Raaj K. Ruparel

Mentor-Guided Self-Directed Learning Affects Resident Practice

OBJECTIVE Self-directed learning (SDL) can be as effective as instructor-led training. It employs less instructional resources and is potentially a more efficient educational approach. Although SDL is encouraged among residents in our surgical training program via 24-hour access to surgical task trainers and online modules, residents report that they seldom practice. We hypothesized that a mentor-guided SDL approach would improve practice habits among our residents. DESIGN From 2011 to 2013, 12 postgraduate year (PGY)-2 general surgery residents participated in a 6-week minimally invasive surgery (MIS) rotation. At the start of the rotation, residents were asked to practice laparoscopic skills until they reached peak performance in at least 3 consecutive attempts at a task (individual proficiency). SETTING Trainees met with the staff surgeon at weeks 3 and 6 to evaluate progress and review a graph of their individual learning curve. All trainees subsequently completed a survey addressing their practice habits and suggestions for improvement of the curriculum. RESULTS By the end of the rotation, 100% of participants improved in all practiced tasks (p < 0.05), and each reported that they practiced more in this rotation than during rotations without mentor-guided SDL. Additionally, 6 (50%) residents reported that their skill level had improved relative to their peers. Some residents (n = 3) felt that the curriculum could be improved by including task-specific goals and additional practice sessions with the staff surgeon. CONCLUSIONS Mentor-guided SDL stimulated surgical residents to practice with greater frequency. This repeated deliberate practice led to significantly improved MIS skills without significantly increasing the need for faculty-led instruction. Some residents preferred more discrete goal setting and increased mentor guidance.

Every Surgical Resident Should Know How to Perform a Cricothyrotomy: An Inexpensive Cricothyrotomy Task Trainer for Teaching and Assessing Surgical Trainees

OBJECTIVE Emergency cricothyrotomy is a rare but potentially lifesaving procedure. Training opportunities for surgical residents to learn this skill are limited, and many graduating residents have never performed one during their training. We aimed to develop and validate a novel and inexpensive cricothyrotomy task trainer that can be constructed from household items. DESIGN A model was constructed using a toilet paper roll (trachea and larynx), Styrofoam (soft tissue), cardboard (thyroid cartilage), zip tie (cricoid), and fabric (skin). Participants were asked to complete a simulated cricothyrotomy procedure using the model. They were then evaluated using a 10-point checklist (5 points total) devised by 6 general surgeons. Participants were also asked to complete an anonymous survey rating the educational value and the degree of enjoyment regarding the model. SETTING A tertiary care teaching hospital. PARTICIPANTS A total of 54 students and general surgery residents (11 medical students, 32 interns, and 11 postgraduate year 3 residents). RESULTS All 54 participants completed the training and assessment. The scores ranged from 0 to 5. The mean (range) scores were 1.8 (1-4) for medical students, 3.5 (1-5) for junior residents, and 4.9 (4-5) for senior-level residents. Medical students were significantly outperformed by junior- and senior-level residents (p < 0.001). Trainees felt that the model was educational (4.5) and enjoyable (4.0). CONCLUSIONS A low-fidelity, low-cost cricothyrotomy simulator distinguished the performance of emergency cricothyrotomy between medical students and junior- and senior-level general surgery residents. This task trainer may be ideally suited to providing basic skills to all physicians in training, especially in settings with limited resources and clinical opportunities.

Assessment of Virtual Reality Robotic Simulation Performance by Urology Resident Trainees

