- Email: [email protected]
Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies
ORIGINAL REPORTS
Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies Courtney A. Green, MD, Carolyn J. Vaughn, MD, Susannah M. Wyles, MD, Patricia S. O’Sullivan, EdD, Edward H. Kim, MD and Hueylan Chern, MD Department of Surgery, University of California, San Francisco, California BACKGROUND: Preparatory courses for senior medical students aim to ease the transition from medical school to residency. We designed a novel adjunct curriculum to enhance students’ readiness for surgical internship. This study addresses the feasibility and outcomes of this course. MATERIALS AND METHODS: A curriculum was designed
based on ACGME surgical milestones. Students participated in 8 (3 h) sessions held over 4 weeks as an adjunct to a well-established intern preparatory course. Course activities involved interactive simulation cases to emphasize care of surgical patients, and skills sessions focused on knot tying and suturing, which were reinforced with home video assignments. Students rated confidence on 14 management skills using a 5-point Likert scale (5 ¼ high confidence). Faculty graded students’ technical performance using a global scale (0-10) for 5 suturing exercises. Comparisons between precourse and postcourse data collected for all measures were made using t-tests (α ¼ 0.05). RESULTS: A total of 11 students entering 4 different surgical fields participated. Overall confidence in patient management improved from 2.41 to 3.89 (standard deviation ¼ 0.49, 0.35; p o 0.05). Students’ scores on all 5 suturing tasks increased (p o 0.05). CONCLUSIONS: We developed a surgery-specific component to the existing preparatory course at our institution. Students demonstrated increased confidence in ward management skills and increased technical scores in all exercises. Although only 3 sessions were dedicated to technical skills, improvements may highlight the benefit of home video assignments. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum highlights skills specific for surgical residency, while
Correspondence: Inquiries to Courtney A. Green, MD, Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, S-321, San Francisco, CA 94143-0470; fax: (415) 502-1259; E-mail: [email protected], [email protected]
C 2016 Associmaximizing resources. ( J Surg Ed ]:]]]-]]]. J ation of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: medical education, intern preparatory course, surgical curriculum COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice
INTRODUCTION The transition from medical school to residency is difficult, stressful, and filled with uncertainty. Educators have attempted to address many of these challenges by developing preparatory courses aimed at bridging the gap between the demands of medical school and residency. These courses have taken many forms; some are designed for senior medical students (SMS) during the fourth year of medical education, whereas others occur throughout the first months of residency.1,2 There are courses that highlight preparation for a specific specialty and others that focus more on the generic transition applicable to all specialties. Despite the various formats and the recognized importance of preparatory courses, implementation of these types of curricula is highly demanding, necessitating significant time, faculty efforts and institutional funds for successful execution.3 Surgery Challenges Surgical residency faces additional challenges.4 The design of most surgical services have the senior residents in the operating room for the majority of the day, whereas the interns provide immediate care to postoperative patients. Additionally, ongoing changes in ACGME requirements put additional pressure on surgical residents to get operative exposure early in their training. The implementation of
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.03.011
1
duty hour restrictions has resulted in the need for basic technical skill acquisition to occur outside the operating room. To this end, a statement released by joint surgical organizations indicated that “all matriculates to surgery residency successfully complete a preparatory course… before the start of their training.”5 Previous Preparatory Courses Although many medical schools have implemented “boot camp” courses for SMS and surgical interns, there is no standardization of these courses. Courses range from daylong sessions to month-long elective courses.6,7 Content covered during these courses also varies considerably, though most courses include technical skills including basic suturing and knot-tying, procedural skills, and ward management skills.2,6-11 The new ACGME milestones have provided some guidelines for competency goals, and some institutions have developed their curricula with these milestones in mind.10 Evaluation of these curricula range from surveys demonstrating improved confidence among students, to technical skills assessments demonstrating improvement in basic surgical skills and knowledge-based tests showing higher scores.7-10 Taken together, the results of these courses suggest that there is a benefit of these courses, though more rigorous research is required to optimize these courses. Our Course We chose to design a novel curriculum that can be embedded into a capstone course to enhance student’s readiness for surgical internship. Since 2001, UCSF School of Medicine has offered their students a multidisciplinary course aimed at improving the transition from medical school to residency.3 Various break-out sessions are offered for the students throughout the 4 week course. In 2014, we offered a supplemental course to students entering surgical fields emphasizing both cognitive and technical components. This article discusses our experience with this supplemental course and investigates its efficacy and feasibility.
