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It’s more than just competency-based education: It’s about radical curricular change Richard K. Reznick, MD, MEd, FRCSC, FACS Dean, Faculty of Health Sciences,

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Presentation on theme: "It’s more than just competency-based education: It’s about radical curricular change Richard K. Reznick, MD, MEd, FRCSC, FACS Dean, Faculty of Health Sciences,"— Presentation transcript:

1 It’s more than just competency-based education: It’s about radical curricular change Richard K. Reznick, MD, MEd, FRCSC, FACS Dean, Faculty of Health Sciences, Queen’s University CEO Southeastern Ontario Academic Medical Organization

2 Fellowship in Surgical Education

3 The story really starts here: And it’s a young and short story Brent Laura Jeramie Sebastian Kevin Matt Mollon Kember Larouche Tomescu Koo Tsuji

4 With a long prologue!

5 Libby Zion Revisited And the prologue has been brewing for three decades

6 Training is too long! Undergraduate4 years Master’s Degree2 years Medical School4 years Residency4-5 years Fellowship2-3 years Research Training2-5 years

7 Switzerland50 hours The Netherlands48 hours Denmark42 hours Germany40 hours Belgium40 hours Sweden40 hours France35 hours Norway35 hours United States80 hours Canada72 hours Ireland49 hours Australia68-75 hours New Zealand72 hours Taiwan70 hours Brazil60 hours Great Britain49 hours It’s a Problem: The House Officer is Dead

8 Transatlantic comparison of the competence of surgeons at the start of their professional career Schiven, Reznick, Ten Cate, Grantcharov, Regehr, Satterthwaite, Thijssen, MacRae British Journal of Surgery 2010; 97: 443–449 Domain T (40) P CIP Cognitive PAME Judgment <.01 OSATS Technical

9 OSATS Scores Examiner Bias

10 18/121 A procedures > 10 83/121 A procedures < 5 31/121 A procedures < 1 63/121 mode = 0 Bell RH et al Annals of Surgery: 249: : 2009

11 Is there such a thing as a surgical principle: Or if you take out a right colon, can you take out a left colon? Transfer, the process of using knowledge or skills acquired in one context in a new or varied context, has long been the topic of spirited debate in the research community

12 Detterman “educators must assume that transfer is as rare as volcanic eruptions and should operate as though it is virtually unachievable as an instructional goal”

13

14 Average Number of Passes Per Year

15 “... we argue that the difference between expert performers and normal adults reflects a life-long period of deliberate effort to improve performance in a specific domain.” K. Anders Ericsson et al The message from Strauss, Otto and Starkes

16 There is a Tension

17 What is this beast: Competency- based Medical Education The solution to all problems in PGME The genesis of problems in PGME “the competencies” Competence versus Time Curricular tweaking Radical reform

18 Competency-based Surgical Training not so new! No matter of person shall employ are said crafts unless he be worthy and expert in all subjects belonging to the said crafts, and he be diligently and advisedly examined Charter of the Royal College of Surgeons of Edinburgh, 1512 Over 500 years old

19 Medical educators now begin with the end in mind and focus on the competencies needed by graduates of medical education needed to meet those they serve, and effect the outcomes of healthcare Frank J and Danoff D: Medical Teacher, 2007: 29: 642

20

21 CBME Competency-based medical education has been criticized for being reductionistic, that is focusing on atomistic skills and failing to capture the essence of professional activities as manifested by complex integrated capabilities Swing SR Medical Teacher, 2010: 32: 663

22 Competency-based Education May not the Holy Grail (necessary, but not sufficient) “Understanding, I have been urging, is active, is an engagement, is a form of agency, and is a form of self-expression. It is an expression of individuality; and it strikes against the conventionalism of competence, insofar as competency is a fulfillment of standards determined in advance”. Ronald Barnett

23 Competency-based Education: May not be the Holy Grail “…tasks are broken down into their sub-units and the assessee is graded according to successful, serial completion of each and these stages. Such a competency construct is a learning paradigm, it is not the same as competence, which is a step on the road to professional excellence”. Talbot M, Med Educ 2004: 38:587

24 Meet Joe Hofstee Angoff Nedelsky Contrasting Groups Ebel The marginally competent, acceptably capable, bare pass, but a pass

25 Raising the Bar An explicitly stated mission of competency-based surgical residency is not only that the bar will continue to be set very high but that deliberate efforts (must) be made to raise it even further Bhatti and Cummings 2007: Academic Medicine: 82:569

26 And it begs the question. Are we striving for competence, or virtuosity?

27 We are at a precipice

28

29 A Six Point Plan to Restructure and Dramatically Shorten Training 1. Tackle politics and finances head on 2. Achieving the competencies through modular- based training 3. Dramatically accelerate the pace of procedural skill acquisition 4.Diminish wasted time 5. Incorporate meaningful assessment into day-to- day activities 6. Develop and promote a culture of collegiality

30 MOHLTC funding signed September 10, 2009

31 2. Modular-based training linked to specific learning objectives 1. Specific modular objectives form the basis of learning contracts 2. Objectives must be comprehensive 3. Objectives are learner-based and streamlined to ultimate career 4. Deploy web-based curricular materials, access to point of care (wireless) information, optimize VR training, and a focus on providing data for evidence based decision making

32 21 Modules to teach the competencies Perception and Judgment Dexterity Compassion and Determination Communication and Professionalism

33 Modular-based training linked to specific learning objectives They finish when they finish! 1. Specific modular objectives form the basis of learning contracts 2. Objectives must be comprehensive 3. Objectives are learner-based and streamlined to ultimate career 4. Deploy modern technology, such as web-based curricular materials, access to point of care (wireless) information, optimize VR training, and a focus on providing data for evidence based decision making

34 This is not about turning professional training into vocational training

35 How surgeons disclose errors (we’re not doing so well) Used the word error or mistake57% Took responsibility for error65% Offered verbal apology47% Acknowledged patient’s emotions55% Discussed future prevention8% Offered second opinion20% Chan D, Gallagher T, Reznick R, Levinson W. Surgery: 138: :2006

36 3. Dramatically accelerate the pace of procedural skill acquisition 1. Developing a “pre-program” of basic skills focusing on fundamental technical skills 2.Dramatically ramping up skills laboratory (ex vivo) practice, using virtual reality, c adavers, surrogate tissue and inanimate training models 3. Developing programs of structured and deliberate practice 4. Maximizing each “real” patient experience by the use of pre-operative technical sessions, by videotape review of self and experts, and by debriefing sessions

37 Starting to operate on the decline

38 So we need to find ways to train specific skills benchmarked to proficiency criteria: AKA You can’t enter the O.R. until you are prepared

