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A preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency with initial feedback
The American Journal of Surgery (2012) 204, 103–109
Surgical Education
A preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency with initial feedback Chandrakanth Are, M.D., F.R.C.S., F.A.C.S.a,b,*, Carol Lomneth, Ph.D.b, Hugh Stoddard, Ph.D.c, Kenneth Azarow, M.D., F.A.C.S.a, Jon S. Thompson, M.D., F.A.C.S.a a
Department of Surgery, University of Nebraska Center, 984030 Nebraska Medical Center, Omaha, NE 68198-4030, USA; bDepartment of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE, USA; cCurriculum and Education Research Office, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA KEYWORDS: Open surgery; Skills training; Surgery residents; Preliminary review; Pilot curriculum; Feedback
Abstract INTRODUCTION: The aim of this study is to provide a preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency and obtain initial feedback. DATA SOURCE: The general surgery residency program introduced an open surgical skills training curriculum in 2009. The skills sessions are undertaken under the guidance of the faculty. An annual survey was distributed to the residents and faculty to obtain their feedback. CONCLUSIONS: A total of 50 sessions were conducted over the last 2 years. Ninety-five percent of the residents perceived this educational activity to be above average to exceptional with nearly 70% rating it as exceptional. Sixty-three percent of the faculty perceived it as above average to exceptional, with nearly 40% rating it as exceptional. The open surgical skills training curriculum was rated as the most educational activity in the program by residents and faculty alike. © 2012 Elsevier Inc. All rights reserved.
The advent of laparoscopy has added a new paradigm to the surgical management of various diseases. Since its introduction in the early 1990s, we have seen an increase in the number of minimally invasive procedures performed by surgical residents.1–5 This has corresponded with a simultaneous and concerning decline in the number of open surgical procedures performed by surgical residents.1–5 Bell et al2 reviewed the operative experience data from the Residency Review Committee (RRC) for graduating US residents in 2005 and documented major deficiencies. They * Corresponding author. Tel.: ⫹1-402-559-8941; fax: ⫹1-402-559-7900. E-mail address: [email protected] Manuscript received May 18, 2011; revised manuscript July 13, 2011
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2011.08.007
reported that most residents did not perform the procedures considered important by the program directors enough number of times during residency. Similarly, Eckert et al3 correlated the nationwide inpatient sample database with Accreditation Council for Graduate Medical Education case log database and confirmed the nationwide decreasing trend in the number of open surgical cases. Chung and Ahmed1 noted that if the current trend continues, within 10 years the percentage of open procedures performed by residents will drop to less than 60% of that in 1993. Most surgical skills training curricula in general surgery residency focus mainly on acquiring training and assessing performance in minimally invasive surgery and other newly introduced techniques.6 –15 Although this is essential to stay
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The American Journal of Surgery, Vol 204, No 1, July 2012
abreast with the rapidly evolving surgical techniques, emphasis also needs to be placed on the methods to ensure that residents continue to remain technically competent in open surgical skills. Open surgery with its associated 3-dimensional aspects of surgical anatomy is the foundation of surgery and is also the platform upon which newer techniques can be taught. Surgical educators are increasingly becoming aware of the importance of teaching open surgical skills. This attains more importance in the current workhour environment and proposed future restrictions to be implemented in July 2011. The aim of this review was to describe a comprehensive skills curriculum to teach open surgical skills that is currently implemented at the University of Nebraska Medical Center with data on initial feedback from residents and faculty. Figure 2 Mobilizing the descending colon along the white line of Toldt for a left hemicolectomy.
Materials and methods Lightly embalmed cadavers Skills center The open surgical skills sessions are conducted in the Advanced Anatomy Laboratory (AAL, Fig. 1), which is a part of the Department of Genetics, Cell Biology and Anatomy at the University of Nebraska Medical Center. The AAL was opened in 2008 and designed with specifications similar to those seen in the operating room. The 890-sq ft AAL can accommodate up to 4 training stations and 24 trainees. These 4 working stations consist of radiolucent surgical tables, overhead surgical lights, compressed air, and both 120 and 220 volt electrical outlets. The Department of Surgery and the Department of Genetics, Cell Biology and Anatomy have pursued collaborative educational activities of mutual benefit since 2007.16,17 The result of these collaborations has led to the institution of several skills-based educational curricula for residents and medical students.
Figure 1 AAL in the Department of Genetics, Cell Biology and Anatomy.
The open surgical skills curriculum uses lightly embalmed cadavers. Several authors have shown the educational benefit of lightly embalmed cadavers.4,18,19 These cadavers are different from the fully embalmed cadavers that are used for dissection for the first-year medical student curriculum. Unlike the fully embalmed cadavers, the tissues in the lightly embalmed cadavers resemble live tissue more closely with regards to appearance and texture (Figs. 2 and 3). Because of this similarity, they are more useful and effective in identifying surgically relevant anatomic structures and teaching surgical procedures. The Deeded Body Program at the Department of Genetics, Cell Biology and Anatomy receives a steady supply of cadavers that are suitable for the lightly embalming process. The lightly embalmed cadavers can be kept in good condition at 2° to 5°C for up to a period of 6 to 8 weeks.
