James R. Korndorffer, Jr. MD MHPE FACS is Associate Professor and Vice Chair of Education in the Department of Surgery at Stanford University. Previously he served as Vice chair of Surgery at Tulane University Health Sciences Center in New Orleans. While at Tulane he also was the Surgery Residency Program Director, the assistant dean for Graduate medical education and the Medical Director of the Tulane Center for Advanced Medical Simulation and Team Training. He received his undergraduate degree in Biomedical Engineering from Tulane University, his Medical Degree from the University of South Florida College of Medicine and his Masters in Health Professions Education from the University of Illinois Chicago. His general surgery residency was completed at The Carolinas Medical Center in Charlotte, North Carolina and his Advanced Laparoscopic Fellowship was completed at Tulane University.
He is actively involved in numerous national societies including the American College of Surgeons, the Society for Gastrointestinal and Endoscopic Surgeons, the Association for Surgical Education, and the Association for Program Directors in Surgery. He serves on the American College of Surgeons Committee on Validation of Surgical Knowledge and Skills, SAGES Fundamentals of Laparoscopic Surgery and Development Committees and also serves as the APDS research committee vice chair.
Dr. Korndorffer has published over 60 papers in peer reviewed journals, 5 book chapters and has presented at over 100 national meetings. Dr. Korndorffer’s clinical interests include minimally invasive surgery for gastrointestinal disorders and hernias. His research interests include surgical education, surgical simulation, patient safety, and patient care quality.
- General Surgery
Associate Professor - Med Center Line, Surgery - General Surgery
Vice Chair of Education, Department of Surgery (2017 - Present)
Honors & Awards
Best Doctors, New Orleans (2017-2018)
Teaching Scholar, Tulane University School of Medicine (2012)
ACS Young Surgeon Representative, ACS Louisiana Chapter (2005)
Best Surgical Resident Teacher, Carolinas Medical Center (1995)
Distinguished Service Award, University of South Florida COM (1990)
Boards, Advisory Committees, Professional Organizations
Member, Southern Surgical Association (2016 - Present)
Member, Editorial Board, Surgical Council on Resident Education (2014 - Present)
Recorder, American College of Surgeons Accredited Education Institutes (2018 - Present)
Chair, Program Committee, American College of Surgeons Accredited Education Institute (2015 - 2016)
Member, Program Committee, American College of Surgeons – Accredited Education Institutes (2013 - Present)
Co-Chair, Research and Development Committee, American College of Surgeons – Accredited Education Institutes (2013 - 2015)
Chair, Graduate Surgical Education Committee, Association for Surgical Education (2011 - 2013)
Member, Graduate Surgical Education Committee, Association for Surgical Education (2008 - Present)
Member, Board of Directors, Association for Surgical Education (2011 - 2013)
VIce Chair, Research and Development Committee , Association of Program Directors in Surgery (2016 - Present)
Co-Chair, Curriculum Task Force Society of American Gastrointestinal and Endoscopic Surgeons (2015 - Present)
Member, Fundamentals of Endoscopic Surgery Committee, Society of American Gastrointestinal and Endoscopic Surgeons (2011 - Present)
Member, Committee on Validation of Surgical Knowledge and Skills, American College of Surgeons (2013 - Present)
Member, Development Committee, Society of American Gastrointestinal and Endoscopic Surgeons (2016 - Present)
Fellowship:Tulane University School of Medicine (2005) LA
Board Certification: General Surgery, American Board of Surgery (1996)
Fellowship, Tulane University School of Medicine, Minimally invasive Surgery (2005)
Residency:Carolinas Medical Center General Surgery Residency (1995) NC
Residency, Carolinas Medical Center, Chalotte NC, Surgery (1995)
Medical Education:University of South Florida College of Medicine Registrar (1990) FL
MHPE, University of Illinois, Chicago, Masters of Health Professions Education (2011)
MD, University of South Florida College of Medicine (1990)
James Korndorffer. "United States Patent 7,802,990 Laparoscopic Camera Navigation Trainer", Sep 28, 2010
How Much Are We Spending on Resident Selection?
Journal of surgical education
INTRODUCTION: Rigorous selection processes are required to identify applicants who will be the best fit for training programs. This study provides a national snapshot of selection practices used within surgical residency programs and their associated financial costs.METHODS: A 17-item online survey was distributed to General Surgery Program Directors (PDs) via the Association of Program Directors in Surgery listserv. The survey examined program characteristics, applicant pool size, and interview day components of the prior match year. PD/coordinator teams also provided hard costs associated with interview day components, as well as time and effort estimations among program faculty, residents, and staff during the past interview season. Effort estimates were translated to dollar values via national salary data reports of hourly wages for faculty and annual wages for administrative staff and residents. Descriptive statistics and one-way analysis of variance via SPSS 24.0 were used to examine the data.RESULTS: One-hundred and twenty-eight responses were received, reflecting 48% (128/267) of programs in the 2017 match. Average hard costs (±SD) were $8053 ± 6467, covering food ($3753 ± 4042), social sessions ($3175 ± 3749), supplies ($329 ± 866), hotel ($328 ± 1381), room reservations ($120 ± 658), shuttle fees ($84 ± 403), tour guide fees ($50 ± 379), and other ($146 + 824). Costs for personnel effort was $77,601 ± 62,413 for faculty, $12,393 ± 33,518 for residents, $6447 ± 11,107 for coordinators, and $1294 ± 1943 for staff. Total average cost associated with the interview process (hard + effort) was $100,438±87,919, with university-based programs ($128,686 ± 101,565) spending significantly more than independent-university affiliated ($61,162 ± 33,945), independent ($74,793 ± 73,261), and military ($62,495 ± 38,532) programs (p < 0.01). Average cost for each residency program per position being filled was $18,648 ± 13,383, and average cost per interviewee was $1221 ± 894.CONCLUSIONS: In an era of declining resources for medical education, PDs must understand the time and effort associated with resident selection. These data reveal that residency programs are spending significant time and resources on the current selection process. Program leaders can use these data to assess their current selection strategies, review faculty and staff time allocation, and identify opportunities for making the process more efficient.
View details for DOI 10.1016/j.jsurg.2018.10.001
View details for PubMedID 30366686
A Surgeon Led Clinically Focused Anatomy Course Increases Student Selection of General Surgery As a Career.
Journal of surgical education
OBJECTIVE: This study aims to identify program-specific critical factors in a student's path to general surgery and how different factors contribute to our high rate of matriculation.DESIGN: Semi-structured interviews were conducted focusing on critical factors in student's decision processes to pursue general surgery. Three investigators independently evaluated the transcripts and identified recurring themes based on phenomenological qualitative methods until saturation was achieved. Inter-rater reliability was determined.SETTING: The study took place at Tulane University School of Medicine, an academic medical center in New Orleans, Louisiana.PARTICIPANTS: Current fourth-year students from our medical school, applying into general surgery, were interviewed for the study.RESULTS: Twelve of 21 students were interviewed. The most common factor cited was the positive effect of clinically based anatomy and of having surgeons in anatomy (81%). Other factors mentioned included interest before medical school, clerkship experience, and mentor interactions; Kappa was 0.76 or higher for each theme.CONCLUSIONS: A clinically focused anatomy course led by surgeons at our institution has a significant impact on a general surgery career choice. With the constant evolution of the medical field, understanding what guides students toward a career in general surgery will better assist medical education planners in providing resources that will positively impact future classes.
View details for DOI 10.1016/j.jsurg.2018.09.009
View details for PubMedID 30318298
The Change in Surgical Case Diversity Over the Past 15 Years and the Influence on the Pursuit of Surgical Fellowship
SOUTHEASTERN SURGICAL CONGRESS. 2018: 1476–79
The surgical community has expressed concern that residents do not receive the same caliber training as their predecessors and the increase in fellowships have been described as secondary to perceived lack of preparation. Yet, data show no change in total cases even after implementation of the 80-hour workweek. It is hypothesized that the increasing subspecialization of general surgery may decrease in certain resident case numbers. Data were collected from the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Logs National Data Report (1999-2014) of mean number of procedures per resident for 19 surgical categories. Statistical analysis was performed with analysis of variance over three time periods between 1999 and 2014. The number of total cases performed by residents has not changed significantly. There was a statistically significant difference observed in the variety of cases: vascular, esophageal, breast, and trauma cases decreased (P < 0.01), whereas major intestinal, hernia, liver, pancreatic, and biliary cases increased (P < 0.01). There are many reasons to pursue additional training after residency. The demonstrated change in case variability, presumably secondary to increasing fellowships, may play a significant role on training and preparation. Close monitoring of curriculums is essential to ensure a comprehensive general surgical education.