39 Surgeon in Africa FLS Box My Simulator Simulator in Africa

40 Skill Transfer: Laparoscopic Surgery Grantcharov et al., Randomized clinical trial of VR simulation for laparoscopic skills training, BJS 2004 Randomized, controlled, blinded design Pre- and post-tests in OR –Gallbladder dissection of from liver –Assessment using modified global ratings scales

41 Faster Better economy of motion Less errors

42 20 Surgery Residents Simulation training to proficiency criteria Basic Lap Chole Lecture AnatomyAnatomy TechniqueTechnique VideosVideos Intra-operative assessment Video-recorded Reviewed by blinded observer Randomization

43 Second generation haptic VR Simulators Improvements in computer and graphics technology have lead to more advanced simulatorsImprovements in computer and graphics technology have lead to more advanced simulators –More realistic graphics –Haptic or force feedback –Ability to perform full procedures

44

45 Mean GOALS Score Blinded Reviewer *p=.001 Mean Goals Score

46

47 4. Diminish Wasted Time 1. Eliminating or minimizing time wasted secondary to a hierarchical model 2. Eliminating or minimizing time wasted doing non-educational activities 3. Increasing support services, increasing nurse autonomy, rationalizing calls, and optimizing technological solutions to service problems 4. Critically assessing the need for and the context of night call 5. Seriously addressing the issue of sleep deprivation

48 STUDYTASK Friedman et al., 1973EKG interpretation Christensen et al, 1977X-ray Interpretation Poulton et al., 1978Review lab results Engel et al., 1978Simulated patients Reznick and Folse, 1987Suturing task Storer et al., 1989ETT, IV insertion Lingenfelser et al., 1994EKG interpretation Haynes et al, 2003Surgery outcomes Howard et al., 2003Anesthesia simulator Ellman et al., 2004Surgery outcomes Stone et al., 2004AMSITE examination Uchal, 2005Laparoscopic simulator Jakubowicz, 2005Simulated endoscopic sinus surgery Clinical Effects of Sleep Deprivation STUDYTASK Goldman et al., 1972Videotape:performance Friedman et al., 1973EKG interpretation Beatty et al., 1977Patient monitoring Storer et al., 1989arterial catheterization Denisco at al., 1987Patient monitoring Bertram, 1988Review resident notes Jaques at al., 1990In-training examination Gottleib et al., 1991Medication errors, LOS Mann and Danz, 1993X-ray Interpretation Lingenfelser et al., 1994EKG interpretation Taffinder et al., 1998VR lap. simulator Grantcharov et al., 2001MIST-VR Landrigen et al., 2004Medical errors Jensen et al., 2004laparoscopic simulator Eastridge, 2004MIST-VR

49 Epworth Sleepiness Scale How likely would you be to doze off in the following situations? Surgery (SD)Non - Surgery (SD) Sitting and Reading2.22 (.84)**1.53 (.97) Watching TV2.13 (.93)**1.39 (.98) Sitting inactive in a public place1.74 (.89)**0.91 (.92) Passenger in a car for 1 hour2.03 (.93)*1.72 (1.06) Lying down to rest2.41 (.85)*2.14 (.92) Sitting and talking to someone.52 (.70)**0.16 (.42) Sitting quietly after lunch without alcohol1.21 (.94)*0.92 (.92) In a car stopped for a few minutes in traffic.56 (.85)0.39 (.76) TOTAL EPWORTH SCORE12.84 (4.7)**9.17 (4.8) ** p < 0.01 * p < 0.05 Woodrow SI, Park J, Murray BJ, Wang C, Bernstein M, Reznick RK, Hamstra SJ: Differences in the Perceived Impact of Sleep Deprivation among Surgical and Non-Surgical Residents. Medical Education 2008: 42 (5): pp

50 ** p < 0.01 * p < = strongly disagree, 2 = somewhat disagree, 3 = no opinion, 4 = somewhat agree, 5 = strongly agree Surgery (SD)Non-Surgery (SD) Less concentration during patient rounds3.76 (1.11)**4.54 (0.78) Unable to retain new patient information3.67 (1.03)**4.32 (0.80) Less effective clinical judgment3.70 (1.12)**4.18 (0.91) Inappropriate discharge orders2.93 (1.28)**3.75 (1.09) More irritable4.20 (0.92)**4.50 (0.79) Decreased empathy towards patients3.55 (1.34)**4.08 (1.04) Poor interaction with colleagues3.76 (1.04)*4.09 (1.00) Poor communication with patients3.62 (1.20)**4.16 (0.92) Decreased motivation to learn4.07 (0.99)**4.56 (0.75) Diminished desire to teach4.16 (0.89)*4.51 (0.84) Slower4.14 (0.80)**4.54 (0.78) Unsafe Driving3.59 (1.21)*3.95 (1.14) TOTAL SDI SCORE45.2 (8.54)**51.5 (5.97) alpha = 0.89, eta 2 =.154 Patient Care Professionalism Sleep Deprivation Impact (SDI) Scale

51 The surgical “machismo” Surgery residents work longer hours Surgery residents perceive less impact of sleep deprivation on their own clinical performance Surgery residents report increased sleepiness ESS Surgery: ESS Non-surgery: 9.17 Epworth Score Normal8 (<11) Obstructive Sleep Apnea11.7 Narcolepsy17.5

52 5. Benchmarking towards Excellence: Daily Assessment is the Key 1. Rigorous, reliable and regular assessment of the multitude of competencies with a special focus on technical achievement 2. Liberal use of formative assessment 3.Linking evaluation instruments to goals, objectives and desired competencies 4.Training the evaluators 5.Focusing effort on performance-based evaluation systems, such as PAME, OSATS, 6. Using a diverse array of assessors, including self, other health professionals, patients, peers, and faculty

53 Assessment Toolbox PAME OSATS ICSAD VR Metrics OSCES Orals MCQ 360 ITER

54

55 Reznick RK, Regehr G, MacRae H, Martin J, McCulloch W: Am J Surg 1997: 173: pp OSATS our first small step

56

57 Summary of OSATS Experiments: Nine Years of Research Inter-rater and Inter-station reliability Construct valid (PGY6>5>4>3>2>1) Concurrent validity (r=.81 with faculty) Not just Toronto (across Ontario) Central preparation and peripheral delivery (Chicago and Los Angeles) Used now in RACS, RCS and GMC

58 Name:Dr. Demitrios Athenas DOBOct 10, 1960 Medical SchoolUniversity of Patras ResidencyG.S. 5 years, Athens University Practice2 years community teaching hospital, Athens, Greece ECFMGPASSED TOFEL/TSEPASSED REFERENCESPositive letter from an elective rotation in Houston ABSITE30 th percentile for PGY-5 DECISION:????