Figure 3 Performing total mesorectal excision for low anterior resection with sharp dissection under direct vision using scissors and electrocautery.
C. Are et al.
Open surgical skills training curriculum
Equipment The equipment consists of all types of open surgical instruments that are traditionally used in the operating room; hemostatic devices such as electrocautery and Ligasure; all types of staplers such as gastrointestinal (GIA), endoscopic GIA, End-to-end (EEA), roticulating, thoracoabdominal (TA) of varying sizes, various types of synthetic materials to repair hernia and perform vascular anastamoses, and suture materials of all types and sizes.
Structure of curriculum The University of Nebraska Medical Center has concentrated all its educational activities to 1 day of the week on a Wednesday. The open surgical skills training curriculum is undertaken on Wednesdays following the core conferences and is scheduled for 2 hours. This curriculum was started as a pilot during the academic years July 2008 to June 2009. During this period, teaching sessions were conducted on ad hoc basis to assess and gauge the level of interest among residents for this type of educational activity. The participating residents universally believed that this type of activity was useful for their training; after which, a structured curriculum was developed. Each open surgical skills training session is targeted for a particular postgraduate year (PGY) of training. These residents are excused from clinical activities during this period. Chief residents are exempted from attending the open skills curriculum. Each session also consists of 2 faculty members. Two lightly embalmed cadavers are requested for each session so that for each training station there are 2 residents and 1 faculty. There are several perceived advantages to this approach that we believe are responsible for the success of this curriculum. The focus on 1 PGY of training at a time leads to minimal disruption of the clinical services because residents from the other PGY years of training can continue with the routine clinical activities. This approach has led to an increase in the attendance at the skills sessions when compared with historical attendance rates at other types of skills activities in our program in the past. Second, the small group sessions are very beneficial because each resident actually gets to perform the procedures. The low faculty to resident ratio of 1:2 has the advantage of ensuring that the faculty member can focus on the training of each resident.
Cases to be covered The cases to be covered during the surgical skills curriculum are identified from the RRC-mandated list of procedures for general surgery residency. The entire curriculum is divided approximately into 6 modules, with each module consisting of 4 sessions. We request 2 lightly embalmed cadavers for each module. The structure of the curriculum enables us to undertake all 4 skills training sessions of each module on 2 cadavers. Each module starts with PGY1 and
105 progresses upwards. Within each module, there is a graded increase in the complexity of procedures performed. The purpose of this is to ensure that the procedures performed at any session do not affect the performance of procedures on subsequent sessions within the module. This enables the efficient use of cadavers to contain costs.
Resources and costs Faculty There has been a keen interest and significant participation by the faculty at our program. Currently, we have solicited the participation of up to 12 faculty members with a growing interest from others to participate. This participation is crucial to the success of any curriculum of this magnitude. Cadavers The cost of each lightly embalmed cadaver is approximately US$1,050. We currently order 12 cadavers for the academic year, which translates to an annual cost of approximately US$12,600. At times, there are lightly embalmed cadavers that are available to us at no cost. These are cadavers that are ordered by other specialties such as otohinolaryngology. Because major portions (ie, abdomen, thorax, and extremities) of the cadavers are not used, we tend to use them. This can contribute to the overall reduction in the cost of administering the curriculum.
Equipment Most of the equipment used in the cadaver laboratory has been obtained from supplies discarded from our operating room. The industry partner that supplies to our hospital assists us in obtaining the remaining equipment such as sutures, staples, and hemostatic devices and synthetic materials such as meshes and grafts. Because these supplies are opened but unused and kept aside for education, they are provided to us at no cost. This also helps us in training the residents to become familiar with all the staplers and hemostatic devices before they use them in the operating room.