MATERIALS AND METHODS A surgical curriculum was designed and executed as an adjunct to the intern preparatory course that is well established at UCSF School of Medicine.3 The established course, called “Coda” is carried out over 3 weeks and is designed to be a high-yield review of medical school curriculum for students preparing to enter residency. Broad topics are covered in didactic lectures supplemented by small group sessions with hands-on skills (Fig. 1). As an adjunct to this course, a surgical curriculum was designed to 2
highlight management of common postoperative issues and technical skills for those entering surgical residencies. These postoperative issues are unique to the surgical patient population and are not covered in detail in the didactic or small group sessions. To highlight some of these nuances and provide focused technical instruction, the surgery adjunctive curriculum consisted of 8, 3-hour sessions held over a 3-week period. These sessions included an introduction, an intensive review of technical skills, ward management and communication skills, and final evaluation (Fig. 1). The ward management and communication skills were presented via hands-on, practical scenarios. The course was developed based on competencies highlighted in the ACGME milestones for general surgery.12 Curriculum Activities highlighting cognitive components included three 3-hour sessions dedicated to interactive simulation cases and mock-page encounters (Fig. 1). These cases were designed to cover common postoperative scenarios interns encounter and aimed to highlight early recognition and management of life-threatening situations. Scenarios addressed the following topics: postoperative pain (expected, more than expected [anastomotic leak, ileus or vomiting]), electrolyte abnormalities (hyper- and hypokalemia), insomnia, agitation or acute mental status change (hypoxia, shock, glucose and electrolyte abnormalities, medications), fall, postoperative fever (concerns based on when, related to the surgery, it occurs [anastomotic leak, surgical site infection—superficial or deep]), oliguria (prerenal presentation, pre- or posttransplant patient), respiratory distress (pulmonary embolism and pneumothorax), chest pain (myocardial infarction), tachycardia (atrial fibrillation and congestive heart failure), hypertension, hypotension (hemorrhagic shock and septic shock). Students took turns individually in front of the class working through various mock-page scenarios. Templates were created for the aforementioned topics using an adapted version of previously published preparatory material.13 The templates were designed to highlight key concepts for the different scenarios and guide the operators through the debriefing session (Appendix A). Instructors including attendings and surgical residents played the roles of patient, nurse, chief resident, etc. A student would work through the scenario and receive immediate feedback at its conclusion. Usually 2 scenarios were covered in each session. At the end of the session, the entire group debriefed together identifying take-home points which highlighted the specific acute ward issue presented. Technical skills were highlighted in an additional three 3-hour sessions (Fig. 1). These sessions focused on basic surgical knot tying and suturing. Instruction in knottying was based on our previously validated kinesthetic Journal of Surgical Education Volume ]/Number ] ] ]]]]
FIGURE 1. UCSF SOM's CODA Course with Integration of Surgical Curriculum: The top portion of this figure demonstrates the design of UCSF SOM's established preparatory course with the recent integration of the surgical curriculum. The adjunctive surgery material was held over 8 sessions. These are shown in bold and labeled 1 through 8. Underneath the CODA course schedule lies a diagram illustrating the break-down of the surgical adjunct curriculum. The surgical curriculum consisted of 8 sessions, 3-hours each, held over a 3-week period. The material was separated into technical sessions and simulation scenarios. Additionally 2 of the 8 sessions were dedicated to introduction or precourse data gathering (Session 1-PRE) and conclusion or postcourse data gathering (Session 8-POST). The simulation scenarios (ward management and communication skills labeled “Scenarios”) were completed in sessions 2, 4, 6 and the technical skills sessions (labeled “Tech”) occurred during sessions 3, 5, 7.
knot-tying curriculum.7 This kinesthetic curriculum breaks knot-tying down into specific steps and movements with a focus on suturing handling, working distance and relative length, and understanding of knot conformation. These topics were covered during the technical skills sessions and students were given the opportunity to practice the skills after they received instruction by faculty. Each session would build on the previous one and cover increasingly challenging skills. The in-person technical skills sessions were supplemented by home video assignments that we have previously published.14 Briefly, the students were referred to instructional videos for each knot tying and suturing task. The home video assignments provide Journal of Surgical Education Volume ]/Number ] ] ]]]]
students with an opportunity for deliberate practice. Students received a tripod, camera, knot-tying board, and suture on the first day of class for these assignments. Students completed the home video assignments and brought completed videos to the following session for review by faculty. After evaluating the videos, faculty provided the students with individualized feedback on the performance. Home video exercises included knottying tasks (one-handed knots, 2-handed knots, tying under tension, tying at depth, and tying atraumatically) and suturing tasks (simple running, subcuticular running, simple interrupted, deep dermal, vertical mattress, and horizontal mattress). 3
Assessment We obtained institutional review board approval before any data collection and participants signed all required consent forms. Students provided demographic data including medical school experiences and future residency plan on the first day of the course. Students rated confidence levels for 14 ward management skills on the first and last day of the course. Results were reported as mean response (Likert scale, 1-5) for each of the 14 skills. Students were videotaped completing technical skills precourse or postcourse. Their performance was evaluated precourse or postcourse by time to completion and by ratings from 3 surgical faculty using a global grading scale (1-10) for 5 defined suturing exercises. Comparison between precourse or postcourse data were made using t-tests (α ¼ 0.05). Students identified strengths and weaknesses of the curriculum on an end of course survey.