View details for Web of Science ID 000445896600053
View details for PubMedID 30268179
Preparing for the American Board of Surgery Flexible Endoscopy Curriculum: Development of multi-institutional proficiency-based training standards and pilot testing of a simulation-based mastery learning curriculum for the Endoscopy Training System
AMERICAN JOURNAL OF SURGERY
2018; 216 (1): 167–73
The Fundamentals of Endoscopic Surgery (FES) exam is required for American Board of Surgery certification. The purpose of this study was to develop performance standards for a simulation-based mastery learning (SBML) curriculum for the FES performance exam using the Endoscopy Training System (ETS).Experienced endoscopists from multiple institutions and specialties performed each ETS task (scope manipulation (SM), tool targeting (TT), retroflexion (RF), loop management (LM), and mucosal inspection (MI)) with scores used to develop performance standards for a SBML training curriculum. Trainees completed the curriculum to determine feasibility, and effect on FES performance.Task specific training standards were determined (SM-121sec, TT-243sec, RF-159sec, LM-261sec, MI-180-480sec, 7 polyps). Trainees required 29.5 ± 3.7 training trials over 2.75 ± 0.5 training sessions to complete the SBML curriculum. Despite high baseline FES performance, scores improved (pre 73.4 ± 7, post 78.1 ± 5.2; effect size = 0.76, p > 0.1), but this was not statistically discernable.This SBML curriculum was feasible and improved FES scores in a group of high performers. This curriculum should be applied to novice endoscopists to determine effectiveness for FES exam preparation.
View details for DOI 10.1016/j.amjsurg.2017.09.010
View details for Web of Science ID 000436472700032
View details for PubMedID 28974312
The Economics of Private Practice versus Academia in Surgery.
Journal of surgical education
OBJECTIVE: Residents often make career decisions regarding future practice without adequate knowledge to the realities of professional life. Currently there is a paucity of data regarding economic differences between practice models. This study seeks to illuminate the financial differences of surgical subspecialties between academic and private practice.DESIGN: Data were collected from the Association of American Medical College (AAMC) and the Medical Group Management Association's (MGMA) 2015 reports of average annual salaries. Salaries were analyzed for general surgery and 7 subspecialties. Fixed time of practice was set at 30 years. Assumptions included 5 years as assistant professor, 10 years as associate professor, and 15 years as full professor. Formula used: (average yearly salary) * [years of practice (30 yrs - fellowship/research yrs)] + ($50,000 * yrs of fellowship/research) = total adjusted lifetime revenue.RESULTS: As a full professor, academic surgeons in all subspecialties make significantly less than their private practice counterparts. The largest discrepancy is in vascular and cardiothoracic surgery, with full professors earning 16% and 14% less than private practitioners. Plastic surgery and general surgery are the only 2 disciplines that have similar lifetime revenues to private practitioners, earning 2% and 6% less than their counterparts' lifetime revenue.CONCLUSIONS: Academic surgeons in all surgical subspecialties examined earn less lifetime revenue compared to those in private practice. This difference in earnings decreases but remains substantial as an academic surgeon advances. With limited exposure to the diversity of professional arenas, residents must be aware of this discrepancy.
View details for DOI 10.1016/j.jsurg.2018.03.006
View details for PubMedID 29674107
Time crunch: increasing the efficiency of assessment of technical surgical skill via brief video clips
MOSBY-ELSEVIER. 2018: 933–37
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.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.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.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.
View details for DOI 10.1016/j.surg.2017.11.011
View details for Web of Science ID 000428971700048
View details for PubMedID 29373170
Learning preferences of surgery residents: a multi-institutional study
MOSBY-ELSEVIER. 2018: 901–5
The VARK model categorizes learners by preferences for 4 modalities: visual, aural, read/write, and kinesthetic. Previous single-institution studies found that VARK preferences are associated with academic performance. This multi-institutional study was conducted to test the hypothesis that the VARK learning preferences of residents differ from the general population and that they are associated with performance on the American Board of Surgery In-Training Examination (ABSITE).The VARK inventory was administered to residents at 5 general surgery programs. The distribution of the VARK preferences of residents was compared with the general population. ABSITE results were analyzed for associations with VARK preferences. χ2, Analysis of variance, and multiple linear regression were used for statistical analysis.A total of 132 residents completed the VARK inventory. The distribution of the VARK preferences of residents was different than the general population (P < .001). The number of aural responses on the VARK inventory was an independent predictor of ABSITE percentile rank (P = .03), percent of questions correct (P = .01), and standard score (P = .01).This study represents the first multi-institutional study to examine VARK preferences among surgery residents. The distribution of preferences among residents was different than that of the general population. Residents with a greater number of aural responses on VARK had greater ABSITE scores. The VARK model may have potential to improve learning efficiency among residents.
View details for DOI 10.1016/j.surg.2017.10.031
View details for Web of Science ID 000428971700042
View details for PubMedID 29395237
The Economics of Academic Advancement Within Surgery
JOURNAL OF SURGICAL EDUCATION
2018; 75 (2): 299–303
The success of an academic surgeon's career is often viewed as directly related to academic appointment; therefore, the sequence of promotion is a demanding, rigorous process. This paper seeks to define the financial implication of academic advancement across different surgical subspecialties.Data was collected from the Association of American Medical College's 2015 report of average annual salaries. Assumptions included 30 years of practice, 5 years as assistant professor, and 10 years as associate professor before advancement. The base formula used was: (average annual salary) × (years of practice [30 years - fellowship/research years]) + ($50,000 × years of fellowship/research) = total adjusted lifetime salary income.There was a significant increase in lifetime salary income with advancement from assistant to associate professor in all subspecialties when compared to an increase from associate to full professor. The greatest increase in income from assistant to associate professor was seen in transplant and cardiothoracic surgery (35% and 27%, respectively). Trauma surgery and surgical oncology had the smallest increases of 8% and 9%, respectively. With advancement to full professor, the increase in lifetime salary income was significantly less across all subspecialties, ranging from 1% in plastic surgery to 8% in pediatric surgery.When analyzing the economics of career advancement in academic surgery, there is a substantial financial benefit in lifetime income to becoming an associate professor in all fields; whereas, advancement to full professor is associated with a drastically reduced economic benefit.
View details for DOI 10.1016/j.jsurg.2017.08.016
View details for Web of Science ID 000430136800008
View details for PubMedID 28870711
Developing a robust suturing assessment: validity evidence for the intracorporeal suturing assessment tool
MOSBY-ELSEVIER. 2018: 560–64
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.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.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 κ 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.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.