59 It’s about knowing where they stand (OSATS scores across years of training) Candidate 1 >Candidate 2 >Candidate 3 >Candidate 4 >Candidate 5 >

60 6. Promote a Culture of Collegiality: Improve Communication through a Culture Change 1. Embrace a multi-professional and patient centered approach to patient care 2. Focus on patient safety 3. Focus on professionalism as a distinct enabler of learning

61

62

63 London, UK EUROEMRO WPRO I SEARO AFRO PAHO I Amman, Jordan Toronto, Canada New Delhi, India Manila, Philippines Ifakara, Tanzania WPRO II Auckland, NZ PAHO II Seattle, USA The WHO Checklist was piloted in 8 cities

64 Results

65 "I cannot recall a clinical care innovation in the past 30 years that has shown results of the magnitude demonstrated by the surgical checklist. This is a change ready right now for adoption by every hospital for adoption by every hospital that performs surgery." Don Berwick, IHI

66 If we want to avoid everyone’s favorite sport

67 New Training Model We haven’t proved anything yet July 2009 and July supra-numery residents Division of Orthpaedic Surgery Estimate $200,000 per year, per program Competency based, not time based Thank you Royal College Bill Kraemer Ben Alman Peter Ferguson

68 CBC Module 2: Hip fracture Cases logged for regular 3m and 6m junior rotations vs CBC Module

69 CBC Residents outperform regular Residents on 9/9 technical skills F(1,19) = p < 0.001

70 CBC residents report more self- confidence

71 It’s more than just competency- based Challenge curricular models Ramp up procedural skill acquisition Rigorously assess educational outcomes Promote team care OLD WAYS WON’T WORK

72

73

74

75 Orthopaedic Competency Based Curriculum (CBC) Progress Report July 27 – August – Module 1 – Technical Skills (Module Leader – Dr Oleg Safir) Half days in SSC, half days in clinic/OR Core elements –Gowning –Prepping & draping –Soft tissue handling –Power tools –Suturing –Casting

76 The Dutch Experiment Based on CanMEDS Modular Structure Assessment strategy to be formative and portfolio-based QA Measures (faculty development and educational quality control) Scheele and colleagues : Medical Teacher; 01/01/08

77 The Dutch Experiment STEP I Structuring the Content into Themes Anatomic Region (Orthopaedics) Context (Psychiatry) Symptoms (General Surgery) Context and Symptoms (Ob Scheele and colleagues : Medical Teacher; 01/01/08

78 The Dutch Experiment-STEP II Choosing Information-Rich Activities (Entrustable Professional Activities) A task of high importance for daily practice A high risk or error prone task A task that is exemplary of (a number) of Can MEDS competencies) TenCate O.2005: Med Educ: 39:1176

79 The Dutch Experiment-STEP III Using Assessment toolbox to match EPA’s to CanMEDS Roles ForcepsObstetric DrillsC Section ExpertDOP, MCQ, Vol Oral OSCE, MCQ DOP Vol CommunicatorMCQ, OSCE Collaborator Manager Advocate ScholarCritical appraisal Professional

80 “There is nothing more useless than a merely well informed man” » Albert North Whitehead

81 S KNOWS HOW (Competence) KNOWS SHOWS HOW DOES

82 The handshake of the world's oldest surgeon St. Petersburg's Fyodor Uglov, 99, who was still doing operations last spring, is as firm as that of a 30-year-old athlete.

83 Paraphrasing Piaget True learning occurs when we are deeply perturbed; when our world view is so challenged that we must reject our current conceptualizations, and we then must (painfully) rebuild our knowledge structures

84 Let me be so bold as to propose to you a new model of training An aspiring iconoclast AKA surgical educator gone mad

85 What percent of your GNP is spent on health care? What percent of your GNP is spent on health training? Harvard sweetens reward for doctors who teach 3 hospitals agree to double budget By Liz Kowalczyk, Globe Staff | March 9, 2007 Harvard Medical School will increase by millions of dollars a year its payments to doctors for teaching students, a recognition of how difficult it has become to persuade busy physicians to devote time to educating the next generation of care givers. $100 per hour Tackle the Finances and Politics

86 Manual and video of fiberoptic intubation Familiarization with bronchoscope Model training (n=12)Didactic training (n=12) Pre-test of fiberoptic manipulation ability Fiberoptic intubation in OR on healthy, anesthetized and paralyzed female patients with “easy” airways

87 Skills Curricula Some skills can be taught with low tech simulation

88 Successful Tracheal Intubation * p < 0.01 * % of Subjects

89 And we need to properly teach new technologies

90 Schema TestTest TestTest TransferTransfer TransferTransfer &Test&Test &Test&Test Massed (One day) Distributed (4 weeks) TestTest TestTest Moulton CA, Dubrowski A, MacRae H, Graham B, Grober E, Reznick RK: Annals of Surgery 2006: 244: pp

91 CME courses: 2 days, 25 hours! Does it makes sense? 1234R 1 hour block 1 month rest 1234R 1 hour block 1 week rest 1 month rest Distributed practice Massed practice T T

92 Test Global Ratings (max. 25) Group Distributed Massed RetentionPost-testPre-test * Transfer * Microsurgical drill Rat Inter-rater reliability = 0.89 * p <.05

93 4. Diminish Wasted Time 1. Eliminating or minimizing time wasted secondary to a hierarchical model 2. Eliminating or minimizing time wasted doing non-educational activities 3. Increasing support services, increasing nurse autonomy, rationalizing calls, and optimizing technological solutions to service problems 4. Critically assessing the need for and the context of night call 5. Seriously addressing the issue of sleep deprivation

94 STUDYTASK Friedman et al., 1973EKG interpretation Christensen et al, 1977X-ray Interpretation Poulton et al., 1978Review lab results Engel et al., 1978Simulated patients Reznick and Folse, 1987Suturing task Storer et al., 1989ETT, IV insertion Lingenfelser et al., 1994EKG interpretation Haynes et al, 2003Surgery outcomes Howard et al., 2003Anesthesia simulator Ellman et al., 2004Surgery outcomes Stone et al., 2004AMSITE examination Uchal, 2005Laparoscopic simulator Jakubowicz, 2005Simulated endoscopic sinus surgery Clinical Effects of Sleep Deprivation STUDYTASK Goldman et al., 1972Videotape:performance Friedman et al., 1973EKG interpretation Beatty et al., 1977Patient monitoring Storer et al., 1989arterial catheterization Denisco at al., 1987Patient monitoring Bertram, 1988Review resident notes Jaques at al., 1990In-training examination Gottleib et al., 1991Medication errors, LOS Mann and Danz, 1993X-ray Interpretation Lingenfelser et al., 1994EKG interpretation Taffinder et al., 1998VR lap. simulator Grantcharov et al., 2001MIST-VR Landrigen et al., 2004Medical errors Jensen et al., 2004laparoscopic simulator Eastridge, 2004MIST-VR

