- Email: [email protected]
Using simulation to address continuity of care in general surgery resident education
Letters to the Editor short sighted and risk reducing the number and quality of applicants to surgical residencies.
Acknowledgments The authors would like to thank the Cardiff University Research Society’s Short Duration Project Scheme (http:// cures.cardiff.ac.uk). James C. Glasbey, M.B.B.Ch., B.Sc. Rhiannon L. Harries, M.B.B.S., M.R.C.S. School of Postgraduate Medical and Dental Education, Cochrane Medical Education Centre, University Hospital of Wales, Heath Park, CF14 4XW, Cardiff, UK
491
3.
4.
5.
6.
7.
Christopher Wilcox, M.B.B.Ch., B.Sc. Cardiff University School of Medicine, Cardiff, UK
8.
Sam H. Myers University College London Medical School, London, UK
9.
http://dx.doi.org/10.1016/j.amjsurg.2015.06.011
10.
References 1. Hagopian T, Vitiello G, Hart A, et al. Does the amount of time medical students spend in the operating room during the general surgery core clerkship affect their career decision? Am J Surg 2015;210:167–72. 2. Core Surgery National Recruitment Office (CSNRO). Core Surgery Recruitment for NHS: Competition Ratios. Available at: http://
11.
12.
www.surgeryrecruitment.nhs.uk/how-to-apply/competition-ratios; 2014. Accessed June 23, 2015. Cardiff University School of Medicine. Courses: Medicine MBBCh. Available at: http://courses.cardiff.ac.uk/undergraduate/course/detail/ A100.html; 2014. Accessed June 23, 2015. Magos T, Loizides S, Panteli M, Pafitanis G, Whitehouse P, Singh KK. UK foundation-year 1 doctorsda survey uncovering infrequent theater experience regardless of time, place, or surgical specialty. J Surg Educ 2015;72:515–21. Health Education England. Broadening the Foundation Programme. Available at: http://hee.nhs.uk/wp-content/uploads/sites/321/2014/02/ Broadening_the_Foundation_V15-Final.pdf; 2014. Accessed June 25, 2015. Richards J, Drummond R, Murray J, et al. What proportion of basic surgical trainees continue in a surgical career? A survey of the factors which are important in influencing career decisions. Surgeon 2009;7: 270–5. Cook M, Yoon M, Hunter J, et al. A nonmetropolitan surgery clerkship increases interest in a surgical career. Am J Surg 2015;209:21–5. Sinclair P, Fitzgerald JE, McDermott FD, et al. Mentoring during surgical training: consensus recommendations for mentoring programmes from the Association of Surgeons in Training. Int J Surg 2014;12(Suppl 3):S5–8. Sutton PA, Mason J, Vimalachandran D, et al. Attitudes, motivators, and barriers to a career in surgery: a national study of U.K. undergraduate medical students. J Surg Educ 2014;71:662–7. Moshtaghi O, Kelley KS, Armstrong WB, et al. Using Google glass to solve communication and surgical education challenges in the operating room. Laryngoscope; 2015. http://dx.doi.org/10.1002/lary. 25249 [Epub ahead of print]. Ahmed S. Surgeon Uses Google Glass during cancer Operation. Available at: http://www.telegraph.co.uk/news/health/10851599/Surgeonuses-Google-Glass-during-cancer-operation.html; 2014. Accessed June 23, 2015. Marshall DC, Salciccioli JD, Walton SJ, et al. Medical student experience in surgery influences their career choices: a systematic review of the literature. J Surg Educ 2015;72:438–45.