Assessment The specific skill sets required and procedures performed during a clinical rotation are targeted to the appropriate level of training as mentioned. In addition, the specific attending staff members responsible for overseeing the operative procedures during clinical rotations are the instructor and assessor during the advanced anatomy laboratory sessions. A global assessment to verify competence and learner skills is undertaken for all procedures performed by each individual resident. The initial aspect of the global assessment consists of verifying adequate knowledge of the different types of sutures and their properties, knots, surgical instruments, and devices with their uses and limitations. The global assessment to test learner skills in operative proce-
106 Table 1
The American Journal of Surgery, Vol 204, No 1, July 2012 A sample of procedures undertaken during the open surgical skills curriculum
Date
Residents
No. of faculty
Procedures
10/6/10
PGY I
2
10/13/10 10/20/10 10/27/10 11/3/10 11/17/10 12/1/10
PGY PGY PGY PGY PGY PGY
II III IV I II III
2 2 2 2 2 2
12/8/10
PGY IV
2
Vascular exposures: femoral, popliteal, anterior tibial, posterior tibial, peroneal, axillary, brachial, radial, ulnar, carotid, subclavian Right hemicolectomy and incisional hernia repair: onlay, underlay Left hemicolectomy, sigmoid colectomy, low anterior resection Pulmonary wedge resection, lobectomy, pneumonectomy Inguinal and femoral hernia repair Left hemicolectomy, sigmoid colectomy, low anterior resection Gastrectomy-distal and total with Roux-en-Y esophagojejunostomy (purse string-anvil and EEA anastomosis)/adrenalectomy-left and right Right hepatectomy, left hepatectomy, left lateral segmentectomy, caudate resection
dures consists of the demonstration of an adequate knowledge of indications for the proposed procedure, types of incisions, key anatomic structures encountered during the procedure, operative steps in detailed sequence, and surgical anatomic tips and pearls for safe performance of the procedure. The demonstration of an adequate knowledge in both these aspects by residents is essential before allowing them to participate in the procedures in the advanced anatomy laboratory. During the procedure, the learner skills that are assessed include handling of instruments and devices, usage of appropriate instruments and devices, handling of tissues, ability to accurately identify key anatomical structures and planes of dissection, usage of appropriate suture material and tie knots, and description of the operative steps in sequence and perform the procedure. A satisfactory performance by residents on this global assessment will be essential before allowing them to perform the procedure on a live patient in the future.
Feedback A survey is distributed annually to the residents and faculty to assess the value of all the educational activities undertaken in the program including the open surgical skills training curriculum.
Results A structured curriculum was designed for the academic year 2009 to 2010 that consisted of 22 open surgical skills training sessions. This was increased to 26 sessions for the academic year 2010 to 2011 and is slated to increase to 27 sessions for 2011 to 2012. The cases to be covered are identified from the RRCmandated list of procedures for general surgery residency. The cases performed with a high degree of frequency during our residency and in surgical practice are also given importance. We currently include cases in the fields of general surgery, thoracic surgery, and vascular surgery. The procedures that are included are appropriate for PGY level of training in terms of complexity. As the academic year pro-
gresses, there is a graded increase in the complexity of cases performed by each PGY group of residents. A sample of the cases covered is shown in Table 1. The University of Nebraska Medical Center general surgery residency program consists of 4 categorical residents, 1 non-designated preliminary resident and 2 designated preliminary resident per year. The male to female ratio is 2:1. The 2 designated preliminary residents are in the urology track, whereas the remaining residents are in the general surgery track. An annual survey is distributed to all residents and faculty to assess the value of all educational activities undertaken during residency. The residents are asked to rate the educational activities ranging from unacceptable, needs improvement, below average, average, above average, to exceptional (Fig. 4). A response rate of 80% was obtained on the annual survey. Ninety-five percent of the residents rated the open skills training curriculum as above average to exceptional. Of these, nearly 70% of the residents believed that the open skills training curriculum was exceptional in educational value. The ratings for the open skills training curriculum are the highest among all the educational activities. The general surgery residents at the University of Nebraska Medical Center interact with approximately 50 faculty members during their training. These faculty members are from various disciplines such as general surgery, vascular surgery, trauma/critical care, surgical oncology, transplant surgery, cardiovascular surgery, plastic and reconstructive surgery, and pediatric surgery. A response rate of 38% was obtained on the survey (Fig. 5). Of the respondents, 63% of the faculty members rated this educational activity as above average to exceptional with 36.8% rating it as exceptional. Similar to the resident perceptions, the faculty rated these skills training sessions as the most educational activity in the residency program. It is likely that the “not applicable” represents the faculty members who have not participated in the skills training sessions.
Conclusions The currently evolving and potential further work-hour restrictions in the future are likely to place an increasing
C. Are et al.
Open surgical skills training curriculum
Figure 4
Residents’ perception of the open skills training curriculum.
strain on the traditional methods of imparting surgical skills to general surgery residents. New avenues to train surgical residents need to be explored or the older avenues of training need to be modulated to accommodate the changing environment. Second, the rapidly evolving field of innovative surgical technology is likely to add further new skills in which residents need to be trained. The surgeon of the future needs to be adequately trained in all the current and poten-
Figure 5
107
tially new surgical skills in a shrinking period. This includes open skills as well as all the various types of minimally invasive skills. The current skills training environment in general surgery residency places an emphasis on acquiring skills in minimally invasive surgery and other new techniques. This has led to a compromise in the time spent in imparting open surgical skills and is likely to worsen in the future.
Faculty perception of the open skills training curriculum.
