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An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members
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An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members Geoffrey W. Cundiff, MD, Roxana Geoffrion, MD Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
Abstract
Résumé
Objective: The Continuing Surgical Education Preceptor program (CSEP) was designed to meet population needs by facilitating development of new skills by practising surgeons. Elements include entry criteria, dedicated OR time, assigned preceptors, structured assessment of competence, a mechanism for credentialing, and a reimbursement model. This study analyzed the effectiveness of the CSEP in increasing the number of clinician educators performing laparoscopic hysterectomy (LH) without compromising rates of vaginal hysterectomy (VH) and in enhancing residents’ training in performing minimally invasive hysterectomy (MIH; either LH or VH).
Objectif : Le programme de préceptorat Continuing Surgical Education Preceptor (CSEP) vise à répondre aux besoins de la population en offrant aux chirurgiens en exercice une formation continue en chirurgie facilitant leur acquisition de nouvelles compétences. Assorti de critères d’admission, le programme propose des heures réservées en salle d’opération, un encadrement par des précepteurs désignés, une évaluation structurée des compétences, un mécanisme d’attestation des compétences et un système de remboursement. Notre étude visait à analyser la capacité du CSEP à augmenter le nombre de cliniciens enseignants pratiquant des hystérectomies par laparoscopie (HL) sans réduire le taux d’hystérectomies vaginales (HV), et à améliorer la formation pratique des résidents en matière d’hystérectomies à effraction minimale (HL ou HV).
Methods: We performed a retrospective descriptive study to longitudinally analyze the numbers and proportions of different surgical approaches to hysterectomy at two hospital sites over five years. The CSEP was implemented differently at the two sites. Success of the program was indicated by a surgeon performing 50% or more of hysterectomies as MIH. To assess the impact on resident education, we longitudinally analyzed the number of hysterectomy teaching cases performed as MIH. Results: The proportion of surgeons performing 50% of hysterectomies as MIH steadily increased in the first five years after implementation of the CSEP. At one hospital, the proportion increased from 13% to 56%, due to an increase in LH cases with no change in VH cases. The proportion of resident LH teaching cases increased from 0% to 26%, with a similar rise in the proportion of MIH cases, although it did not quite reach the target proportion of 50% or more. Contrasting the experience of the CSEP between two hospitals revealed that having OR time dedicated to MIH cases provided significantly better results. Conclusions: The CSEP is an effective and sustainable model of lifelong learning applied to teaching practising surgeons new surgical skills.
Key Words: Continuing professional development, faculty development, lifelong learning, Competence by Design, laparoscopic hysterectomy, vaginal hysterectomy Competing Interests: None declared. Received on July 13, 2016 Accepted on August 11, 2016 http://dx.doi.org/10.1016/j.jogc.2016.09.005
Méthodologie : Au moyen d’une étude descriptive rétrospective, nous avons analysé de façon longitudinale, sur une période de cinq ans, des données statistiques (nombre et proportion) relatives aux différentes approches chirurgicales en matière d’hystérectomie adoptées dans deux hôpitaux. Les deux établissements ont procédé différemment pour la mise en œuvre du CSEP, mais le succès du programme était aux deux endroits déterminé en fonction du critère suivant : un chirurgien pratique au moins 50 % des hystérectomies selon une technique à effraction minimale. Pour évaluer l’incidence sur l’apprentissage des résidents, nous avons analysé de façon longitudinale le nombre d’études de cas d’hystérectomie à effraction minimale. Résultats : La proportion de chirurgiens pratiquant 50 % de leurs hystérectomies selon une technique à effraction minimale s’est constamment accrue dans les cinq premières années suivant la mise en œuvre du CSEP. Dans l’un des hôpitaux, elle est passée de 13 à 56 % vu l’augmentation des cas d’HL et la stabilité du nombre de cas d’HV. La proportion d’études de cas d’HL par des résidents est passée de 0 à 26 %, une hausse semblable à celle observée pour les hystérectomies à effraction minimale, soit en deçà de la cible de 50 % et plus. En comparant les expériences vécues avec le CSEP dans les deux hôpitaux, nous avons constaté que le fait de réserver du temps en salle d’opération pour les hystérectomies à effraction minimale permet d’obtenir des résultats considérablement supérieurs. Conclusion : Le CSEP est un modèle efficace et durable de formation continue permettant aux chirurgiens en exercice d’acquérir de nouvelles compétences en chirurgie.
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Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;-(-):1-8
INTRODUCTION
T
he Royal College of Physicians and Surgeons of Canada recently introduced Competence by Design as a new framework for medical education.1 CBD applies the concepts of competency-based medical education to the full spectrum of postgraduate medical practice, from residency to professional development, for practising physicians. In this context, it prioritizes meeting the health care needs of the population as the foundational basis for medical education and recognizes that meeting this evolving need requires adaptation of the workforce through lifelong learning. The CBD applies the CanMEDS physician competencies to a curriculum that blurs the lines between certification and practice to allow physicians to continue to evolve through professional development.2 However, significant barriers to this vision have been identified. Perhaps the greatest barriers are that practising physicians lack access to quality data to inform their learning needs, and that there are insufficient means to address learning needs, for those physicians who identify them, through established professional development.3 This is especially true for the development of new surgical skills. Moreover, the lack of effective mechanisms for physicians to develop new surgical skills has additional consequences beyond not meeting the immediate needs of the populations they serve. Limitations in the surgical portfolios of clinician educators (clinical faculty members whose primary academic mission is teaching clinical skills) are an impediment to postgraduate educational goals as well.4,5
ABBREVIATIONS AH
abdominal hysterectomy
CBD
Competence by Design
CPD
continuing professional development
CSEP
Continuing Surgical Education Preceptor program
LH
laparoscopic hysterectomy
MIH
minimally invasive hysterectomy
OR
operating room
OSATS
Objective Structured Assessment of Technical Skills
UBC
University of British Columbia
VH
vaginal hysterectomy
