- Email: [email protected]
A needs-assessment study for continuing professional development in advanced minimally invasive surgery
The American Journal of Surgery 193 (2007) 593–596
Scientific paper
A needs-assessment study for continuing professional development in advanced minimally invasive surgery Tom Wallace, M.D., Daniel W. Birch, M.Sc., M.D.* Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Department of Surgery, University of Alberta, Royal Alexandra Hospital, Capital Health, 10240 Kingsway, Edmonton, Alberta, Canada T5H 3V9 Manuscript received December 2, 2006; revised manuscript January 21, 2007 Presented at the 93rd Annual Meeting of the North Pacific Surgical Association, Spokane, WA, November 10 –11, 2006
Abstract Background: The ideal continuing professional development (CPD) model to transfer advanced minimally invasive surgical (MIS) skills to surgeons in practice has not yet been determined. Methods: A survey of general surgeons practicing in Alberta was conducted to determine attitudes toward CPD with a focus on MIS colon surgery. Two separate mailings of the survey were conducted in both hard copy and e-mail format. Data were collected and analyzed. Results: Seventy-one of 92 surveys were returned, yielding a response rate of 77%. The majority (62%) of surgeons had received their training while in practice. The most prevalent form of CPD was short courses, with 82% of surgeons having attended at least 1 short course in MIS. When directly comparing short courses with mentorship, 69% of respondents rated courses as less helpful, whereas 21% thought they were equivalent to mentorship. Sixty-one percent of surgeons are interested in a comprehensive approach, such as a mini-fellowship, to learning laparoscopic colorectal surgery. Conclusions: General surgeons want access to different modalities of training, including both mentorship experiences and short courses. They are willing to take time away from their practices to learn new MIS skills. The best way to provide CPD to practicing surgeons is likely through a combination of teaching interventions, including courses, mentoring relationships, and the application of new technologies. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Education; Laparoscopy; Mentor; Physician practice patterns
Minimally invasive surgery (MIS) has evolved dramatically since its inception for gastrointestinal disease in 1988 [1]. Laparoscopic colorectal resection was reported as early as 1991 [2]. Despite initial reports of unacceptable complication rates, recent publications have described the safety and efficacy of a minimally invasive approach to colorectal disease [3]. These reports have renewed the interest in laparoscopic colorectal surgery (LCS) and created a need for a training model for surgeons in practice. Currently, the optimal continuing professional development (CPD) format for practicing surgeons has not been determined [4]. The challenge for the surgical community is the safe transfer of new surgical skills and technologies to surgeons in practice. During the adoption of laparoscopic cholecystectomy by surgeons, short courses were the most prevalent * Corresponding author. Tel.: ⫹1-780-735-4786; fax: ⫹1-780-735-4771. E-mail address: [email protected]
form of CPD [5]. However, the appropriateness of short courses to teach new surgical skills has been widely questioned [6]. Despite these concerns, few viable alternatives have been developed, and short courses remain the most common form of CPD for MIS [7,8]. Alternatives to short courses have been proposed [9 –11]. These alternatives offer longer exposure to training and consist of a mentoring relationship between a preceptor and learner. Our experience with mentoring in LCS suggests that it may become a successful model; however, its limitations and feasibility for surgeons in practice have yet to be clearly defined. To facilitate the development of a provincial mentoring network for LCS, we completed a needs assessment for general surgeons in Alberta on mentoring of advanced MIS. Methods A list of all general surgeons practicing in Alberta was obtained from the College of Physicians and Surgeons of
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.01.004
594
T. Wallace and D.W. Birch / The American Journal of Surgery 193 (2007) 593–596