95 Epworth Sleepiness Scale How likely would you be to doze off in the following situations? Surgery (SD)Non - Surgery (SD) Sitting and Reading2.22 (.84)**1.53 (.97) Watching TV2.13 (.93)**1.39 (.98) Sitting inactive in a public place1.74 (.89)**0.91 (.92) Passenger in a car for 1 hour2.03 (.93)*1.72 (1.06) Lying down to rest2.41 (.85)*2.14 (.92) Sitting and talking to someone.52 (.70)**0.16 (.42) Sitting quietly after lunch without alcohol1.21 (.94)*0.92 (.92) In a car stopped for a few minutes in traffic.56 (.85)0.39 (.76) TOTAL EPWORTH SCORE12.84 (4.7)**9.17 (4.8) ** p < 0.01 * p < 0.05 Woodrow SI, Park J, Murray BJ, Wang C, Bernstein M, Reznick RK, Hamstra SJ: Differences in the Perceived Impact of Sleep Deprivation among Surgical and Non-Surgical Residents. Medical Education 2008: 42 (5): pp

96 ** p < 0.01 * p < = strongly disagree, 2 = somewhat disagree, 3 = no opinion, 4 = somewhat agree, 5 = strongly agree Surgery (SD)Non-Surgery (SD) Less concentration during patient rounds3.76 (1.11)**4.54 (0.78) Unable to retain new patient information3.67 (1.03)**4.32 (0.80) Less effective clinical judgment3.70 (1.12)**4.18 (0.91) Inappropriate discharge orders2.93 (1.28)**3.75 (1.09) More irritable4.20 (0.92)**4.50 (0.79) Decreased empathy towards patients3.55 (1.34)**4.08 (1.04) Poor interaction with colleagues3.76 (1.04)*4.09 (1.00) Poor communication with patients3.62 (1.20)**4.16 (0.92) Decreased motivation to learn4.07 (0.99)**4.56 (0.75) Diminished desire to teach4.16 (0.89)*4.51 (0.84) Slower4.14 (0.80)**4.54 (0.78) Unsafe Driving3.59 (1.21)*3.95 (1.14) TOTAL SDI SCORE45.2 (8.54)**51.5 (5.97) alpha = 0.89, eta 2 =.154 Patient Care Professionalism Sleep Deprivation Impact (SDI) Scale

97 The surgical “machismo” Surgery residents work longer hours Surgery residents perceive less impact of sleep deprivation on their own clinical performance Surgery residents report increased sleepiness ESS Surgery: ESS Non-surgery: 9.17 Epworth Score Normal8 (<11) Obstructive Sleep Apnea11.7 Narcolepsy17.5

98 It’s not necessarily axiomatic that all things majestic have an strong underlying network, that all things meager lack an extensive foundation

99 5. Benchmarking towards Excellence: Daily Assessment is the Key 1. Rigorous, reliable and regular assessment of the multitude of competencies with a special focus on technical achievement 2. Liberal use of formative assessment 3.Linking evaluation instruments to goals, objectives and desired competencies 4.Training the evaluators 5.Focusing effort on performance-based evaluation systems, such as PAME, OSATS, 6. Using a diverse array of assessors, including self, other health professionals, patients, peers, and faculty

100 Assessment Toolbox PAME OSATS ICSAD VR Metrics OSCES Orals MCQ 360 ITER

101 6. Develop and Promote a Culture of Collegiality 1. Embrace a multi-professional and patient centered approach to patient care 2. Focuses on patient safety 3. Focus on professionalism as a distinct enabler of learning

102 Sharp Contrasts F-16 Fighter Pilot Training 1.Pre-simulator sessions 2.Simulator sessions 3.Debriefing of simulator sessions 4.Pre-flight review 5.1 hour flight 6.6 hours of one on one debriefing

103 VR Training- A Part of our Future? Estimates suggest 4B industry by 2013* Recent FDA recommendation that VR training precede carotid stenting Frost & Sullivan study suggest 6 mo ROI** 1:0.2 versus 1:0.8 * US Market for VR in Surgery and Imaging MedMarket Dilligence LLC (2005) **Return of Investment Study for Medical Simulation Training (Frost & Sullivan 2004)

104 Lessons for England Boy, are we presumptuous The pyramid being abandoned, now shorten training Time based training is antiquated An ST1 can and should take out a colon See one, simulate 100, do one Break down the hierarchy

105 Shorten Training Medical school 4-6 years (could be 3) Foundation 2 years(eliminate) ST Core 2 -3 years(eliminate) ST Higher 6 yearsCBC ~ 4 years Research 2-3 yearsonly for academics Fellowship 1 yearleave as is

106 You are accepting the best and the brightest GPA>3.6 MCAT>11 Awards Sports Music Volunteerism Parted the Red Sea

107 Skills Labs: An Emerging Reality for Every Training Program

108 Novice Attentional capacity threshold Technical skills Depth perception Environment Operative Judgment Additional Learning Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning

109 Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning

110 Novice Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Technical skills Depth perception Environment Operative Judgment Additional Learning

111 Novice Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Technical skills Depth perception Environment Operative Judgment Additional Learning

112 Novice Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Technical skills Depth perception Environment Operative Judgment Additional Learning

113 Training Phase 50 PGY 1-3 surgical residents n = 10 DidacticSilicone Tube Live Rat-Vas Deferens Low-Fidelity High-FidelityControl n= 19 n = 21

114 Results -Post-Test Chi-square: p=0.048

115 Playing well in the sandbox

116

117 A new concept of graded responsibility “sign-off” on cognitive elements Review of 1000’s of intra-operative situations and controversies Accepted algorithms Obligatory web-cast during first year of “independence” Mandatory second opinions for defined conditions

118

119 We are accepting he best and the brightest

120 Essentials of Surgical Training Clearly defined selection criteria An efficient, fair and transparent selection process A “fit-for-purpose learning environment Appropriate access for trainees to clinical practice Trained motivated trainers An integrated progression of learning Effective and objective assessment of competency progression Creating an attitude that encourages life-long learning Thomas WEG: ANZ J Surg: 79: (2009)

121

122 What do team members hear? Surgeons: “Surgeons are the only ones who really care if all the patients get done – the nurse is a shift worker.” Anesthetists: “Surgeons have a distorted sense of operative time – it’s all about their time.” Nurses: “Surgeons are just worried about money – if a case gets cancelled it’s less money for them.”

