- Email: [email protected]
Video Review as a Tool to Improve Orthopedic Residents׳ Performance of Closed Manipulative Reductions
ORIGINAL REPORTS
Video Review as a Tool to Improve Orthopedic Residents' Performance of Closed Manipulative Reductions Nickul S. Jain, MD,* Ran Schwarzkopf, MD,† and John A. Scolaro, MD, MA‡ Department of Orthopaedic Surgery, University of California, Irvine, Orange, California; †Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York University Langone Medical Center, New York, New York; and ‡Department of Orthopaedic Surgery, University of California, Irvine, Orange, California *
OBJECTIVE: Orthopedic residents commonly perform closed manipulative reductions as a part of their training. Traditionally, this skill is taught early in training but difficult to simulate. Proficiency is achieved through repetition and experience; faculty observation and instruction is unfortunately often limited. Direct resident teaching has been shown to increase competency, comfort, and longterm skill retention. We hypothesize that video review of closed fracture reductions will provide an inexpensive and valuable tool for resident education and improve skill performance. DESIGN: Closed reductions performed by orthopaedic
residents were recorded using a secured mobile tablet device in the emergency department (ED). Video review sessions were performed with both peer and faculty feedback/ analysis of reduction technique. Anonymous resident and faculty surveys were completed following each session to evaluate the usage and perceived benefit of the program. SETTING: University-based Level I Trauma Center.
(PGY 4-5), PGY-1s believed that this technique helped them prepare for ED fracture care (p ¼ 0.02). CONCLUSIONS: Video review provides a useful, innova-
tive, and inexpensive method to improve resident competency in closed fracture reduction—a critical skill in orthopedic patient care. These procedures are uncommonly available for direct faculty observation. We have demonstrated that both residents and faculty were satisfied with the ability to review procedures, identify weaknesses, and obtain or provide direct feedback on this skill. Additionally, fracture reduction video review may help residents meet and achieve clinical milestones, an area of future investigation. ( J Surg Ed C 2017 Association of Program Directors in ]:]]]-]]]. J Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: technology, video, orthopedics, fracture, reduction, feedback COMPETENCIES: Patient Care, Medical Knowledge, Practice-based Learning and Improvement
PARTICIPANTS: Orthopedic surgery residents and faculty. RESULTS: All junior orthopedic residents (postgraduate
year [PGY] 1-3) reported that direct video observation by faculty was beneficial. Furthermore, 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future. Residents and faculty both strongly agreed that video review was more useful than other methods, improved resident preparation for ED fracture care, and felt this technique would improve patient care and outcomes. Compared with senior residents
Correspondence: Inquiries to John A. Scolaro, MD, MA, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Building 29A, Pavilion III-2nd Floor, Orange, CA 92868; fax: (714) 456-8971; E-mail: [email protected], [email protected]
INTRODUCTION Orthopedic residents frequently perform closed reductions of displaced fractures and joint dislocation as a part of their training. Traditionally, reduction techniques are reviewed in a controlled environment such as a didactic lecture or simulation. Unfortunately, simulations use uninjured limbs and joints that do not present the challenges frequently encountered in the traumatized patient. Limb swelling, muscle spasm, concurrent injuries, and varying fracture morphology are just a few factors that make actual closed reductions difficult. Residents are expected to obtain proficiency simply through repetition and hands-on experience. Junior orthopedic residents (postgraduate year [PGY] 1-3) commonly perform manipulative reductions in the emergency
Journal of Surgical Education & 2017 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.2017.01.003
1
department (ED). Direct observation of these procedures by more senior residents (PGY 4-5) or faculty or both is rare because of multiple factors such as senior resident and attending physician availability as well as the necessity for timely fracture reduction. This leads to a paucity of direct observation of residents' performance and an inability for junior residents to receive timely instruction or feedback. Multiple studies have demonstrated that expert assessment of resident skills via direct observation leads to increased competency, resident comfort in these procedures, and long-term retention of skills.1,2 Additionally, as orthopedic residency programs move toward a competency-based framework, direct assessment of required skills will be required for resident education and advancement.3 The purpose of this study was to develop a mode by which video recordings of closed reductions performed by the residents in the ED could be used as an educational platform. Using mobile tablet devices to obtain video footage, we wanted to specifically assess whether postprocedure video review session, with residents and faculty present, was an effective and desirable educational technique. We hypothesized that both residents and faculty alike would report a high level of satisfaction from using video technology in this manner to improve the technical skills required for routine orthopedic patient care.