Using simulation to address continuity of care in general surgery resident education To the Editor: We read with interest the article entitled ‘‘Continuity of care in general surgery resident education’’ by Daly et al1 and agree that resident clinical experiences are increasingly isolated and lacking in continuity under current training paradigms. In addition to the Accreditation Council for Graduate Medical Education guidelines, it is noted that the American Board of Surgery training requirements also include an increasing number of performance assessments that span operative as well as clinical (ie, preoperative and postoperative) settings, and that a selection of assessment forms are provided for this purpose.2 Exactly as the authors say, ‘‘it is incumbent on training programs to provide residents with experience managing individual
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2014.11.016
patients through their entire course of treatment,’’1 though specific implementation remain a challenge. To address resident training in continuity of care, we developed a simulation-based educational curriculum for junior residents. This was based on sequences or pathways of simulations spanning preoperative, intraoperative, and postoperative care for patients undergoing laparoscopic cholecystectomy,3 laparoscopic appendectomy,4 colectomy (ileocolic anastomosis),5 and gastrectomy (gastrojejunal anastomosis).6 Simulation education has often focused on the acquisition of isolated technical skills outside their clinical context, but can be applied systematically as a potential strategy to address the continuum of care for a range of disease states. During these immersive simulations, residents proceeded through sequential encounters that allowed them to experience and learn the management of a patient presenting with a common surgical disease state from initial presentation through surgery and follow-up in
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The American Journal of Surgery, Vol 211, No 2, February 2016
a time-efficient manner. The preoperative encounter occurred in the simulated outpatient or emergency room setting with a standardized patient presenting with a surgical problem, followed by the corresponding surgical task in the simulated operating room with animal or synthetic models, as available. The sequence concluded with a postoperative visit with the same standardized patient in the simulated recovery area, or clinic. Learner performance was assessed using existing, validated rating scales provided by the American Board of Surgery.2 We integrated the above simulations as part of the residency curriculum for 18 learners (class of first-year general surgery residents), involving over 30 surgery faculty as teachers over a 12-month academic year. Faculty and learner evaluations were exceedingly positive.3–6 The challenge remains to translate the process and findings of such educational curricula to clinical practice. This is an important issue for surgical educators, faculty, and of utmost importance to ensuring accountability in providing a high quality of patient care.
Kiyoyuki W. Miyasaka, M.D., M.T.R. Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Penn Medicine Clinical Simulation Center, Penn Medicine at Rittenhouse, Philadelphia PA, USA
Rajesh Aggarwal, M.B.B.S., M.A., Ph.D., F.R.C.S. Arnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University Montreal, Canada http://dx.doi.org/10.1016/j.amjsurg.2015.07.030
References 1. Daly SC, Klairmont MM, Rinewalt D, et al. Continuity of care in general surgery resident education. Am J Surg 2015;210:175–8. 2. American Board of Surgery, General surgery resident training Requirements. Available at: http://www.absurgery.org/default.jsp?certgsqe_ resassess. Accessed July 1, 2015. 3. Buchholz J, Miyasaka KW, Vollmer C, et al. Design, development and implementation of a surgical simulation pathway curriculum for biliary disease. Surg Endosc 2015;29:68–76. 4. Buchholz J, Miyasaka KW, Martin ND, et al. Pathway-based acute care surgery training using a novel simulation method. J Am Coll Surg 2014; 219:e157–8 (Supplement). 5. Miyasaka KW. Pathway-based Simulation Training Curriculum for Colorectal Surgery. Oral presentation at the 2014 International Conference on Residency Education, Toronto, Canada. Available at: http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/events/ icre/2014proceedings/slides/Simulation_in_Residency_Education/K_ Miyasaka.pdf. Accessed July 1, 2015. 6. Miyasaka KW, Buchholz J, LaMarra D, et al. Development and implementation of a clinical pathway approach to simulation-based training for foregut surgery. J Surg Educ 2015;72:625–35.
Risk factors of gangrenous cholecystitis To the Editor: We read with interest the article Risk factors for acute gangrenous cholecystitis in emergency general surgery patients by Bourikian et al1 published online in the American Journal of Surgery. The authors analyzed the risk factors for acute gangrenous cholecystitis. They have found that acute gangrenous cholecystitis had an increased mortality rate compared with cholecystitis without necrosis and was associated with high mortality. And also they have stated that older patients with diabetes, coronary artery disease, and elevated bilirubin should have been suspected of having acute gangrenous cholecystitis. However, I believe that additional data regarding the details of the patient population would be useful. Gangrenous cholecystitis, a histological diagnosis, is a severe form of acute cholecystitis with a high risk of complications.2–5 It is more common in some patients who
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2015.05.003 There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. The authors declare no conflicts of interest.
had risk factors. These include male gender, increasing age, leukocytosis, elevation of C-reactive protein, decrease in platelets, hormonal therapy, total parenteral nutrition, fasting, diabetes, coronary artery disease, major surgery, chronic obstructive pulmonary disease, cardiovascular accident, trauma, preoperative hypotension, sepsis, obesity, gallbladder wall thickening at ultrasound, pericholecystic fluid collection at ultrasound, and critical illness.2–5 The authors have analyzed age, sex, diabetes, preoperative hypotension, preoperative diagnosis of systemic inflammatory response syndrome, weight, and admission laboratory work including serum lactate and total bilirubin related to patients characteristics. However, some of the conditions and risk factors known to be associated with acute gangrenous cholecystitis were not described and analyzed. I believe that knowledge of these risk factors in the patient population would be beneficial and interesting to the readers. Ali Kagan Coskun, M.D. Department of Surgery, Gulhane School of Medicine, Ankara, Turkey http://dx.doi.org/10.1016/j.amjsurg.2015.07.026
Acknowledgments The authors would like to thank the Cardiff University Research Society’s Short Duration Project Scheme (http:// cures.cardiff.ac.uk). James C. Glasbey, M.B.B.Ch., B.Sc. Rhiannon L. Harries, M.B.B.S., M.R.C.S. School of Postgraduate Medical and Dental Education, Cochrane Medical Education Centre, University Hospital of Wales, Heath Park, CF14 4XW, Cardiff, UK
491
3.