View details for DOI 10.1016/j.surg.2017.10.029
View details for Web of Science ID 000426536500013
View details for PubMedID 29274941
Simulation-based mastery learning for endoscopy using the endoscopy training system: a strategy to improve endoscopic skills and prepare for the fundamentals of endoscopic surgery (FES) manual skills exam
SPRINGER. 2018: 413–20
The fundamentals of endoscopic surgery (FES) program has considerable validity evidence for its use in measuring the knowledge, skills, and abilities required for competency in endoscopy. Beginning in 2018, the American Board of Surgery will require all candidates to have taken and passed the written and performance exams in the FES program. Recent work has shown that the current ACGME/ABS required case volume may not be enough to ensure trainees pass the FES skills exam. The aim of this study was to investigate the feasibility of a simulation-based mastery-learning curriculum delivered on a novel physical simulation platform to prepare trainees to pass the FES manual skills exam.The newly developed endoscopy training system (ETS) was used as the training platform. Seventeen PGY 1 (10) and PGY 2 (7) general surgery residents completed a pre-training assessment consisting of all 5 FES tasks on the GI Mentor II. Subjects then trained to previously determined expert performance benchmarks on each of 5 ETS tasks. Once training benchmarks were reached for all tasks, a post-training assessment was performed with all 5 FES tasks.Two subjects were lost to follow-up and never returned for training or post-training assessment. One additional subject failed to complete any portion of the curriculum, but did return for post-training assessment. The group had minimal endoscopy experience (median 0, range 0-67) and minimal prior simulation experience. Three trainees (17.6%) achieved a passing score on the pre-training FES assessment. Training consisted of an average of 48 ± 26 repetitions on the ETS platform distributed over 5.1 ± 2 training sessions. Seventy-one percent achieved proficiency on all 5 ETS tasks. There was dramatic improvement demonstrated on the mean post-training FES assessment when compared to pre-training (74.0 ± 8 vs. 50.4 ± 16, p < 0.0001, effect size = 2.4). The number of ETS tasks trained to proficiency correlated moderately with the score on the post-training assessment (r = 0.57, p = 0.028). Fourteen (100%) subjects who trained to proficiency on at least one ETS task passed the post-training FES manual skills exam.This simulation-based mastery learning curriculum using the ETS is feasible for training novices and allows for the acquisition of the technical skills required to pass the FES manual skills exam. This curriculum should be strongly considered by programs wishing to ensure that trainees are prepared for the FES exam.
View details for DOI 10.1007/s00464-017-5697-4
View details for Web of Science ID 000422854700050
View details for PubMedID 28698900
- SAGES University MASTERS Program: a structured curriculum for deliberate, lifelong learning (vol 31, pg 3061, 2017) SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES 2017; 31 (11): 4863
- Is the Title worth the Cost? Economic Nuances of Academic Surgery ELSEVIER SCIENCE INC. 2017: E89
Using Simulation to Improve Systems-Based Practices
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
2017; 43 (9): 484–91
Ensuring the safe, effective management of patients requires efficient processes of care within a smoothly operating system in which highly reliable teams of talented, skilled health care providers are able to use the vast array of high-technology resources and intensive care techniques available. Simulation can play a unique role in exploring and improving the complex perioperative system by proactively identifying latent safety threats and mitigating their damage to ensure that all those who work in this critical health care environment can provide optimal levels of patient care.A panel of five experts from a wide range of institutions was brought together to discuss the added value of simulation-based training for improving systems-based aspects of the perioperative service line. Panelists shared the way in which simulation was demonstrated at their institutions. The themes discussed by each panel member were delineated into four avenues through which simulation-based techniques have been used.Simulation-based techniques are being used in (1) testing new clinical workspaces and facilities before they open to identify potential latent conditions; (2) practicing how to identify the deteriorating patient and escalate care in an effective manner; (3) performing prospective root cause analyses to address system weaknesses leading to sentinel events; and (4) evaluating the efficiency and effectiveness of the electronic health record in the perioperative setting.This focused review of simulation-based interventions to test and improve components of the perioperative microsystem, which includes literature that has emerged since the panel's presentation, highlights the broad-based utility of simulation-based technologies in health care.
View details for DOI 10.1016/j.jcjq.2017.05.006
View details for Web of Science ID 000424164800007
View details for PubMedID 28844234
SAGES University MASTERS Program: a structured curriculum for deliberate, lifelong learning
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2017; 31 (8): 3061–71
Postgraduate training has been haphazard to date. Surgeons have relied on attendance to annual meetings and multiple choice study guides to demonstrate maintenance of certification and continuing medical education.SAGES held a retreat to develop the concept and scope of the Masters Program. Surveys were sent to SAGES members to guide curriculum development and selection of anchoring operations.SAGES has developed an educational curriculum across eight domains (Acute Care, Biliary, Bariatric, Colorectal, Hernia, Foregut, Flex Endoscopy, and Robotic Surgery) incorporating SAGES educational materials and guidelines, social media, coaching and mentoring.Deliberate, lifelong learning should be a better way to teach and learn.
View details for DOI 10.1007/s00464-017-5626-6
View details for Web of Science ID 000409037100001
View details for PubMedID 28634631
Is it All About the Money? Not All Surgical Subspecialization Leads to Higher Lifetime Revenue when Compared to General Surgery.
Journal of surgical education
OBJECTIVE: It is believed that spending additional years gaining expertise in surgical subspecialization leads to higher lifetime revenue. Literature shows that more surgeons are pursuing fellowship training and dedicated research years; however, there are no data looking at the aggregate economic impact when training time is accounted for. It is hypothesized that there will be a discrepancy in lifetime income when delay to practice is considered.DESIGN: Data were collected from the Medical Group Management Association's 2015 report of average annual salaries. Fixed time of practice was set at 30 years, and total adjusted revenue was calculated based on variable years spent in research and fellowship. All total revenue outcomes were compared to general surgery and calculated in US dollars.PARTICIPANTS: The financial data on general surgeons and 9 surgical specialties (vascular, pediatric, plastic, breast, surgical oncology, cardiothoracic, thoracic primary, transplant, and trauma) were examined.RESULTS: With fellowship and no research, breast and surgical oncology made significantly less than general surgery (-$1,561,441, -$1,704,958), with a difference in opportunity cost equivalent to approximately 4 years of work. Pediatric and cardiothoracic surgeons made significantly more than general surgeons, with an increase of opportunity cost equivalent to $5,301,985 and $3,718,632, respectively. With 1 research year, trauma surgeons ended up netting less than a general surgeon by $325,665. With 2 research years, plastic and transplant surgeons had total lifetime revenues approximately equivalent to that of a general surgeon.CONCLUSIONS: Significant disparities exist in lifetime total revenue between surgical subspecialties and in comparison, to general surgery. Although most specialists do gross more than general surgeons, breast and surgical oncologists end up netting significantly less over their lifetime as well as trauma surgeons if they do 1 year of research. Thus, the economic advantage of completing additional training is dependent on surgical field and duration of research.
View details for DOI 10.1016/j.jsurg.2017.06.027
View details for PubMedID 28705484
Choosing Surgery: Identifying Factors Leading to Increased General Surgery Matriculation Rate
2017; 83 (3): 290–95
Tulane graduates have, over the past six years, chosen general surgical residency at a rate above the national average (mean 9.6% vs 6.6%). With much of the recent career choice research focusing on disincentives and declining general surgery applicants, we sought to identify factors that positively influenced our students' decision to pursue general surgery. A 50-question survey was developed and distributed to graduates who matched into a general surgery between the years 2006 and 2014. The survey evaluated demographics, exposure to surgery, and factors affecting interest in a surgical career. We achieved a 54 per cent (61/112) response rate. Only 43 per cent considered a surgical career before medical school matriculation. Fifty-nine per cent had strongly considered a career other than surgery. Sixty-two per cent chose to pursue surgery during or immediately after their surgery clerkship. The most important factors cited for choosing general surgery were perceived career enjoyment of residents and faculty, resident/faculty relationship, and mentorship. Surgery residents and faculty were viewed as role models by 72 and 77 per cent of responders, respectively. This study demonstrated almost half of those choosing a surgical career did so as a direct result of the core rotation experience. We believe that structuring the medical student education experience to optimize the interaction of students, residents, and faculty produces a positive environment encouraging students to choose a general surgery career.
View details for Web of Science ID 000397998900025
View details for PubMedID 28316314
Muscle-Cooling Intervention to Reduce Fatigue and Fatigue-Induced Tremor in Novice and Experienced Surgeons: A Preliminary Investigation
SURGERY JOURNAL-NEW YORK
2016; 2 (4): E126–E130
A localized, intermittent muscle-cooling protocol was implemented to determine cooling garment efficacy in reducing upper extremity muscular fatigue and tremor in novice ( n = 10) and experienced surgeons ( n = 9). Subjects wore a muscle-cooling garment while performing multiple trials of a forearm exercise and paired suturing task to induce muscular fatigue and exercise-induced tremor. A reduction in tremor amplitude and an extension in time to fatigue were expected with muscle cooling as compared with control trials. Each subject completed an intervention session (5°C cooling condition) and a control session (32°C or thermal neutral condition). A paired samples t test indicated that tremor amplitude was significantly reduced ( t  = 1.89458; p < 0.05) in experienced surgeons in two dimensions (up and down, and back and forth). Tremor amplitude was reduced in novice surgeons but the effect was not significant. Time to fatigue and suture time improved in both cohorts with muscle cooling, but the effect did not reach significance. Results from the pilot work suggest muscle cooling as an intervention for reduction of fatigue and tremor is very promising, warranting further investigation. Surgical specialties that require prolonged procedures might benefit more from this intervention.