MATERIALS AND METHODS This study was performed at a single level I trauma center. The study was approved by the Institutional Review Board. From July 2015 to May 2016, patients who presented to the ED with a displaced traumatic fracture or dislocation requiring a closed reduction were approached to participate in the study. Consent specifically allowed video recording to be obtained of the residents while they performed the reduction procedure. Exclusion criteria included patients less than the age of 18 years, patients who were obtunded or could not provide consent, and patients who could not read or converse in the English language. Informed consent was obtained from both participating patients as well as participating junior orthopedic resident trainees. Fracture/dislocation reduction maneuvers and initial splinting, performed by junior orthopedic residents (PGY 1-3), were then recorded on a secured tablet device during the course of routine patient care. Four portable mobile tablet devices were used for this study. These devices were encrypted and secured before usage and remained in the hospital throughout the course of the investigation. The Coach's Eye application (TechSmith, Okemos, MI, USA) was used on the Apple iOS platform (Apple, Cupertino, CA, USA) to record each procedure and provide an easy means of video analysis and review. The application was selected as it allowed for later video markup with graphical instructions (Fig.). Individual personal devices were not 2
FIGURE. Still-shot taken from digital video recording of closed fracture reduction procedure used during formal review sessions with faculty members.
used for this phase of the study. Video recordings included only the resident performing the reduction as well as the patient's injured limb. All potential patient identifiers, as well as audio, were removed from video recordings before their presentation and review. Reduction videos were then collected and associated with de-identified prereduction and postreduction radiographs, when available. Formal video review sessions were conducted with all residents present and in the presence of 4 fellowship-trained orthopedic surgeons. For each video presented, an initial set of injury radiographs was shown, followed by the video of the reduction, and then a set of postreduction radiographs. A step-by-step analysis of the reduction technique and commentary on various steps of the procedure was initially performed by the orthopedic staff and specifically addressed: (1) prereduction patient positioning and setup, (2) administration of analgesia (if applicable), (3) hand placement during reduction, (4) reduction maneuver, (5) use of assistants, (6) maintenance of reduction, and (7) splint application. Videos were replayed as needed and feedback was provided as necessary by faculty and residents. Four review sessions were completed during this initial evaluation. On average, 5 videos were able to be reviewed during each session. Following each review, anonymous resident and faculty surveys were provided to assess for participant satisfaction using a standardized 10-point Likert scale. A total of 20 orthopedic resident trainees (PGY 1-5) and 4 orthopedic traumatology faculty participated in the educational conferences and surveys. Collected data from multiple review sessions were aggregated and analyzed using a Student's t-test.