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The American Journal of Surgery, Vol 204, No 1, July 2012
Open surgery and its associated appreciation of the 3-dimensional anatomy form the basis of surgical training. Open surgical anatomy is also the platform upon which trainees can be introduced to new techniques and technologies. Most surgical residents undertake anatomy education during their first year of medical school. This is administered for the entire class with minimal emphasis placed on surgical anatomy or students who may be interested in pursuing a surgical career. The period of anatomy education at most of the medical schools varies from 8 weeks to 10 weeks with some dedicating an even lesser period. It is also unlikely that these students will remember their anatomy 4 years afterwards. Studies have shown that medical students would prefer to return to the anatomy dissection laboratory later in the medical school years.20 –22 Insull et al20 noted that a great proportion of students believed that their knowledge of gross anatomy is inadequate for safe medical practice and expressed interest in revisiting the cadaver dissection. There are several advantages to the current curriculum. Our cadaver laboratory sessions provide the opportunity for surgical residents to revisit the human anatomy. This will help them appreciate the human anatomy from a surgical perspective. The cadavers also provide the opportunity to become familiar with anatomic variations and anomalies as seen in patients in the operating room. A better understanding of anatomy helps them to be more proficient not only in open procedures but also in minimally invasive procedures. Because these procedures are performed outside of the real operating room, skills training can be undertaken with low levels of stress in a learner-friendly environment. It is possible that, depending on the rotation, residents can perform procedures on cadavers before going to the operating room to undertake the same. Although a cost-comparative study is essential, it appears that the overall cost of the curriculum is acceptable when compared with many of the currently available simulators. In addition to the initial cost, further expenses for maintenance and upgrading of the training modules add to the overall cost of simulators. Any or nearly all procedures can be taught on the cadavers because there is a similarity to real patients in the operating room. In contrast, the limitations of the current mechanical trainers and simulators prevent them from being the ubiquitous tool for teaching surgical skills. Levine et al23 noted the difficulties in teaching residents skills related to dissection within the pelvis and the space of Retzius on mechanical trainers. Similarly, Leblanc et al18 highlighted the weaknesses of simulator-based training for colectomy in terms of replication of human anatomy, tissue planes, and consistency. Finally, there is currently a dearth of viable educational tools outside of the operating room to teach open surgical skills. Until such tools are available, skills training in cadaver laboratory may be the closest alternative to teaching open surgical skills. This curriculum also provides the platform for testing proficiency in technical skills in the future. The success of
such curricula can lend itself to devising various methods to assess the technical proficiency upon graduation from general surgery residency. We are in the process of developing such methods to assess proficiency in the technical aspects of surgical training. There are some disadvantages to the proposed curriculum. The availability of cadavers can be a limiting factor. Not all general surgery residency programs may have access to the type of facility described here with an adequate supply of cadavers. Second, although the interest among our faculty is growing, the indirect costs incurred because of the involvement of faculty need to be borne in mind. In summary, the article reviews a type of open surgical skills curriculum that is currently implemented at the University of Nebraska Medical Center. This curriculum is due to be expanded in the following years and can serve as a prototype for broader implementation.
References 1. Chung RS, Ahmed N. The impact of minimally invasive surgery on resident’s open operative experience. Ann Surg 2010;251:205–12. 2. Bell RH, Bieser TW, Tabuenca A, et al. Operative experience of residents in US general surgery programs. Ann Surg 2009;249:719 –24. 3. Eckert M, Cuadrado D, Steele S, et al. The changing face of the general surgeon: national and local trends in resident operative experience. Am J Surg 2010;199:652– 6. 4. DiMaggio PJ, Waer AL, Desmarais TJ, et al. The use of lightly preserved cadavers and full thickness pig skin to teach technical skills on the surgery clerkship-a response to the economic pressures facing academic medicine today. Am J Surg 2010;200:162– 6. 5. Alkhoury F, Martin JT, Contessa J, et al. The impact of laparoscopy on the volume of open cases in General Surgery training. J Surg Educ 2010;67:316 –9. 6. Kapadia MR, DaRosa DA, MacRae HM, et al. Current assessment and future directions of surgical skills laboratories. J Surg Educ 2007;64: 260 –5. 7. Korndorffer JR Jr, Stefanidis D, Scott DJ. Laparoscopic skills laboratories: current assessment and a call for resident training standards. Am J Surg 2005;191:17–22. 8. Aggarwal R, Crochet P, Dias A, et al. Development of a virtual reality training curriculum for laparoscopic cholecystectomy. Br J Surg 2009; 96:1086 –93. 9. Jamshidi R, LaMasters T, Eisenberg D, et al. Video self-assessment augments development of videoscopic suturing skill. J Am Coll Surg 2009;209:622–5. 10. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic training on bench models: better and more cost effective than operating room experience. J Am Coll Surg 2000;191:272– 83. 11. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance—results of an randomized double-blinded study. Ann Surg 2002;236:458 – 64. 12. Rosenthal ME, Castellvi AO, Goova MT, et al. Pretraining on southwestern stations decreases training time and cost for proficiency-based fundamentals of laparoscopic surgery training. J Am Coll Surg 2009; 209:626 –31. 13. Derevianko AY, Schwaitzberg SD, Tsuda S, et al. Malpractice carrier underwrites Fundamentals of laparoscopic Surgery training and testing: a benchmark for patient safety. Surg Endosc [Epub ahead of print]. 14. Castellvi AO, Hollett LA, Minhajuddin A, et al. Maintaining proficiency after fundamentals of laparoscopic surgery training: a 1-year analysis of skill retention for surgery residents. Surgery 2009;146: 387–93.