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We developed the Continuing Surgical Education Preceptor program as a professional development program to allow practising general gynaecologists to enhance their skills in new surgical techniques. We describe here the use of the CSEP to enhance practising general gynaecologists’ skills in laparoscopic hysterectomy. Both vaginal hysterectomy and LH offer a minimally invasive approach to hysterectomy and are associated with a shorter length of stay, fewer minor and major complications, and a faster return to normal activity compared to abdominal hysterectomy.6 A Cochrane review of 47 studies with 5102 women concluded that VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. LH has advantages over AH including more rapid recovery and fewer wound infections but also has a longer operating time. As LH has no advantages over VH, when technically feasible, VH should be performed in preference to AH and LH, and LH should be performed in preference to AH.7 However, many gynaecologists have neither the surgical skills to perform LH nor access to training programs to develop them. The objective of this study was to evaluate the effectiveness of the CSEP in meeting its goals of allowing professional development for clinicians; we also wished to evaluate the impact of the CSEP on resident education. METHODS
We conducted a retrospective descriptive study to evaluate the impact of the CSEP on clinician educators’ ability to perform LH independently and to investigate how the CSEP affected the surgical education of residents. Program Development
The University of British Columbia has a distributed Faculty of Medicine, with four university campuses and a large clinical faculty distributed across multiple academic and community hospitals throughout the province. A primary goal of the Faculty of Medicine is to train “generalists” with broad-based skill sets, in an effort to meet the needs of the provincial population in community and rural hospital settings. Towards this end, the faculty of the UBC Department of Obstetrics and Gynaecology includes a large number of clinician educators, whose principal academic activity is teaching clinical skills. They provide clinical teaching opportunities in general gynaecology practice for both undergraduate and postgraduate learners. Ensuring that these clinician educators are adequately prepared to teach learners is imperative for meeting curricular goals. The CSEP was developed by an ad hoc committee of the UBC Department that was tasked with creating a
An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members
professional development program to assist clinician educators in the acquisition of needed surgical skills for procedures with proven efficacy and safety. The committee included members from each of the Department’s surgical divisions (Gynaecologic Oncology, Reproductive Endocrinology and Infertility, Gynaecologic Specialties, and General Obstetrics & Gynaecology). The committee also included clinical gynaecology faculty members from community hospitals. Program Description
The program uses a preceptor model to facilitate new skill development for practising gynaecologists. The essential elements of the CSEP include clearly defined procedures for participant enrolment, documentation of progress and successful completion of the requirements, a mechanism for credentialing, and a system to remunerate preceptors. Ultimately, department heads at individual sites were responsible for implementing this process, but the CSEP committee provided templates for the preceptor program and the credentialing process. An individual surgeon who wishes to pursue further training through the CSEP initiates this process by submitting a written request to their hospital department head. The surgeon must provide evidence that they have acquired knowledge of the related anatomy and pathophysiology, usually through didactic continuing medical education, and evidence that they have adequate clinical volume to allow maintenance of surgical skills through ongoing practice at the completion of the program. With approval, the hospital department head provides a list of available preceptor surgeons. The program depends on having faculty members with teaching ability and surgical skills matching the procedure to be taught. Preceptors do not need to be primarily located at the learner’s site but should perform the procedure regularly and must be willing to mentor the learner. If the preceptor surgeon does not have surgical privileges at the learner’s institution, temporary privileges must be arranged through the hospital department head; this process has become easier since the implementation of a provincial credentialing system. The learner notifies the preceptor of his or her wish to schedule patients for surgery with the preceptor through the CSEP. This provides an opportunity for the preceptor to discuss his or her expectations and the skills required to proceed. The learner provides surgical patients from his or her own practice. These patients are informed that the learner is working through the CSEP to enhance his or her skills. The patient must understand that her attending
gynaecologist will be working with a preceptor surgeon during her case, and this is part of the informed consent process that is documented in the medical record. In addition, both surgeons are listed on the OR schedule and consent form. The learner provides the preceptor with a complete history and physical examination documenting the patient’s case, including indications for surgery, prior interventions, and comorbidities. The learner also sends the preceptor a copy of the OR scheduling form, so the preceptor can ensure that adequate OR time and the appropriate equipment are provided. The preceptor may request a formal consultation with the patient, although this is not mandatory. In the hospitals involved in this study, cases were either scheduled during OR time dedicated to the preceptor program (Hospital A) or during the learner’s OR time allotment (Hospital B). Residents and medical students do not participate in and are not present at these cases. The preceptor determines surgical roles during the case, with the goal of advancing the learner’s skills. The preceptor provides specific feedback to the learner based on a global rating scale of an Objective Structured Assessment of Technical Skills and suggests a curriculum for improvement of skills when indicated.8 Final determination of the learner’s ability to perform procedures independently and safely is the preceptor’s responsibility. Because learners develop skills at different speeds, competency is not based on volume but on the preceptor surgeon’s confidence in the learner’s ability to perform the procedure independently, which should be informed by the global rating scale of OSATS. A learner does not need to schedule all of their cases with a single preceptor, and any preceptor can approve the learner as competent in the new surgical technique. Surgeons who are approved by a preceptor as able to perform the procedure independently are given provisional privileges for that procedure by their hospital Department Head. Following approval of a surgeon for a new technique, re-credentialing is based on a review of outcomes and complications during a one-year probationary period. Rewarding department members for participating as preceptors is essential for the program’s sustainability, and we sought to accomplish this without industry support. Towards that end, the preceptor surgeon receives financial compensation by billing the provincial health insurance plan as the primary surgeon for all preceptor cases, while the learner surgeon bills as an assistant. The preceptor surgeon also benefits from having additional surgical time, since this will enhance his or her future allocations of OR