RESULTS A total of 4 formal review sessions were held with analysis of a total of 25 manipulative reductions. Furthermore, 100% Journal of Surgical Education Volume ]/Number ] ] 2017
of junior orthopedic residents (PGY 1-3) and faculty responses reported that direct video observation by faculty of closed fracture reductions with review was beneficial for their training, and 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future (Table 1). Average 10-point Likert scale scores revealed that video review was more useful than other educational methods (resident: 8.2 ⫾ 1.8; faculty: 8.7 ⫾ 2.0), improved resident preparation for ED fracture care (resident: 8.3 ⫾ 1.6; faculty: 9.3 ⫾ 1.0), and felt this technique would improve patient care and outcomes (resident: 9.0 ⫾ 1.1; faculty: 9.4 ⫾ 0.8) (Table 2). Furthermore, residents agreed that video review of fracture reduction provided them valuable information regarding placement of their hands during reduction maneuvers (junior residents: 8.3 ⫾ 1.9; senior residents: 5.9 ⫾ 3.7; faculty: 9.4 ⫾ 1.0), improved their knowledge of patient positioning (junior residents: 9.2 ⫾ 2.0; senior residents: 6.1 ⫾ 3.7; faculty 9.2 ⫾ 1.0), and helped instruct splint application techniques (junior residents: 8.2 ⫾ 1.9; senior residents 5.9 ⫾ 3.6; faculty: 9.3 ⫾ 1.0). Faculty members also responded that they strongly wished this technique to be available when they were learning about closed fracture reduction (average Likert score 9.6 ⫾ 1.1). PGY-1s were significantly more likely to feel that this technique would help prepare them for ED fracture care when compared with senior residents (PGY 4-5) (p ¼ 0.02).
DISCUSSION Surgical education and patient care have benefited from techniques and practices used in other fields; the TABLE 1. Average Survey 10-Point Likert Score Results From Aggregate Data for Resident Trainees (PGY 1-5) and Faculty Members
Journal of Surgical Education Volume ]/Number ] ] 2017
TABLE 2. Percentage of Survey Respondents in Agreement With Statements Regarding Digital Video Recording as an Educational Technology for Fracture Reduction Instruction
preoperative surgical checklist system adapted from the aviation industry is probably the best known example.4 In the world of athletics, video performance review and analysis is an integral part of training to improve athletic performance.5 Video recording with later instruction/review has been demonstrated as well in medical disciplines as an effective way for directed learning, structured direct observational feedback, self-assessment of skills, objective observer assessment of skills, and identification of deficiencies.5-12 Surgical training in the United States is undergoing a dramatic paradigm shift. Resident work hour limitations and creation of specific skill and knowledge benchmarks have increased the oversight and formal evaluation of surgical trainees. It is recognized that the lack of supervision can contribute to adverse patient outcomes, and conversely, that oversight of resident clinical care improves patient care.13,14 Additionally, supervision of resident physicians with subsequent feedback is critical for resident skill acquisition.15 Unfortunately, in surgical subspecialties, attention is generally directed to operative instruction and supervision. Manipulative reduction of fractures and dislocations is one of the most common and basic procedures performed by the orthopedic resident outside of the operating room. It is included in many of the ACGME level I and II orthopedic resident patient care milestones for common injuries, including ankle and distal radius fractures. For ankle fractures, specifically, “splints fracture appropriately” is a level 1 skill and “performs a closed reduction” is a level 2 skill.16 Residents' confidence, skill, and ability may be negatively affected when nonsurgical procedures do not receive appropriate oversight. We sought to develop an easy and inexpensive way to review and improve the performance of junior residents performing manipulative reduction procedures in the ED. A 3
secondary purpose of this project was to allow orthopedic faculty and staff to review residents' performance in the ED when direct observation was not possible. In our pilot study, we demonstrated that video review provides a useful, innovative, and inexpensive method to potentially improve resident competency in closed fracture reduction and that both faculty and residents alike saw great value in it. These procedures were previously uncommonly available for direct observation by faculty/senior residents, and junior-level residents were left to learn on their own, potentially perpetuating suboptimal techniques or not incorporating helpful fracture manipulation and reduction methods. This study was an initial assessment of video acquisition and review. We evaluated 25 recorded videos from various residents. Limitations include the total number of videos reviewed as well as the fact that this study was performed at one institution with a limited number of residents. Some selection bias does exist about cases recorded and injuries that required reduction. As no outcome measures were being evaluated, this is less relevant. Residents may also have felt some reluctance to be recorded if they anticipated a difficult reduction. Future work will try to evaluate whether the use of video recordings can objectively improve the quality of reductions performed over a period and if early review of videos improves the confidence and skill of junior residents. In this pilot study, we demonstrated that both residents and faculty were very satisfied with an ability to review ED fracture manipulation and reduction procedures, were able to identify weaknesses, and were able to obtain or give direct feedback on these procedures. Interns (PGY-1) were significantly more satisfied than senior residents (PGY 4-5) with this technique for preparing them for ED fracture care, indicating a potential use of this technique as a part of the preresidency “boot camps” as well as the ABOS Surgical Skills Modules for PGY-1 residents. Our results also showed that senior residents were slightly less enthusiastic about this educational technique, which may indicate their familiarity with the information and skills presented. We also feel that there is potential for fracture manipulation and reduction video review to be used to formally assess residents, as they are evaluated in their ability to perform core competencies based on the defined ACGME Orthopedic Surgery Milestones. Videos can be used to instruct residents early in their training on proper technique to avoid development of bad habits. As noted, closed reductions and splinting are infrequently directly monitored by orthopedic instructors/ staff, and portable video recording may allow for accurate assessment of this skill for every resident, especially if recordings are required for each resident. They can also be used to remediate and instruct residents who may fall short of meeting early milestones. Our institution plans to continue our use of this program to improve resident education and for resident performance evaluation.