RESULTS Demographics Overall, 11 fourth-year medical students participated in the adjunctive course that was held throughout the last 4 weeks of the academic year. Students’ previous surgical experiences varied substantially. They received their core surgical exposure at 4 different sites: a county trauma hospital, a private community hospital, and 2 large academic tertiary
care centers. All 11 students completed a sub-internship surgical rotation and 6/11 rotated at outside institutions during the fourth year of training. Although all students had matched into surgical residency programs the most common field was general surgery (5/11, 45%) followed by orthopedics (4/11, 36%) (Table). Confidence in Ward Management Tasks Students’ confidence improved in all 14 skill domains from the beginning to the end of the course (Fig. 2). The largest gains were seen in “Placement of central lines” (average gain of 2.0, p o 0.05) and “Interpretation and management of arterial blood gases” (average gain of 1.6, p o 0.05). Technical surgical skills performance A significant improvement in global score was seen for all evaluated suturing tasks (Fig. 3). Time to completion for each task did not significantly differ from pre- to postcourse evaluation.
DISCUSSION Boot camp courses are becoming popular adjuncts to the final months of medical school training. Course content and structure vary significantly between institutions. The overall goal of these courses is to decrease anxiety and increase competence of SMS by providing exposure to common
TABLE. Demographic Data of Course Participants Demographic Data
Sub-Category
# Of Students
% Of Students
Country trauma hospital Academic tertiary care center Private community hospital General surgery Orthopedics Urology Plastics Other Institution
5 3 2 11 8 4 1 2 6
45.45% 27.27% 18.18% 100.00% 72.73% 36.36% 9.09% 18.18% 54.55%
General surgery Categorical Preliminary Orthopedics Plastic surgery Urology
5 4 1 4 1 1
45.45% 36.36% 9.09% 36.36% 9.09% 9.09%
California Other State East Coast West Coast
2 8 4 5
18.18% 72.73% 36.36% 45.45%
Surgery 110 site
Surgical sub-internship
Future specialty
Location of future institute
Overall, 11 fourth-year medical students enrolled in the course offered in spring of 2014. This table highlights demographic data that were collected during the first session. Core surgical exposure was defined as the 8-week required general surgery rotation done during third year of medical school. 4
Journal of Surgical Education Volume ]/Number ] ] ]]]]
Level of Confidence
5
Confidence By Skill: Pre- and Post- Course Averages
4
Pre-Course
3
Post-Course
2
= p <0.05
1
Skill Type FIGURE 2. Confidence by skill: students reported their level of confidence in 14 ward management tasks at 2 separate time points (precourse and postcourse). Level of confidence was reported using a 5-point Likert scale. This graph illustrates the results (reported as mean response) for each of the 14 skills. When comparing confidence levels on the first and last day of the course, statistical significance (p o 0.05) is seen across all 14 categories.
problems and introducing learners to basic skills they would need to succeed in internship. Our surgical boot camp curriculum is incorporated into a month-long course for all graduating medical students at our institution. As these courses can be resource intensive in terms of time, money, and faculty availability, we sought to consolidate the sessions that are specific to interns going into surgical fields. These eight 3-hour sessions focus on the information that is unique to surgical interns, as to not duplicate information being taught during other sessions throughout the month. This study demonstrates that in three 3-hour sessions students are able to improve their confidence in managing common problems in surgical patients. The ward management and communication skills were presented via handson, practical scenarios that required participants to assimilate medical knowledge from various contexts to determine appropriate patient management. This served as a unique adjunct to “Coda,” as the postoperative issues discussed emphasized unique features based on specific surgical patient populations. Students also demonstrate improvement in technical skills by participating in three 3-hour skills sessions. Unique to our course was the addition of the take-home video assignments. We believe that the home video assignments allow students to review proper technique at home and then participate in deliberate practice of new skills. The home video component of this course was developed for our Journal of Surgical Education Volume ]/Number ] ] ]]]]
intern basic surgical skills curriculum. Self-directed videobased curriculum is considered to be an effective method for gaining basic surgical skills.15–17 Videotaping the tasks at home allows students to individually review their performance and make necessary changes. This significantly reduces classroom and faculty demands while still allowing a platform for students to develop and master skills. One of the main criticisms of preparatory courses is their extensive resource burden. The home video assignments provide an avenue for self-assessment and skill acquisition with minimal resource utilization. Future studies quantifying the amount of nonclassroom time spent practicing these skills could be compared to students’ pre- and postcourse performance to identify a potential correlation between time practiced to degree of improvement. Although students’ global scores improve for all tasks from pre- to postcourse evaluation, their time to completion does not significantly improve. We suspect that as students focus on proper technique their cognitive load increases, likely accounting for time. We expect efficiency and speed to come with further practice. Future investigations could examine a study designed to specifically evaluate this type of learning in surgical trainees. Although the importance of preparatory courses for surgical residents has been recognized on a national level,4 the extensive resource demands exclude many institutions from designing and implementing similar courses for their 5
10
Technical Skills: Pre- and Post-Course Global Score
9
8
Score
7
6
5
Pre-Course Post-Course
4
3
= p < 0.05
2
1 Simple Interrupted Interrupted Suturing Vertical-Mattress Suturing
Simple Running Subticular Running Suture Suture
Subticular Interrupted Suturing
Exercise Type FIGURE 3. Technical skills: surgical technical skills were evaluated for 5 different exercises at 2 separate time points (pre- and postcourse). Faculty scored students using a global score (1-10) at both time points. Students' scores were averaged for each exercise and illustrated in this figure. When comparing scores from the first to last day of the course, statistical significance (p o 0.05) is seen in all 5 exercises.