View details for DOI 10.1055/s-0036-1594246
View details for Web of Science ID 000388824200004
View details for PubMedID 28825005
View details for PubMedCentralID PMC5553493
Simulation-based summative assessments in surgery
MOSBY-ELSEVIER. 2016: 528–35
The American College of Surgeons-Accredited Education Institutes (ACS-AEI) Consortium aims to enhance patient safety and advance surgical education through the use of cutting-edge simulation-based training and assessment methods. The annual ACS-AEI Consortium meeting provides a forum to discuss the latest simulation-based training and assessment methods and includes special panel presentations on key topics.During the 8th annual Consortium, there was a panel presentation on simulation-based summative assessments, during which experiences from across surgical disciplines were presented. The formal presentations were followed by a robust discussion between the conference attendees and the panelists.This report summarizes the panelists' presentations and their ensuing discussion with attendees.The focus of this report is on the basis for and advances in simulation-based summative assessments, the current practices employed across various surgical disciplines, and future directions that may be pursued by the ACS-AEI Consortium.
View details for DOI 10.1016/j.surg.2016.03.030
View details for Web of Science ID 000381243300002
View details for PubMedID 27206332
The value proposition of simulation
MOSBY-ELSEVIER. 2016: 546–51
Simulation has been shown to improve trainee performance at the bedside and in the operating room. As the use of simulation-based training is expanded to address a host of health care challenges, its added value needs to be clearly demonstrated. Demonstrable improvements will support the expansion of infrastructure, staff, and programs within existing simulation facilities as well as the establishment of new facilities to meet growing needs and demands. Thus, organizational and institutional leaders, faculty members, and other stakeholders can be assured of the best use of existing resources and can be persuaded to make greater investments in simulation-based training for the future.A multidisciplinary panel was convened during the 8th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes (Simulation Centers) in March 2015 to discuss the added value of simulation-based training. Panelists shared the ways in which the value of simulation was demonstrated at their institutions.The value of simulation-based training was considered and described in terms of educational impact, patient care outcomes, and costs.
View details for DOI 10.1016/j.surg.2016.03.028
View details for Web of Science ID 000381243300004
View details for PubMedID 27206331
Using simulation for disaster preparedness
MOSBY-ELSEVIER. 2016: 565–70
As it addresses both technical and nontechnical skills, simulation-based training is playing an increasingly important role in surgery. In addition to the focus on skill acquisition, it is also important to ensure that surgeons are able to perform a variety of tasks in unique and challenging situations. These situations include responding to mass casualties, dealing with disease outbreaks, and preparing for wartime missions. Simulation-based training can be a valuable training modality in these situations, as it allows opportunities to practice and prepare for high-risk and often low-frequency events.During the 8th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes in March 2015, a multidisciplinary panel was assembled to discuss how simulation can be used to prepare the surgical community for such high-risk events.An overview of how simulation has been used to address needs in each of these situations is presented.
View details for DOI 10.1016/j.surg.2016.03.027
View details for Web of Science ID 000381243300006
View details for PubMedID 27206335
Force feedback vessel ligation simulator in knot-tying proficiency training
AMERICAN JOURNAL OF SURGERY
2016; 211 (2): 411–15
Tying gentle secure knots is an important skill. We have developed a force feedback simulator that measures force exerted during knot tying. This pilot study examines the benefits of this simulator in a deliberate practice curriculum.The simulator consists of silastic tubing with a force sensor. Knot quality was assessed using digital caliper measurement. Participants performed 10 vessel ligations as a pretest, then were shown force readings and tied knots until reaching proficiency targets. Average peak forces precurriculum and postcurriculum were compared using Student t test.Participants exerted significantly less force after completing the curriculum (.61 N ± .22 vs 1.42 N ± .53, P < .001), and had fewer air knots (10% vs 27%). The curriculum was completed in an average of 19.4 ± 6.27 minutes and required an average of 11.7 ± 4.03 knots to reach proficiency.This study demonstrates the feasibility of real-time feedback in learning to tie delicate knots. The curriculum can be completed in a reasonable amount of time, and may also work as a warm-up exercise before a surgical case.
View details for DOI 10.1016/j.amjsurg.2015.09.009
View details for Web of Science ID 000368344800016
View details for PubMedID 26723838
Pre-Operative Antisepsis Protocol Compliance and the Effect on Bacterial Load Reduction
2016; 17 (1): 32–37
Adequate skin preparation is essential to preventing surgical site infection. Many products are available, each with specific manufacturers' directions. This lack of standardization may lead to incorrect use of the agents and affect the bacterial load reduction. We hypothesize that a lack of adherence to utilization protocols for surgical skin antiseptics affects bacterial load reduction.Thirty subjects who routinely perform surgical skin preparation were recruited from four hospitals. Participants completed a questionnaire of both demographics and familiarity with two of the most common skin prep formulas: Chlorhexidine gluconate-isopropyl alcohol (CHG-IPA) and povidone-iodine (PVI) scrub and paint. Randomly selecting one formula, subjects performed skin preparation for ankle surgery on a healthy standardized patient. This was repeated using the second formula on the opposite ankle. Performance was recorded and reviewed by two independent evaluators using standardized dichotomous checklists created against the manufacturer's recommended application. Swabs of the patients' first interweb space and medial malleolus were obtained before, 1 min after, and 30 min after prep, and plated on Luria Bertani agar. Bacterial loads were measured in colony forming units (CFUs) for each anatomical site. Data was analyzed using a univariate linear regression.Subjects had an average of 12.7 ± 2.2 y operating room experience and 8.8 ± 1.5 y of skin prep experience. Despite this, no participant performed 100% of the manufacturers' steps correctly. All essential formula-specific steps were performed 90% of the time for CHG-IPA and 33.3% for PVI (p = 0.0001). No correlation was found between experience or familiarity and number of correct steps for either formula. Average reduction in CFUs was not different between CHG-IPA and PVI at 30 min for all anatomical sites (75.2 ± 5.4% vs. 73.7 ± 4.5%, p = 0.7662). Bacterial reductions at 30 min following skin prep were not substantially correlated with operator experience, protocol compliance, or total prep time for either formula.This study demonstrates existing problems with infection prevention as those tasked with pre-operative skin preparation do so with tremendous incongruence according to manufacturer guidelines. No effect on bacterial load was identified, however with a larger sample size this may be noted. Standardization of the prep solutions as well as simplification and education of the correct techniques may enhance protocol compliance.
View details for DOI 10.1089/sur.2015.107
View details for Web of Science ID 000368599900007
View details for PubMedID 26431266
- Effect of Visuospatial Training on Surgical Skill Acquisition ELSEVIER SCIENCE INC. 2015: S50–S51
- Choosing surgery: identifying factors leading to increased general surgery matriculation rate ELSEVIER SCIENCE INC. 2015: E72
Design of vessel ligation simulator for deliberate practice
JOURNAL OF SURGICAL RESEARCH
2015; 197 (2): 231–35
Surgical residents develop technical skills at variable rates, often based on random chance of cases encountered. One such skill is tying secure knots without exerting excessive force. This study describes the design of a simulator using a force sensor to measure instantaneous forces exerted on a blood vessel analog during vessel ligation and the development of expert-derived performance goals.Vessel ligations were performed on Silastic tubing at an offset from a Vernier Force Sensor. Nine experts (surgical faculty and senior residents) and 10 novices (junior residents) were recruited to each perform 10 vessel ligations (two square knots each) with two-handed and one-handed techniques. Internal consistency for the series of vessel ligations was tested with Cronbach alpha. Maximum forces exerted by novices and experts were compared using Student t-test.Internal consistency across the 10 ligations on the simulator was excellent (Cronbach alpha = 0.91). The expert group on average exerted a significantly lower maximum force when compared with novices while performing two-handed (0.76 ± 0.39 N versus 1.12 ± 0.49 N, P < 0.01) and one-handed (0.84 ± 0.32 N versus 1.36 ± 0.44 N, P < 0.01) vessel ligations.Although the expert group performed vessel ligations with significantly lower peak force than the novice group, there were novices who performed at the expert level. This is consistent with the conceptual framework of milestones and suggests that the skill of gentle knot-tying can be measured and develops at different chronologic levels of training in different individuals. This simulator can be used as part of a deliberate practice curriculum with instantaneous visual feedback.