REFERENCES
4
Journal of Surgical Education Volume ]/Number ] ] 2017
1. Porte MC, Xeroulis G, Reznick RK, Dubrowski A.
Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. Am J Surg. 2007;193 (1):105-110. 2. Shelesky G, D'Amico F, Marfatia R, Munshi A,
Wilson SA. Does weekly direct observation and formal feedback improve intern patient care skills development? A randomized controlled trial Fam Med. 2012;44(7):486-492. 3. Alman BA, Ferguson P, Kraemer W, Nousiainen MT,
Reznick RK. Competency-based education: a new model for teaching orthopaedics. Instr Course Lect. 2013;62:565-569. 4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety
checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. 5. Smith DJ, Norris SR, Hogg JM. Performance evalua-
tion of swimmers: scientific tools. Sports Med. 2002;32 (9):539-554. 6. Friedman Z, Katznelson R, Devito I, Siddiqui M,
Chan V. Objective assessment of manual skills and proficiency in performing epidural anesthesia—videoassisted validation. Reg Anesth Pain Med. 2006;31 (4):304-310. 7. Santora TA, Trooskin SZ, Blank CA, Clarke JR,
Schinco MA. Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med. 1996;14(6):564-569. 8. Scherer LA, Chang MC, Meredith JW, Battistella FD.
Videotape review leads to rapid and sustained learning. Am J Surg. 2003;185(6):516-520. 9. Hu YY, Peyre SE, Arriaga AF, et al. Postgame analysis:
using video-based coaching for continuous professional development. J Am Coll Surg. 2012;214(1):115124. 10. Driscoll PJ, Paisley AM, Paterson-Brown S. Video
assessment of basic surgical trainees0 operative skills. Am J Surg. 2008;196(2):265-272.
11. Jamshidi R, LaMasters T, Eisenberg D, Duh QY,
Curet M. Video self-assessment augments development of videoscopic suturing skill. J Am Coll Surg. 2009;209(5):622-625. 12. Mehrpour SR, Aghamirsalim M, Motamedi SM,
Ardeshir Larijani F, Sorbi R. A supplemental video teaching tool enhances splinting skills. Clin Orthop Relat Res. 2013;471(2):649-654.
13. Singh H, Thomas EJ, Petersen LA, Studdert DM.
15. Whalen T and Wendel G. Chapter 6: New supervision
Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167(19):2030-2036.
standards: Discussion and justification. In: Philibert I and Amis S eds. The ACGME 2011 Duty Hour Standard. p. 39-43.
14. Fallon WF Jr, Wears RL, Tepas JJ 3rd. Resident
16. Orthopaedic Surgery Milestone Project, ACGME/ABOS
supervision in the operating room: does this impact on outcome? J Trauma. 1993;35(4):556-560; [discussion 560-1].
joint initiative, July 2015. Available at: http://www. acgme.org/Portals/0/PDFs/Milestones/Orthopaedic SurgeryMilestones.pdf.
