The COVID-19 pandemic presents a unique challenge to surgical residency programs. Due to the restrictions recommended by the Centers for Disease Control and Prevention and other organizations, the ...educational landscape for surgical residents is rapidly changing. In addition, the time course of these changes is undefined.
We attempt to define the scope of the problem of maintaining surgical resident education while maintaining the safety of residents, educators, and patients. Within the basic framework of limiting in-person gatherings, postponing or canceling elective operations in hospitals, and limiting rotations between sites, we propose innovative solutions to maintain rigorous education.
We propose several innovative solutions including the flipped classroom model, online practice questions, teleconferencing in place of in-person lectures, involving residents in telemedicine clinics, procedural simulation, and the facilitated use of surgical videos. Although there is no substitute for hands-on learning through operative experience and direct patient care, these may be ways to mitigate the loss of learning exposure during this time.
These innovative solutions utilizing technology may help to bridge the educational gap for surgical residents during this unprecedented circumstance. The support of national organizations may be beneficial in maintaining rigorous surgical education.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This Guide to Statistics and Methods describes aspects of methods of survey research in surgical education, important considerations, and pitfalls and limitations.
Online videos are among the most common resources for case preparation. Using crowd sourcing, we evaluated the relationship between operative quality and viewing characteristics of online ...laparoscopic cholecystectomy videos.
We edited 160 online videos of laparoscopic cholecystectomy to 60 seconds or less. Crowd workers (CW) rated videos using Global Objective Assessment of Laparoscopic Skills (GOALS), the critical view of safety (CVS) criteria, and assigned overall pass/fail ratings if CVS was achieved; linear mixed effects models derived average ratings. Views, likes, dislikes, subscribers, and country were recorded for subset analysis of YouTube videos. Spearman correlation coefficient (SCC) assessed correlation between performance measures.
One video (0.06%) achieved a passing CVS score of ≥5; 23%, ≥4; 44%, ≥3; 79%, ≥2; and 100% ≥1. Pass/fail ratings correlated to CVS, SCC 0.95 (p < 0.001) and to GOALS, SCC 0.79 (p < 0.001). YouTube videos (n = 139) with higher views, likes, or subscribers did not correlate with better quality. The average CVS and GOALS scores were no different for videos with >20,000 views (22%) compared with those with <20,000 (78%).
There is an incredibly low frequency of CVS and average GOALS technical performance in frequently used online surgical videos of LC. Favorable characteristics, such as number of views or likes, do not translate to higher quality.
To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America.
A multidomain, global assessment survey designed by the Fellowship ...Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains.
There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.
Abstract Background A recent survey of fellowship directors suggested significant deficits in the technical laparoscopic skills of graduated general surgery residents. Our aim was to define the need ...for and possible content of a simulation-based curriculum in advanced laparoscopic skills (ALS). Methods An anonymous online survey was distributed to all Fellowship Council program directors (PDs), current fellows, and recent fellowship graduates. The survey was designed to assess the perceived need for, possible content of, and implementation challenges to an ALS curriculum. Recently developed simulation-based advanced laparoscopic tasks included off-angle camera work and restricted space suturing. Images and descriptions of these tasks were evaluated by respondents, and suggestions for modifications or improvements solicited via free text response. Results Of 186 respondents (response rate: 64%), 40% were current fellows, 22% were fellowship graduates, and 37% were PDs. Respondents primarily self-identified as minimally invasive and/or bariatric surgeons (78%) and hepatobiliary surgeons (12%). Most respondents (73%) identified a need for an ALS curriculum. All 3 respondent groups cited laparoscopic needle positioning and suturing (78%) and bimanual coordination during dissection and retraction (72%) as the skills in most need of improvement. In addition, most of the responding PDs identified “lack of familiarity with anatomy and procedure” (74% of PDs) and “lack of proficiency at laparoscopic bowel anastomosis” (59% of PDs) as problem areas. Respondents felt that successful implementation of an ALS curriculum depended on both overall feasibility and the ability for repeated practice and should not be dependent on cost. Thematic analysis of free responses revealed the following priorities for possible ALS skills and tasks: (1) difficult dissections and exposures, (2) forehand and/or backhand and suturing under tension, (3) nondominant hand drills, (4) working with an off-set camera, and (5) suturing and handling fragile tissue with properties similar to peritoneum or bowel. Conclusions We present survey results identifying several specific ALS set deficits among graduating general surgery residents, including advanced suturing, bimanual coordination, and managing difficult anatomy. Next, the results of this needs assessment will be used to develop an advanced laparoscopic curriculum for residents entering minimally invasive surgery fellowships and careers.
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Background
As neoadjuvant therapy of borderline resectable pancreatic cancer (BRPC) is becoming more widely used, better indicators of progression are needed to help guide therapeutic decisions.
...Materials and Methods
A retrospective review was performed on all patients with BRPC who received 24 weeks of neoadjuvant chemotherapy. Patients with chemotoxicity or medical comorbidities limiting treatment completion and nonexpressors of carbohydrate antigen 19‐9 (CA19‐9) were excluded. Serum CA19‐9 response was analyzed as a predictor of disease progression, recurrence, and survival.