View details for DOI 10.1016/j.jss.2015.02.068
View details for Web of Science ID 000356095100003
View details for PubMedID 25840488
Using Simulation to Improve Systems
SURGICAL CLINICS OF NORTH AMERICA
2015; 95 (4): 885-+
Simulation technology provides an important opportunity to prospectively identify systemic problems with minimal risk to patient safety and quality. Health care systems are implementing simulation-based exercises on a more regular basis, especially in high-risk settings such as the emergency department and operating room. The adoption of simulation-based and other system-oriented improvement strategies by the health care industry, especially regarding quality and safety, was preceded by its development in the manufacturing and aviation sectors.
View details for DOI 10.1016/j.suc.2015.04.007
View details for Web of Science ID 000359891000017
View details for PubMedID 26210978
Camera navigation and cannulation: validity evidence for new educational tasks to complement the Fundamentals of Laparoscopic Surgery Program
SPRINGER. 2015: 552–57
Experts identified camera navigation and cannulation as important skills that are not assessed by the Fundamentals of Laparoscopic Surgery (FLS) hands-on examination. The purpose of this study was to create metrics for and evaluate the validity for two new tasks: camera navigation (N) and cannulation (C), and to explore the potential value of adding these tasks to the FLS program.Participants were assessed by two raters during performance of N and C in addition to the five standard FLS tasks. They also completed a questionnaire regarding the educational value of the new tasks. Validity evidence was assessed by comparing performance between Novice (PGY 1 and 2) and Experienced (PGY 3 and higher) participants, and by correlating new task scores with standard FLS scores. The ability to predict level of training using scores was evaluated by regression analysis.Sixty subjects participated from five North American centers. Inter-rater reliabilities for both tasks were 0.99. Novice and Experienced participants scored 74 ± 17.8 versus 85 ± 8.3 (p < 0.01) and 21 ± 17.3 versus 39 ± 20.1 (p < 0.01) on N and C tasks, respectively. Correlations with total FLS scores for N and C were 0.39 and 0.53, respectively. Prediction of training level using the combination of all seven tasks was 52.6 % (R (2) = 0.526, p < 0.01), adding an additional 2.2 % to the five FLS tasks. Of 55 participants with laparoscopic experience, 51 % reported N to be similar in difficulty to reality. Of 28 participants who perform intraoperative cholangiograms, 43 % found C to be more difficult than reality. Most (70 %) participants thought the new tasks added value to FLS.This study provides preliminary validity evidence for the metrics of these new tasks. The value of adding these tasks to the FLS manual skills assessment is marginal in terms of predicting level of training.
View details for DOI 10.1007/s00464-014-3721-5
View details for Web of Science ID 000349296400010
View details for PubMedID 25034381
Multicenter longitudinal assessment of resident technical skills
AMERICAN JOURNAL OF SURGERY
2015; 209 (1): 120–25
Our aim was to report the longitudinal assessment of technical performance of general surgery residents on select tasks from multiple programs over a 2-year period.An institutional review board-approved, multi-institutional collaborative study was undertaken with yearly resident performance assessments over a 3-year period. General surgery residents (postgraduate year [PGY] 1 to 5) were tested on 3 laparoscopic and 5 open simulated surgical tasks. Resident performance was compared individually over time and among interns and more senior residents.Forty-one residents from 4 residency programs were evaluated. Scores increased in all tasks with each assessment, plateauing at a lower PGY level for open tasks compared with laparoscopic tasks. Change in performance scores between assessments were higher for interns compared with more senior residents (P < .003).Resident performance on basic open and laparoscopic tasks assessed over time improved the most between the PGY 1 and 2 levels and was dependent on task difficulty. This documented skill evolution may allow tailoring of skills curricula to both meet existing needs and minimize performance variability.
View details for DOI 10.1016/j.amjsurg.2014.09.018
View details for Web of Science ID 000346121100019
View details for PubMedID 25466766
Establishing technical performance norms for general surgery residents
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2014; 28 (11): 3179–85
Surgery residents are required to achieve performance milestones to advance in their residency. Level-specific, technical performance norms that could be used as milestones, however, do not currently exist. Our aim was to develop level-specific, technical performance norms for general surgery residents on select simulated tasks across multiple institutions.An IRB-approved, prospective, multi-institutional collaborative study with voluntary participation of residents was undertaken at the start of the 2011-2012 academic year. General surgery residents (PGY I-V) from seven institutions were tested on three laparoscopic and five open simulated surgical tasks, and their performance was assessed based on task time and errors. Means and standard deviations of performance for each resident level were calculated and compared. Residents with performance 1 standard deviation below the mean were considered outliers.A total of 147 residents were evaluated. Mean resident age was 28 ± 3 years; 42 % were female; and they had attended 74 different medical schools. Senior residents (PGY III-V) had more clinical and simulator experience than junior residents (PGY I-II) (p < 0.001). Resident performance scores progressively increased in all tasks reaching a plateau at a lower PGY level for open tasks. Depending on the task, 0-18 % of residents were outliers. When surveyed, 66 % of residents agreed that national performance norms for residents should exist.Performance norms were established for select tasks in a representative sample of US surgery residents. Such performance norms allow a more informed assessment of resident skill through comparison to national data and enable the identification of outliers who may benefit from additional training.
View details for DOI 10.1007/s00464-014-3582-y
View details for Web of Science ID 000344168200020
View details for PubMedID 24939154
Using simulation to improve root cause analysis of adverse surgical outcomes
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
2014; 26 (2): 144–50
The purpose of this study was to develop and test a simulation method of conducting investigation of the causality of adverse surgical outcomes.Six hundred and thirty-one closed claims of a major medical malpractice insurance company were reviewed. Each case had undergone conventional root cause analysis (RCA). Claims were categorized by comparing the predominant underlying cause documented in the case files. Three cases were selected for simulation.All records (medical and legal) were analyzed. Simulation scenarios were developed by abstracting data from the records and then developing paper and electronic medical records, choosing appropriateincluding test subjects and confederates, scripting the simulation and choosing the appropriate simulated environment.In a simulation center, each case simulation was run 6-7 times and recorded, with participants debriefed at the conclusion.Sources of error identified during simulation were compared with those noted in the closed claims. Test subject decision-making was assessed qualitatively.Simulation of adverse outcomes (SAOs) identified more system errors and revealed the way complex decisions were made by test subjects. Compared with conventional RCA, SAO identified root causes less focused on errors by individuals and more on systems-based error.The use of simulation for investigation of adverse surgical outcomes is feasible and identifies causes that may be more amenable to effective systems changes than conventional RCA. The information that SAO provides may facilitate the implementation of corrective measures, decreasing the risk of recurrence and improving patient safety.