123 6. Develop and promote a culture of collegiality 7. If it ain’t broke, don’t fix it 8. Address potential deleterious byproducts

124

125

126 Do sub-specialists need generalist training? Richard K. Reznick, MD, MEd, FRCSC, FACS R.S. McLaughlin Professor and Chair Department of Surgery University of Toronto Richard K. Reznick, MD, MEd, FRCSC, FACS R.S. McLaughlin Professor and Chair Department of Surgery University of Toronto MSKCC Ground Rounds

127 There is a Tension Call for GeneralismNeed for Focused Training Reduced Work Week and Sleep Deprivation Training is Already Too Long Patient Safety and Public Expectation Need for Graduated Independence I Did It!Marital Disharmony, Substance Abuse, Depression

128 We’ve got a big problem! Current ForcesGeneral EffectEffect on Training Fiscal RestraintPressure for speed Fewer opportunities Growth of Knowledge Increasingly complex cases Fewer opportunities Societal Influences Medical error Patient safety Fewer opportunities The O.R. ItselfIncreasingly stressful Fewer opportunities

129 SCORE Competency-based education Promoting simulation and skills labs Common curricula Assessment of competence

130 Assessment toolbox for technical skill is rich OSATS MISTELS Error assessment Product analysis ICSAD VR Metrics Video-tape review Intra-op review ITER Patient outcomes

131 Models of Surgical Education Vs.

132 Is there such a thing as a surgical principle: Or if you can take out a left colon can you take out a right colon? Transfer, the process of using knowledge or skills acquired in one context in a new or varied context, has long been the topic of spirited debate in the research community

133

134 How much gain? Plate Fixation - Global Score PGY 5 PGY 1 (course) PGY 1 (control) Posttest Pretest Delay Test

135 No gain for similar task! K-Wire Fixation - Global Score PGY 5 PGY 1 (course) PGY 1 (control) Posttest Pretest Delay Test Experiment replicated with upper and lower limb casting

136 Detterman “educators must assume that transfer is as rare as volcanic eruptions and should operate as though it is virtually unachievable as an instructional goal”

137 Generalizations about transfer Transfer of knowledge and procedures occurs far less often than educators and educational researchers would hope ( The literature is replete with testimonials to the relative ineffectiveness of “training for transfer” studies) Transfer is an essential aspect of competent performance in any complex domain (There is ample evidence in the literature that highly competent learners, experts regularly perform tasks for which they have never been directly trained)

138 Generalizations about transfer Transfer is more apt to occur when the learning environment is intentionally orchestrated to encourage cross-situation and cross-domain transfer and rewards such efforts (explicitness of instructional content, attention to basic problem-solving procedures or strategies, multiple and varied opportunities for transfer, and mindful reflection and abstraction of the materials to be taught)

139 Identifying the seeds of transfer Stages of domain learning (Novice learners have limited and fragmented knowledge of the domain and their interests are relegated more by the aspects of the immediate situation or context) Domain-specific analogical reasoning (willingness to engage in effortful processing) Profiles of academic achievement (domain knowledge, motivation, and general strategic ability are three needed ingredients)

140 Recognizing potential instructional barriers to transfer Mentioning versus teaching (teachers invested far too little time exploring important knowledge and strategies richly and deeply) Instructional enabling (given high marks if they perform well on relatively undemanding tasks, display compliance, and behave as good citizens in the classroom) Decontextualized and disconnected instruction (Learners need a well articulated map for what could or should transpire)

141 Nurturing transfer Stage a three-pronged attack focus on the learner, the task and the context Strive for principled understanding central concepts within this domain can function as the source or grounding for analogical reasoning Model and reward analogical thinking

142 Anatomy of a Surgeon is Complex Skill transfer Dexterity Compassion and Determination Communication and Professionalism

143 Concepts of Professionalism Two Departments of Surgery 43 semi-structured interviews 25 residents, 18 faculty 700 pages of transcript

144 Playing well in the sandbox

145 Anatomy of a Surgeon is Complex Skill transfer Dexterity Compassion and Determination Communication and Professionalism

146 What can we learn from others? Axel Strauss, Jim Otto, Janet Starkes Began playing the violin at 4 and won his first competition at age 8 First German artist to win the Naumburg Violin Award in 1998 Described by an opponent as “meaner than a bear and tougher than an old boot Professor and Chair, Department of Kinesiology, McMaster University,

147 Message from Jim Otto Determination Grit Playing with adversity Desire to be the best

148 Anatomy of a Surgeon is Complex Skill transfer Dexterity and Technical Skill Development Compassion and Determination Communication and Professionalism

149

150 Skills Labs: An Emerging Reality for Every Training Program

151 Training Phase 50 PGY 1-3 surgical residents n = 10 DidacticSilicone Tube Live Rat-Vas Deferens Low-Fidelity High-FidelityControl n= 19 n = 21

152 Results -Post-Test Chi-square: p=0.048

153 Results -Post-Test Chi-square: p=0.02

154 Manual and video of fiberoptic intubation Familiarization with bronchoscope Model training (n=12)Didactic training (n=12) Pre-test of fiberoptic manipulation ability Fiberoptic intubation in OR on healthy, anesthetized and paralyzed female patients with “easy” airways

155 Skills Curricula Procedural skills can be taught in the laboratory

156 Successful Tracheal Intubation * p < 0.01 * % of Subjects

157 VR Training- A Part of our Future? Estimates suggest 4B industry by 2013* Recent FDA recommendation that VR training precede carotid stenting Frost & Sullivan study suggest 6 mo ROI** 1:0.2 versus 1:0.8 * US Market for VR in Surgery and Imaging MedMarket Dilligence LLC (2005) **Return of Investment Study for Medical Simulation Training (Frost & Sullivan 2004)

158

159 Simulators can make a difference

160 Randomization of Residents Video Instruction & EquipmentFamiliarization EquipmentFamiliarization Pre-test on Simulator (Case 1) Simulator Practice (Cases 1, 2, 4, 5, 6) Pre-test on Simulator (Case 1) No Intervention Post-test on Simulator (Case 3) Post-test on Simulator (Case 3) Clinical Post-test TreatmentGroup ControlGroup Familiarization Phase Simulator Pre-test Phase Treatment Phase Simulator Post-test Phase

161 Effects of Simulator Training on Clinical Colonoscopic Performance Park, Reznick et al., Unpublished Data Mean +/- 1.0 SE * * p = 0.04

162 Sharp Contrasts F-16 Fighter Pilot Training 1.Pre-simulator sessions 2.Simulator sessions 3.Debriefing of simulator sessions 4.Pre-flight review 5.1 hour flight 6.15 hours of one on one debriefing

163 What is Telesimulation? Uses the camera in the simulator as a webcam Skype is used for video conferencing software – Free!