Journal of Surgical Education Volume ]/Number ] ] 2017
5
Video Review as a Tool to Improve Orthopedic Residents' Performance of Closed Manipulative Reductions Nickul S. Jain, MD,* Ran Schwarzkopf, MD,† and John A. Scolaro, MD, MA‡ Department of Orthopaedic Surgery, University of California, Irvine, Orange, California; †Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York University Langone Medical Center, New York, New York; and ‡Department of Orthopaedic Surgery, University of California, Irvine, Orange, California *
OBJECTIVE: Orthopedic residents commonly perform closed manipulative reductions as a part of their training. Traditionally, this skill is taught early in training but difficult to simulate. Proficiency is achieved through repetition and experience; faculty observation and instruction is unfortunately often limited. Direct resident teaching has been shown to increase competency, comfort, and longterm skill retention. We hypothesize that video review of closed fracture reductions will provide an inexpensive and valuable tool for resident education and improve skill performance. DESIGN: Closed reductions performed by orthopaedic
residents were recorded using a secured mobile tablet device in the emergency department (ED). Video review sessions were performed with both peer and faculty feedback/ analysis of reduction technique. Anonymous resident and faculty surveys were completed following each session to evaluate the usage and perceived benefit of the program. SETTING: University-based Level I Trauma Center.
(PGY 4-5), PGY-1s believed that this technique helped them prepare for ED fracture care (p ¼ 0.02). CONCLUSIONS: Video review provides a useful, innova-
tive, and inexpensive method to improve resident competency in closed fracture reduction—a critical skill in orthopedic patient care. These procedures are uncommonly available for direct faculty observation. We have demonstrated that both residents and faculty were satisfied with the ability to review procedures, identify weaknesses, and obtain or provide direct feedback on this skill. Additionally, fracture reduction video review may help residents meet and achieve clinical milestones, an area of future investigation. ( J Surg Ed C 2017 Association of Program Directors in ]:]]]-]]]. J Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: technology, video, orthopedics, fracture, reduction, feedback COMPETENCIES: Patient Care, Medical Knowledge, Practice-based Learning and Improvement
PARTICIPANTS: Orthopedic surgery residents and faculty. RESULTS: All junior orthopedic residents (postgraduate
year [PGY] 1-3) reported that direct video observation by faculty was beneficial. Furthermore, 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future. Residents and faculty both strongly agreed that video review was more useful than other methods, improved resident preparation for ED fracture care, and felt this technique would improve patient care and outcomes. Compared with senior residents
Correspondence: Inquiries to John A. Scolaro, MD, MA, Department of Orthopaedic Surgery, University of California, 101 The City Drive South, Building 29A, Pavilion III-2nd Floor, Orange, CA 92868; fax: (714) 456-8971; E-mail: [email protected], [email protected]
INTRODUCTION Orthopedic residents frequently perform closed reductions of displaced fractures and joint dislocation as a part of their training. Traditionally, reduction techniques are reviewed in a controlled environment such as a didactic lecture or simulation. Unfortunately, simulations use uninjured limbs and joints that do not present the challenges frequently encountered in the traumatized patient. Limb swelling, muscle spasm, concurrent injuries, and varying fracture morphology are just a few factors that make actual closed reductions difficult. Residents are expected to obtain proficiency simply through repetition and hands-on experience. Junior orthopedic residents (postgraduate year [PGY] 1-3) commonly perform manipulative reductions in the emergency
Journal of Surgical Education & 2017 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.2017.01.003
1
department (ED). Direct observation of these procedures by more senior residents (PGY 4-5) or faculty or both is rare because of multiple factors such as senior resident and attending physician availability as well as the necessity for timely fracture reduction. This leads to a paucity of direct observation of residents' performance and an inability for junior residents to receive timely instruction or feedback. Multiple studies have demonstrated that expert assessment of resident skills via direct observation leads to increased competency, resident comfort in these procedures, and long-term retention of skills.1,2 Additionally, as orthopedic residency programs move toward a competency-based framework, direct assessment of required skills will be required for resident education and advancement.3 The purpose of this study was to develop a mode by which video recordings of closed reductions performed by the residents in the ED could be used as an educational platform. Using mobile tablet devices to obtain video footage, we wanted to specifically assess whether postprocedure video review session, with residents and faculty present, was an effective and desirable educational technique. We hypothesized that both residents and faculty alike would report a high level of satisfaction from using video technology in this manner to improve the technical skills required for routine orthopedic patient care.