View details for DOI 10.1093/intqhc/mzu011
View details for Web of Science ID 000334687500006
View details for PubMedID 24521702
Fundamentals of endoscopic surgery: creation and validation of the hands-on test
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2014; 28 (3): 704–11
The Fundamentals of Endoscopic Surgery™ (FES) program consists of online materials and didactic and skills-based tests. All components were designed to measure the skills and knowledge required to perform safe flexible endoscopy. The purpose of this multicenter study was to evaluate the reliability and validity of the hands-on component of the FES examination, and to establish the pass score.Expert endoscopists identified the critical skill set required for flexible endoscopy. They were then modeled in a virtual reality simulator (GI Mentor™ II, Simbionix™ Ltd., Airport City, Israel) to create five tasks and metrics. Scores were designed to measure both speed and precision. Validity evidence was assessed by correlating performance with self-reported endoscopic experience (surgeons and gastroenterologists [GIs]). Internal consistency of each test task was assessed using Cronbach's alpha. Test-retest reliability was determined by having the same participant perform the test a second time and comparing their scores. Passing scores were determined by a contrasting groups methodology and use of receiver operating characteristic curves.A total of 160 participants (17 % GIs) performed the simulator test. Scores on the five tasks showed good internal consistency reliability and all had significant correlations with endoscopic experience. Total FES scores correlated 0.73, with participants' level of endoscopic experience providing evidence of their validity, and their internal consistency reliability (Cronbach's alpha) was 0.82. Test-retest reliability was assessed in 11 participants, and the intraclass correlation was 0.85. The passing score was determined and is estimated to have a sensitivity (true positive rate) of 0.81 and a 1-specificity (false positive rate) of 0.21.The FES hands-on skills test examines the basic procedural components required to perform safe flexible endoscopy. It meets rigorous standards of reliability and validity required for high-stakes examinations, and, together with the knowledge component, may help contribute to the definition and determination of competence in endoscopy.
View details for DOI 10.1007/s00464-013-3298-4
View details for Web of Science ID 000331961500002
View details for PubMedID 24253562
Fundamentals of Endoscopic Surgery cognitive examination: development and validity evidence
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2014; 28 (2): 631–38
Flexible endoscopy is an integral part of surgical care. Exposure to endoscopic procedures varies greatly in surgical training. The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES), which serves to teach and assess the fundamental knowledge and skills required to practice flexible endoscopy of the gastrointestinal tract. This report describes the validity evidence in the development of the FES cognitive examination.Core areas in the practice of gastrointestinal endoscopy were identified through facilitated expert focus groups to establish validity evidence for the test content. Test items then were developed based on the content areas. Prospective enrollment of participants at various levels of training and experience was used for beta testing. Two FES cognitive test versions then were developed based on beta testing data. The Angoff and contrasting group methods were used to determine the passing score. Validity evidence was established through correlation of experience level with examination score.A total of 220 test items were developed in accordance with the defined test blueprint and formulated into two versions of 120 questions each. The versions were administered randomly to 363 participants. The correlation between test scores and training level was high (r = 0.69), with similar results noted for contrasting groups based on endoscopic rotation and endoscopic procedural experience. Items then were selected for two test forms of 75 items each, and a passing score was established.The FES cognitive examination is the first test with validity evidence to assess the basic knowledge needed to perform flexible endoscopy. Combined with the hands-on skills examination, this assessment tool is a key component for FES certification.
View details for DOI 10.1007/s00464-013-3220-0
View details for Web of Science ID 000331961100033
View details for PubMedID 24100859
Development and Verification of a Taxonomy of Assessment Metrics for Surgical Technical Skills
2014; 89 (1): 153–61
To create and empirically verify a taxonomy of metrics for assessing surgical technical skills, and to determine which types of metrics, skills, settings, learners, models, and instruments were most commonly reported in the technical skills assessment literature.In 2011-2012, the authors used a rational analysis of existing and emerging metrics to create the taxonomy, and used PubMed to conduct a systematic literature review (2001-2011) to test the taxonomy's comprehensiveness and verifiability. Using 202 articles identified from the review, the authors classified metrics according to the taxonomy and coded data concerning their context and use. Frequencies (counts, percentages) were calculated for all variables.The taxonomy contained 12 objective and 4 subjective categories. Of 567 metrics identified in the literature, 520 (92%) were classified using the new taxonomy. Process metrics outnumbered outcome metrics by 8:1. The most frequent metrics were "time," "manual techniques" (objective and subjective), "errors," and "procedural steps." Only one new metric, "learning curve," emerged. Assessments of basic motor skills and skills germane to laparoscopic surgery dominated the literature. Novices, beginners, and intermediate learners were the most frequent subjects, and box trainers and virtual reality simulators were the most frequent models used for assessing performance.Metrics convey what is valued in human performance. This taxonomy provides a common nomenclature. It may help educators and researchers in procedurally oriented disciplines to use metrics more precisely and consistently. Future assessments should focus more on bedside tasks and open surgical procedures and should include more outcome metrics.
View details for DOI 10.1097/ACM.0000000000000056
View details for Web of Science ID 000329189900034
View details for PubMedID 24280844
The American College of Surgeons/Association of Program Directors in Surgery National Skills Curriculum: Adoption rate, challenges and strategies for effective implementation into surgical residency programs
MOSBY-ELSEVIER. 2013: 13–20
The American College of Surgeons/Association of Program Directors in Surgery (ACS/APDS) National Skills Curriculum is a 3-phase program targeting technical and nontechnical skills development. Few data exist regarding the adoption of this curriculum by surgical residencies. This study attempted to determine the rate of uptake and identify implementation enablers/barriers.A web-based survey was developed by an international expert panel of surgical educators (5 surgeons and 1 psychologist). After piloting, the survey was sent to all general surgery program directors via email link. Descriptive statistics were used to determine the residency program characteristics and perceptions of the curriculum. Implementation rates for each phase and module were calculated. Adoption barriers were identified quantitatively and qualitatively using free text responses. Standardized qualitative methodology of emergent theme analysis was used to identify strategies for success and details of support required for implementation.Of the 238 program directors approached, 117 (49%) responded to the survey. Twenty-one percent (25/117) were unaware of the ACS/APDS curriculum. Implementation rates for were 36% for phase I, 19% for phase II, and 16% for phase III. The most common modules adopted were the suturing, knot-tying, and chest tube modules of phase I. Over 50% of respondents identified lack of faculty protected time, limited personnel, significant costs, and resident work-hour restrictions as major obstacles to implementation. Strategies for effective uptake included faculty incentives, adequate funding, administrative support, and dedicated time and resources.Despite the availability of a comprehensive curriculum, its diffusion into general surgery residency programs remains low. Obstacles related to successful implementation include personnel, learner, and administrative issues. Addressing these issues may improve the adoption rate of the curriculum.
View details for DOI 10.1016/j.surg.2013.04.061
View details for Web of Science ID 000321168400002
View details for PubMedID 23809479
Does the Incorporation of Motion Metrics Into the Existing FLS Metrics Lead to Improved Skill Acquisition on Simulators? A Single Blinded, Randomized Controlled Trial
ANNALS OF SURGERY
2013; 258 (1): 46–52
We hypothesized that training to expert-derived levels of speed and motion will lead to improved learning and will translate to better operating room (OR) performance of novices than training to goals of speed or motion alone.Motion tracking has been suggested to be a more sensitive performance metric than time and errors for the assessment of surgical performance.An institutional review board-approved, single blinded, randomized controlled trial was conducted at our level-I American College of Surgeons accredited Education Institute. Forty-two novices trained to proficiency in laparoscopic suturing after being randomized into 3 groups: The speed group (n = 14) had to achieve expert levels of speed, the motion group (n = 15) expert levels of motion (path length and smoothness), and the speed and motion group (n = 13) both levels. To achieve proficiency, all groups also had to demonstrate error-free performance. The FLS suture module (task 5) was used for training inside the ProMIS simulator that tracks instrument motion. All groups participated in transfer and retention tests in the OR. OR performance was assessed by a blinded expert rater using Global Operative Assessment of Laparoscopic Skills, speed, accuracy, and inadvertent injuries.Thirty (71%) participants achieved proficiency and participated in the transfer and retention tests. The speed group achieved simulator proficiency significantly faster than the other groups (P < 0.001). With the exception of a higher injury rate during the transfer test for the speed group (that reversed during the retention test), there were no significant performance differences among the groups on all assessed parameters.The incorporation of motion metrics into the time/accuracy goals of the FLS laparoscopic suturing curriculum had limited impact on participant skill transfer to the OR. Given the increased training requirements for such a curriculum, further study is needed before the addition of motion metrics to the current FLS metrics can be recommended.