Alberta. All subspecialists and retired surgeons, as well as those who do not practice colorectal surgery, were excluded. In addition, an up-to-date list of e-mail addresses was prepared. A survey was drafted by a group of general surgeons with an interest in MIS, surgical education, and surgical oncology. The survey consisted of sections on demographics, previous MIS training, and attitudes toward the short course and mentorship models of training. Two mailings of the survey were carried out to maximize response rate. This included mailings and group e-mails. A cover letter from all involved parties stating the purposes of the study was included. Respondents returned hard copies of completed surveys or submitted responses online. All responses were entered into an online survey program for final analysis. Results Ninety-two surveys were mailed out; of these, 71 were returned (response rate 77%). Respondents had a mean age of 48 years, and 84% were male and had been in surgical practice for 15 years. Sixty six percent of respondents described their surgical practice as “community based.” The majority of respondents (62%) claimed they had received MIS training while in practice. Eight percent had completed fellowships, and 31% had most of their MIS training during residency. While in practice, 82% had attended some sort of advanced MIS course. The types of courses attended included general (45%), incisional hernia (38%), gastroesophageal reflux disease (24%), and colorectal (62%). The most common reason cited for not attending a course was time restraints. Most surgeons (83%) were interested in attending a MIS colorectal course if it was held within Alberta. Respondents believed that MIS colorectal surgery were either comparable (48%) or more difficult than open surgery skills (52%); no surgeons reported MIS as being easier than open surgery skills. Surgeons were asked to estimate the number of MIS cases for which they had been mentored. These results are listed in Table 1. An assessment of surgeons’ impressions of short courses and mentorship-type training was made. Surgeons were asked if they believed that these different methods prepared them for introducing MIS techniques into practice. On a 1 to 5 scale (1 being never helpful and 5 being very helpful), the average response for short courses was 3.59, whereas for mentoring it was 4.27. When asked to directly compare the two methods, 69% of respondents rated courses as less helpful; 21% thought they were equivalent; and only 10%
Fig. 1. Potential barriers to adopting advanced minimally invasive surgery into practice. Likert scale anchors: 1 ⫽ unimportant, 3 ⫽ somewhat important, and 5 ⫽ very important.
thought courses were superior to mentorship. The majority of respondents (62%) believe that advanced MIS should not be attempted without a mentor, whereas 31% indicated it may be acceptable in certain instances. The majority of respondents believed that surgeons performing advanced MIS should not require credentials from a licensing body (74%). The barriers to performing advanced MIS were ranked and are presented in Fig. 1. Time away from practice is believed to be the most important reason why surgeons may be unable to attend a comprehensive MIS training program. Despite this, surgeons indicated they would be willing to spend an appreciable amount of time away from practice to learn advanced MIS (Fig. 2). Sixty-one percent of surgeons were interested in a comprehensive approach, such as a mini-fellowship, to learning laparoscopic colorectal surgery. Several open-ended questions were included in the survey. When asked what short courses lacked to help prepare surgeons for incorporating routine advanced MIS into their practices, the most common responses were a lack of hands-on experience (n ⫽ 24 responses) and the absence of a mentoring-type relationship (n ⫽ 13 responses). When the same question was asked about mentoring, availability of mentors was the most common response (n ⫽ 7 responses). When asked if there was any substitute for mentoring, the most common response (n ⫽ 15 responses) was “no.”
Table 1 Reported mentoring by respondents (N ⫽ 79) for advanced MIS No. procedures
Colorectal
Incisional hernia repair
Upper GI
Hepatobiliary
0 1–5 6–10 11–20 21–30 ⬎30
29 12 9 2 1 3
24 17 7 0 0 1
26 9 6 1 1 2
22 6 5 3 2 12
GI ⫽ gastrointestinal.
Fig. 2. Surgeon allowance of time away from practice for mentoring in advanced minimally invasive surgery.