MATERIALS AND METHODS This study was performed at a single level I trauma center. The study was approved by the Institutional Review Board. From July 2015 to May 2016, patients who presented to the ED with a displaced traumatic fracture or dislocation requiring a closed reduction were approached to participate in the study. Consent specifically allowed video recording to be obtained of the residents while they performed the reduction procedure. Exclusion criteria included patients less than the age of 18 years, patients who were obtunded or could not provide consent, and patients who could not read or converse in the English language. Informed consent was obtained from both participating patients as well as participating junior orthopedic resident trainees. Fracture/dislocation reduction maneuvers and initial splinting, performed by junior orthopedic residents (PGY 1-3), were then recorded on a secured tablet device during the course of routine patient care. Four portable mobile tablet devices were used for this study. These devices were encrypted and secured before usage and remained in the hospital throughout the course of the investigation. The Coach's Eye application (TechSmith, Okemos, MI, USA) was used on the Apple iOS platform (Apple, Cupertino, CA, USA) to record each procedure and provide an easy means of video analysis and review. The application was selected as it allowed for later video markup with graphical instructions (Fig.). Individual personal devices were not 2
FIGURE. Still-shot taken from digital video recording of closed fracture reduction procedure used during formal review sessions with faculty members.
used for this phase of the study. Video recordings included only the resident performing the reduction as well as the patient's injured limb. All potential patient identifiers, as well as audio, were removed from video recordings before their presentation and review. Reduction videos were then collected and associated with de-identified prereduction and postreduction radiographs, when available. Formal video review sessions were conducted with all residents present and in the presence of 4 fellowship-trained orthopedic surgeons. For each video presented, an initial set of injury radiographs was shown, followed by the video of the reduction, and then a set of postreduction radiographs. A step-by-step analysis of the reduction technique and commentary on various steps of the procedure was initially performed by the orthopedic staff and specifically addressed: (1) prereduction patient positioning and setup, (2) administration of analgesia (if applicable), (3) hand placement during reduction, (4) reduction maneuver, (5) use of assistants, (6) maintenance of reduction, and (7) splint application. Videos were replayed as needed and feedback was provided as necessary by faculty and residents. Four review sessions were completed during this initial evaluation. On average, 5 videos were able to be reviewed during each session. Following each review, anonymous resident and faculty surveys were provided to assess for participant satisfaction using a standardized 10-point Likert scale. A total of 20 orthopedic resident trainees (PGY 1-5) and 4 orthopedic traumatology faculty participated in the educational conferences and surveys. Collected data from multiple review sessions were aggregated and analyzed using a Student's t-test.