View details for DOI 10.1097/SLA.0b013e318285f531
View details for Web of Science ID 000330460400016
View details for PubMedID 23470570
The Modern Surgery Department Chairman The Job Description as Identified by Chairmen
2013; 148 (6): 511–15
The role of the chairman of a surgery department is critical in academic surgery. However, little is known about the variability of job responsibilities.To evaluate chairmen's responsibilities, methods of support, determinants of job performance success, and concerns.Internet-based survey.Electronic survey system.Seventy-two chairmen.Survey data on job responsibilities, methods of support, determinants of job performance success, and concerns.Of 168 chairmen who received the survey, 72 (43%) responded. The mean age of chairmen was 57 years (range, 44-78 years). Of 72 chairmen who responded, 69 (96%) were men, 67 (93%) were white, 65 (90%) were professors, 11 (15%) held a previous chair, 35 (49%) have advanced degrees, and 19 (26%) are program directors. Respondents are responsible for an average of 8.7 divisions, 60 (83%) spent 1 to 10 hours per week in the clinic, 45 (63%) performed surgery 1 to 10 hours per week, 54 (75%) took less than 6 call days per month, 44 (61%) published 1 to 6 papers per year and attended a mean (SD) of 4.3 (1.7) essential meetings per year, and 48 (67%) took 1 to 3 weeks of vacation annually. Chair salary support includes (from least to most) faculty tax, grants, endowment, school, and hospital. Compensation correlates with age, additional degree, specialty, location, contract, and tenure but not clinical hours. Reported compensation was consistent with data from the Association of American Medical Colleges, but 24 (33%) felt undercompensated. Incentives for job performance were given for clinical productivity (34 chairmen [47%]), department performance (50 [70%]), institutional performance (27 [38%]), and personal accomplishment (14 [19%]). Of 72 chairmen, 30 (42%) were concerned about personal liability related to the job, 15 (21%) had purchased personal liability insurance, and 20 (28%) have defended a lawsuit related to nonclinical responsibilities.Academic surgery department chairmen have a wide array of responsibilities that have changed from historic standards. Success in the role of chairman may improve by appreciating the responsibilities, time allocation, methods of support, and concerns of other chairmen.
View details for DOI 10.1001/jamasurg.2013.1230
View details for Web of Science ID 000321981600008
View details for PubMedID 23754568
The Ethics of Conducting Graduate Medical Education Research on Residents
2013; 88 (4): 449–53
The field of graduate medical education (GME) research is attracting increased attention and broader participation. The authors review the special ethical and methodological considerations pertaining to medical education research. Because residents are at once a convenient and captive study population, a risk of coercion exists, making the provision of consent important. The role of the institutional review board (IRB) is often difficult to discern because GME activities can have multiple simultaneous purposes, educational activities may go forward with or without a research component, and the subjects of educational research studies are not patients. The authors provide a road map for researchers with regard to research oversight by the IRB and also address issues related to research quality. The matters of whether educational research studies should have educational value for the study subject and whether to use individual information obtained when residents participate as research subjects are explored.
View details for DOI 10.1097/ACM.0b013e3182854bef
View details for Web of Science ID 000316853100011
View details for PubMedID 23425981
Can simulation improve the traditional method of root cause analysis: A preliminary investigation
2012; 152 (3): 489–97
The Joint Commission on Accreditation of Healthcare Organizations recommendations for conducting root cause analysis (RCA) include identifying "root causes" and "common-cause variation" rather than "proximate causes" and "special-cause variation" to create interventions. Simulation for health care RCA is a novel technique but has not been compared with traditional RCA methods.All of the RCAs of adverse events conducted at Tulane Hospital between September 2010 and September 2011 were reviewed. A case of missed postprocedural, preoperative hemorrhage resulting in death was chosen. Hospital records were analyzed to identify the presumed root causes. A simulation of the event was developed and conducted. Six test subjects (preoperative and postanesthesia care unit nurses) participated in the simulation. Root causes identified by simulation analysis were compared with those identified by traditional RCA.In 2 of 6 simulations, the adverse event was duplicated. The root cause identified by standard RCA technique was inattention to signs of bleeding in the patient/ lack of appropriate monitoring of the patient by nursing staff ("special-cause variation"). Simulation-based RCA revealed that the root cause was not only inadequate monitoring, but also the lack of physical presence of physicians in the care environment ("common-cause variation"). Simulation-based RCA identified root causes more amenable to intervention.This study demonstrates that simulation-based RCA can identify additional root causes amenable to making health care interventions when compared with traditional RCA.
View details for DOI 10.1016/j.surg.2012.07.029
View details for Web of Science ID 000308623500025
View details for PubMedID 22938908
Effective home laparoscopic simulation training: a preliminary evaluation of an improved training paradigm
EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2012: 1–7
Laparoscopic simulation training has proven to be effective in developing skills but requires expensive equipment, is a challenge to integrate into a work-hour restricted surgical residency, and may use nonoptimal practice schedules. The purpose of this study was to evaluate the efficacy of laparoscopic skills training at home using inexpensive trainer boxes.Residents (n = 20, postgraduate years 1-5) enrolled in an institutional review board-approved laparoscopic skills training protocol. An instructional video was reviewed, and baseline testing was performed using the fundamentals of laparoscopic surgery (FLS) peg transfer and suturing tasks. Participants were randomized to home training with inexpensive, self-contained trainer boxes or to simulation center training using standard video trainers. Discretionary, goal-directed training of at least 1 hour per week was encouraged. A posttest and retention test were performed. Intragroup and intergroup comparisons as well as the relationship between the suture score and the total training sessions, the time in training, and attempts were studied.Intragroup comparisons showed significant improvement from baseline to the posttest and the retention test. No differences were shown between the groups. The home-trained group practiced more, and the number of sessions correlated with suture retention score (r(2) = .54, P < .039).Home training results in laparoscopic skill acquisition and retention. Training is performed in a more distributed manner and trends toward improved skill retention.
View details for DOI 10.1016/j.amjsurg.2011.07.001
View details for Web of Science ID 000298633200002
View details for PubMedID 22172481
Research Regarding Methods of Assessing Learning Outcomes
SIMULATION IN HEALTHCARE
2011; 6: S48–S51
As the use of simulation-based assessment expands for healthcare workers, there is a growing need for research to quantify the psychometric properties of the associated process and outcome measures.
View details for DOI 10.1097/SIH.0b013e31822237d0
View details for Web of Science ID 000294209700008
View details for PubMedID 21705967
Effect of Structuring Clinical Services Based on Resident Educational Objectives
ELSEVIER SCIENCE INC. 2011: 696–701
Traditionally, surgical rotations are established based on attending surgeon clinical specialty and department/section organizational structure. Consequently, resident clinical rotations are forced to adopt an underlying structure that may not align with resident educational needs. An option is to realign clinical services based on resident educational objectives.We performed a comprehensive reorganization of the clinical service lines by emphasizing resident educational objectives. Effects on resident education were evaluated qualitatively and using a semistructured interview. Effects on clinical referral patterns and patient volumes for individual faculty and sections were also evaluated.New rotations and services (clarifying faculty roles and appointments) were designed. Examples of new rotations include hepatobiliary/transplant, acute care surgery, elective surgery, cardiac/vascular, and minimally invasive surgery. Clinical case mix was evaluated by using Residency Review Committees-defined categories for general surgery and used as a component of clinical service reorganization. Since the reorganization, all residents completed the minimum case number requirements before beginning postgraduate year 5. Program quality improved in key measurable areas, including American Board of Surgery In-Training Examination mean and median and total resident operative cases performed. Individual faculty clinical volume increased during the same time period. Evaluation of faculty volumes reveals that the new clinical services lines allowed for coordination of clinical services into centers with a multidisciplinary focus.If carefully performed, reorganization of clinical rotations based on resident goals and objectives can result in measurable improvements in resident education without disrupting faculty practices. Unanticipated benefits for faculty include new collaborative opportunities that cross traditional section/department barriers. The process allows for rapid change focused on educational effectiveness, not simply revision of existing paradigms, but it requires faculty cooperation and willingness to change traditional clinical service organization.