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time. As this does not fully remunerate the time spent teaching in the program, participation in the CSEP as a preceptor is also recognized as academic service to the department that counts towards expected academic contributions. Assessment of Effectiveness
As the data used in this analysis was derived from Continuing Quality Initiative, Research Ethics Board approval was not required and was not requested. On the understanding that operative laparoscopy should be a core competency of a generalist obstetrician gynaecologist, the members of our Department sought to enhance their clinician educator skills in operative laparoscopy as a means of ensuring adequate surgical volume for the resident teaching curriculum. Specifically, Department members wanted to ensure that there were adequate numbers of minimally invasive hysterectomy (including both VH and LH). Importantly, increasing the number of LH cases needed to be accomplished by converting AH cases to LH cases, rather than by converting cases of VH to LH. Consequently, we sought to increase rates of MIH without changing rates of VH. Prior to the initiation of the CSEP, the laparoscopic skills of the majority of clinician educators in general gynaecology were limited to diagnostic laparoscopy. In this study, we longitudinally analyzed the surgeons’ numbers of hysterectomies stratified by surgical approach for two sites, combined and individually, during a five-year interval (2007 to 2012). Data are reported by fiscal year. Some tertiary centres achieved MIH rates of 95%, although an MIH rate of 50% was our initial goal.6 We stratified surgeons according to whether or not they performed 50% or more of hysterectomies by MIH. To investigate the importance of specific components of the preceptor program, we compared its effectiveness at two academic hospital sites (Hospital A and Hospital B) that were early adopters of the program. These were valuable sites because of their high surgical volumes and their different approaches to implementation of the program; the primary difference was that one hospital had OR time dedicated to the program. The comparison included comparing the uptake of LH and its effect on the number of VH cases, using AH cases as a control, and identifying the number of surgeons who met the 50% MIH criterion. To assess the impact of the program on resident education, we analyzed the number of hysterectomy teaching cases available to residents stratified by surgical approach. The residency program had rotations at multiple sites including Hospitals A and B. The resident case numbers described in
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Table. Comparison of the two hospitals where CSEP was implemented Hospital A
Hospital B
Attending gynaecologists
18
15
Established laparoscopic specialists
1
2
Annual number of hysterectomies (mean for 5-year period)
329
363
Annual number (percentage) of vaginal hysterectomies prior to initiation of CSEP
47 (17%)
54 (16%)
Annual number (percentage) of laparoscopic hysterectomies prior to initiation of CSEP
8 (6%)
48 (14%)
OR days dedicated to CSEP per month
2
0
CSEP preceptors 5 years after initiation
5
3
Mean number of residents on service
5
5
this study included all hospitals providing resident training. We used descriptive statistics for analysis. RESULTS
The CSEP was initiated in 2007, with a focus on LH, at two hospitals. Both hospitals are urban tertiary academic health care centres with in-house resident staff. The relevant characteristics of the two hospitals are compared in the Table. Hospital A serves urban and indigent populations. It has 12 ORs and two ambulatory ORs, although none of the cases for this study took place in the ambulatory ORs. The Departmental Divisions of Urogynaecology and General Obstetrics and Gynaecology are based at Hospital A, which is also the tertiary care hospital for maternal complications during pregnancy for the region. Hospital B is the largest hospital in British Columbia, with 21 ORs and eight outpatient ORs at a geographically separate location. Approximately 60% of the reported cases for Hospital B were performed in the outpatient ORs. Forty percent of Hospital B’s patients were referred from other parts of the province. The Departmental Divisions of Gynaecologic Oncology and General Gynaecology and the Department’s Pelvic Pain Program are sited at Hospital B. There is no maternity service. Both hospitals added two staff members during the five years of the study. At the beginning of the study interval, LH was being performed by two surgeons at Hospital B but was not performed at Hospital A. Hospital A began the CSEP with one preceptor but had five by the end of the study interval, while Hospital B began with two
An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members
Figure 1. Cumulative number of hysterectomies, stratified by surgical approach, performed at both hospitals (ADB) per period. TLH: total laparoscopic hysterectomy; TVH: total vaginal hysterectomy; TAH: total abdominal hysterectomy
preceptors and added one. The additional mentors successfully completed the CSEP before becoming preceptors.
At Hospital A, the number of VH cases rose in years 3 and 4 and then stabilized at the same level as the initial year; at Hospital B, the number of VH cases declined from a high of 54 cases in the initial year to a low of 22 cases per year in year 4. Both hospitals had sustained increases in the number of LH cases, although this also differed between the two sites. Hospital A saw a steady increase in the number of staff performing LH, as reflected by the number of surgeons who performed 50% or more of cases as MIH (Figure 3). By the third year of the program, more than half of the staff members at Hospital A met the 50% MIH criterion, and this was sustained over the five-year study interval. In contrast, Hospital B began with twice as many staff members meeting the 50% MIH criterion as Hospital A but had inconsistent growth subsequently. In fact, the increase in the total number of LH cases performed at hospital B was primarily in the practices of the two surgeons who were performing LH at the beginning of the study and who increased their numbers of LH cases during the study period. Moreover, one third of the surgeons meeting the 50% MIH criterion at Hospital B did not participate in the CSEP, did not perform LH, and met the 50% MIH criterion by performing high numbers of VH cases.
The annual total number of hysterectomies remained stable over the five-year study interval (mean 470, range 443 to 524, SD 32.36), although the annual total number of LH cases increased 2.6-fold from 63 to 160, with a concurrent 30% decrease in the number of AH cases (Figure 1). The decrease in the number of AH cases was similar at both hospitals, although the changes in numbers of VH and LH cases differed (Figure 2).