SMS. A recent cost analysis of the American College of Surgeons or Association of Program Directors in Surgery National Technical Skills Curriculum revealed an annual operating cost of $110,300 with 20% allocated to faculty teaching hours.18 Using self-directed home videos and sharing resources with other specialties (as is done with the capstone course offered at UCSF) we illustrate a new curriculum that could significantly reduce these costs. Additional investigation is needed to identify the cost-benefit ratio that this type of adjunct curriculum could provide. There are several limitations to this study. First, there was no direct assessment of pre- and postcourse ward management skills. Evaluation of ward management skills was only based on student perspective. Though not demonstrated in this study, other articles have reported a nearly 1:1 linear relationship between self-reported confidence and objectively assessed competence of surgical interns.19 Self-efficacy has been shown to correspond with student performance on various tasks.20 Bandura’s theory of self-efficacy additionally highlights its importance in the facilitation of learning.21,22 Therefore, student’s improved confidence may correlate to improved efficiency on the ward and better patient outcomes. Students who are more confident handling a problem and initiating a diagnostic and treatment plan likely waste less time before enacting that plan. Future evaluation of this course may include knowledge-based testing to more rigorously assess the ward management and mock-page encounters portion of the curriculum. 6
Additionally, the study was not blinded so the scoring on the surgical skills may be biased. Lastly, previous studies suggest that the gains from surgical boot camps are shortlived; at 6 months, there is no difference in technical skills between interns who did not participate in boot camp and those who did.6 However, it is possible that these courses accelerate the learning curve. With the format of our adjunct curriculum, we covered a wide range of content with minimal classroom and faculty hours. Additionally, the scenarios allowed for students to integrate concepts discussed in the “Coda” lectures into a clinical decision-making structure—a very realistic illustration of their soon-to-be role as interns.
CONCLUSION In conclusion, we have developed and incorporated a surgical component to the existing preparatory course at our institution. Our results illustrate the feasibility of an adjunctive specialty-specific curriculum for SMS entering surgical residencies. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum allows for consolidation of efforts to maximize resources while still highlighting specific skills to prepare students for surgical residency. Students demonstrated increased confidence in ward management skills and increased technical scores in all measured exercises. The Journal of Surgical Education Volume ]/Number ] ] ]]]]
technical improvement is noteworthy because only 3 sessions were dedicated to these skills. The significant progress may be due to the additional implementation of the home video component. Investigation into long-term gains in technical skills is warranted.
ACKNOWLEDGMENTS All those directly involved in the project have been identified. There were no additional sources of funding or services utilized in the creation of this article.
8. Lewis FR, Klingensmith ME. Issues in general surgery
residency training—2012. Ann Surg. 2012;256 (4):553-559. http://dx.doi.org/10.1097/SLA.0b013 e31826bf98c. 9. Lyss-lerman P, Teherani A, Aagaard E. What training
is needed in the fourth year of medical school ? views of residency program Acad Med. 2009;84(7):823-829. 10. Naylor Ra, Hollett La, Castellvi A, Valentine RJ, Scott
DJ. Preparing medical students to enter surgery residencies. Am J Surg. 2010;199(1):105-109. http://dx.doi.org/ 10.1016/j.amjsurg.2009.09.003. 11. Parent RJ, Plerhoples TA, Long EE, et al. Early,
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Ketchum J, Dunnington G. A senior elective designed to prepare medical students for surgical residency. Am J Surg. 2004;187(6):695-697. http://dx.doi.org/ 10.1016/j.amjsurg.2003.12.052.
intermediate, and late effects of a surgical skills boot camp on an objective structured assessment of technical skills: a randomized controlled study. J Am Coll Surg. 2010;210(6):984-989. http://dx.doi.org/10.1016/ j.jamcollsurg.2010.03.006. 12. The Accreditation Council for Graduate Medical
Education. (2014). The General Surgery Milestone Project.
2. Brunt LM, Halpin VJ, Klingensmith ME, et al.
13. Antonoff MB, Green CA, D’Cunha J Critical skills for
Accelerated skills preparation and assessment for senior medical students entering surgical internship. J Am Coll Surg. 2008;206(5):897-904. http://dx.doi.org/ 10.1016/j.jamcollsurg.2007.12.018.
the senior medical student entering surgery. MedEdPORTAL; 2012. 〈http://www.mededportal.org/publi cation/9372〉.
3. Teo Alan R, Sullivan PSO. The key role of a transition
course in preparing medical students for internship. Acad Med. 2011;86(7):860-865. http://dx.doi.org/ 10.1097/ACM.0b013e31821d6ae2.The. 4. American Board of Surgery; American College of
Surgeons; Association of Program Directors in Surgery; Association for Surgical Education. Statement on surgical pre-residency preparatory courses. J Am Coll Surg. 2014;219(5):851-852. http://dx.doi.org/10.1007/ BF01866587.