OBJECTIVES To examine resident performance on the Mimic dV-Trainer (MdVT; Mimic Technologies, Inc., Seattle, WA) for correlation with resident trainee level (postgraduate year [PGY]), console experience (CE), and simulator exposure in their training program to assess for internal bias with the simulator. DESIGN Residents from programs of the Southeastern Section of the American Urologic Association participated. Each resident was scored on 4 simulator tasks (peg board, camera targeting, energy dissection [ED], and needle targeting) with 3 different outcomes (final score, economy of motion score, and time to complete exercise) measured for each task. These scores were evaluated for association with PGY, CE, and simulator exposure. SETTING Robotic skills training laboratory. PARTICIPANTS A total of 27 residents from 14 programs of the Southeastern Section of the American Urologic Association participated. RESULTS Time to complete the ED exercise was significantly shorter for residents who had logged live robotic console compared with those who had not (p = 0.003). There were no other associations with live robotic console time that approached significance (all p ≥ 0.21). The only measure that was significantly associated with PGY was time to complete ED exercise (p = 0.009). No associations with previous utilization of a robotic simulator in the residents home training program were statistically significant. CONCLUSIONS The ED exercise on the MdVT is most associated with CE and PGY compared with other exercises. Exposure of trainees to the MdVT in training programs does not appear to alter performance scores compared with trainees who do not have the simulator.

Synchronous splenectomy during cholecystectomy for hereditary spherocytosis: Is it really necessary?

BACKGROUND/PURPOSE Expert guidelines recommend performing synchronous splenectomy in patients with mild hereditary spherocytosis (HS) and symptoms of gallstone disease. This recommendation has not been widely explored in the literature. The aim of this study is to determine if our data support expert opinion and if different practice patterns should exist. METHODS This is an IRB-approved retrospective study. All HS patients under 18 years of age who underwent cholecystectomy for symptomatic gallstones at a single institution between 1981 and 2009 were identified. Patients who underwent cholecystectomy without concurrent splenectomy were reviewed retrospectively for future need for splenectomy and evidence of recurrent gallstone disease. RESULTS Of the 32 patients identified, 27 underwent synchronous splenectomy. The remaining 5 patients underwent cholecystectomy without splenectomy and had a mean age of 9.4 years. One of the 5 patients eventually required splenectomy for left upper quadrant pain. None of the remaining 4 required hospitalization for symptoms related to hemolysis or hepatobiliary disease. Median follow-up is 15.6 years. CONCLUSION The need for splenectomy in patients with mild HS and symptomatic cholelithiasis should be assessed on a case by case basis. Our recommendation is to not perform synchronous splenectomy in conjunction with cholecystectomy for these patients if no indication for splenectomy exists.

Video Skills Curricula and Simulation: A Synergistic Way to Teach 2-Layered, Hand-Sewn Small Bowel Anastomosis

BACKGROUND We sought to determine if general surgery (GS) interns could learn a side-to-side, 2-layered, hand-sewn small bowel anastomosis (HSBA) using an online instructional video and low-fidelity simulation model. METHODS A 3-hour HSBA technical skills training session was held among GS interns. Participants were asked to write down the steps for performing a side-to-side, 2-layered HSBA (pretest). An online 13-minute instructional video on HSBA was then viewed. Low-fidelity bowel simulators were then provided for deliberate practice under staff supervision. A posttest (identical to pretest) concluded the session. The maximum test score was 20 points. At 4 months later, a retention test was administered. Trainees were anonymously surveyed to determine the sessions educational value. Pretest, posttest, and retention test scores were compared. RESULTS Participants were 25 GS interns. The mean pretest score was 5 (range: 0-11). Posttest scores improved (mean = 15; range: 11-19, p = 0.016), whereas retention test scores were stable (mean = 14; range: 8-18). Of those who participated in retention testing (24/25), 7 had now performed a 2-layered HSBA, 11 had witnessed HSBA, and 6 had neither performed nor witnessed an HSBA since the educational session. Retention test scores were higher among those who had performed HSBA (mean = 16; range: 13-18) vs those who had not performed nor witnessed an HSBA (mean = 14; range: 8-18, p = 0.04). Mean Likert scores supported the educational value of the session. CONCLUSION Initial intern performance of HSBA was abysmal. A contemporary online video skills curriculum coupled with low-fidelity bowel simulators improved trainee knowledge of how to perform a 2-layered HSBA. This effect remained stable over 4 months.

Assimilating endocrine anatomy through simulation: a pre-emptive strike!