View details for DOI 10.1016/j.jamcollsurg.2010.12.018
View details for Web of Science ID 000289430000052
View details for PubMedID 21463815
Simulation training for vascular access interventions
JOURNAL OF VASCULAR ACCESS
2010; 11 (3): 181–90
Training and learning in the field of access for dialysis, including peritoneal and hemodialysis and access for oncologic patients, is well suited for the use of simulators, simulated case learning, and root cause analysis of adverse outcomes and team training. Simulators range over a wide spectrum from simple suture learning devices, inexpensive systems for venous puncture simulation, such as a turkey breast or leg with a pressurized tunneled rubber or graft conduit, to sophisticated computer designed simulators to teach interventional procedures such as vascular access angiogram, balloon angioplasty and stent placing. Team training capitalizes on the principles used in aviation, known as Crew Resource Management (CRM) or Human Factor (HF). The objectives of team training are to improve communication and leadership skills, to use checklists to prevent errors, to promote a change in the attitudes towards vascular access from learning through mistakes in a non-punitive environment, to impacting positively the employee performance and to increase staff retention by making the workplace safer, more efficient and user-friendly.
View details for Web of Science ID 000287465200001
View details for PubMedID 21240863
- SAGES guideline for laparoscopic appendectomy SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES 2010; 24 (4): 757–61
Initial Laparoscopic Basic Skills Training Shortens the Learning Curve of Laparoscopic Suturing and Is Cost-Effective
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2010; 210 (4): 436–40
Laparoscopic suturing is an advanced skill that is difficult to acquire. Simulator-based skills curricula have been developed that have been shown to transfer to the operating room. Currently available skills curricula need to be optimized. We hypothesized that mastering basic laparoscopic skills first would shorten the learning curve of a more complex laparoscopic task and reduce resource requirements for the Fundamentals of Laparoscopic Surgery suturing curriculum.Medical students (n = 20) with no previous simulator experience were enrolled in an IRB-approved protocol, pretested on the Fundamentals of Laparoscopic Surgery suturing model, and randomized into 2 groups. Group I (n = 10) trained (unsupervised) until proficiency levels were achieved on 5 basic tasks; Group II (n = 10) received no basic training. Both groups then trained (supervised) on the Fundamentals of Laparoscopic Surgery suturing model until previously reported proficiency levels were achieved. Two weeks later, they were retested to evaluate their retention scores, training parameters, instruction requirements, and cost between groups using t-test.Baseline characteristics and performance were similar for both groups, and 9 of 10 subjects in each group achieved the proficiency levels. The initial performance on the simulator was better for Group I after basic skills training, and their suturing learning curve was shorter compared with Group II. In addition, Group I required less active instruction. Overall time required to finish the curriculum was similar for both groups; but the Group I training strategy cost less, with a savings of $148 per trainee.Teaching novices basic laparoscopic skills before a more complex laparoscopic task produces substantial cost savings. Additional studies are needed to assess the impact of such integrated curricula on ultimate educational benefit.
View details for DOI 10.1016/j.jamcollsurg.2009.12.015
View details for Web of Science ID 000276563800007
View details for PubMedID 20347735
Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2010; 24 (2): 377–82
Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room.Medical students (n = 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical, live, porcine Nissen fundoplication models; they placed three gastro-gastric sutures using conventional laparoscopic instruments in one model and using robotic assistance (da Vinci) in the other, in random order. Each knot was objectively scored based on time, accuracy, and security. Injuries to surrounding structures were recorded. Workload was assessed using the validated National Aeronautics and Space Administration (NASA) task load index (TLX) questionnaire, which measures the subjects' self-reported performance, effort, frustration, and mental, physical, and temporal demands of the task. Analysis was by paired t-test; p < 0.05 was considered significant.Compared with laparoscopy, robotic assistance enabled subjects to suture faster (595 +/- 22 s versus 459 +/- 137 s, respectively; p < 0.001), achieve higher overall scores (0 +/- 1 versus 95 +/- 128, respectively; p < 0.001), and commit fewer errors per knot (1.15 +/- 1.35 versus 0.05 +/- 0.26, respectively; p < 0.001). Subjects' overall score did not improve between the first and third attempt for laparoscopic suturing (0 +/- 0 versus 0 +/- 0; p = NS) but improved significantly for robotic suturing (49 +/- 100 versus 141 +/- 152; p < 0.001). Moreover, subjects indicated on the NASA-TLX scale that the task was more difficult to perform with laparoscopic instruments compared with robotic assistance (99 +/- 15 versus 57 +/- 23; p < 0.001).Compared with standard laparoscopy, robotic assistance significantly improved intracorporeal suturing performance and safety of novices in the operating room while decreasing their workload. Moreover, the robot significantly shortened the learning curve of this difficult task. Further study is needed to assess the value of robotic assistance for experienced surgeons, and validated robotic training curricula need to be developed.
View details for DOI 10.1007/s00464-009-0578-0
View details for Web of Science ID 000274141400016
View details for PubMedID 19536599
A call for the utilization of consensus standards in the surgical education literature
EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2010: 99–104
Assessment methods and theory continue to evolve in the general education literature. Nowhere is this more evident than in the framework of validity methods and concepts. The consensus standards of the American Educational Research Association, American Psychological Association, and National Council on Measurement in Education have changed from "types of validity" (criterion, construct, and content) and "valid instruments," last used in 1974, to a concept of identifying evidence for the validity of results and the use of those results. The purpose of this study was to evaluate the surgical education literature for the adoption of the current consensus standards.As a representative sample of the surgical educational literature, the validation effort in laparoscopic simulator education was chosen. A MEDLINE search using the terms validity.tw and laparoscop$.tw between 1996 and 2008 (September week 1) yielded 192 citations. All titles and abstracts were reviewed, resulting in 47 studies appropriate for in-depth analysis.Validation studies have evaluated 21 different simulators. Twenty-three percent of the studies adhere, in part, to the new consensus standards for validity. One hundred percent use the old framework of types of validity including 75% using construct validity, 38% using face validity, and 11% using content.The widespread use of the currently (after 1999) accepted framework for validity is lacking in the surgical education literature. Surgical educators must remain current and begin to investigate our assessments within the contemporary framework of validity to avoid improper judgments of performance.
View details for DOI 10.1016/j.amjsurg.2009.08.018
View details for Web of Science ID 000276959000016
View details for PubMedID 20103073
Do Metrics Matter? Time Versus Motion Tracking for Performance Assessment of Proficiency-Based Laparoscopic Skills Training
SIMULATION IN HEALTHCARE
2009; 4 (2): 104–8
The purpose of this study was to compare the added value of motion metrics in determining training completion during a proficiency-based simulator curriculum compared with traditional metrics (time).Novices (n=16) practiced on a basic laparoscopic task of a hybrid simulator until expert-derived proficiency levels for time, path length, and smoothness were achieved on two consecutive attempts. The order by which proficiency in each metric was achieved was recorded and correlated to baseline characteristics. Motion metrics were considered valuable if their incorporation led to extension of training duration.Compared with baseline participant performance improved at training completion according to all metrics (time 67+/-17 to 20+/-6 seconds; P<0.001, pathlength 5326+/-1444 to 2339+/-545 cm; P<0.001, and smoothness from 529+/-185 to 133+/-59; P<0.001). Pathlength was the easiest metric to reach the proficiency level and time the most difficult. Four (33%) participants benefited from the motion metrics as their training was prolonged by an average of 50% compared with using time alone. Baseline characteristics did not correlate to the order of achievement of these metrics.Time may be superior to motion tracking metrics for performance assessment during proficiency-based simulator training. Nevertheless, in this study one third of trainees benefited from motion analysis metrics by having their training duration extended. Further study is needed to establish the value of motion metrics during simulator training and their impact on operating room performance improvement.
View details for DOI 10.1097/SIH.0b013e31819171ec
View details for Web of Science ID 000277049900007
View details for PubMedID 19444048