14. Chern H, Sheu L, O’Sullivan P, Kim E. Home video
curriculum for basic surgical skills. MedEdPORTAL Publications; 2014. 〈https://www.mededportal.org/ publication/9683〉 10.15766/mep_2374-8265.9683. 15. Jowett N, LeBlanc V, Xeroulis G, MacRae H,
Dubrowski A. Surgical skill acquisition with self– directed practice using computer–based video training. Am J Surg. 2007;193:237-242. http://dx.doi.org/ 10.1016/j.amjsurg.2006.11.003. 16. Xeroulis GJ, Park J, Moulton C-A, Reznick RK,
student Boot Camp: can result in increased selfconfidence before starting surgery internships. Curr Surg. 2006;63(4):264-268. http://dx.doi.org/10.1016/ j.cursur.2006.03.004.
Leblanc V, Dubrowski A. Teaching suturing and knot–tying skills to medical students: a randomized controlled study comparing computer–based video instruction and (concurrent and summary) expert feedback. Surgery. 2007;141:442-449. http://dx.doi. org/10.1016/j.surg.2006.09.012.
6. Fernandez GL, Page DW, Coe NP, et al. Boot cAMP:
17. Nousiainen M, Brydges R, Backstein D, Dubrowski A.
educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship. J Surg Educ. 2012;69(2):242-248. http://dx.doi.org/ 10.1016/j.jsurg.2011.08.007.
Comparison of expert instruction and computer–based video training in teaching fundamental surgical skills to medical students. Surgery. 2008;143:539-544. http://dx.doi.org/10.1016/j.surg.2007.10.022.
7. Huang E, Chern H, O’Sullivan P, et al. A better way
18. Henry B, Clark P, Sudan R. Cost and logistics of
to teach knot tying: a randomized controlled trial comparing the kinesthetic and traditional methods. Am J Surg. 2014;208(4):690-694. http://dx.doi.org/ 10.1016/j.amjsurg.2014.05.028.
implementing a tissue-based American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for general surgery residents of all clinical years. Am J Surg. 2014;207:201-208.
5. Esterl RM, Henzi DL, Cohn SM. Senior medical
Journal of Surgical Education Volume ]/Number ] ] ]]]]
7
19. Antonoff MB, Swanson JA, Green CA, Mann BD,
Maddaus MA, D’Cunha J. The significant impact of a competency-based preparatory course for senior medical students entering surgical residency. Acad Med. 2012;87(3):308-319.
21. Bandura A. Self-efficacy: toward a unifying theory of
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SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at httmp://dx.doi.org/10.1016/j.jsurg. 2016.03.011.
8
Journal of Surgical Education Volume ]/Number ] ] ]]]]
Evaluation of a Surgery-Based Adjunct Course for Senior Medical Students Entering Surgical Residencies Courtney A. Green, MD, Carolyn J. Vaughn, MD, Susannah M. Wyles, MD, Patricia S. O’Sullivan, EdD, Edward H. Kim, MD and Hueylan Chern, MD Department of Surgery, University of California, San Francisco, California BACKGROUND: Preparatory courses for senior medical students aim to ease the transition from medical school to residency. We designed a novel adjunct curriculum to enhance students’ readiness for surgical internship. This study addresses the feasibility and outcomes of this course. MATERIALS AND METHODS: A curriculum was designed
based on ACGME surgical milestones. Students participated in 8 (3 h) sessions held over 4 weeks as an adjunct to a well-established intern preparatory course. Course activities involved interactive simulation cases to emphasize care of surgical patients, and skills sessions focused on knot tying and suturing, which were reinforced with home video assignments. Students rated confidence on 14 management skills using a 5-point Likert scale (5 ¼ high confidence). Faculty graded students’ technical performance using a global scale (0-10) for 5 suturing exercises. Comparisons between precourse and postcourse data collected for all measures were made using t-tests (α ¼ 0.05). RESULTS: A total of 11 students entering 4 different surgical fields participated. Overall confidence in patient management improved from 2.41 to 3.89 (standard deviation ¼ 0.49, 0.35; p o 0.05). Students’ scores on all 5 suturing tasks increased (p o 0.05). CONCLUSIONS: We developed a surgery-specific component to the existing preparatory course at our institution. Students demonstrated increased confidence in ward management skills and increased technical scores in all exercises. Although only 3 sessions were dedicated to technical skills, improvements may highlight the benefit of home video assignments. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum highlights skills specific for surgical residency, while
Correspondence: Inquiries to Courtney A. Green, MD, Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, S-321, San Francisco, CA 94143-0470; fax: (415) 502-1259; E-mail: [email protected], [email protected]
C 2016 Associmaximizing resources. ( J Surg Ed ]:]]]-]]]. J ation of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: medical education, intern preparatory course, surgical curriculum COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-Based Practice
INTRODUCTION The transition from medical school to residency is difficult, stressful, and filled with uncertainty. Educators have attempted to address many of these challenges by developing preparatory courses aimed at bridging the gap between the demands of medical school and residency. These courses have taken many forms; some are designed for senior medical students (SMS) during the fourth year of medical education, whereas others occur throughout the first months of residency.1,2 There are courses that highlight preparation for a specific specialty and others that focus more on the generic transition applicable to all specialties. Despite the various formats and the recognized importance of preparatory courses, implementation of these types of curricula is highly demanding, necessitating significant time, faculty efforts and institutional funds for successful execution.3 Surgery Challenges Surgical residency faces additional challenges.4 The design of most surgical services have the senior residents in the operating room for the majority of the day, whereas the interns provide immediate care to postoperative patients. Additionally, ongoing changes in ACGME requirements put additional pressure on surgical residents to get operative exposure early in their training. The implementation of
Journal of Surgical Education & 2016 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.03.011
1