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Open surgical skills training curriculum
15. Hogle NJ, Chang L, Strong VE, et al. Validation of laparoscopic surgical skills training outside the operating room: a long road. Surg Endosc 2009;23:1476 – 82. 16. Are C, Stoddard H, Northam LC, et al. An experience in surgical anatomy to provide first-year medical students with an early exposure to general surgery: a pilot study. J Surg Educ 2010;66:186 –9. 17. Are C, Stoddard HA, Thompson JS, et al. The influence of surgical demonstrations during an anatomy course on the perceptions of firstyear medical students towards surgeons and a surgical career. J Surg Educ 2010;67:320 – 4. 18. Leblanc F, Senagor AJ, Ellis CN, et al. Hand-assisted laparoscopic sigmoid colectomy skills acquisition: augmented reality simulator versus human cadaver training models. J Surg Educ 2010;67:200 – 4.
109 19. Katz R, Hoznek A, Antiphon P, et al. Cadaveric versus porcine models in urological laparoscopic training. Urol Int 2003;71:310 –5. 20. Insull PJ, Kejriwal R, Blyth P. Surgical inclination and anatomy teaching at eh University of Auckland. ANZ J Surg 2006;76:1056 –9. 21. Waterston SW, Stewart IJ. Survey of clinicians attitudes to the anatomical teaching and knowledge of medical students. Clin Anat 2005; 18:380 – 4. 22. Pabst R. Gross anatomy: an outdated subject or an essential part of a modern medical curriculum? Results of a questionnaire circulated to final-year medical students. Anat Rec 1993;23:431–3. 23. Levine RL, Kives S, Cathey G, et al. The use of lightly embalmed (fresh tissue) cadavers for resident laparoscopic training. J Minim Invasive Gynecol 2006;13:451– 6.
Surgical Education
A preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency with initial feedback Chandrakanth Are, M.D., F.R.C.S., F.A.C.S.a,b,*, Carol Lomneth, Ph.D.b, Hugh Stoddard, Ph.D.c, Kenneth Azarow, M.D., F.A.C.S.a, Jon S. Thompson, M.D., F.A.C.S.a a
Department of Surgery, University of Nebraska Center, 984030 Nebraska Medical Center, Omaha, NE 68198-4030, USA; bDepartment of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE, USA; cCurriculum and Education Research Office, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA KEYWORDS: Open surgery; Skills training; Surgery residents; Preliminary review; Pilot curriculum; Feedback
Abstract INTRODUCTION: The aim of this study is to provide a preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency and obtain initial feedback. DATA SOURCE: The general surgery residency program introduced an open surgical skills training curriculum in 2009. The skills sessions are undertaken under the guidance of the faculty. An annual survey was distributed to the residents and faculty to obtain their feedback. CONCLUSIONS: A total of 50 sessions were conducted over the last 2 years. Ninety-five percent of the residents perceived this educational activity to be above average to exceptional with nearly 70% rating it as exceptional. Sixty-three percent of the faculty perceived it as above average to exceptional, with nearly 40% rating it as exceptional. The open surgical skills training curriculum was rated as the most educational activity in the program by residents and faculty alike. © 2012 Elsevier Inc. All rights reserved.
The advent of laparoscopy has added a new paradigm to the surgical management of various diseases. Since its introduction in the early 1990s, we have seen an increase in the number of minimally invasive procedures performed by surgical residents.1–5 This has corresponded with a simultaneous and concerning decline in the number of open surgical procedures performed by surgical residents.1–5 Bell et al2 reviewed the operative experience data from the Residency Review Committee (RRC) for graduating US residents in 2005 and documented major deficiencies. They * Corresponding author. Tel.: ⫹1-402-559-8941; fax: ⫹1-402-559-7900. E-mail address: [email protected] Manuscript received May 18, 2011; revised manuscript July 13, 2011
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2011.08.007
reported that most residents did not perform the procedures considered important by the program directors enough number of times during residency. Similarly, Eckert et al3 correlated the nationwide inpatient sample database with Accreditation Council for Graduate Medical Education case log database and confirmed the nationwide decreasing trend in the number of open surgical cases. Chung and Ahmed1 noted that if the current trend continues, within 10 years the percentage of open procedures performed by residents will drop to less than 60% of that in 1993. Most surgical skills training curricula in general surgery residency focus mainly on acquiring training and assessing performance in minimally invasive surgery and other newly introduced techniques.6 –15 Although this is essential to stay
104
The American Journal of Surgery, Vol 204, No 1, July 2012
abreast with the rapidly evolving surgical techniques, emphasis also needs to be placed on the methods to ensure that residents continue to remain technically competent in open surgical skills. Open surgery with its associated 3-dimensional aspects of surgical anatomy is the foundation of surgery and is also the platform upon which newer techniques can be taught. Surgical educators are increasingly becoming aware of the importance of teaching open surgical skills. This attains more importance in the current workhour environment and proposed future restrictions to be implemented in July 2011. The aim of this review was to describe a comprehensive skills curriculum to teach open surgical skills that is currently implemented at the University of Nebraska Medical Center with data on initial feedback from residents and faculty. Figure 2 Mobilizing the descending colon along the white line of Toldt for a left hemicolectomy.