T. Wallace and D.W. Birch / The American Journal of Surgery 193 (2007) 593–596
Comments We have previously shown that surgeons in practice will adopt advanced MIS procedures into practice without any form of formal training or following attendance at short postgraduate courses [7,8]. We believe this may be caused by a lack of appropriate training initiatives within Canada to address the problem of training surgeons in new techniques and technologies. See et al described the risk associated with the adoption of MIS procedures by American urologists following a short course as well as the positive impact of further training [12–14]. Several investigators have described their learning curve for various procedures in MIS [15,16]. Remarkable variation exists in the number of procedures that are believed to be necessary to achieve competence. A recent publication highlighted this predicament. Fazio et al recently suggested that the learning curve for a laparoscopic right hemicolectomy may be as high as 55 procedures [17]. The learning curve is an important concept because it describes the willingness of surgeons to embark on a “self-training” initiative in new and complex surgical procedures. The safety and appropriateness of this approach remains to be seen, although historically this has not proven to be successful. There is growing dissatisfaction with this concept, and several investigators have discussed the associated ethical and moral dilemmas associated with the learning curve [4]. Moreover, the learning curve often implies the experience of an expert surgeon with a dedicated surgical team and may have little relevance or applicability to the community of surgeons [18,19]. Specialty groups have published guidelines for developing MIS courses as well as for granting MIS privileges [20,21]. To comply with these guidelines, a surgeon is required to attend a course, to assist on several procedures, and then to complete additional procedures with a mentor until proficient. However, in the past, compliance with guidelines has been poor. Only 50% of surgeons satisfied the Society of American Gastrointestinal and Endoscopic Surgeons guidelines for introducing laparoscopic surgery into their practice. They cited various challenges, including lack of training opportunities, funds, and experienced colleagues [22]. Based on our data, surgeons would likely resist the implementation of mandatory credentials to perform advanced MIS. Respondents to our survey seemed to prefer a mentorship model to short courses. Seventy-three percent of respondents stated that mentorship may be a more appropriate method by which to acquire MIS and may be more likely to lead to adoption of MIS procedures into practice. Surgeons ranked time away from work as the most important obstacle to MIS training. However, 77% indicated that they would take at least 1 week to learn advanced MIS, and 36% indicated they would take at least 3 weeks. Centers of excellence have developed short courses for practicing surgeons, but they are likely inadequate as standalone teaching interventions. Alternatives, such as mentoring, have not been widely adopted for various reasons. Our survey shows that general surgeons want access to different modalities of training, including both mentorship experiences and short courses. Also, they are willing to take time away from their practices to learn new MIS skills. The best
595
way to provide CPD for MIS to practicing surgeons is likely through a combination of teaching interventions, including courses, mentoring relationships, and the application of new technologies. Acknowledgments The authors wish to thank the staff of Cancer Surgery Alberta for their assistance in administering this survey. References [1] Litynski GS. Profiles in laparoscopy: Mouret, Dubois and Perissat— The laparoscopic breakthrough in Europe (1987–1988). J Soc Laparoendosc Surg 1999;3:163–7. [2] Saclarides TJ, Ko ST, Airan M, et al. Laparoscopic removal of a large colonic lipoma. Report of a case. Dis Colon Rectum 1991;34(11): 1027–9. [3] The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350(20):2050 –9. [4] Rogers D. Ethical and educational considerations in minimally invasive surgery training for practicing surgeons. Semin Laparosc Surg 2002;9(4):206 –11. [5] Bailey RW, Imbembo AL, Zucker KA. Establishment of a laparoscopic cholecystectomy training program. Am Surg 1991;57(4):231– 6. [6] Hunter JG, Sackier JM, Berci G. Training in laparoscopic cholecystectomy. Quantifying the learning curve. Surg Endosc 1994;8(1):28 –31. [7] Birch DW, Misra M, Farrokhyar F. The feasibility of introducing advanced minimally invasive surgery into practice. Can J Surg 2007 (in press). [8] Birch DW, Sample C, Gupta R. The impact of a comprehensive course