duty hour restrictions has resulted in the need for basic technical skill acquisition to occur outside the operating room. To this end, a statement released by joint surgical organizations indicated that “all matriculates to surgery residency successfully complete a preparatory course… before the start of their training.”5 Previous Preparatory Courses Although many medical schools have implemented “boot camp” courses for SMS and surgical interns, there is no standardization of these courses. Courses range from daylong sessions to month-long elective courses.6,7 Content covered during these courses also varies considerably, though most courses include technical skills including basic suturing and knot-tying, procedural skills, and ward management skills.2,6-11 The new ACGME milestones have provided some guidelines for competency goals, and some institutions have developed their curricula with these milestones in mind.10 Evaluation of these curricula range from surveys demonstrating improved confidence among students, to technical skills assessments demonstrating improvement in basic surgical skills and knowledge-based tests showing higher scores.7-10 Taken together, the results of these courses suggest that there is a benefit of these courses, though more rigorous research is required to optimize these courses. Our Course We chose to design a novel curriculum that can be embedded into a capstone course to enhance student’s readiness for surgical internship. Since 2001, UCSF School of Medicine has offered their students a multidisciplinary course aimed at improving the transition from medical school to residency.3 Various break-out sessions are offered for the students throughout the 4 week course. In 2014, we offered a supplemental course to students entering surgical fields emphasizing both cognitive and technical components. This article discusses our experience with this supplemental course and investigates its efficacy and feasibility.
MATERIALS AND METHODS A surgical curriculum was designed and executed as an adjunct to the intern preparatory course that is well established at UCSF School of Medicine.3 The established course, called “Coda” is carried out over 3 weeks and is designed to be a high-yield review of medical school curriculum for students preparing to enter residency. Broad topics are covered in didactic lectures supplemented by small group sessions with hands-on skills (Fig. 1). As an adjunct to this course, a surgical curriculum was designed to 2
highlight management of common postoperative issues and technical skills for those entering surgical residencies. These postoperative issues are unique to the surgical patient population and are not covered in detail in the didactic or small group sessions. To highlight some of these nuances and provide focused technical instruction, the surgery adjunctive curriculum consisted of 8, 3-hour sessions held over a 3-week period. These sessions included an introduction, an intensive review of technical skills, ward management and communication skills, and final evaluation (Fig. 1). The ward management and communication skills were presented via hands-on, practical scenarios. The course was developed based on competencies highlighted in the ACGME milestones for general surgery.12 Curriculum Activities highlighting cognitive components included three 3-hour sessions dedicated to interactive simulation cases and mock-page encounters (Fig. 1). These cases were designed to cover common postoperative scenarios interns encounter and aimed to highlight early recognition and management of life-threatening situations. Scenarios addressed the following topics: postoperative pain (expected, more than expected [anastomotic leak, ileus or vomiting]), electrolyte abnormalities (hyper- and hypokalemia), insomnia, agitation or acute mental status change (hypoxia, shock, glucose and electrolyte abnormalities, medications), fall, postoperative fever (concerns based on when, related to the surgery, it occurs [anastomotic leak, surgical site infection—superficial or deep]), oliguria (prerenal presentation, pre- or posttransplant patient), respiratory distress (pulmonary embolism and pneumothorax), chest pain (myocardial infarction), tachycardia (atrial fibrillation and congestive heart failure), hypertension, hypotension (hemorrhagic shock and septic shock). Students took turns individually in front of the class working through various mock-page scenarios. Templates were created for the aforementioned topics using an adapted version of previously published preparatory material.13 The templates were designed to highlight key concepts for the different scenarios and guide the operators through the debriefing session (Appendix A). Instructors including attendings and surgical residents played the roles of patient, nurse, chief resident, etc. A student would work through the scenario and receive immediate feedback at its conclusion. Usually 2 scenarios were covered in each session. At the end of the session, the entire group debriefed together identifying take-home points which highlighted the specific acute ward issue presented. Technical skills were highlighted in an additional three 3-hour sessions (Fig. 1). These sessions focused on basic surgical knot tying and suturing. Instruction in knottying was based on our previously validated kinesthetic Journal of Surgical Education Volume ]/Number ] ] ]]]]
FIGURE 1. UCSF SOM's CODA Course with Integration of Surgical Curriculum: The top portion of this figure demonstrates the design of UCSF SOM's established preparatory course with the recent integration of the surgical curriculum. The adjunctive surgery material was held over 8 sessions. These are shown in bold and labeled 1 through 8. Underneath the CODA course schedule lies a diagram illustrating the break-down of the surgical adjunct curriculum. The surgical curriculum consisted of 8 sessions, 3-hours each, held over a 3-week period. The material was separated into technical sessions and simulation scenarios. Additionally 2 of the 8 sessions were dedicated to introduction or precourse data gathering (Session 1-PRE) and conclusion or postcourse data gathering (Session 8-POST). The simulation scenarios (ward management and communication skills labeled “Scenarios”) were completed in sessions 2, 4, 6 and the technical skills sessions (labeled “Tech”) occurred during sessions 3, 5, 7.