The noted differences between Hospitals A and B may reflect differences in how the CSEP was implemented at the two sites. Hospital A had an OR dedicated to the CSEP available on two days per month. Preceptors and learners could book cases on these days without adversely affecting their own OR bookings. Moreover, as surgeons became newly credentialed in LH, they became preceptors for other faculty members, which increased the number of
Figure 2. Hysterectomies stratified by site and surgical approach. TAH: total abdominal hysterectomy; TVH: total vaginal hysterectomy; TLH: total laparoscopic hysterectomy
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Figure 3. Proportion of surgeons performing at least 50% MIH by site
has steadily increased each year. During the study interval, the total number of VH cases also increased from 68 to 107 per year, reflecting an increase in the number of hysterectomy cases overall. DISCUSSION
available mentors. Hospital B did not have OR time dedicated to the CSEP and had a significantly lower uptake; in addition, the phenomenon of developing new mentors did not occur at Hospital B. One of the primary goals of the CSEP was to build a base of generalist laparoscopic surgeons to meet the needs of the surgical curriculum for residents. Before the CSEP began, resident teaching cases did not include LH (Figure 4). Having OR time that was dedicated to the CSEP and that excluded residents delayed an increase in available LH teaching cases, but with time the number of cases rose. The annual rate of MIH was 32% before the CSEP was introduced, but by the second year of the program, it had increased to 46%, where it subsequently remained. The proportion of LH cases in the MIH group Figure 4. Proportion of resident hysterectomy teaching cases stratified by surgical approach. Lap: laparoscopic hysterectomy; Vag: vaginal hysterectomy; Abd: abdominal hysterectomy
A health care system that is flexible enough to evolve to meet the needs of the population it serves is the foundation of the Royal College of Physicians and Surgeons of Canada’s CBD framework.1 Lifelong learning is inherent to the concept, and this depends on having models of professional development that are flexible enough to allow practising surgeons to expand their surgical repertoire without adversely affecting patient care or postgraduate learners.3 We sought to develop such a preceptor model that was sustainable, insulated from the influence of industry, and capable of providing objective assessment of competency. The CSEP meets these criteria; this study shows that it was effective in facilitating the development of competence in LH for a group of clinician educators without adversely affecting postgraduate education. The importance of continuing professional development to sustaining quality health care is universally recognized, but its application to the development of new surgical skills is inadequate. The method used most commonly for CPD is to take short courses, although their value in developing new surgical skills is questionable.9,10 While these courses can provide knowledge transfer and can familiarize surgeons with new technology, they are insufficient to permit the acquisition of new motor skills. Preceptorships and mini-fellowships are more appropriate for motor skill development; they are considered superior by surgeons seeking CPD and have been shown to correlate better with successful implementation of new surgical skills.9,11,12 Surgeons value mentorship for its hands-on training with immediate feedback as well as the fact that it facilitates exchange of tacit knowledge.13 However, scheduling and issues of sponsorship and funding have been identified as key barriers to wider use of mentoring.13 The CSEP provides for a preceptorship model with sustainable scheduling and funding. The model appears to be more effective when implemented with dedicated OR time, which encourages participation by minimizing the impact on the learner’s practice. It also helps to build up a cadre of preceptors that sustains the momentum of the program. Unlike CPD short courses and sponsored preceptorships, which are generally financed by the surgical industry providing the products to be used, the CSEP is independent of outside funding. Moreover, beyond the ethical issues related to bias and conflict of interest, and the
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fact that it is limited to procedures marketed by industry, the industry-funded model is disconnected from the credentialing responsibilities of hospitals. A CPD event may be accredited, but it contains no mechanism for objective evaluation of a surgeon’s competence with a new skill.14
teaching sites, we actually added to the total number of VH cases available for residents. We are currently encouraging the use of VH when feasible and using the CSEP as a means to increase the number surgeons with the technical skills to perform VH cases.
Lifelong learning is generally considered to be a responsibility of individual surgeons, with monitoring by institutional credentialing bodies and by provincial and national licensing bodies. The CSEP links new skill development with credentialing, from the point where a surgeon identifies a learning need to mastery of the technique. The development of new surgical techniques must be balanced with the optimization of the quality of patient care, including patient safety. We believe our program achieves this balance by using clearly defined criteria for competence and embedding credentialing within the program.
Strengths of the study include the dual assessment of the CSEP for its impact on clinical gynaecologic surgeons’ practices and on resident education, and the ability to compare the implementation of the CSEP at two institutions. We feel that it supports the value of our CSEP as an accountable, sustainable, and scalable means of providing CPD for surgery.
While this study has focused on LH, the CSEP is applicable to any new surgical procedure that has proven safety and efficacy. It is also scalable. Our provincial department has applied CSEP to performing mid-urethral slings and prolapse procedures in addition to LH and other endoscopic techniques. Its use has expanded beyond Hospitals A and B to community and rural hospitals across the province. The department currently has 10 surgical mentors who have been preceptors in more than 80 cases province-wide. Ultimately, we hope this will lead to better patient care and to the enhancement of our educational mission. In addition to its value for CPD, the CSEP is also an effective faculty development tool that can facilitate the development of a faculty base of clinician educators with the necessary skills to implement a new postgraduate surgical curriculum.15 Prior to implementation of the CSEP, advanced laparoscopic training for our residents was limited to sub-specialty rotations. The CSEP increased our base of laparoscopic teachers, but also moved the skill into the realm of the generalist, consistent with our teaching philosophy. This study was limited by its retrospective design and by the fact that data for residents were not limited to Hospitals A and B. We sought to develop LH as a minimally invasive technique for performing hysterectomy in both our clinical service and our resident curriculum. At the same time, we did not want to reduce the number of cases of the less invasive VH. Our results in balancing these two goals were mixed. The increase in LH cases occurred without any change in the number of VH cases at Hospital A but not at Hospital B. By adding additional
CONCLUSIONS
The CSEP provides a preceptor model that is sustainable, insulated from industry influence, and capable of providing objective assessment of competency linked to credentialing. We found that it was effective for our clinician educators in facilitating competence in performing LH.
REFERENCES 1. Competence by Design: Reshaping Canadian Medical Education. Royal College of Physicians and Surgeons of Canada. March 2014. Available at: http://www.royalcollege.ca/rcsite/documents/educational-strategyaccreditation/royal-college-competency-by-design-ebook-e.pdf. Accessed on March 31, 2016. 2. CanMEDS 2015: Physician Competency Framework. Royal College of Physicians and Surgeons of Canada. Available at: http://canmeds.royal college.ca/uploads/en/framework/CanMEDS%202015%20Framework_ EN_Reduced.pdf. Accessed on March 31, 2016. 3. Lockyer J, Silver I, Oswald A, Bullock G, Campbell C, Frank JR, et al. The Continuum of Medical Education. Royal College of Physicians and Surgeons of Canada. March 2014. Available at: http://www.royalcollege.ca/ portal/page/portal/rc/common/documents/educational_initiatives/ continuum.pdf. Accessed on March 31, 2016. 4. Fung Kee Fung MP, Temple LM, Ash KM, Laparoscopic Education Study Group. What are the components of a successful laparoscopic education programme. J Soc Obstet Gynaecol Can 1996;18:859e67. 5. Cundiff GW. Analysis of the effectiveness of an endoscopy education program in improving residents’ laparoscopic skills. Obstet Gynecol 1997;90:854e9. 6. Grant-Orser A, El Sugy R, Singh SS. Does laparoscopy safely improve technicity for complex hysterectomy cases? J Obstet Gynaecol Can 2014;36:248e52. 7. Aarts JW, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BW, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015;(8):CD003677. 8. Reznick R, Regehr G, MacRae H, Martin J, McCulloch. Testing technical skill via an innovative “bench station” examination. Am J Surg 1987;173:226e30. 9. Wallace T, Birch DW. A needs-assessment study for continuing professional development in advanced minimally invasive surgery. Am J Surg 2007;193:593e5. discussion 596.