Materials and methods Lightly embalmed cadavers Skills center The open surgical skills sessions are conducted in the Advanced Anatomy Laboratory (AAL, Fig. 1), which is a part of the Department of Genetics, Cell Biology and Anatomy at the University of Nebraska Medical Center. The AAL was opened in 2008 and designed with specifications similar to those seen in the operating room. The 890-sq ft AAL can accommodate up to 4 training stations and 24 trainees. These 4 working stations consist of radiolucent surgical tables, overhead surgical lights, compressed air, and both 120 and 220 volt electrical outlets. The Department of Surgery and the Department of Genetics, Cell Biology and Anatomy have pursued collaborative educational activities of mutual benefit since 2007.16,17 The result of these collaborations has led to the institution of several skills-based educational curricula for residents and medical students.
Figure 1 AAL in the Department of Genetics, Cell Biology and Anatomy.
The open surgical skills curriculum uses lightly embalmed cadavers. Several authors have shown the educational benefit of lightly embalmed cadavers.4,18,19 These cadavers are different from the fully embalmed cadavers that are used for dissection for the first-year medical student curriculum. Unlike the fully embalmed cadavers, the tissues in the lightly embalmed cadavers resemble live tissue more closely with regards to appearance and texture (Figs. 2 and 3). Because of this similarity, they are more useful and effective in identifying surgically relevant anatomic structures and teaching surgical procedures. The Deeded Body Program at the Department of Genetics, Cell Biology and Anatomy receives a steady supply of cadavers that are suitable for the lightly embalming process. The lightly embalmed cadavers can be kept in good condition at 2° to 5°C for up to a period of 6 to 8 weeks.
Figure 3 Performing total mesorectal excision for low anterior resection with sharp dissection under direct vision using scissors and electrocautery.
C. Are et al.
Open surgical skills training curriculum
Equipment The equipment consists of all types of open surgical instruments that are traditionally used in the operating room; hemostatic devices such as electrocautery and Ligasure; all types of staplers such as gastrointestinal (GIA), endoscopic GIA, End-to-end (EEA), roticulating, thoracoabdominal (TA) of varying sizes, various types of synthetic materials to repair hernia and perform vascular anastamoses, and suture materials of all types and sizes.
Structure of curriculum The University of Nebraska Medical Center has concentrated all its educational activities to 1 day of the week on a Wednesday. The open surgical skills training curriculum is undertaken on Wednesdays following the core conferences and is scheduled for 2 hours. This curriculum was started as a pilot during the academic years July 2008 to June 2009. During this period, teaching sessions were conducted on ad hoc basis to assess and gauge the level of interest among residents for this type of educational activity. The participating residents universally believed that this type of activity was useful for their training; after which, a structured curriculum was developed. Each open surgical skills training session is targeted for a particular postgraduate year (PGY) of training. These residents are excused from clinical activities during this period. Chief residents are exempted from attending the open skills curriculum. Each session also consists of 2 faculty members. Two lightly embalmed cadavers are requested for each session so that for each training station there are 2 residents and 1 faculty. There are several perceived advantages to this approach that we believe are responsible for the success of this curriculum. The focus on 1 PGY of training at a time leads to minimal disruption of the clinical services because residents from the other PGY years of training can continue with the routine clinical activities. This approach has led to an increase in the attendance at the skills sessions when compared with historical attendance rates at other types of skills activities in our program in the past. Second, the small group sessions are very beneficial because each resident actually gets to perform the procedures. The low faculty to resident ratio of 1:2 has the advantage of ensuring that the faculty member can focus on the training of each resident.
Cases to be covered The cases to be covered during the surgical skills curriculum are identified from the RRC-mandated list of procedures for general surgery residency. The entire curriculum is divided approximately into 6 modules, with each module consisting of 4 sessions. We request 2 lightly embalmed cadavers for each module. The structure of the curriculum enables us to undertake all 4 skills training sessions of each module on 2 cadavers. Each module starts with PGY1 and
105 progresses upwards. Within each module, there is a graded increase in the complexity of procedures performed. The purpose of this is to ensure that the procedures performed at any session do not affect the performance of procedures on subsequent sessions within the module. This enables the efficient use of cadavers to contain costs.