164

165 A new concept of graded responsibility “sign-off” on cognitive elements Review of 1000’s of intra-operative situations and controversies Accepted algorithms Obligatory web-cast during first year of “independence” Mandatory second opinions for defined conditions

166 We have been indoctrinated with the philosophy that the route to expertise is the creation of a totipotential trainee, one with a broad base of experiences. And that this broad base is essential to the development of a surgical specialist Focused Training

167 It’s not necessarily axiomatic that all things majestic have an strong underlying network, that all things meager lack an extensive foundation

168 1.Anatomy of a surgeon is complex 2.Transfer of skills a challenge 3.Emerging concepts of professionalism 4.New reality means new models 5.Simulation a part of our future 6.Halsted is dead

169

170 Mike Gartner (before a game) Eat well, good sleep review videotapes of last game anticipate game situations preview potential mistakes prayer

171 The pendulum needs equilibrium Sleep deprivation, restricted hours vs. volume outcome relationship There is no “I” in team vs. the intimacy of the patient-doctor relationship The expectation to operate is a right or a privilege?

172 Virtual-reality-based laparoscopic surgical training: The role of simulation fidelity in haptic feedback 11 Authors: Hyun K. Kim a ; David W. Rattner b ; Mandayam A. Srinivasan a Value of Haptic Feedback

173

174 An Evidence-Based Virtual Reality Training Program for Novice Laparoscopic Surgeons Rajesh Aggarwal, MRCS,* Teodor P. Grantcharov, PhD,† Jens R. Eriksen, MD, et al, time path length error score

175 Virtual reality simulation objectively differentiates level of carotid stent experience in experienced interventionalists Van Herzeele, Aggarwal, Choong, et al: JOURNAL OF VASCULAR SURGERY November 2007

176 Virtual reality simulation objectively differentiates level of carotid stent experience in experienced interventionalists Van Herzeele, Aggarwal, Choong, et al: JOURNAL OF VASCULAR SURGERY November 2007

177 World Leader in Physician Competency Approval of a new model of Residency Education Supportive of Hybrid Programs Royal College of Physicians and Surgeons of Canada

178 A Six Point Plan to Restructure and Dramatically Shorten Training 1. Tackle politics and finances head on 2. Achieving the competencies through modular- based training 3. Dramatically accelerate the pace of procedural skill acquisition 4.Diminish wasted time 5. Incorporate meaningful assessment into day-to- day activities 6. Develop and promote a culture of collegiality

179 “ It’s not practice that makes perfect, (stupid) It’s perfect practice that makes perfect.” Vince Lombardi It’s a Problem: No Time for Practice

180 Principles of Good Practice Morning practice most effective Strong correlation between rest and effective practice Maximum benefit from a combination of individual practice, sessions with a coach, and performances

181 Novice Attentional capacity threshold Technical skills Depth perception Environment Operative Judgment Additional Learning Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning

182 Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning

183 Novice Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Technical skills Depth perception Environment Operative Judgment Additional Learning

184 Novice Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Technical skills Depth perception Environment Operative Judgment Additional Learning

185 Novice Attentional capacity threshold Trained Novice Technical skills Depth perception Environment Operative Judgment Additional Learning Technical skills Depth perception Environment Operative Judgment Additional Learning

186

187 "If I don't practice one day, I know it; two days, the critics know it; three days, the public knows it." - Heifetz

188 Playing well in the sandbox

189 2. Modular-based training linked to specific learning objectives 1. Specific modular objectives form the basis of learning contracts 2. Objectives must be comprehensive 3. Objectives are learner-based and streamlined to ultimate career 4. Deploy modern technology, such as web-based curricular materials, access to point of care (wireless) information, optimize VR training, and a focus on providing data for evidence based decision making

190

191 You have to know when to slow down!

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193

194

195

196 Are we creating the shift-work doctor?

197 Concepts of Professionalism Two Departments of Surgery 43 semi-structured interviews 25 residents, 18 faculty 700 pages of transcript Park J, Woodrow SI, Reznick RK, Beales J, MacRae HM: Patient Care is a Collective Responsibility: Perceptions of Professional Responsibility in Surgery Surgery :142:107: 2007

198 Responsibilities Patient Care SelfEducationColleagues PatientRelationships Safety Continuity Principle Family & Relationships Affect Health Lifestyle Value Gatekeepers Inculcation Obligation Obedience

199 Five Criteria to Define Competency Focus on performance of the end product Reflects expectations that are applications of what is learned in the programme Expressible in terms of measurable behaviour Should use a standard that is NOT reliant on performance of other learners Inform learners, as well as other stakeholders, about what is expected of them Albanese et al: 2008, Med Educ 42:248

200

201 The explicit relationship of simulation- based procedural education to established clinical practice benchmarks leads to an outcomes based competency benchmarked assessment strategy for simulation. In such a setting, the use of non outcomes based standards-setting methods (ex Angoff, Hofstee etc.) would only serve to weaken the link between competency assessment and clinical performance. Michelson JD and Manning L: AmJSurg: 2008,196:609

202 Brief Overview of “the Competency Movement” 1990 Society for Teaching of Family Medicine proposes “Essentials for Family Practice 1993 CanMEDS project inaugurated focusing on doctors competencies to meet societal needs 1996 Medical school objectives project of the AAMC

203 Brief Overview of “the Competency Movement” (cont.) ACGME/ABMS agreed to 6 competencies for certification 1999 Harden and collegeus published a 5 part guide to “Outcome-Based Education”

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205

206 Focused Modular Training Turn it upside down

207 Are we creating the shift-work doctor?

208 This is not about turning professional training into vocational training

209 How surgeons disclose errors (we’re not doing so well) Used the word error or mistake57% Took responsibility for error65% Offered verbal apology47% Acknowledged patient’s emotions55% Discussed future prevention8% Offered second opinion20% Chan D, Gallagher T, Reznick R, Levinson W. Surgery: 138: :2006

210 Lessons for England Boy, are we presumptuous 35 is too old! Consider a competency-based paradigm Participator learning>observational learning Quickly transform a rank novice to trained novice We are living in a world of team care

211 Skill Transfer: Laparoscopic Surgery Randomized, controlled, blinded design Pre- and post-tests in OR –Gallbladder dissection of from liver –Assessment using modified global ratings scales Grantcharov et al., Randomized clinical trial of VR simulation for laparoscopic skills training, BJS 2004

212 Faster Better economy of motion Less errors

213 Warm-up in a Virtual Reality Environment Improves Performance in the Operating Room Sonal Arora, Rajesh Aggarwal, Dan Catalyud, Irina Kruglikova, Svend Schulze,Peter Funch-Jensen, Teodor Grantcharov Department of Surgery D, Glostrup University Hospital, Glostrup, Denmark Department of Biosurgery and Surgical Technology, Imperial College, London Department of Surgery L, Aarhus University Hospital, Aarhus, Denmark Division of General Surgery, St. Michael’s Hospital, Toronto, Canada

214 Introduction VR simulators validated for assessment of surgical skill Evidence of transferability of skills from VR to the OR Implementation in clinical practice is still limited Warm up used by other high performance industries (athletes, musicians etc) Should surgeons undergo warm up before operating on patients?