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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;233:159e66.
13. Gagliardi AR, Wright FC, Victor JC, Brouwers MC, Silver IL. Self-directed learning needs, patterns, and outcomes among general surgeons. J Contin Educ Health Prof 2009;29:269e75.
11. Lord JL, Cottam DR, Dallal RM, Mattar SG, Watson AR, Glasscock JM, et al. The impact of laparoscopic bariatric workshops on the practice patterns of surgeons. Surg Endosc 2006;20:929e33.
14. Maillet B, Maisonneuve H. Long-life learning for medical specialist doctors in Europe: CME, DPC, and qualification. Presse Med 2011;40(4 Pt 1):357e65.
12. Cottam D, Holover S, Mattar SG, Sharma SK, Medlin W, Ramananthan R, et al. The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery. Surg Endosc 2007;21:2237e9.
15. Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med 1998;73:387e96.
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An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members Geoffrey W. Cundiff, MD, Roxana Geoffrion, MD Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
Abstract
Résumé
Objective: The Continuing Surgical Education Preceptor program (CSEP) was designed to meet population needs by facilitating development of new skills by practising surgeons. Elements include entry criteria, dedicated OR time, assigned preceptors, structured assessment of competence, a mechanism for credentialing, and a reimbursement model. This study analyzed the effectiveness of the CSEP in increasing the number of clinician educators performing laparoscopic hysterectomy (LH) without compromising rates of vaginal hysterectomy (VH) and in enhancing residents’ training in performing minimally invasive hysterectomy (MIH; either LH or VH).
Objectif : Le programme de préceptorat Continuing Surgical Education Preceptor (CSEP) vise à répondre aux besoins de la population en offrant aux chirurgiens en exercice une formation continue en chirurgie facilitant leur acquisition de nouvelles compétences. Assorti de critères d’admission, le programme propose des heures réservées en salle d’opération, un encadrement par des précepteurs désignés, une évaluation structurée des compétences, un mécanisme d’attestation des compétences et un système de remboursement. Notre étude visait à analyser la capacité du CSEP à augmenter le nombre de cliniciens enseignants pratiquant des hystérectomies par laparoscopie (HL) sans réduire le taux d’hystérectomies vaginales (HV), et à améliorer la formation pratique des résidents en matière d’hystérectomies à effraction minimale (HL ou HV).
Methods: We performed a retrospective descriptive study to longitudinally analyze the numbers and proportions of different surgical approaches to hysterectomy at two hospital sites over five years. The CSEP was implemented differently at the two sites. Success of the program was indicated by a surgeon performing 50% or more of hysterectomies as MIH. To assess the impact on resident education, we longitudinally analyzed the number of hysterectomy teaching cases performed as MIH. Results: The proportion of surgeons performing 50% of hysterectomies as MIH steadily increased in the first five years after implementation of the CSEP. At one hospital, the proportion increased from 13% to 56%, due to an increase in LH cases with no change in VH cases. The proportion of resident LH teaching cases increased from 0% to 26%, with a similar rise in the proportion of MIH cases, although it did not quite reach the target proportion of 50% or more. Contrasting the experience of the CSEP between two hospitals revealed that having OR time dedicated to MIH cases provided significantly better results. Conclusions: The CSEP is an effective and sustainable model of lifelong learning applied to teaching practising surgeons new surgical skills.
Key Words: Continuing professional development, faculty development, lifelong learning, Competence by Design, laparoscopic hysterectomy, vaginal hysterectomy Competing Interests: None declared. Received on July 13, 2016 Accepted on August 11, 2016 http://dx.doi.org/10.1016/j.jogc.2016.09.005
Méthodologie : Au moyen d’une étude descriptive rétrospective, nous avons analysé de façon longitudinale, sur une période de cinq ans, des données statistiques (nombre et proportion) relatives aux différentes approches chirurgicales en matière d’hystérectomie adoptées dans deux hôpitaux. Les deux établissements ont procédé différemment pour la mise en œuvre du CSEP, mais le succès du programme était aux deux endroits déterminé en fonction du critère suivant : un chirurgien pratique au moins 50 % des hystérectomies selon une technique à effraction minimale. Pour évaluer l’incidence sur l’apprentissage des résidents, nous avons analysé de façon longitudinale le nombre d’études de cas d’hystérectomie à effraction minimale. Résultats : La proportion de chirurgiens pratiquant 50 % de leurs hystérectomies selon une technique à effraction minimale s’est constamment accrue dans les cinq premières années suivant la mise en œuvre du CSEP. Dans l’un des hôpitaux, elle est passée de 13 à 56 % vu l’augmentation des cas d’HL et la stabilité du nombre de cas d’HV. La proportion d’études de cas d’HL par des résidents est passée de 0 à 26 %, une hausse semblable à celle observée pour les hystérectomies à effraction minimale, soit en deçà de la cible de 50 % et plus. En comparant les expériences vécues avec le CSEP dans les deux hôpitaux, nous avons constaté que le fait de réserver du temps en salle d’opération pour les hystérectomies à effraction minimale permet d’obtenir des résultats considérablement supérieurs. Conclusion : Le CSEP est un modèle efficace et durable de formation continue permettant aux chirurgiens en exercice d’acquérir de nouvelles compétences en chirurgie.