in advanced minimal access surgery on surgeon practice. Can J Surg 2007 (in press). [9] Heniford BT, Backus CL, Matthews BD, et al. Optimal teaching environment for laparoscopic splenectomy. Am J Surg 2001;181(3):226 –30. [10] Rogers DA, Elstein AS, Bordage G. Improving continuing medical education for surgical techniques: applying the lessons learned in the first decade of minimal access surgery. Ann Surg 2001;233:159 – 66. [11] Heniford BT, Matthews BD, Box EA, et al. Optimal teaching environment for laparoscopic ventral herniorrhaphy. Hernia 2002;6(1): 17–20. [12] See WA, Fisher RJ, Winfield HN, et al. Laparoscopic surgical training: effectiveness and impact on urological surgical practice patterns. J Urol 1993;149(5):1054 –7. [13] See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic complications after formal training in laparoscopic surgery. JAMA 1993; 270(22):2689 –92. [14] See WA, Cooper CS, Fisher RJ. Urological laparoscopic practice patterns 1 year after formal training. J Urol 1994;151(6):1595– 8. [15] Voitk AJ. The learning curve in laparoscopic inguinal hernia repair for the community general surgeon. Can J Surg 1998;41(6):446 –50. [16] Voitk AJ, Joffe J, Alvarez, et al. Factors contributing to laparoscopic failure during the learning curve for laparoscopic Nissen fundoplication in a community hospital. J Laparoendosc Adv Surg Tech 1999; 9(3):243– 8. [17] Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 2005;242(1):83–91. [18] Winer WK. The role of the operating room staff in operative laparoscopy. J Am Assoc Gynecol Laparosc 1993;1(1):86 – 8. [19] Kenyon TA, Lenker MP, Bax TW, et al. Cost and benefit of the trained laparoscopic team. A comparative study of a designated nursing team vs a nontrained team. Surg Endosc 1997;11(8):812– 4. [20] Society of American Gastrointestinal and Endoscopic Surgeons. Framework for Post-Residency Surgical Education and Training. A SAGES Guideline. Los Angeles, CA: Society of American Gastrointestinal and Endoscopic Surgeons; 1995. [21] Society of American Gastrointestinal and Endoscopic Surgeons. Granting of privileges for laparoscopic general surgery. Am J Surg 1991;161:324 –5. [22] Escarce JJ, Shea JA, Schwartz JS. How practicing surgeons trained for laparoscopic cholecystectomy. Med Care 1997;35:291– 6.
596
T. Wallace and D.W. Birch / The American Journal of Surgery 193 (2007) 593–596
Discussion Marc D. Horton, M.D. (Seattle, WA): This issue is an ongoing problem in our profession. I applaud the authors in tackling what is clearly a challenge for all of us. Whether our practice settings are academic, private, urban, rural, north, or south of the border—they have addressed a problem for which a perfect solution has not yet been found. In the previous report, Dr Birch presented the advantages their group found to having a mentor to help introduce new MIS procedures. In this paper, Dr Wallace presented the results of a survey of general surgeons in Alberta to ascertain their needs in continuing professional development in the arena of minimally invasive colon surgery. Having now heard both of these papers, my question to the authors is what has the University of Alberta done to address the needs of their surgeons? What are your recommendations regarding strategies for continuing professional development in advanced MIS skills? McGill University developed the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills. This was incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons in their Fundamentals
of Laparoscopic Surgery program. It was shown to be a practical and inexpensive system to teach and measure technical laparoscopic skills. The American College of Surgeons is investigating mechanisms to measure the core competencies of their members ranging from professionalism to clinical capabilities, to maintain excellence. MIS skills could fall into this mix. How the College plans to measure such competencies remains unclear. As we continue to have MIS training be part of a residency program, the problem of training private practice surgeons in MIS techniques may only be a problem for another 10 to 15 years. By that time the gross majority of practicing surgeons will probably have received their MIS training as a resident, nullifying the need for additional training. Since the onset of laparoscopy in our profession, the issue of how best to disseminate the knowledge and clinical acumen of basic to more advanced laparoscopic procedures to the private practice surgeon has been a burning question. The majority of surgeons would agree that a personal mentor method (that most resembled our residency experience) would be best. However, formatting the logistics of such a program in any private practice clinical setting has continued to be very difficult.