215 Aims To evaluate the impact of a short VR warm-up curriculum on laparoscopic performance in the Operating Room

216 Methods Participants 10 General Surgeons (5 experienced) at two University Hospitals All patients had Grade 1 biliary colic with no complicating factors. BMI< 35

217 Methods Study Design

218 Methods Simulator curriculum warm-up program performed immediately prior to the operative procedure three exercises: lifting and grasping, clip applying and fine dissection one run of each exercise on medium level

219 Methods Outcomes OSATS-based global rating scale Procedures videotaped and assessed by two blinded independent observers Statistical Analysis Comparison of performance scores with or without warm-up curriculum (Wilcoxon’s test) Reliability of assessment scores provided by 2 observers (Cronbach’s alpha)

220 Results Inter-rater reliability of OSATS based global rating (Cronbach’s alpha =0.92)

221 Results

222 Surgical performance better for the warm up compared to control (p = 0.042)

223 Conclusions Warm-up improves laparoscopic performance in the operating room. This warm-up program is short, easy to perform, and realistic to implement in a busy surgical department. Warm up may enhance procedural outcome and contribute to improved patient safety and better resource utilization Further studies should determine the optimal composition of a surgical VR warm-up program

224 Training Impact and Cost efficiency of a Comprehensive Curriculum for Advanced Laparoscopic Skills: A Randomized Controlled Trial

225 Background Laparoscopic Suturing: Most technically demanding laparoscopic skill to acquire Requires extensive practice prior to proficiency Requisite skill for any MIS procedure

226 Purpose of the Study To design and validate two proficiency- based training curricula involving tools with proven validity for advanced skills training in Minimally Invasive Surgery (MIS)

227 Purpose of the Study Demonstrate transfer of skills to the OR Perform a cost analysis of the efficiency of pre-OR training

228 Study Design Randomized Controlled Trial Department of General Surgery, Univ. of Toronto Tertiary-level teaching hospitals

229 Study Design Subjects 26 General Surgery residents PGY 3 & 4 Intermediate MIS experience Exclusion Criteria: < 10 MIS cases as the “primary” surgeon

230 26 Surgical Residents VR Curriculum LAPARPSCOPIC SUTURING STUDY DESIGN VR Group (N=10 ) Baseline Assessment TB Group (N=10) Trainer Box Curriculum LapSim VR Suturing Task x2

231 Virtual Reality Curriculum LapSim® (Surgical Science, Gothenburg Sweden) VR Surgical Simulator w/ haptic interface (Immersion Medical, USA). Proficiency-based progression Summative and formative feedback from LapSim

232 26 Surgical Residents LAPARPSCOPIC SUTURING STUDY DESIGN VR Group (N=10 ) Baseline Assessment Trainer Box Curriculum TB Group (N=10)

233 Trainer Box Curriculum FLS trainer box / “Intracorporeal Suturing Task” Expert instructor / examiner FLS normalized scoring criteria Feedback: From expert instructor

234 Trainer Box Curriculum Courtesy of 3-DMed

235 26 Surgical Residents VR Curriculum Post Test 1 LAPARPSCOPIC SUTURING STUDY DESIGN VR Group (N=10 ) Baseline Assessment Trainer Box Curriculum TB Group (N=10) Lap.Fundo Model / FLS Box

236 Laparoscopic Nissen fundoplication model Synthetic esophagus and gastric fundus Identical setup as for FLS grp Post-Test 1 Courtesy of Mount Sinai Hospital Surgical Skills Center, University of Toronto

237 Both groups FLS trainer box Expert rater / FLS certified Post-Test 1

238

239 3 interrupted, three-throw, squared knots to perform the “wrap” Instruments and sutures same as in OR Familiarization Live scoring Post-Test 1

240 Metrics: 1.Laparoscopic suturing checklist 2.OSATS global rating scale Post-Test 1

241 (D) Technique of KnottingYN 17 Two-handed Overwrap/underwrap followed by same10 OR if one handed, one followed by the other 18 Correct "C" loop (no "S" or "O" loops)10 19 Smoothly executed throw, no fumbles10 20 Correct inverse "C" loop (no "S" or "O" loops)10 21 Smoothly executed throw, no fumbles10 22 Knot squared (capsized reef/surgical)10 23 Correct third "C" loop (no "S" or "O" loops)10 24 Smoothly executed throw, no fumbles10 (E) Knot Slippage After the First Two ThrowsYN 25 Knot left loose to slip10 26 Knot slippage attempts (3 or <3)10 (F) Knot QualityYN 27 All throws squared10 28 Secure knot10 29 All knots laid on the side (not over the incision)10 TOTAL /29 (A-1) Needle Position (entry to incision)YN 1 Held at 1/2 to 2/3 from the tip10 2 Angle of 90 degrees +/- 20 degrees10 3 Uses tissue or other instrument for stability10 4 Attempts at positioning (3 or <3)10 (B-1) Needle Driving Through Tissue (entry to incision)YN 5 Entry at 60 to 90 degrees to the tissue plane10 6 Driving with one movement10 7 Single point of entry through tissue10 8 Removing the needle along its curve10 (A-2) Needle Position (incision to exit)YN 9 Held at 1/2 to 2/3 from the tip10 10 Angle of 90 degrees +/ Uses tissue or other instrument for stability10 12 Attempts at positioning (3 or <3)10 (B-2) Needle Driving (incision to exit)YN 13 Driving with one movement10 14 Removing the needle along its curve10 (C) Pulling the Suture ThroughYN 15 Needle held on needle holder in view at all times10 16 Using pulley concept or walking along the suture10 Endoscopic Suturing Check List (Moorthy et al. 2004)