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Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;-(-):1-8
INTRODUCTION
T
he Royal College of Physicians and Surgeons of Canada recently introduced Competence by Design as a new framework for medical education.1 CBD applies the concepts of competency-based medical education to the full spectrum of postgraduate medical practice, from residency to professional development, for practising physicians. In this context, it prioritizes meeting the health care needs of the population as the foundational basis for medical education and recognizes that meeting this evolving need requires adaptation of the workforce through lifelong learning. The CBD applies the CanMEDS physician competencies to a curriculum that blurs the lines between certification and practice to allow physicians to continue to evolve through professional development.2 However, significant barriers to this vision have been identified. Perhaps the greatest barriers are that practising physicians lack access to quality data to inform their learning needs, and that there are insufficient means to address learning needs, for those physicians who identify them, through established professional development.3 This is especially true for the development of new surgical skills. Moreover, the lack of effective mechanisms for physicians to develop new surgical skills has additional consequences beyond not meeting the immediate needs of the populations they serve. Limitations in the surgical portfolios of clinician educators (clinical faculty members whose primary academic mission is teaching clinical skills) are an impediment to postgraduate educational goals as well.4,5
ABBREVIATIONS AH
abdominal hysterectomy
CBD
Competence by Design
CPD
continuing professional development
CSEP
Continuing Surgical Education Preceptor program
LH
laparoscopic hysterectomy
MIH
minimally invasive hysterectomy
OR
operating room
OSATS
Objective Structured Assessment of Technical Skills
UBC
University of British Columbia
VH
vaginal hysterectomy
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We developed the Continuing Surgical Education Preceptor program as a professional development program to allow practising general gynaecologists to enhance their skills in new surgical techniques. We describe here the use of the CSEP to enhance practising general gynaecologists’ skills in laparoscopic hysterectomy. Both vaginal hysterectomy and LH offer a minimally invasive approach to hysterectomy and are associated with a shorter length of stay, fewer minor and major complications, and a faster return to normal activity compared to abdominal hysterectomy.6 A Cochrane review of 47 studies with 5102 women concluded that VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. LH has advantages over AH including more rapid recovery and fewer wound infections but also has a longer operating time. As LH has no advantages over VH, when technically feasible, VH should be performed in preference to AH and LH, and LH should be performed in preference to AH.7 However, many gynaecologists have neither the surgical skills to perform LH nor access to training programs to develop them. The objective of this study was to evaluate the effectiveness of the CSEP in meeting its goals of allowing professional development for clinicians; we also wished to evaluate the impact of the CSEP on resident education. METHODS
We conducted a retrospective descriptive study to evaluate the impact of the CSEP on clinician educators’ ability to perform LH independently and to investigate how the CSEP affected the surgical education of residents. Program Development
The University of British Columbia has a distributed Faculty of Medicine, with four university campuses and a large clinical faculty distributed across multiple academic and community hospitals throughout the province. A primary goal of the Faculty of Medicine is to train “generalists” with broad-based skill sets, in an effort to meet the needs of the provincial population in community and rural hospital settings. Towards this end, the faculty of the UBC Department of Obstetrics and Gynaecology includes a large number of clinician educators, whose principal academic activity is teaching clinical skills. They provide clinical teaching opportunities in general gynaecology practice for both undergraduate and postgraduate learners. Ensuring that these clinician educators are adequately prepared to teach learners is imperative for meeting curricular goals. The CSEP was developed by an ad hoc committee of the UBC Department that was tasked with creating a
An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members
professional development program to assist clinician educators in the acquisition of needed surgical skills for procedures with proven efficacy and safety. The committee included members from each of the Department’s surgical divisions (Gynaecologic Oncology, Reproductive Endocrinology and Infertility, Gynaecologic Specialties, and General Obstetrics & Gynaecology). The committee also included clinical gynaecology faculty members from community hospitals. Program Description
The program uses a preceptor model to facilitate new skill development for practising gynaecologists. The essential elements of the CSEP include clearly defined procedures for participant enrolment, documentation of progress and successful completion of the requirements, a mechanism for credentialing, and a system to remunerate preceptors. Ultimately, department heads at individual sites were responsible for implementing this process, but the CSEP committee provided templates for the preceptor program and the credentialing process. An individual surgeon who wishes to pursue further training through the CSEP initiates this process by submitting a written request to their hospital department head. The surgeon must provide evidence that they have acquired knowledge of the related anatomy and pathophysiology, usually through didactic continuing medical education, and evidence that they have adequate clinical volume to allow maintenance of surgical skills through ongoing practice at the completion of the program. With approval, the hospital department head provides a list of available preceptor surgeons. The program depends on having faculty members with teaching ability and surgical skills matching the procedure to be taught. Preceptors do not need to be primarily located at the learner’s site but should perform the procedure regularly and must be willing to mentor the learner. If the preceptor surgeon does not have surgical privileges at the learner’s institution, temporary privileges must be arranged through the hospital department head; this process has become easier since the implementation of a provincial credentialing system. The learner notifies the preceptor of his or her wish to schedule patients for surgery with the preceptor through the CSEP. This provides an opportunity for the preceptor to discuss his or her expectations and the skills required to proceed. The learner provides surgical patients from his or her own practice. These patients are informed that the learner is working through the CSEP to enhance his or her skills. The patient must understand that her attending
