Nicholas E. Anton

What stress coping strategies are surgeons relying upon during surgery

BACKGROUND The objective of this study was to determine sources of intraoperative stress, impact on surgical outcomes, coping strategies, and surgeon interest in stress management training. METHODS An anonymous survey was electronically distributed to surgeons at a tertiary care hospital. Respondents were asked to rate the perceived impact of 9 stressors on operative performance, identify stress coping strategies, list witnessed stress-related complications, and opine on the perceived need for stress management training. RESULTS Seventy-two responses were received (76% relative risk). Complex or rarely performed cases and poor assistance were associated with the highest stress, while personal life distractions were associated with the least. Importantly, 40% of surgeons indicated that they had witnessed an intraoperative complication directly related to surgeon stress. Respondents (82%) believed that formal stress management training is needed. CONCLUSIONS Several stressors affect surgical performance and contribute to complications. Surgeons use a variety of stress coping strategies. Formal stress management training is needed.

Multicenter proficiency benchmarks for advanced laparoscopic suturing tasks

BACKGROUND Advanced laparoscopic suturing (LS) tasks were developed based on a needs assessment. Initial validity evidence has been shown. The purpose of this multicenter study was to determine expert proficiency benchmarks for these tasks. METHODS 6 tasks were included: needle handling (NH), offset-camera forehand suturing (OF), offset-camera backhand suturing (OB), confined space suturing (CF), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons experienced in LS completed the tasks twice. Mean time and median accuracy scores were used to establish the benchmarks. RESULTS Seventeen MIS surgeons enrolled, from 7 academic centers. Mean (95% CI) time in seconds to complete each task was: NH 169 (149-189), OF 158 (134-181), OB 189 (154-224), CF 181 (156-205), UT 379 (334-423), and CS 416 (354-477). Very few errors in accuracy were made by experts in each of the tasks. CONCLUSIONS Time- and accuracy-based proficiency benchmarks for 6 advanced LS tasks were established. These benchmarks will be included in an advanced laparoscopic surgery curriculum currently under development.

Mental skills training effectively minimizes operative performance deterioration under stressful conditions: Results of a randomized controlled study

BACKGROUND Stress can negatively impact surgical performance, but mental skills may help. We hypothesized that a comprehensive mental skills curriculum (MSC) would minimize resident performance deterioration under stress. METHODS Twenty-four residents were stratified then randomized to receive mental skills and FLS training (MSC group), or only FLS training (control group). Laparoscopic suturing skill was assessed on a live porcine model with and without external stressors. Outcomes were compared with t-tests. RESULTS Twenty-three residents completed the study. The groups were similar at baseline. There were no differences in suturing at posttest or transfer test under normal conditions. Both groups experienced significantly decreased performance when stress was applied, but the MSC group significantly outperformed controls under stress. CONCLUSIONS This MSC enabled residents to perform significantly better than controls in the simulated OR under unexpected stressful conditions. These findings support the use of psychological skills as an integral part of a surgical resident training.

Time crunch: increasing the efficiency of assessment of technical surgical skill via brief video clips

Background. Video review for assessment of surgical performance is gaining popularity but is time consuming for busy expert reviewers, making review delays inevitable. Decreasing review time and including nonexpert reviewers may facilitate more timely reviews. We hypothesized that a shorter duration video clip would not affect the quality of expert ratings compared with full‐length review. A secondary aim was to examine the reliability between expert and novice raters and how it was affected by video clip duration. Methods. Videos of laparoscopic suturing performed on a live porcine model by premedical students, surgery residents, and fully trained surgeons were edited into 3 different durations: full, part, and 30‐second versions. Video clips (n = 36) were reviewed by experienced surgeons (n = 3) and novice volunteers (n = 4) using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) assessment. Videos were assigned randomly during 3 review cycles held 1 week apart. Each cycle included 1 iteration of the 12 performance videos. We assessed the impact of the duration of the video on reviewer scores and inter‐rater reliability. Results. Variance in scores for 2 of 4 GOALS domains was dependent on the duration of the video clip (P < .05). Total GOALS scores were greater for part and 30‐second clips compared with full clips (P < .05). Inter‐rater reliability was greatest for full clips (intraclass correlation = 0.68) and decreased significantly for shorter clips. Conclusion. Our hypothesis was rejected as shorter video durations for surgical performance assessment led to inflated reviewer ratings both for expert and novice reviewers. Shortening duration of the video cannot be recommended for accurate performance assessment.