knot-tying curriculum.7 This kinesthetic curriculum breaks knot-tying down into specific steps and movements with a focus on suturing handling, working distance and relative length, and understanding of knot conformation. These topics were covered during the technical skills sessions and students were given the opportunity to practice the skills after they received instruction by faculty. Each session would build on the previous one and cover increasingly challenging skills. The in-person technical skills sessions were supplemented by home video assignments that we have previously published.14 Briefly, the students were referred to instructional videos for each knot tying and suturing task. The home video assignments provide Journal of Surgical Education Volume ]/Number ] ] ]]]]
students with an opportunity for deliberate practice. Students received a tripod, camera, knot-tying board, and suture on the first day of class for these assignments. Students completed the home video assignments and brought completed videos to the following session for review by faculty. After evaluating the videos, faculty provided the students with individualized feedback on the performance. Home video exercises included knottying tasks (one-handed knots, 2-handed knots, tying under tension, tying at depth, and tying atraumatically) and suturing tasks (simple running, subcuticular running, simple interrupted, deep dermal, vertical mattress, and horizontal mattress). 3
Assessment We obtained institutional review board approval before any data collection and participants signed all required consent forms. Students provided demographic data including medical school experiences and future residency plan on the first day of the course. Students rated confidence levels for 14 ward management skills on the first and last day of the course. Results were reported as mean response (Likert scale, 1-5) for each of the 14 skills. Students were videotaped completing technical skills precourse or postcourse. Their performance was evaluated precourse or postcourse by time to completion and by ratings from 3 surgical faculty using a global grading scale (1-10) for 5 defined suturing exercises. Comparison between precourse or postcourse data were made using t-tests (α ¼ 0.05). Students identified strengths and weaknesses of the curriculum on an end of course survey.
RESULTS Demographics Overall, 11 fourth-year medical students participated in the adjunctive course that was held throughout the last 4 weeks of the academic year. Students’ previous surgical experiences varied substantially. They received their core surgical exposure at 4 different sites: a county trauma hospital, a private community hospital, and 2 large academic tertiary
care centers. All 11 students completed a sub-internship surgical rotation and 6/11 rotated at outside institutions during the fourth year of training. Although all students had matched into surgical residency programs the most common field was general surgery (5/11, 45%) followed by orthopedics (4/11, 36%) (Table). Confidence in Ward Management Tasks Students’ confidence improved in all 14 skill domains from the beginning to the end of the course (Fig. 2). The largest gains were seen in “Placement of central lines” (average gain of 2.0, p o 0.05) and “Interpretation and management of arterial blood gases” (average gain of 1.6, p o 0.05). Technical surgical skills performance A significant improvement in global score was seen for all evaluated suturing tasks (Fig. 3). Time to completion for each task did not significantly differ from pre- to postcourse evaluation.
DISCUSSION Boot camp courses are becoming popular adjuncts to the final months of medical school training. Course content and structure vary significantly between institutions. The overall goal of these courses is to decrease anxiety and increase competence of SMS by providing exposure to common
TABLE. Demographic Data of Course Participants Demographic Data
Sub-Category
# Of Students
% Of Students
Country trauma hospital Academic tertiary care center Private community hospital General surgery Orthopedics Urology Plastics Other Institution
5 3 2 11 8 4 1 2 6
45.45% 27.27% 18.18% 100.00% 72.73% 36.36% 9.09% 18.18% 54.55%
General surgery Categorical Preliminary Orthopedics Plastic surgery Urology
5 4 1 4 1 1
45.45% 36.36% 9.09% 36.36% 9.09% 9.09%
California Other State East Coast West Coast
2 8 4 5
18.18% 72.73% 36.36% 45.45%
Surgery 110 site
Surgical sub-internship
Future specialty
Location of future institute
Overall, 11 fourth-year medical students enrolled in the course offered in spring of 2014. This table highlights demographic data that were collected during the first session. Core surgical exposure was defined as the 8-week required general surgery rotation done during third year of medical school. 4
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Level of Confidence
5
Confidence By Skill: Pre- and Post- Course Averages
4
Pre-Course
3
Post-Course
2
= p <0.05
1
Skill Type FIGURE 2. Confidence by skill: students reported their level of confidence in 14 ward management tasks at 2 separate time points (precourse and postcourse). Level of confidence was reported using a 5-point Likert scale. This graph illustrates the results (reported as mean response) for each of the 14 skills. When comparing confidence levels on the first and last day of the course, statistical significance (p o 0.05) is seen across all 14 categories.