242 Global Rating scale – OSATS (Martin et al. Br J Surg, 1997) Respect For TissueFrequently used unnecessary force on tissue or caused damage Careful handling of tissue but occasionally caused inadvertent damage Consistently handled tissues appropriately with minimal damage Time & MotionMany unnecessary moves Efficient time/motion but some unnecessary moves Economy of movement and maximum efficiency Instrument HandlingRepeatedly makes tentative or awkward moves with instruments Competent use of instruments although occasionally appeared stiff or awkward Fluid moves with instruments and no awkwardness Knowledge of Instruments Frequently asked for the wrong instrument or used an inappropriate instrument Knew the names of most instruments and used appropriate instrument or the task Obviously familiar with the instruments required and their names Use of AssistantsConsistently placed assistants poorly or failed to use them Good use of assistants most of the time Strategically used assistant to the best advantage at all times Flow of Operation & Forward Planning Frequently stopped operating or needed to discuss next move Demonstrated ability for forward planning with steady progression Obviously planned course of operation with effortless flow Knowledge of Specific Procedure Deficient knowledge. Needed specific instruction Knew all important aspects of the operation Demonstrated familiarity with all aspects of the operation

243 26 Surgical Residents VR Curriculum Post Test 1 LAPARPSCOPIC SUTURING STUDY DESIGN VR Group (N=10 ) Baseline Assessment Trainer Box Curriculum TB Group (N=10) Post Test 2 In the OR

244 Patient consent Intra-operative performance during Laparoscopic Nissen Fundoplication One of two blinded MIS Surgeons Post-Test 2

245 Video capture for analysis Post-operative scoring Metrics: 1.Laparoscopic suturing checklist 2.OSATS global rating scale Post-Test 2

246 26 Surgical Residents VR Curriculum LAPARPSCOPIC SUTURING STUDY DESIGN VR Group (N=10 ) Baseline Assessment Trainer Box Curriculum TB Group (N=10)Ctrl Group (N=6)Expert Group (N=3) 3 MIS Surgeons Post Test 1 Post Test 2

247 26 Surgical Residents RESULTS VR Group (N=10 ) TB Group (N=10)Ctrl Group (N=6)Expert Group (N=3) 3 MIS Surgeons No significant differences between Groups (Experience, demographics)

248 26 Surgical Residents RESULTS VR Group (N=10 ) Baseline Assessment TB Group (N=10)Ctrl Group (N=6)Expert Group (N=3) 3 MIS Surgeons No significant difference (LapSim Suturing Task)

249 26 Surgical Residents RESULTS VR Group (N=10 ) Baseline Assessment TB Group (N=10) Training time to proficiency - VR Grp significantly faster (p<.002) VR Curriculum Trainer Box Curriculum

250 26 Surgical Residents RESULTS VR Group (N=10 ) Baseline Assessment TB Group (N=10) Lap.Fundo Model / FLS Box No significant difference (Time, CL, OSATS) Post Test 1 VR Curriculum Trainer Box Curriculum

251 26 Surgical Residents VR Curriculum Post Test 1 (Trainer Box) RESULTS VR Group (N=10 ) Baseline Assessment Trainer Box Curriculum TB Group (N=10)Ctrl Group (N=6)Expert Group (N=3) Post Test 2 (Intra-operative) 3 MIS Surgeons

252 Post-Test 2: 29 operative cases recorded Compared subjects performance:  Time to suture completion  Laparoscopic suturing checklist scores  OSATS scores Results

253 Time (Sec)

254 Checklist Scores

255 OSAT Scores

256 Time to complete an intra-corporeal knot control group

257 Cost Analysis: Comparison Based on 5 Residents1 Year Cost5 Year Cost10 Year Cost TRAINER BOX $ 9, $ 23, $ 47, CTRL Curriculum $ 8, $ 43, $ 86, VR Curriculum $ 77, $ 80, $ 87,500.00

258 Cost Analysis: Comparison Based on 10 Residents1 Year Cost5 Year Cost10 Year Cost TRAINER BOX $ 11, $ 36, $ 72, CTRL Curriculum $ 17, $ 86, $ 173, VR Curriculum $ 77, $ 80, $ 87,500.00

259 Impact on the MIS Curriculum Residency programs can choose either/both curricula depending on their needs/resources Shifting the initial learning curve to the skills laboratory Safety / Resources / Time Simulation-based curricula are more cost effective than conventional OR training

260 Learning curve patterns in laparoscopic surgery. Can everyone learn it? Teodor Grantcharov MD, PhD, Peter Funch-Jensen MD, DSc 1 Department of Surgery, The Western Pennsylvania Hospital, Temple University School of Medicine, Pittsburgh, USA 2 Department of Surgery, Aarhus University Hospital, Aarhus, Denmark

261 Laparoscopic surgery loss of 3-D degraded tactile feed-back hand-eye coordination ”fulcrum effect”

262 Learning curves: the concept learning zone proficiency zone number of cases performance 1 2 3

263 Design 37 surgical trainees (< 10 lap. procedures) well-validated assessment tool (Procedicus MIST) 10 repetitions of 6 VR tasks in 1 month standardized distribution of practice proficiency levels established by experienced lap. surgeons (>100 lap. procedures) Friedman’s non-parametric test

264 Procedicus MIST™ PC based system basic surgical skills (CoreSkills) intracorporal suturing module progressive complexity training and assessment of key psychomotor skills

265 Procedicus MIST™: performance score TIME to complete the tasks number of ERRORS ECONOMY of movements

266 MIST –valid tool for assessment of laparoscopic psychomotor skills MIST-VR can differentiate between surgeons of different experience levels MIST-VR performance score correlates with performance score demonstrated during in-vivo procedures learning curves proportional to experience MIST-VR perfomence score demonstrates good test- retest reliability

267 VR as assessment tools: EAES consensus VR simulators are valid tools for training and assessment of lapsroscopic technical skills VR offers unique advantages and systems are considered suitable for implementation in an integrated surgical training and assessment programme EAES Working Group Recommendations, 2005

268 Results: time 8%

269 Results: errors attempt 8%

270 Results: economy of movements 8%

271 Conclusions 4 types of learning curves identified 8% of surgical trainees failed to demonstrate improvement with practice not everyone can achieve proficiency with laparoscopic technical skills challange for the training programmes of the future selection: when, how, by whom?

272 Time (Sec)

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274

275 Reznick and Folse Am.J.Surg. 154:520-25, surgery resident (PGY1-6) Rested ~7 hr. Fatigued <3hr. Factual recall test, identify abnormal laboratory values, purdue pegboard, simulated suturing No difference observed in any task Small sample size Heterogeneous sample population Sleep Measures Non-validated performance measures Relevant tasks???

276 Years of study in the O.R

277 Years of Study in the O.R. Focus on communication failures Qualitative methodologies Ethnographic approach 100’s of pages of transcript Emerging themes

278

279 Preliminary Checklist Results 252 cases: Frequency of Communication Failure

280 Effect of the Checklist 172 cases randomized Frequency of Failures t(170) = 6.91 p<.001


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