Scientific paper
A needs-assessment study for continuing professional development in advanced minimally invasive surgery Tom Wallace, M.D., Daniel W. Birch, M.Sc., M.D.* Centre for the Advancement of Minimally Invasive Surgery (CAMIS), Department of Surgery, University of Alberta, Royal Alexandra Hospital, Capital Health, 10240 Kingsway, Edmonton, Alberta, Canada T5H 3V9 Manuscript received December 2, 2006; revised manuscript January 21, 2007 Presented at the 93rd Annual Meeting of the North Pacific Surgical Association, Spokane, WA, November 10 –11, 2006
Abstract Background: The ideal continuing professional development (CPD) model to transfer advanced minimally invasive surgical (MIS) skills to surgeons in practice has not yet been determined. Methods: A survey of general surgeons practicing in Alberta was conducted to determine attitudes toward CPD with a focus on MIS colon surgery. Two separate mailings of the survey were conducted in both hard copy and e-mail format. Data were collected and analyzed. Results: Seventy-one of 92 surveys were returned, yielding a response rate of 77%. The majority (62%) of surgeons had received their training while in practice. The most prevalent form of CPD was short courses, with 82% of surgeons having attended at least 1 short course in MIS. When directly comparing short courses with mentorship, 69% of respondents rated courses as less helpful, whereas 21% thought they were equivalent to mentorship. Sixty-one percent of surgeons are interested in a comprehensive approach, such as a mini-fellowship, to learning laparoscopic colorectal surgery. Conclusions: General surgeons want access to different modalities of training, including both mentorship experiences and short courses. They are willing to take time away from their practices to learn new MIS skills. The best way to provide CPD to practicing surgeons is likely through a combination of teaching interventions, including courses, mentoring relationships, and the application of new technologies. © 2007 Excerpta Medica Inc. All rights reserved. Keywords: Education; Laparoscopy; Mentor; Physician practice patterns
Minimally invasive surgery (MIS) has evolved dramatically since its inception for gastrointestinal disease in 1988 [1]. Laparoscopic colorectal resection was reported as early as 1991 [2]. Despite initial reports of unacceptable complication rates, recent publications have described the safety and efficacy of a minimally invasive approach to colorectal disease [3]. These reports have renewed the interest in laparoscopic colorectal surgery (LCS) and created a need for a training model for surgeons in practice. Currently, the optimal continuing professional development (CPD) format for practicing surgeons has not been determined [4]. The challenge for the surgical community is the safe transfer of new surgical skills and technologies to surgeons in practice. During the adoption of laparoscopic cholecystectomy by surgeons, short courses were the most prevalent * Corresponding author. Tel.: ⫹1-780-735-4786; fax: ⫹1-780-735-4771. E-mail address: [email protected]
form of CPD [5]. However, the appropriateness of short courses to teach new surgical skills has been widely questioned [6]. Despite these concerns, few viable alternatives have been developed, and short courses remain the most common form of CPD for MIS [7,8]. Alternatives to short courses have been proposed [9 –11]. These alternatives offer longer exposure to training and consist of a mentoring relationship between a preceptor and learner. Our experience with mentoring in LCS suggests that it may become a successful model; however, its limitations and feasibility for surgeons in practice have yet to be clearly defined. To facilitate the development of a provincial mentoring network for LCS, we completed a needs assessment for general surgeons in Alberta on mentoring of advanced MIS. Methods A list of all general surgeons practicing in Alberta was obtained from the College of Physicians and Surgeons of
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.01.004
594
T. Wallace and D.W. Birch / The American Journal of Surgery 193 (2007) 593–596