Do Objective Measures of Communication Predict Clinical Performance? – Application in Acute Care Trauma Simulation

Effective communication in healthcare is critical for effective patient care. This study explored communication in an acute care team simulation where medical students were asked to perform as the physician in charge to manage pre-and post-operative patients. Students’ speech was analyzed to determine differences according to communication receiver (i.e., student to nurse, student to patient). Statistical analyses revealed that speech ratio, speech intensity, and number of questions students asked to the nurse or patient were significantly different between communication receivers (p<0.05). Furthermore, communications initiated by student to nurse contributed 34% of the total time, and 31% from student to patient. Lastly, students spoke 3% higher volume to patient than to nurse, 20% more questions were asked to nurse than to patient. Findings indicated an overall positive relationship between measured audio variables and performance.

Surgeons see anatomical structures faster and more accurately compared to novices: development of a pattern recognition skill assessment platform

BACKGROUND This study aimed to identify differences in pattern recognition skill among individuals with varying surgical experience. METHODS Participants reviewed laparoscopic cholecystectomy videos of various difficulty, and paused them when the cystic duct or artery was identified to outline each structure on the monitor. Time taken to identify each structure, accuracy and work load, which was assessed using the NASA-Task Load Index (TLX), were compared among the three groups. RESULTS Ten students, ten residents and eight attendings participated in the study. Attendings identified the cystic duct and artery significantly faster and more accurately than students, and identified the cystic artery faster than residents. The NASA-TLX score of attendings was significantly lower than that of students and residents. CONCLUSIONS Attendings identified anatomical structures faster, more accurately, and with less effort than students or residents. This platform may be valuable for the assessment and teaching of pattern recognition skill to novice surgeons. SHORT SUMMARY Accurate anatomical recognition is paramount to proceeding safely in surgery. The assessment platform used in this study differentiated recognition skill among individuals with varing surgical experience.

Developing a robust suturing assessment: validity evidence for the intracorporeal suturing assessment tool

Background. Assessment tools specific to intracorporeal suturing are lacking. The purpose of this study was to validate a novel Intracorporeal Suturing Assessment Tool (ISAT) by comparing it with existing measures that have been reported to have validity evidence. Methods. Videos of laparoscopic suturing were assessed by 3 blinded laparoscopic experts using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) scale and the ISAT. Correlations between these instruments were calculated, and sensitivity analyses compared both tools with objective suturing scores. A factor analysis was also performed. Results. The ISAT and GOALS ratings were significantly correlated with the objective suturing score (r = 0.58 and 0.61, respectively; P < .0001), and with each other (r = 0.92, P < .0001). A weighted &kgr; test indicated significantly higher agreement than expected between these instruments (P < .0001). All ISAT items had a factor loading approaching or greater than 0.50. Conclusion. The ISAT accurately assessed laparoscopic suturing skill related to other instruments. ISAT was highly correlated with GOALS, which is often used for laparoscopic performance assessment. Unlike the generic GOALS, ISAT includes specific information that can provide feedback on trainee suturing ability and targeted performance improvements. ISAT may provide a better alternative for intracorporeal suturing assessment.

Minimizing Deterioration of Simulator-Acquired Skills During Transfer to the Operating Room: A Novel Approach

Purpose of ReviewSurgical skill deteriorates due to stress, but mental skills may negate this skill deterioration. We recently developed a mental skills curriculum (MSC) to address this, and present findings of its effectiveness compared to historical controls.Recent FindingsThe MSC was implemented with surgical novices during simulator training, and results were compared to historical controls who had no mental skills training. The groups were comparable at baseline. Compared with the MSC group, historical controls trained longer and achieved higher performance on the simulator but without appreciable differences during the transfer test. Deterioration was less in the MSC group during transfer.SummaryOur review highlights the effectiveness of mental skills training in surgical education in general, and our novel, comprehensive MSC in minimizing performance deterioration during transfer of simulator-acquired skill. Inexperienced surgical trainees who use a comprehensive MSC may be better prepared to handle the stressful OR environment and optimize their performance.

Simulation Training in Surgical Education

Purpose of ReviewOur review aims to describe the use of simulation-based training throughout the continuum of surgical education.Recent FindingsIn addition to well-known procedural-based surgical simulation modalities like the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery, there are several novel uses of simulation including its use for preparing medical students for surgical residency, resident interviews and onboarding, residency training, mental skills training, and continuing education for practicing surgeons.SummarySimulation is a cost effective and useful method to improve trainee exposure and confidence to execute technical and nontechnical skills throughout the surgical career. There is clearly a role for simulation-based training with medical students, residents, and practicing surgeons to optimize performance through deliberate practice of skills in a safe environment. Due to the evolution of surgical techniques and an increased emphasis for proficiency-based training and certification of skills, simulation will play an increasingly integral role in surgical education.