4.
5.
6.
7.
Christopher Wilcox, M.B.B.Ch., B.Sc. Cardiff University School of Medicine, Cardiff, UK
8.
Sam H. Myers University College London Medical School, London, UK
9.
http://dx.doi.org/10.1016/j.amjsurg.2015.06.011
10.
References 1. Hagopian T, Vitiello G, Hart A, et al. Does the amount of time medical students spend in the operating room during the general surgery core clerkship affect their career decision? Am J Surg 2015;210:167–72. 2. Core Surgery National Recruitment Office (CSNRO). Core Surgery Recruitment for NHS: Competition Ratios. Available at: http://
11.
12.
www.surgeryrecruitment.nhs.uk/how-to-apply/competition-ratios; 2014. Accessed June 23, 2015. Cardiff University School of Medicine. Courses: Medicine MBBCh. Available at: http://courses.cardiff.ac.uk/undergraduate/course/detail/ A100.html; 2014. Accessed June 23, 2015. Magos T, Loizides S, Panteli M, Pafitanis G, Whitehouse P, Singh KK. UK foundation-year 1 doctorsda survey uncovering infrequent theater experience regardless of time, place, or surgical specialty. J Surg Educ 2015;72:515–21. Health Education England. Broadening the Foundation Programme. Available at: http://hee.nhs.uk/wp-content/uploads/sites/321/2014/02/ Broadening_the_Foundation_V15-Final.pdf; 2014. Accessed June 25, 2015. Richards J, Drummond R, Murray J, et al. What proportion of basic surgical trainees continue in a surgical career? A survey of the factors which are important in influencing career decisions. Surgeon 2009;7: 270–5. Cook M, Yoon M, Hunter J, et al. A nonmetropolitan surgery clerkship increases interest in a surgical career. Am J Surg 2015;209:21–5. Sinclair P, Fitzgerald JE, McDermott FD, et al. Mentoring during surgical training: consensus recommendations for mentoring programmes from the Association of Surgeons in Training. Int J Surg 2014;12(Suppl 3):S5–8. Sutton PA, Mason J, Vimalachandran D, et al. Attitudes, motivators, and barriers to a career in surgery: a national study of U.K. undergraduate medical students. J Surg Educ 2014;71:662–7. Moshtaghi O, Kelley KS, Armstrong WB, et al. Using Google glass to solve communication and surgical education challenges in the operating room. Laryngoscope; 2015. http://dx.doi.org/10.1002/lary. 25249 [Epub ahead of print]. Ahmed S. Surgeon Uses Google Glass during cancer Operation. Available at: http://www.telegraph.co.uk/news/health/10851599/Surgeonuses-Google-Glass-during-cancer-operation.html; 2014. Accessed June 23, 2015. Marshall DC, Salciccioli JD, Walton SJ, et al. Medical student experience in surgery influences their career choices: a systematic review of the literature. J Surg Educ 2015;72:438–45.
Using simulation to address continuity of care in general surgery resident education To the Editor: We read with interest the article entitled ‘‘Continuity of care in general surgery resident education’’ by Daly et al1 and agree that resident clinical experiences are increasingly isolated and lacking in continuity under current training paradigms. In addition to the Accreditation Council for Graduate Medical Education guidelines, it is noted that the American Board of Surgery training requirements also include an increasing number of performance assessments that span operative as well as clinical (ie, preoperative and postoperative) settings, and that a selection of assessment forms are provided for this purpose.2 Exactly as the authors say, ‘‘it is incumbent on training programs to provide residents with experience managing individual
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2014.11.016
patients through their entire course of treatment,’’1 though specific implementation remain a challenge. To address resident training in continuity of care, we developed a simulation-based educational curriculum for junior residents. This was based on sequences or pathways of simulations spanning preoperative, intraoperative, and postoperative care for patients undergoing laparoscopic cholecystectomy,3 laparoscopic appendectomy,4 colectomy (ileocolic anastomosis),5 and gastrectomy (gastrojejunal anastomosis).6 Simulation education has often focused on the acquisition of isolated technical skills outside their clinical context, but can be applied systematically as a potential strategy to address the continuum of care for a range of disease states. During these immersive simulations, residents proceeded through sequential encounters that allowed them to experience and learn the management of a patient presenting with a common surgical disease state from initial presentation through surgery and follow-up in
492
The American Journal of Surgery, Vol 211, No 2, February 2016
a time-efficient manner. The preoperative encounter occurred in the simulated outpatient or emergency room setting with a standardized patient presenting with a surgical problem, followed by the corresponding surgical task in the simulated operating room with animal or synthetic models, as available. The sequence concluded with a postoperative visit with the same standardized patient in the simulated recovery area, or clinic. Learner performance was assessed using existing, validated rating scales provided by the American Board of Surgery.2 We integrated the above simulations as part of the residency curriculum for 18 learners (class of first-year general surgery residents), involving over 30 surgery faculty as teachers over a 12-month academic year. Faculty and learner evaluations were exceedingly positive.3–6 The challenge remains to translate the process and findings of such educational curricula to clinical practice. This is an important issue for surgical educators, faculty, and of utmost importance to ensuring accountability in providing a high quality of patient care.