RESULTS A total of 4 formal review sessions were held with analysis of a total of 25 manipulative reductions. Furthermore, 100% Journal of Surgical Education Volume ]/Number ] ] 2017
of junior orthopedic residents (PGY 1-3) and faculty responses reported that direct video observation by faculty of closed fracture reductions with review was beneficial for their training, and 97% of junior resident and 100% of faculty responses reported that they would use this educational technology in the future (Table 1). Average 10-point Likert scale scores revealed that video review was more useful than other educational methods (resident: 8.2 ⫾ 1.8; faculty: 8.7 ⫾ 2.0), improved resident preparation for ED fracture care (resident: 8.3 ⫾ 1.6; faculty: 9.3 ⫾ 1.0), and felt this technique would improve patient care and outcomes (resident: 9.0 ⫾ 1.1; faculty: 9.4 ⫾ 0.8) (Table 2). Furthermore, residents agreed that video review of fracture reduction provided them valuable information regarding placement of their hands during reduction maneuvers (junior residents: 8.3 ⫾ 1.9; senior residents: 5.9 ⫾ 3.7; faculty: 9.4 ⫾ 1.0), improved their knowledge of patient positioning (junior residents: 9.2 ⫾ 2.0; senior residents: 6.1 ⫾ 3.7; faculty 9.2 ⫾ 1.0), and helped instruct splint application techniques (junior residents: 8.2 ⫾ 1.9; senior residents 5.9 ⫾ 3.6; faculty: 9.3 ⫾ 1.0). Faculty members also responded that they strongly wished this technique to be available when they were learning about closed fracture reduction (average Likert score 9.6 ⫾ 1.1). PGY-1s were significantly more likely to feel that this technique would help prepare them for ED fracture care when compared with senior residents (PGY 4-5) (p ¼ 0.02).
DISCUSSION Surgical education and patient care have benefited from techniques and practices used in other fields; the TABLE 1. Average Survey 10-Point Likert Score Results From Aggregate Data for Resident Trainees (PGY 1-5) and Faculty Members
Journal of Surgical Education Volume ]/Number ] ] 2017
TABLE 2. Percentage of Survey Respondents in Agreement With Statements Regarding Digital Video Recording as an Educational Technology for Fracture Reduction Instruction
preoperative surgical checklist system adapted from the aviation industry is probably the best known example.4 In the world of athletics, video performance review and analysis is an integral part of training to improve athletic performance.5 Video recording with later instruction/review has been demonstrated as well in medical disciplines as an effective way for directed learning, structured direct observational feedback, self-assessment of skills, objective observer assessment of skills, and identification of deficiencies.5-12 Surgical training in the United States is undergoing a dramatic paradigm shift. Resident work hour limitations and creation of specific skill and knowledge benchmarks have increased the oversight and formal evaluation of surgical trainees. It is recognized that the lack of supervision can contribute to adverse patient outcomes, and conversely, that oversight of resident clinical care improves patient care.13,14 Additionally, supervision of resident physicians with subsequent feedback is critical for resident skill acquisition.15 Unfortunately, in surgical subspecialties, attention is generally directed to operative instruction and supervision. Manipulative reduction of fractures and dislocations is one of the most common and basic procedures performed by the orthopedic resident outside of the operating room. It is included in many of the ACGME level I and II orthopedic resident patient care milestones for common injuries, including ankle and distal radius fractures. For ankle fractures, specifically, “splints fracture appropriately” is a level 1 skill and “performs a closed reduction” is a level 2 skill.16 Residents' confidence, skill, and ability may be negatively affected when nonsurgical procedures do not receive appropriate oversight. We sought to develop an easy and inexpensive way to review and improve the performance of junior residents performing manipulative reduction procedures in the ED. A 3
secondary purpose of this project was to allow orthopedic faculty and staff to review residents' performance in the ED when direct observation was not possible. In our pilot study, we demonstrated that video review provides a useful, innovative, and inexpensive method to potentially improve resident competency in closed fracture reduction and that both faculty and residents alike saw great value in it. These procedures were previously uncommonly available for direct observation by faculty/senior residents, and junior-level residents were left to learn on their own, potentially perpetuating suboptimal techniques or not incorporating helpful fracture manipulation and reduction methods. This study was an initial assessment of video