Surgery, Southern Illinois University School of Medicine, were reviewed to determine the percentage of times end-of-rotation performance ratings and/or comments detected deficiencies leading to negative end-of-year progress decisions. Results. Thirteen of 1,986 individual post-rotation ratings (0.7%) nominally noted a deficit. Post-rotation ratings of “good” or below were predictive of negative end-of-year progress decisions. Eighteen percent of residents determined to have some deficiency requiring remediation received no post-rotation performance ratings indicating that deficiency. Written comments on post-rotation evaluation forms detected deficits more accurately than did numeric ratings. Physicians detected technical skills performance deficits more frequently than applied knowledge and professional behavior deficits. More physicians’ post-rotation numeric ratings contradicted performance deficits than supported them. More written comments supported deficits than contradicted them in the technical skills area. In the applied knowledge and professional behavior areas, more written comments contradicted deficits than supported them. Conclusions. A large percentage of performance deficiencies only became apparent when the attending physicians discussed performance at the annual evaluation meetings. Annual evaluation meetings may (1) make patterns of residents’ behavior apparent that were not previously apparent to individual physicians, (2) provide evidence that strengthens the individual attendings preexisting convictions about residents’ performance deficiencies, or (3) lead to erroneous conclusions. The authors believe deficiencies were real and that their findings can be explained by a combination of reasons one and two.

Teaching operating room conflict management to surgeons: clarifying the optimal approach

Medical Education 2011:45: 939–945

Skills coaches as part of the educational team: A randomized controlled trial of teaching of a basic surgical skill in the laboratory setting

BACKGROUND The aim of this study was to compare the laboratory teaching of a basic technical skill by a nonphysician skills coach and a faculty surgeon. METHODS Medical students were randomized to instruction of skin suturing in the skills laboratory by a faculty surgeon or by a nonphysician skills coach. Testing of performance occurred at 3 time points. Other faculty surgeons, blinded to identities and training groups, rated performance. RESULTS Forty-nine students participated. Baseline fourth-year student mean scores showed no significant difference between training groups. Third-year and fourth-year student performance showed no difference between training groups on postintervention testing. Delayed testing also showed no difference in third-year student scores. CONCLUSIONS Training by either a nonsurgeon skills coach or a faculty surgeon resulted in no difference in performance on a basic surgical skill. This was true for students with and without prior experience and was also true after subsequent clinical experiences. Nonphysician coaches may ease the teaching burden of surgical faculty members while providing similar quality of instruction for trainees.

Using the Hidden Curriculum to Teach Professionalism During the Surgery Clerkship

BACKGROUND It has been shown that medical student professionalism is influenced by the hidden curriculum, although the extent to which this occurs during the surgery clerkship is unknown. Furthermore, the processes within the hidden curriculum have been used to teach professionalism to medical students, but this strategy has not been used during the surgery clerkship. The purpose of this study was to review a 2-year experience with a surgery clerkship instructional session where the hidden curriculum was used to teach professionalism to medical students. STUDY DESIGN Medical student essays were analyzed to evaluate the influence of the hidden curriculum on their ideas about professionalism and to identify specific behaviors that they regarded as professional and unprofessional. The instructional session was evaluated using the average satisfaction session ratings and through an analysis of medical student session evaluation comments. RESULTS Seventy-five percent of medical students reported that their ideas about professionalism changed. This change involved their general concepts about professionalism, identifying specific behaviors that they planned to adopt or avoid, or developing opinions about the professionalism of surgeons. The average satisfaction rating was consistently high throughout the study period, and the most helpful session feature was reported as the opportunity to share and discuss their observations. CONCLUSIONS The hidden curriculum has a substantial influence on the development of professionalism of medical students during the surgery clerkship. It was possible to illuminate and use the hidden curriculum to create an instructional session devoted to professionalism for medical students on the surgery clerkship.

Pursuing Professional Accountability An Evidence-Based Approach to Addressing Residents With Behavioral Problems

OBJECTIVE To develop an evidence-based approach to the identification, prevention, and management of surgical residents with behavioral problems. DESIGN The American College of Surgeons and Southern Illinois University Department of Surgery hosted a 1-day think tank to develop strategies for early identification of problem residents and appropriate interventions. Participants read a selection of relevant literature before the meeting and reviewed case reports. SETTING American College of Surgeons headquarters, Chicago, Illinois. PARTICIPANTS Medical and nursing leaders in the field of resident education; individuals with expertise in dealing with academic law, mental health issues, learning deficiencies, and disruptive physicians; and surgical residents. MAIN OUTCOME MEASURES Evidence-based strategies for the identification, prevention, and management of problem residents. RESULTS Recommendations based on the literature and expert opinions have been made for the identification, remediation, and reassessment of problem residents. CONCLUSIONS It is essential to set clear expectations for professional behavior with faculty and residents. A notice of deficiency should define the expected acceptable behavior, timeline for improvement, and consequences for noncompliance. Faculty should note and address systems problems that unintentionally reinforce and thus enable unprofessional behavior. Complaints, particularly by new residents, should be investigated and addressed promptly through a process that is transparent, fair, and reasonable. The importance of early intervention is emphasized.

Who are the surgery clerkship directors and what are their educational needs

BACKGROUND The surgery clerkship director is a key individual in the surgery departments educational mission and yet there has been no prior effort to describe this group or identify their learning needs. The purpose of this study was to develop a demographic profile and an educational needs assessment for surgery clerkship directors. METHODS A survey instrument was designed based on existing literature and distributed to surgery clerkship directors in the United States and Canada. RESULTS Surveys were returned from 108 subjects (77%). The majority of clerkship directors strongly agree that directing is a positive experience but express concern that the job demands may impede their professional careers. The perceived educational needs identified related primarily to the development and management of the student education curriculum. CONCLUSIONS Surgery clerkship directors are experienced academic surgeons who report high levels of satisfaction. They identify a number of important educational needs of the position and express concern about the requirements of the position on their academic careers.

Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors

BACKGROUND Developing an operating room conflict management educational program for surgeons requires a formal needs assessment and information about behaviors that represent effective conflict management. METHODS Focus groups of circulating room nurses and surgeons were conducted at 5 participating centers. Participants responded to queries about conflict management training, conflict consequences, and effective conflict management behaviors. Transcripts of these sessions served as the data for this study. RESULTS Educational preparation for conflict management was inadequate consisting of trial and error with observed behaviors. Conflict and conflict mismanagement had negative consequences for team members and team performance. Four behaviors emerge as representing effective ways for surgeons to manage conflict. CONCLUSIONS There is a clear educational need for conflict management education. Target behaviors have now been identified that can provide the basis for a theoretically grounded and contextually adapted instruction and assessment of surgeon conflict management.