Alberta. All subspecialists and retired surgeons, as well as those who do not practice colorectal surgery, were excluded. In addition, an up-to-date list of e-mail addresses was prepared. A survey was drafted by a group of general surgeons with an interest in MIS, surgical education, and surgical oncology. The survey consisted of sections on demographics, previous MIS training, and attitudes toward the short course and mentorship models of training. Two mailings of the survey were carried out to maximize response rate. This included mailings and group e-mails. A cover letter from all involved parties stating the purposes of the study was included. Respondents returned hard copies of completed surveys or submitted responses online. All responses were entered into an online survey program for final analysis. Results Ninety-two surveys were mailed out; of these, 71 were returned (response rate 77%). Respondents had a mean age of 48 years, and 84% were male and had been in surgical practice for 15 years. Sixty six percent of respondents described their surgical practice as “community based.” The majority of respondents (62%) claimed they had received MIS training while in practice. Eight percent had completed fellowships, and 31% had most of their MIS training during residency. While in practice, 82% had attended some sort of advanced MIS course. The types of courses attended included general (45%), incisional hernia (38%), gastroesophageal reflux disease (24%), and colorectal (62%). The most common reason cited for not attending a course was time restraints. Most surgeons (83%) were interested in attending a MIS colorectal course if it was held within Alberta. Respondents believed that MIS colorectal surgery were either comparable (48%) or more difficult than open surgery skills (52%); no surgeons reported MIS as being easier than open surgery skills. Surgeons were asked to estimate the number of MIS cases for which they had been mentored. These results are listed in Table 1. An assessment of surgeons’ impressions of short courses and mentorship-type training was made. Surgeons were asked if they believed that these different methods prepared them for introducing MIS techniques into practice. On a 1 to 5 scale (1 being never helpful and 5 being very helpful), the average response for short courses was 3.59, whereas for mentoring it was 4.27. When asked to directly compare the two methods, 69% of respondents rated courses as less helpful; 21% thought they were equivalent; and only 10%
Fig. 1. Potential barriers to adopting advanced minimally invasive surgery into practice. Likert scale anchors: 1 ⫽ unimportant, 3 ⫽ somewhat important, and 5 ⫽ very important.
thought courses were superior to mentorship. The majority of respondents (62%) believe that advanced MIS should not be attempted without a mentor, whereas 31% indicated it may be acceptable in certain instances. The majority of respondents believed that surgeons performing advanced MIS should not require credentials from a licensing body (74%). The barriers to performing advanced MIS were ranked and are presented in Fig. 1. Time away from practice is believed to be the most important reason why surgeons may be unable to attend a comprehensive MIS training program. Despite this, surgeons indicated they would be willing to spend an appreciable amount of time away from practice to learn advanced MIS (Fig. 2). Sixty-one percent of surgeons were interested in a comprehensive approach, such as a mini-fellowship, to learning laparoscopic colorectal surgery. Several open-ended questions were included in the survey. When asked what short courses lacked to help prepare surgeons for incorporating routine advanced MIS into their practices, the most common responses were a lack of hands-on experience (n ⫽ 24 responses) and the absence of a mentoring-type relationship (n ⫽ 13 responses). When the same question was asked about mentoring, availability of mentors was the most common response (n ⫽ 7 responses). When asked if there was any substitute for mentoring, the most common response (n ⫽ 15 responses) was “no.”
Table 1 Reported mentoring by respondents (N ⫽ 79) for advanced MIS No. procedures
Colorectal
Incisional hernia repair
Upper GI
Hepatobiliary
0 1–5 6–10 11–20 21–30 ⬎30
29 12 9 2 1 3
24 17 7 0 0 1
26 9 6 1 1 2
22 6 5 3 2 12
GI ⫽ gastrointestinal.
Fig. 2. Surgeon allowance of time away from practice for mentoring in advanced minimally invasive surgery.