acquisition and review. We evaluated 25 recorded videos from various residents. Limitations include the total number of videos reviewed as well as the fact that this study was performed at one institution with a limited number of residents. Some selection bias does exist about cases recorded and injuries that required reduction. As no outcome measures were being evaluated, this is less relevant. Residents may also have felt some reluctance to be recorded if they anticipated a difficult reduction. Future work will try to evaluate whether the use of video recordings can objectively improve the quality of reductions performed over a period and if early review of videos improves the confidence and skill of junior residents. In this pilot study, we demonstrated that both residents and faculty were very satisfied with an ability to review ED fracture manipulation and reduction procedures, were able to identify weaknesses, and were able to obtain or give direct feedback on these procedures. Interns (PGY-1) were significantly more satisfied than senior residents (PGY 4-5) with this technique for preparing them for ED fracture care, indicating a potential use of this technique as a part of the preresidency “boot camps” as well as the ABOS Surgical Skills Modules for PGY-1 residents. Our results also showed that senior residents were slightly less enthusiastic about this educational technique, which may indicate their familiarity with the information and skills presented. We also feel that there is potential for fracture manipulation and reduction video review to be used to formally assess residents, as they are evaluated in their ability to perform core competencies based on the defined ACGME Orthopedic Surgery Milestones. Videos can be used to instruct residents early in their training on proper technique to avoid development of bad habits. As noted, closed reductions and splinting are infrequently directly monitored by orthopedic instructors/ staff, and portable video recording may allow for accurate assessment of this skill for every resident, especially if recordings are required for each resident. They can also be used to remediate and instruct residents who may fall short of meeting early milestones. Our institution plans to continue our use of this program to improve resident education and for resident performance evaluation.
REFERENCES
4
Journal of Surgical Education Volume ]/Number ] ] 2017
1. Porte MC, Xeroulis G, Reznick RK, Dubrowski A.
Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. Am J Surg. 2007;193 (1):105-110. 2. Shelesky G, D'Amico F, Marfatia R, Munshi A,
Wilson SA. Does weekly direct observation and formal feedback improve intern patient care skills development? A randomized controlled trial Fam Med. 2012;44(7):486-492. 3. Alman BA, Ferguson P, Kraemer W, Nousiainen MT,
Reznick RK. Competency-based education: a new model for teaching orthopaedics. Instr Course Lect. 2013;62:565-569. 4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety
checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. 5. Smith DJ, Norris SR, Hogg JM. Performance evalua-
tion of swimmers: scientific tools. Sports Med. 2002;32 (9):539-554. 6. Friedman Z, Katznelson R, Devito I, Siddiqui M,
Chan V. Objective assessment of manual skills and proficiency in performing epidural anesthesia—videoassisted validation. Reg Anesth Pain Med. 2006;31 (4):304-310. 7. Santora TA, Trooskin SZ, Blank CA, Clarke JR,
Schinco MA. Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med. 1996;14(6):564-569. 8. Scherer LA, Chang MC, Meredith JW, Battistella FD.
Videotape review leads to rapid and sustained learning. Am J Surg. 2003;185(6):516-520. 9. Hu YY, Peyre SE, Arriaga AF, et al. Postgame analysis:
using video-based coaching for continuous professional development. J Am Coll Surg. 2012;214(1):115124. 10. Driscoll PJ, Paisley AM, Paterson-Brown S. Video
assessment of basic surgical trainees0 operative skills. Am J Surg. 2008;196(2):265-272.
11. Jamshidi R, LaMasters T, Eisenberg D, Duh QY,
Curet M. Video self-assessment augments development of videoscopic suturing skill. J Am Coll Surg. 2009;209(5):622-625. 12. Mehrpour SR, Aghamirsalim M, Motamedi SM,
Ardeshir Larijani F, Sorbi R. A supplemental video teaching tool enhances splinting skills. Clin Orthop Relat Res. 2013;471(2):649-654.
13. Singh H, Thomas EJ, Petersen LA, Studdert DM.
15. Whalen T and Wendel G. Chapter 6: New supervision
Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167(19):2030-2036.
standards: Discussion and justification. In: Philibert I and Amis S eds. The ACGME 2011 Duty Hour Standard. p. 39-43.
14. Fallon WF Jr, Wears RL, Tepas JJ 3rd. Resident
16. Orthopaedic Surgery Milestone Project, ACGME/ABOS
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Journal of Surgical Education Volume ]/Number ] ] 2017
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