Results
One hundred four patients were included; 39 (37%) progressed on treatment (18 local and 21 distant) and 65 (63%) were resected (68% R0). Multivariate logistic regression analysis determined that the percent decrease in CA19‐9 from baseline to minimum value (odds ratio OR 0.947, p ≤ .0001) and the percent increase from minimum value to final restaging CA19‐9 (OR 1.030, p ≤ .0001) were predictive of progression. A receiver operating characteristics curve analysis determined cutoff values predictive of progression, which were used to create four prognostic groups. CA19‐9 responses were categorized as follows: (1) always normal (n = 6); (2) poor response (n = 31); (3) unsustained response (n = 19); and (4) sustained response (n = 48). Median overall survival for Groups 1–4 was 58, 16, 20, and 38 months, respectively (p ≤ .0001).
Conclusion
Patients with initially elevated CA19‐9 levels who do not have a decline to a sustained low level are at risk for progression, recurrence, and poor survival. Alternative treatment strategies prior to an attempt at curative resection should be considered in this cohort.
Implications for Practice
This study identified percent changes in carbohydrate antigen 19‐9 blood levels while on chemotherapy that predict tumor growth in patients with advanced pancreas cancer. These changes could be used to better select patients who would benefit from surgical removal of their tumors and improve survival.
Treatment of patients with borderline resectable pancreas cancer is a topic of great debate. This article analyzes serum CA19‐9 response as a predictor of disease progression, recurrence, and survival.
BACKGROUND:BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based ...recommendations for safe cholecystectomy and prevention of BDI.
METHODS:Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.
RESULTS:Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.
CONCLUSIONS:These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
BACKGROUND:
Previous reports suggest that structured training in minimally invasive pancreatic surgery (MIPS) can ensure a safe implementation into standard practice. Although some training programs ...have been constructed, worldwide consensus on fundamental items of these training programs is lacking. This study aimed to determine items for a structured MIPS training program using the Delphi consensus methodology.
STUDY DESIGN:
The study process consisted of 2 Delphi rounds among international experts in MIPS, identified by a literature review. The study committee developed a list of items for 3 key domains of MIPS training: (1) framework, (2) centers and surgeons eligible for training, and (3) surgeons eligible as proctor. The experts rated these items on a scale from 1 (not important) to 5 (very important). A Cronbach’s α of 0.70 or greater was defined as the cut-off value to achieve consensus. Each item that achieved 80% or greater of expert votes was considered as fundamental for a training program in MIPS.
RESULTS:
Both Delphi study rounds were completed by all invited experts in MIPS, with a median experience of 20 years in MIPS. Experts included surgeons from 31 cities in 13 countries across 4 continents. Consensus was reached on 38 fundamental items for the framework of training (16 of 35 items, Cronbach’s α = 0.72), centers and surgeons eligible for training (19 of 30 items, Cronbach’s α = 0.87), and surgeons eligible as proctor (3 of 10 items, Cronbach’s α = 0.89). Center eligibility for MIPS included a minimum annual volume of 10 distal pancreatectomies and 50 pancreatoduodenectomies.
CONCLUSION:
Consensus among worldwide experts in MIPS was reached on fundamental items for the framework of training and criteria for participating surgeons and centers. These items act as a guideline and intend to improve training, proctoring, and safe worldwide dissemination of MIPS.
Background
Burnout among physicians is an increasing concern, and surgeons are not immune to this threat. The ongoing COVID-19 pandemic has caused dramatic changes to surgeon workflow, often leading ...to redeployment to other clinical areas, slowdown and shutdown of elective surgery practices, and an uncertain future of surgical practice in the post-pandemic setting. Paradoxically, for many surgeons who had to prepare for but not immediately care for a major surge, the crisis did allow for reflective opportunities and a resetting of priorities that could serve to mitigate chronic patterns contributory to Burnout.
Methods
SAGES Reimagining the Practice of Surgery task force convened a webinar to discuss lessons learned from the COVID pandemic that may address burnout.
Results
Burnout is multifactorial and may vary in cause among different generation/experience groups. Those that report burnout symptoms often complain of lacking purpose or meaning in their work. Although many mechanisms to address Burnout are from a defensive standpoint—including coping mechanisms, problem solving, and identification of a physician having wellness difficulties—offensive mechanisms such as pursuing purpose and meaning and finding joy in one's work can serve as reset points that promote thriving and fulfillment. Understanding what motivates physicians will help physician leaders to develop and sustain effective teams. Reinvigorating the surgical workforce around themes of meaning and joy in the service rendered via our surgical skills may diminish Burnout through generative and aspirational strategies, as opposed to merely reactive ones. Fostering an educational environment free of discriminatory or demeaning behavior may produce a new workforce conducive to enhanced and resilient wellbeing at the start of careers.
Conclusion
Surgeon wellness and self-care must be considered an important factor in the future of all healthcare delivery systems, a need reaffirmed by the COVID-19 pandemic.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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