problems and introducing learners to basic skills they would need to succeed in internship. Our surgical boot camp curriculum is incorporated into a month-long course for all graduating medical students at our institution. As these courses can be resource intensive in terms of time, money, and faculty availability, we sought to consolidate the sessions that are specific to interns going into surgical fields. These eight 3-hour sessions focus on the information that is unique to surgical interns, as to not duplicate information being taught during other sessions throughout the month. This study demonstrates that in three 3-hour sessions students are able to improve their confidence in managing common problems in surgical patients. The ward management and communication skills were presented via handson, practical scenarios that required participants to assimilate medical knowledge from various contexts to determine appropriate patient management. This served as a unique adjunct to “Coda,” as the postoperative issues discussed emphasized unique features based on specific surgical patient populations. Students also demonstrate improvement in technical skills by participating in three 3-hour skills sessions. Unique to our course was the addition of the take-home video assignments. We believe that the home video assignments allow students to review proper technique at home and then participate in deliberate practice of new skills. The home video component of this course was developed for our Journal of Surgical Education Volume ]/Number ] ] ]]]]
intern basic surgical skills curriculum. Self-directed videobased curriculum is considered to be an effective method for gaining basic surgical skills.15–17 Videotaping the tasks at home allows students to individually review their performance and make necessary changes. This significantly reduces classroom and faculty demands while still allowing a platform for students to develop and master skills. One of the main criticisms of preparatory courses is their extensive resource burden. The home video assignments provide an avenue for self-assessment and skill acquisition with minimal resource utilization. Future studies quantifying the amount of nonclassroom time spent practicing these skills could be compared to students’ pre- and postcourse performance to identify a potential correlation between time practiced to degree of improvement. Although students’ global scores improve for all tasks from pre- to postcourse evaluation, their time to completion does not significantly improve. We suspect that as students focus on proper technique their cognitive load increases, likely accounting for time. We expect efficiency and speed to come with further practice. Future investigations could examine a study designed to specifically evaluate this type of learning in surgical trainees. Although the importance of preparatory courses for surgical residents has been recognized on a national level,4 the extensive resource demands exclude many institutions from designing and implementing similar courses for their 5
10
Technical Skills: Pre- and Post-Course Global Score
9
8
Score
7
6
5
Pre-Course Post-Course
4
3
= p < 0.05
2
1 Simple Interrupted Interrupted Suturing Vertical-Mattress Suturing
Simple Running Subticular Running Suture Suture
Subticular Interrupted Suturing
Exercise Type FIGURE 3. Technical skills: surgical technical skills were evaluated for 5 different exercises at 2 separate time points (pre- and postcourse). Faculty scored students using a global score (1-10) at both time points. Students' scores were averaged for each exercise and illustrated in this figure. When comparing scores from the first to last day of the course, statistical significance (p o 0.05) is seen in all 5 exercises.
SMS. A recent cost analysis of the American College of Surgeons or Association of Program Directors in Surgery National Technical Skills Curriculum revealed an annual operating cost of $110,300 with 20% allocated to faculty teaching hours.18 Using self-directed home videos and sharing resources with other specialties (as is done with the capstone course offered at UCSF) we illustrate a new curriculum that could significantly reduce these costs. Additional investigation is needed to identify the cost-benefit ratio that this type of adjunct curriculum could provide. There are several limitations to this study. First, there was no direct assessment of pre- and postcourse ward management skills. Evaluation of ward management skills was only based on student perspective. Though not demonstrated in this study, other articles have reported a nearly 1:1 linear relationship between self-reported confidence and objectively assessed competence of surgical interns.19 Self-efficacy has been shown to correspond with student performance on various tasks.20 Bandura’s theory of self-efficacy additionally highlights its importance in the facilitation of learning.21,22 Therefore, student’s improved confidence may correlate to improved efficiency on the ward and better patient outcomes. Students who are more confident handling a problem and initiating a diagnostic and treatment plan likely waste less time before enacting that plan. Future evaluation of this course may include knowledge-based testing to more rigorously assess the ward management and mock-page encounters portion of the curriculum. 6
Additionally, the study was not blinded so the scoring on the surgical skills may be biased. Lastly, previous studies suggest that the gains from surgical boot camps are shortlived; at 6 months, there is no difference in technical skills between interns who did not participate in boot camp and those who did.6 However, it is possible that these courses accelerate the learning curve. With the format of our adjunct curriculum, we covered a wide range of content with minimal classroom and faculty hours. Additionally, the scenarios allowed for students to integrate concepts discussed in the “Coda” lectures into a clinical decision-making structure—a very realistic illustration of their soon-to-be role as interns.
CONCLUSION In conclusion, we have developed and incorporated a surgical component to the existing preparatory course at our institution. Our results illustrate the feasibility of an adjunctive specialty-specific curriculum for SMS entering surgical residencies. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum allows for consolidation of efforts to maximize resources while still highlighting specific skills to prepare students for surgical residency. Students demonstrated increased confidence in ward management skills and increased technical scores in all measured exercises. The Journal of Surgical Education Volume ]/Number ] ] ]]]]
technical improvement is noteworthy because only 3 sessions were dedicated to these skills. The significant progress may be due to the additional implementation of the home video component. Investigation into long-term gains in technical skills is warranted.
ACKNOWLEDGMENTS All those directly involved in the project have been identified. There were no additional sources of funding or services utilized in the creation of this article.
8. Lewis FR, Klingensmith ME. Issues in general surgery
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SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at httmp://dx.doi.org/10.1016/j.jsurg. 2016.03.011.
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