Kiyoyuki W. Miyasaka, M.D., M.T.R. Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Penn Medicine Clinical Simulation Center, Penn Medicine at Rittenhouse, Philadelphia PA, USA
Rajesh Aggarwal, M.B.B.S., M.A., Ph.D., F.R.C.S. Arnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University Montreal, Canada http://dx.doi.org/10.1016/j.amjsurg.2015.07.030
References 1. Daly SC, Klairmont MM, Rinewalt D, et al. Continuity of care in general surgery resident education. Am J Surg 2015;210:175–8. 2. American Board of Surgery, General surgery resident training Requirements. Available at: http://www.absurgery.org/default.jsp?certgsqe_ resassess. Accessed July 1, 2015. 3. Buchholz J, Miyasaka KW, Vollmer C, et al. Design, development and implementation of a surgical simulation pathway curriculum for biliary disease. Surg Endosc 2015;29:68–76. 4. Buchholz J, Miyasaka KW, Martin ND, et al. Pathway-based acute care surgery training using a novel simulation method. J Am Coll Surg 2014; 219:e157–8 (Supplement). 5. Miyasaka KW. Pathway-based Simulation Training Curriculum for Colorectal Surgery. Oral presentation at the 2014 International Conference on Residency Education, Toronto, Canada. Available at: http:// www.royalcollege.ca/portal/page/portal/rc/common/documents/events/ icre/2014proceedings/slides/Simulation_in_Residency_Education/K_ Miyasaka.pdf. Accessed July 1, 2015. 6. Miyasaka KW, Buchholz J, LaMarra D, et al. Development and implementation of a clinical pathway approach to simulation-based training for foregut surgery. J Surg Educ 2015;72:625–35.
Risk factors of gangrenous cholecystitis To the Editor: We read with interest the article Risk factors for acute gangrenous cholecystitis in emergency general surgery patients by Bourikian et al1 published online in the American Journal of Surgery. The authors analyzed the risk factors for acute gangrenous cholecystitis. They have found that acute gangrenous cholecystitis had an increased mortality rate compared with cholecystitis without necrosis and was associated with high mortality. And also they have stated that older patients with diabetes, coronary artery disease, and elevated bilirubin should have been suspected of having acute gangrenous cholecystitis. However, I believe that additional data regarding the details of the patient population would be useful. Gangrenous cholecystitis, a histological diagnosis, is a severe form of acute cholecystitis with a high risk of complications.2–5 It is more common in some patients who
DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2015.05.003 There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. The authors declare no conflicts of interest.
had risk factors. These include male gender, increasing age, leukocytosis, elevation of C-reactive protein, decrease in platelets, hormonal therapy, total parenteral nutrition, fasting, diabetes, coronary artery disease, major surgery, chronic obstructive pulmonary disease, cardiovascular accident, trauma, preoperative hypotension, sepsis, obesity, gallbladder wall thickening at ultrasound, pericholecystic fluid collection at ultrasound, and critical illness.2–5 The authors have analyzed age, sex, diabetes, preoperative hypotension, preoperative diagnosis of systemic inflammatory response syndrome, weight, and admission laboratory work including serum lactate and total bilirubin related to patients characteristics. However, some of the conditions and risk factors known to be associated with acute gangrenous cholecystitis were not described and analyzed. I believe that knowledge of these risk factors in the patient population would be beneficial and interesting to the readers. Ali Kagan Coskun, M.D. Department of Surgery, Gulhane School of Medicine, Ankara, Turkey http://dx.doi.org/10.1016/j.amjsurg.2015.07.026