gynaecologist will be working with a preceptor surgeon during her case, and this is part of the informed consent process that is documented in the medical record. In addition, both surgeons are listed on the OR schedule and consent form. The learner provides the preceptor with a complete history and physical examination documenting the patient’s case, including indications for surgery, prior interventions, and comorbidities. The learner also sends the preceptor a copy of the OR scheduling form, so the preceptor can ensure that adequate OR time and the appropriate equipment are provided. The preceptor may request a formal consultation with the patient, although this is not mandatory. In the hospitals involved in this study, cases were either scheduled during OR time dedicated to the preceptor program (Hospital A) or during the learner’s OR time allotment (Hospital B). Residents and medical students do not participate in and are not present at these cases. The preceptor determines surgical roles during the case, with the goal of advancing the learner’s skills. The preceptor provides specific feedback to the learner based on a global rating scale of an Objective Structured Assessment of Technical Skills and suggests a curriculum for improvement of skills when indicated.8 Final determination of the learner’s ability to perform procedures independently and safely is the preceptor’s responsibility. Because learners develop skills at different speeds, competency is not based on volume but on the preceptor surgeon’s confidence in the learner’s ability to perform the procedure independently, which should be informed by the global rating scale of OSATS. A learner does not need to schedule all of their cases with a single preceptor, and any preceptor can approve the learner as competent in the new surgical technique. Surgeons who are approved by a preceptor as able to perform the procedure independently are given provisional privileges for that procedure by their hospital Department Head. Following approval of a surgeon for a new technique, re-credentialing is based on a review of outcomes and complications during a one-year probationary period. Rewarding department members for participating as preceptors is essential for the program’s sustainability, and we sought to accomplish this without industry support. Towards that end, the preceptor surgeon receives financial compensation by billing the provincial health insurance plan as the primary surgeon for all preceptor cases, while the learner surgeon bills as an assistant. The preceptor surgeon also benefits from having additional surgical time, since this will enhance his or her future allocations of OR
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time. As this does not fully remunerate the time spent teaching in the program, participation in the CSEP as a preceptor is also recognized as academic service to the department that counts towards expected academic contributions. Assessment of Effectiveness
As the data used in this analysis was derived from Continuing Quality Initiative, Research Ethics Board approval was not required and was not requested. On the understanding that operative laparoscopy should be a core competency of a generalist obstetrician gynaecologist, the members of our Department sought to enhance their clinician educator skills in operative laparoscopy as a means of ensuring adequate surgical volume for the resident teaching curriculum. Specifically, Department members wanted to ensure that there were adequate numbers of minimally invasive hysterectomy (including both VH and LH). Importantly, increasing the number of LH cases needed to be accomplished by converting AH cases to LH cases, rather than by converting cases of VH to LH. Consequently, we sought to increase rates of MIH without changing rates of VH. Prior to the initiation of the CSEP, the laparoscopic skills of the majority of clinician educators in general gynaecology were limited to diagnostic laparoscopy. In this study, we longitudinally analyzed the surgeons’ numbers of hysterectomies stratified by surgical approach for two sites, combined and individually, during a five-year interval (2007 to 2012). Data are reported by fiscal year. Some tertiary centres achieved MIH rates of 95%, although an MIH rate of 50% was our initial goal.6 We stratified surgeons according to whether or not they performed 50% or more of hysterectomies by MIH. To investigate the importance of specific components of the preceptor program, we compared its effectiveness at two academic hospital sites (Hospital A and Hospital B) that were early adopters of the program. These were valuable sites because of their high surgical volumes and their different approaches to implementation of the program; the primary difference was that one hospital had OR time dedicated to the program. The comparison included comparing the uptake of LH and its effect on the number of VH cases, using AH cases as a control, and identifying the number of surgeons who met the 50% MIH criterion. To assess the impact of the program on resident education, we analyzed the number of hysterectomy teaching cases available to residents stratified by surgical approach. The residency program had rotations at multiple sites including Hospitals A and B. The resident case numbers described in
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Table. Comparison of the two hospitals where CSEP was implemented Hospital A
Hospital B
Attending gynaecologists
18
15
Established laparoscopic specialists
1
2
Annual number of hysterectomies (mean for 5-year period)
329
363
Annual number (percentage) of vaginal hysterectomies prior to initiation of CSEP
47 (17%)
54 (16%)
Annual number (percentage) of laparoscopic hysterectomies prior to initiation of CSEP
8 (6%)
48 (14%)
OR days dedicated to CSEP per month
2
0
CSEP preceptors 5 years after initiation
5
3
Mean number of residents on service
5
5
this study included all hospitals providing resident training. We used descriptive statistics for analysis. RESULTS
The CSEP was initiated in 2007, with a focus on LH, at two hospitals. Both hospitals are urban tertiary academic health care centres with in-house resident staff. The relevant characteristics of the two hospitals are compared in the Table. Hospital A serves urban and indigent populations. It has 12 ORs and two ambulatory ORs, although none of the cases for this study took place in the ambulatory ORs. The Departmental Divisions of Urogynaecology and General Obstetrics and Gynaecology are based at Hospital A, which is also the tertiary care hospital for maternal complications during pregnancy for the region. Hospital B is the largest hospital in British Columbia, with 21 ORs and eight outpatient ORs at a geographically separate location. Approximately 60% of the reported cases for Hospital B were performed in the outpatient ORs. Forty percent of Hospital B’s patients were referred from other parts of the province. The Departmental Divisions of Gynaecologic Oncology and General Gynaecology and the Department’s Pelvic Pain Program are sited at Hospital B. There is no maternity service. Both hospitals added two staff members during the five years of the study. At the beginning of the study interval, LH was being performed by two surgeons at Hospital B but was not performed at Hospital A. Hospital A began the CSEP with one preceptor but had five by the end of the study interval, while Hospital B began with two
An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members
Figure 1. Cumulative number of hysterectomies, stratified by surgical approach, performed at both hospitals (ADB) per period. TLH: total laparoscopic hysterectomy; TVH: total vaginal hysterectomy; TAH: total abdominal hysterectomy
preceptors and added one. The additional mentors successfully completed the CSEP before becoming preceptors.
At Hospital A, the number of VH cases rose in years 3 and 4 and then stabilized at the same level as the initial year; at Hospital B, the number of VH cases declined from a high of 54 cases in the initial year to a low of 22 cases per year in year 4. Both hospitals had sustained increases in the number of LH cases, although this also differed between the two sites. Hospital A saw a steady increase in the number of staff performing LH, as reflected by the number of surgeons who performed 50% or more of cases as MIH (Figure 3). By the third year of the program, more than half of the staff members at Hospital A met the 50% MIH criterion, and this was sustained over the five-year study interval. In contrast, Hospital B began with twice as many staff members meeting the 50% MIH criterion as Hospital A but had inconsistent growth subsequently. In fact, the increase in the total number of LH cases performed at hospital B was primarily in the practices of the two surgeons who were performing LH at the beginning of the study and who increased their numbers of LH cases during the study period. Moreover, one third of the surgeons meeting the 50% MIH criterion at Hospital B did not participate in the CSEP, did not perform LH, and met the 50% MIH criterion by performing high numbers of VH cases.
The annual total number of hysterectomies remained stable over the five-year study interval (mean 470, range 443 to 524, SD 32.36), although the annual total number of LH cases increased 2.6-fold from 63 to 160, with a concurrent 30% decrease in the number of AH cases (Figure 1). The decrease in the number of AH cases was similar at both hospitals, although the changes in numbers of VH and LH cases differed (Figure 2).