BACKGROUND We sought to determine if endocrine anatomy could be learned with the aid of a hands-on, low-cost, low-fidelity surgical simulation curriculum and pre-emptive 60-second YouTube video clip. METHODS A 3-hour endocrine surgery simulation session was held on back-to-back Fridays. A video clip was made available to the 2nd group of learners. A comprehensive 40-point test was administered before (pre-test) and after (post-test) the sessions. RESULTS General surgery interns (n = 26) participated. The video was viewed 19 times by 80% (12 of 15) of interns with access. Viewers outperformed nonviewers on subsequent post-testing (mean [SD], 29.7 [1.3] vs 24.4 [1.6]; P = .015). Mean scores on the anatomy section of the post-test were higher among viewers than nonviewers (mean [SD] 14.2 [.9] vs 10.3 [1.0]; P = .012). CONCLUSIONS Low-cost simulation models can be used to teach endocrine anatomy. Pre-emptive viewing of a 60-second video may have been a key factor resulting in higher post-test scores compared with controls, suggesting that the video intervention improved the educational effectiveness of the session.

Simulation, Mastery Learning and Healthcare

ABSTRACT Healthcare organizations, becoming increasingly complex, need to use simulation techniques as a tool to provide consistently safe care. Mastery learning techniques minimize variation in learner outcome, thus improving the consistency and cost‐effectiveness of care. Todays organizations (and their teams of decision makers) exist within varying states of transformation. These transformational times afford opportunities to use mastery learning concepts at an organizational level and to affect necessary change(s). Evolving technologies, including simulation, have provided mechanisms to enhance system performance, reducing reliance on custom‐built “problem‐solving” solutions for individual system needs. As such, simulation has emerged as an increasingly necessary organizational tool in improving value‐driven, consistent processes of care. Both computer‐based and non‐computer‐based algorithms of healthcare simulations offer distinct advantages in improving system performance over traditional methods of quality improvement. Simulation as a process engineering tool, integrated with mastery learning techniques, provides powerful platforms for improving value‐based care.

Maximum cosmesis for patients with primary hyperparathyroidism: a case for larger incisions

Abstract While minimally invasive parathyroidectomy is an advantage to many properly selected patients, longer incisions and even wide skin resection may be optimal in a select few. We present an 80-year-old woman with primary hyperparathyroidism and bothersome excess neck skin and subcutaneous fat. The parathyroid adenoma was easily excised through a vertically-oriented cervical excision that removed an ellipse of fat and skin. Midline wound closure with a small Z-plasty to avoid wound tethering facilitated a cosmetic closure well within the surgical capabilities of endocrine surgeons. This technique is useful for select patients and their surgeons and may avoid the expense of cosmetic surgery. We offer this controversial case to highlight the pros and cons of maximizing efficient surgical care to our endocrine surgery patients.

Forequarter amputation for recurrent breast cancer

Highlights • Forequarter amputation is an aggressive treatment for recurrent breast cancer.• Some patients with regional metastatic disease do benefit from forequarter amputation.• Patients with unrelenting cancer pain do gain relief from forequarter amputation.

Board #147 - Research Abstract Pancreaticoduodenectomy and Hepaticojejunostomy: Simple, Low-cost, and Effective Modeling of Advanced Surgical Techniques (Submission #9933)

Hypothesis General Surgery (GS) residents salivate at the opportunity to participate in major hepatobiliary (HPB) operations. Pancreaticoduodenectomy (PD) along with its associated pancreaticojejunostomy (PJ) and hepaticojejunostomy (HJ) are technically complex procedures which are highly revered and eagerly sought by surgical trainees. Exposure to the basic concepts underlying these procedures in a simulated environment may lead to better understanding of such advanced techniques. We aimed to construct an effective HPB skills session for GS interns using low-cost, low-fidelity models. Methods An inexpensive model was constructed using cardboard, fabric (liver, jejunum), portion of a Penrose drain (common bile duct) and portion of a hot dog (pancreas). GS interns (n=18) initially participated in a 3-hour didactic/simulation session which taught technique for the components of a PD. Residents were then asked to perform a PD with the associated PJ and HJ using the model. Knowledge evaluation was accomplished using a 10-question pre- and post-task written exam. Participants were surveyed anonymously and asked to rate degree of model realism, enjoyment, and educational benefit using a 5-point Likert scale (1= strongly disagree, 5= strongly agree). Results All residents completed the session. Each model cost roughly