Resources and costs Faculty There has been a keen interest and significant participation by the faculty at our program. Currently, we have solicited the participation of up to 12 faculty members with a growing interest from others to participate. This participation is crucial to the success of any curriculum of this magnitude. Cadavers The cost of each lightly embalmed cadaver is approximately US$1,050. We currently order 12 cadavers for the academic year, which translates to an annual cost of approximately US$12,600. At times, there are lightly embalmed cadavers that are available to us at no cost. These are cadavers that are ordered by other specialties such as otohinolaryngology. Because major portions (ie, abdomen, thorax, and extremities) of the cadavers are not used, we tend to use them. This can contribute to the overall reduction in the cost of administering the curriculum.
Equipment Most of the equipment used in the cadaver laboratory has been obtained from supplies discarded from our operating room. The industry partner that supplies to our hospital assists us in obtaining the remaining equipment such as sutures, staples, and hemostatic devices and synthetic materials such as meshes and grafts. Because these supplies are opened but unused and kept aside for education, they are provided to us at no cost. This also helps us in training the residents to become familiar with all the staplers and hemostatic devices before they use them in the operating room.
Assessment The specific skill sets required and procedures performed during a clinical rotation are targeted to the appropriate level of training as mentioned. In addition, the specific attending staff members responsible for overseeing the operative procedures during clinical rotations are the instructor and assessor during the advanced anatomy laboratory sessions. A global assessment to verify competence and learner skills is undertaken for all procedures performed by each individual resident. The initial aspect of the global assessment consists of verifying adequate knowledge of the different types of sutures and their properties, knots, surgical instruments, and devices with their uses and limitations. The global assessment to test learner skills in operative proce-
106 Table 1
The American Journal of Surgery, Vol 204, No 1, July 2012 A sample of procedures undertaken during the open surgical skills curriculum
Date
Residents
No. of faculty
Procedures
10/6/10
PGY I
2
10/13/10 10/20/10 10/27/10 11/3/10 11/17/10 12/1/10
PGY PGY PGY PGY PGY PGY
II III IV I II III
2 2 2 2 2 2
12/8/10
PGY IV
2
Vascular exposures: femoral, popliteal, anterior tibial, posterior tibial, peroneal, axillary, brachial, radial, ulnar, carotid, subclavian Right hemicolectomy and incisional hernia repair: onlay, underlay Left hemicolectomy, sigmoid colectomy, low anterior resection Pulmonary wedge resection, lobectomy, pneumonectomy Inguinal and femoral hernia repair Left hemicolectomy, sigmoid colectomy, low anterior resection Gastrectomy-distal and total with Roux-en-Y esophagojejunostomy (purse string-anvil and EEA anastomosis)/adrenalectomy-left and right Right hepatectomy, left hepatectomy, left lateral segmentectomy, caudate resection
dures consists of the demonstration of an adequate knowledge of indications for the proposed procedure, types of incisions, key anatomic structures encountered during the procedure, operative steps in detailed sequence, and surgical anatomic tips and pearls for safe performance of the procedure. The demonstration of an adequate knowledge in both these aspects by residents is essential before allowing them to participate in the procedures in the advanced anatomy laboratory. During the procedure, the learner skills that are assessed include handling of instruments and devices, usage of appropriate instruments and devices, handling of tissues, ability to accurately identify key anatomical structures and planes of dissection, usage of appropriate suture material and tie knots, and description of the operative steps in sequence and perform the procedure. A satisfactory performance by residents on this global assessment will be essential before allowing them to perform the procedure on a live patient in the future.
Feedback A survey is distributed annually to the residents and faculty to assess the value of all the educational activities undertaken in the program including the open surgical skills training curriculum.
Results A structured curriculum was designed for the academic year 2009 to 2010 that consisted of 22 open surgical skills training sessions. This was increased to 26 sessions for the academic year 2010 to 2011 and is slated to increase to 27 sessions for 2011 to 2012. The cases to be covered are identified from the RRCmandated list of procedures for general surgery residency. The cases performed with a high degree of frequency during our residency and in surgical practice are also given importance. We currently include cases in the fields of general surgery, thoracic surgery, and vascular surgery. The procedures that are included are appropriate for PGY level of training in terms of complexity. As the academic year pro-
gresses, there is a graded increase in the complexity of cases performed by each PGY group of residents. A sample of the cases covered is shown in Table 1. The University of Nebraska Medical Center general surgery residency program consists of 4 categorical residents, 1 non-designated preliminary resident and 2 designated preliminary resident per year. The male to female ratio is 2:1. The 2 designated preliminary residents are in the urology track, whereas the remaining residents are in the general surgery track. An annual survey is distributed to all residents and faculty to assess the value of all educational activities undertaken during residency. The residents are asked to rate the educational activities ranging from unacceptable, needs improvement, below average, average, above average, to exceptional (Fig. 4). A response rate of 80% was obtained on the annual survey. Ninety-five percent of the residents rated the open skills training curriculum as above average to exceptional. Of these, nearly 70% of the residents believed that the open skills training curriculum was exceptional in educational value. The ratings for the open skills training curriculum are the highest among all the educational activities. The general surgery residents at the University of Nebraska Medical Center interact with approximately 50 faculty members during their training. These faculty members are from various disciplines such as general surgery, vascular surgery, trauma/critical care, surgical oncology, transplant surgery, cardiovascular surgery, plastic and reconstructive surgery, and pediatric surgery. A response rate of 38% was obtained on the survey (Fig. 5). Of the respondents, 63% of the faculty members rated this educational activity as above average to exceptional with 36.8% rating it as exceptional. Similar to the resident perceptions, the faculty rated these skills training sessions as the most educational activity in the residency program. It is likely that the “not applicable” represents the faculty members who have not participated in the skills training sessions.