The noted differences between Hospitals A and B may reflect differences in how the CSEP was implemented at the two sites. Hospital A had an OR dedicated to the CSEP available on two days per month. Preceptors and learners could book cases on these days without adversely affecting their own OR bookings. Moreover, as surgeons became newly credentialed in LH, they became preceptors for other faculty members, which increased the number of
Figure 2. Hysterectomies stratified by site and surgical approach. TAH: total abdominal hysterectomy; TVH: total vaginal hysterectomy; TLH: total laparoscopic hysterectomy
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Figure 3. Proportion of surgeons performing at least 50% MIH by site
has steadily increased each year. During the study interval, the total number of VH cases also increased from 68 to 107 per year, reflecting an increase in the number of hysterectomy cases overall. DISCUSSION
available mentors. Hospital B did not have OR time dedicated to the CSEP and had a significantly lower uptake; in addition, the phenomenon of developing new mentors did not occur at Hospital B. One of the primary goals of the CSEP was to build a base of generalist laparoscopic surgeons to meet the needs of the surgical curriculum for residents. Before the CSEP began, resident teaching cases did not include LH (Figure 4). Having OR time that was dedicated to the CSEP and that excluded residents delayed an increase in available LH teaching cases, but with time the number of cases rose. The annual rate of MIH was 32% before the CSEP was introduced, but by the second year of the program, it had increased to 46%, where it subsequently remained. The proportion of LH cases in the MIH group Figure 4. Proportion of resident hysterectomy teaching cases stratified by surgical approach. Lap: laparoscopic hysterectomy; Vag: vaginal hysterectomy; Abd: abdominal hysterectomy
A health care system that is flexible enough to evolve to meet the needs of the population it serves is the foundation of the Royal College of Physicians and Surgeons of Canada’s CBD framework.1 Lifelong learning is inherent to the concept, and this depends on having models of professional development that are flexible enough to allow practising surgeons to expand their surgical repertoire without adversely affecting patient care or postgraduate learners.3 We sought to develop such a preceptor model that was sustainable, insulated from the influence of industry, and capable of providing objective assessment of competency. The CSEP meets these criteria; this study shows that it was effective in facilitating the development of competence in LH for a group of clinician educators without adversely affecting postgraduate education. The importance of continuing professional development to sustaining quality health care is universally recognized, but its application to the development of new surgical skills is inadequate. The method used most commonly for CPD is to take short courses, although their value in developing new surgical skills is questionable.9,10 While these courses can provide knowledge transfer and can familiarize surgeons with new technology, they are insufficient to permit the acquisition of new motor skills. Preceptorships and mini-fellowships are more appropriate for motor skill development; they are considered superior by surgeons seeking CPD and have been shown to correlate better with successful implementation of new surgical skills.9,11,12 Surgeons value mentorship for its hands-on training with immediate feedback as well as the fact that it facilitates exchange of tacit knowledge.13 However, scheduling and issues of sponsorship and funding have been identified as key barriers to wider use of mentoring.13 The CSEP provides for a preceptorship model with sustainable scheduling and funding. The model appears to be more effective when implemented with dedicated OR time, which encourages participation by minimizing the impact on the learner’s practice. It also helps to build up a cadre of preceptors that sustains the momentum of the program. Unlike CPD short courses and sponsored preceptorships, which are generally financed by the surgical industry providing the products to be used, the CSEP is independent of outside funding. Moreover, beyond the ethical issues related to bias and conflict of interest, and the
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An Assessment of the Continuing Surgical Education Program, a Surgical Preceptor Program for Faculty Members
fact that it is limited to procedures marketed by industry, the industry-funded model is disconnected from the credentialing responsibilities of hospitals. A CPD event may be accredited, but it contains no mechanism for objective evaluation of a surgeon’s competence with a new skill.14
teaching sites, we actually added to the total number of VH cases available for residents. We are currently encouraging the use of VH when feasible and using the CSEP as a means to increase the number surgeons with the technical skills to perform VH cases.
Lifelong learning is generally considered to be a responsibility of individual surgeons, with monitoring by institutional credentialing bodies and by provincial and national licensing bodies. The CSEP links new skill development with credentialing, from the point where a surgeon identifies a learning need to mastery of the technique. The development of new surgical techniques must be balanced with the optimization of the quality of patient care, including patient safety. We believe our program achieves this balance by using clearly defined criteria for competence and embedding credentialing within the program.
Strengths of the study include the dual assessment of the CSEP for its impact on clinical gynaecologic surgeons’ practices and on resident education, and the ability to compare the implementation of the CSEP at two institutions. We feel that it supports the value of our CSEP as an accountable, sustainable, and scalable means of providing CPD for surgery.
While this study has focused on LH, the CSEP is applicable to any new surgical procedure that has proven safety and efficacy. It is also scalable. Our provincial department has applied CSEP to performing mid-urethral slings and prolapse procedures in addition to LH and other endoscopic techniques. Its use has expanded beyond Hospitals A and B to community and rural hospitals across the province. The department currently has 10 surgical mentors who have been preceptors in more than 80 cases province-wide. Ultimately, we hope this will lead to better patient care and to the enhancement of our educational mission. In addition to its value for CPD, the CSEP is also an effective faculty development tool that can facilitate the development of a faculty base of clinician educators with the necessary skills to implement a new postgraduate surgical curriculum.15 Prior to implementation of the CSEP, advanced laparoscopic training for our residents was limited to sub-specialty rotations. The CSEP increased our base of laparoscopic teachers, but also moved the skill into the realm of the generalist, consistent with our teaching philosophy. This study was limited by its retrospective design and by the fact that data for residents were not limited to Hospitals A and B. We sought to develop LH as a minimally invasive technique for performing hysterectomy in both our clinical service and our resident curriculum. At the same time, we did not want to reduce the number of cases of the less invasive VH. Our results in balancing these two goals were mixed. The increase in LH cases occurred without any change in the number of VH cases at Hospital A but not at Hospital B. By adding additional
CONCLUSIONS
The CSEP provides a preceptor model that is sustainable, insulated from industry influence, and capable of providing objective assessment of competency linked to credentialing. We found that it was effective for our clinician educators in facilitating competence in performing LH.
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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;233:159e66.
13. Gagliardi AR, Wright FC, Victor JC, Brouwers MC, Silver IL. Self-directed learning needs, patterns, and outcomes among general surgeons. J Contin Educ Health Prof 2009;29:269e75.
11. Lord JL, Cottam DR, Dallal RM, Mattar SG, Watson AR, Glasscock JM, et al. The impact of laparoscopic bariatric workshops on the practice patterns of surgeons. Surg Endosc 2006;20:929e33.
14. Maillet B, Maisonneuve H. Long-life learning for medical specialist doctors in Europe: CME, DPC, and qualification. Presse Med 2011;40(4 Pt 1):357e65.
12. Cottam D, Holover S, Mattar SG, Sharma SK, Medlin W, Ramananthan R, et al. The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery. Surg Endosc 2007;21:2237e9.
15. Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med 1998;73:387e96.
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