T. Wallace and D.W. Birch / The American Journal of Surgery 193 (2007) 593–596
Comments We have previously shown that surgeons in practice will adopt advanced MIS procedures into practice without any form of formal training or following attendance at short postgraduate courses [7,8]. We believe this may be caused by a lack of appropriate training initiatives within Canada to address the problem of training surgeons in new techniques and technologies. See et al described the risk associated with the adoption of MIS procedures by American urologists following a short course as well as the positive impact of further training [12–14]. Several investigators have described their learning curve for various procedures in MIS [15,16]. Remarkable variation exists in the number of procedures that are believed to be necessary to achieve competence. A recent publication highlighted this predicament. Fazio et al recently suggested that the learning curve for a laparoscopic right hemicolectomy may be as high as 55 procedures [17]. The learning curve is an important concept because it describes the willingness of surgeons to embark on a “self-training” initiative in new and complex surgical procedures. The safety and appropriateness of this approach remains to be seen, although historically this has not proven to be successful. There is growing dissatisfaction with this concept, and several investigators have discussed the associated ethical and moral dilemmas associated with the learning curve [4]. Moreover, the learning curve often implies the experience of an expert surgeon with a dedicated surgical team and may have little relevance or applicability to the community of surgeons [18,19]. Specialty groups have published guidelines for developing MIS courses as well as for granting MIS privileges [20,21]. To comply with these guidelines, a surgeon is required to attend a course, to assist on several procedures, and then to complete additional procedures with a mentor until proficient. However, in the past, compliance with guidelines has been poor. Only 50% of surgeons satisfied the Society of American Gastrointestinal and Endoscopic Surgeons guidelines for introducing laparoscopic surgery into their practice. They cited various challenges, including lack of training opportunities, funds, and experienced colleagues [22]. Based on our data, surgeons would likely resist the implementation of mandatory credentials to perform advanced MIS. Respondents to our survey seemed to prefer a mentorship model to short courses. Seventy-three percent of respondents stated that mentorship may be a more appropriate method by which to acquire MIS and may be more likely to lead to adoption of MIS procedures into practice. Surgeons ranked time away from work as the most important obstacle to MIS training. However, 77% indicated that they would take at least 1 week to learn advanced MIS, and 36% indicated they would take at least 3 weeks. Centers of excellence have developed short courses for practicing surgeons, but they are likely inadequate as standalone teaching interventions. Alternatives, such as mentoring, have not been widely adopted for various reasons. Our survey shows that general surgeons want access to different modalities of training, including both mentorship experiences and short courses. Also, they are willing to take time away from their practices to learn new MIS skills. The best
595
way to provide CPD for MIS to practicing surgeons is likely through a combination of teaching interventions, including courses, mentoring relationships, and the application of new technologies. Acknowledgments The authors wish to thank the staff of Cancer Surgery Alberta for their assistance in administering this survey. References [1] Litynski GS. Profiles in laparoscopy: Mouret, Dubois and Perissat— The laparoscopic breakthrough in Europe (1987–1988). J Soc Laparoendosc Surg 1999;3:163–7. [2] Saclarides TJ, Ko ST, Airan M, et al. Laparoscopic removal of a large colonic lipoma. Report of a case. Dis Colon Rectum 1991;34(11): 1027–9. [3] The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350(20):2050 –9. [4] Rogers D. Ethical and educational considerations in minimally invasive surgery training for practicing surgeons. Semin Laparosc Surg 2002;9(4):206 –11. [5] Bailey RW, Imbembo AL, Zucker KA. Establishment of a laparoscopic cholecystectomy training program. Am Surg 1991;57(4):231– 6. [6] Hunter JG, Sackier JM, Berci G. Training in laparoscopic cholecystectomy. Quantifying the learning curve. Surg Endosc 1994;8(1):28 –31. [7] Birch DW, Misra M, Farrokhyar F. The feasibility of introducing advanced minimally invasive surgery into practice. Can J Surg 2007 (in press). [8] Birch DW, Sample C, Gupta R. The impact of a comprehensive course