Conclusions The currently evolving and potential further work-hour restrictions in the future are likely to place an increasing
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Open surgical skills training curriculum
Figure 4
Residents’ perception of the open skills training curriculum.
strain on the traditional methods of imparting surgical skills to general surgery residents. New avenues to train surgical residents need to be explored or the older avenues of training need to be modulated to accommodate the changing environment. Second, the rapidly evolving field of innovative surgical technology is likely to add further new skills in which residents need to be trained. The surgeon of the future needs to be adequately trained in all the current and poten-
Figure 5
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tially new surgical skills in a shrinking period. This includes open skills as well as all the various types of minimally invasive skills. The current skills training environment in general surgery residency places an emphasis on acquiring skills in minimally invasive surgery and other new techniques. This has led to a compromise in the time spent in imparting open surgical skills and is likely to worsen in the future.
Faculty perception of the open skills training curriculum.
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The American Journal of Surgery, Vol 204, No 1, July 2012
Open surgery and its associated appreciation of the 3-dimensional anatomy form the basis of surgical training. Open surgical anatomy is also the platform upon which trainees can be introduced to new techniques and technologies. Most surgical residents undertake anatomy education during their first year of medical school. This is administered for the entire class with minimal emphasis placed on surgical anatomy or students who may be interested in pursuing a surgical career. The period of anatomy education at most of the medical schools varies from 8 weeks to 10 weeks with some dedicating an even lesser period. It is also unlikely that these students will remember their anatomy 4 years afterwards. Studies have shown that medical students would prefer to return to the anatomy dissection laboratory later in the medical school years.20 –22 Insull et al20 noted that a great proportion of students believed that their knowledge of gross anatomy is inadequate for safe medical practice and expressed interest in revisiting the cadaver dissection. There are several advantages to the current curriculum. Our cadaver laboratory sessions provide the opportunity for surgical residents to revisit the human anatomy. This will help them appreciate the human anatomy from a surgical perspective. The cadavers also provide the opportunity to become familiar with anatomic variations and anomalies as seen in patients in the operating room. A better understanding of anatomy helps them to be more proficient not only in open procedures but also in minimally invasive procedures. Because these procedures are performed outside of the real operating room, skills training can be undertaken with low levels of stress in a learner-friendly environment. It is possible that, depending on the rotation, residents can perform procedures on cadavers before going to the operating room to undertake the same. Although a cost-comparative study is essential, it appears that the overall cost of the curriculum is acceptable when compared with many of the currently available simulators. In addition to the initial cost, further expenses for maintenance and upgrading of the training modules add to the overall cost of simulators. Any or nearly all procedures can be taught on the cadavers because there is a similarity to real patients in the operating room. In contrast, the limitations of the current mechanical trainers and simulators prevent them from being the ubiquitous tool for teaching surgical skills. Levine et al23 noted the difficulties in teaching residents skills related to dissection within the pelvis and the space of Retzius on mechanical trainers. Similarly, Leblanc et al18 highlighted the weaknesses of simulator-based training for colectomy in terms of replication of human anatomy, tissue planes, and consistency. Finally, there is currently a dearth of viable educational tools outside of the operating room to teach open surgical skills. Until such tools are available, skills training in cadaver laboratory may be the closest alternative to teaching open surgical skills. This curriculum also provides the platform for testing proficiency in technical skills in the future. The success of
such curricula can lend itself to devising various methods to assess the technical proficiency upon graduation from general surgery residency. We are in the process of developing such methods to assess proficiency in the technical aspects of surgical training. There are some disadvantages to the proposed curriculum. The availability of cadavers can be a limiting factor. Not all general surgery residency programs may have access to the type of facility described here with an adequate supply of cadavers. Second, although the interest among our faculty is growing, the indirect costs incurred because of the involvement of faculty need to be borne in mind. In summary, the article reviews a type of open surgical skills curriculum that is currently implemented at the University of Nebraska Medical Center. This curriculum is due to be expanded in the following years and can serve as a prototype for broader implementation.
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