in advanced minimal access surgery on surgeon practice. Can J Surg 2007 (in press). [9] Heniford BT, Backus CL, Matthews BD, et al. Optimal teaching environment for laparoscopic splenectomy. Am J Surg 2001;181(3):226 –30. [10] Rogers DA, Elstein AS, Bordage G. Improving continuing medical education for surgical techniques: applying the lessons learned in the first decade of minimal access surgery. Ann Surg 2001;233:159 – 66. [11] Heniford BT, Matthews BD, Box EA, et al. Optimal teaching environment for laparoscopic ventral herniorrhaphy. Hernia 2002;6(1): 17–20. [12] See WA, Fisher RJ, Winfield HN, et al. Laparoscopic surgical training: effectiveness and impact on urological surgical practice patterns. J Urol 1993;149(5):1054 –7. [13] See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic complications after formal training in laparoscopic surgery. JAMA 1993; 270(22):2689 –92. [14] See WA, Cooper CS, Fisher RJ. Urological laparoscopic practice patterns 1 year after formal training. J Urol 1994;151(6):1595– 8. [15] Voitk AJ. The learning curve in laparoscopic inguinal hernia repair for the community general surgeon. Can J Surg 1998;41(6):446 –50. [16] Voitk AJ, Joffe J, Alvarez, et al. Factors contributing to laparoscopic failure during the learning curve for laparoscopic Nissen fundoplication in a community hospital. J Laparoendosc Adv Surg Tech 1999; 9(3):243– 8. [17] Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg 2005;242(1):83–91. [18] Winer WK. The role of the operating room staff in operative laparoscopy. J Am Assoc Gynecol Laparosc 1993;1(1):86 – 8. [19] Kenyon TA, Lenker MP, Bax TW, et al. Cost and benefit of the trained laparoscopic team. A comparative study of a designated nursing team vs a nontrained team. Surg Endosc 1997;11(8):812– 4. [20] Society of American Gastrointestinal and Endoscopic Surgeons. Framework for Post-Residency Surgical Education and Training. A SAGES Guideline. Los Angeles, CA: Society of American Gastrointestinal and Endoscopic Surgeons; 1995. [21] Society of American Gastrointestinal and Endoscopic Surgeons. Granting of privileges for laparoscopic general surgery. Am J Surg 1991;161:324 –5. [22] Escarce JJ, Shea JA, Schwartz JS. How practicing surgeons trained for laparoscopic cholecystectomy. Med Care 1997;35:291– 6.
596
T. Wallace and D.W. Birch / The American Journal of Surgery 193 (2007) 593–596
Discussion Marc D. Horton, M.D. (Seattle, WA): This issue is an ongoing problem in our profession. I applaud the authors in tackling what is clearly a challenge for all of us. Whether our practice settings are academic, private, urban, rural, north, or south of the border—they have addressed a problem for which a perfect solution has not yet been found. In the previous report, Dr Birch presented the advantages their group found to having a mentor to help introduce new MIS procedures. In this paper, Dr Wallace presented the results of a survey of general surgeons in Alberta to ascertain their needs in continuing professional development in the arena of minimally invasive colon surgery. Having now heard both of these papers, my question to the authors is what has the University of Alberta done to address the needs of their surgeons? What are your recommendations regarding strategies for continuing professional development in advanced MIS skills? McGill University developed the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills. This was incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons in their Fundamentals
of Laparoscopic Surgery program. It was shown to be a practical and inexpensive system to teach and measure technical laparoscopic skills. The American College of Surgeons is investigating mechanisms to measure the core competencies of their members ranging from professionalism to clinical capabilities, to maintain excellence. MIS skills could fall into this mix. How the College plans to measure such competencies remains unclear. As we continue to have MIS training be part of a residency program, the problem of training private practice surgeons in MIS techniques may only be a problem for another 10 to 15 years. By that time the gross majority of practicing surgeons will probably have received their MIS training as a resident, nullifying the need for additional training. Since the onset of laparoscopy in our profession, the issue of how best to disseminate the knowledge and clinical acumen of basic to more advanced laparoscopic procedures to the private practice surgeon has been a burning question. The majority of surgeons would agree that a personal mentor method (that most resembled our residency experience) would be best. However, formatting the logistics of such a program in any private practice clinical setting has continued to be very difficult.