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Virtual Reality Simulator Training for Shoulder Arthroscopy Procedures
Vol. 225, No. 4S1, October 2017
Scientific Forum Abstracts
S185
RESULTS: We identified 11,230 procedures for this analysis. Operating room (OR) times were shorter for procedures with attendings alone (122.8 mins) when compared with junior (135.3 mins) or senior (146.3 mins) participation (p < 0.001). Hospital stays were marginally longer with senior residents (2.33 vs 2.35 vs 2.51 days, p ¼ 0.050). Resident involvement at any level did not increase the rate of wound-related complications: superficial surgical site infections (SSI, p ¼ 0.276), deep incisional SSI (p ¼ 0.272), organ space SSI (p ¼ 0.188), and wound disruptions (p ¼ 0.502), or the rate of medical complications: pneumonia (p ¼ 0.517), pulmonary embolisms (p ¼ 0.294), urinary tract infections (p ¼ 0.150), bleeding requiring transfusion (p ¼ 0.688), and deep vein thrombosis (p ¼ 0.561). Returns to the operating room did not significantly differ between groups (p ¼ 0.680). CONCLUSIONS: Although resident involvement may increase OR times, there is no evidence of adverse perioperative outcomes. Training outside the OR to improve resident surgical skills should be pursued as well as continued focus on increasing perioperative efficiencies. Variations in Surgical Outcomes: Is it the Residency Program, the Surgeon or the Practice Venue? Rebecca L Hoffman, MD, Rachel R Kelz, MD, FACS, Christopher J Wirtalla, Luke J Keele, PhD, Jon B Morris, MD, FACS, Elizabeth A Bailey, MD, Morgan Sellers, MD University of Pennsylvania, Philadelphia, PA; Georgetown University Washington, DC INTRODUCTION: We aimed to estimate the role of residency program, surgeon, and practice venue in explaining variation in patient outcomes. METHODS: General surgical procedures performed in the ambulatory and inpatient setting in NY, FL, and PA (2012 to 2013) were identified using state datasets. A hybrid dataset was created to link surgeon education and outcomes for surgeons up to 20 years in practice. Generalized linear mixed effects models were used to explain the variation in outcomes using the Intraclass Correlation Coefficient (ICC). Subset analysis was performed by operation type and surgeon experience. RESULTS: A total of 183,283 operations were performed by 1,128 surgeons who trained at 97 residency programs and performed surgery at 601 institutions. The overall complication rate was 10.7% (range by operation type 1.3% to 47.5%), 1.7% died, and procedure-specific prolonged length of stay (pLOS) was 17.8%. In the model including 24 operation types, variation in patient outcomes due to residency was 0.1% (ICC 95% CI <0.01e1.6), the practice venue 1.2% (ICC 95% CI <0.01e4.5), and the surgeon 6.2% (ICC 95% CI 5.4e7.1). The magnitude of the effects varied by operation and experience (Figure).
Figure. A, The relative contribution of the residensy program, the practice venue and the surgeon to variation in operation-specific complications. B, by surgeon experience.
CONCLUSIONS: The role of the residency program in explaining variation in outcomes is minimal, except for complex operations performed soon after transition to practice. Practice venue explains an inconsistent amount of the variation, and appears important in specific complex operations. The individual surgeon explains a moderate and consistent amount of variation in outcomes. These patterns should be considered when designing credentialing systems for new surgeons. Virtual Reality Simulator Training for Shoulder Arthroscopy Procedures Anthony E Johnson, MD, FAOA, Christopher J Roach, MD, Travis C Burns, MD, Jessica C Rivera, MD Brooke Army Medical Center, JBSA-Fort Sam, Houston, TX INTRODUCTION: Arthroscopic procedures, as compensatory tracking tasks requiring refined eye-hand coordination, are conducive to virtual reality (VR) simulation. This study tested the efficacy of a VR simulator vs a Sawbones static simulator in training orthopaedic residents to perform specific shoulder arthroscopic tasks. METHODS: Thirty-eight residents were randomized into a training routine on either a VR or static simulator for learning an arthroscopic shoulder stabilization technique. Before and after 4 weeks of prescribed training on their respective simulators, each resident performed shoulder stabilization on cadavers, during which basic skills and ability to perform the specific procedures were graded by a staff surgeon. Regression modeling was used to assess “pre” and “post” training scores, and simulator preference was compared between simulator used for training and baseline resident experience. RESULTS: There was no difference in observed scores or change in scores between residents who trained on the VR vs static simulator (p ¼ 0.3805); however, the whole group experienced an increase in score regardless of training simulator (20.8 18 vs 24.3 6.3 points, p ¼ 0.0424). Majority (89%) of residents requested more simulator training during residency. Junior
S186
Scientific Forum Abstracts
arthroscopists preferred the VR simulator, while senior arthroscopists preferred the static simulator (p ¼ 0.043). CONCLUSIONS: All participants improved after 4 weeks of prescribed training regardless of simulator model. Senior residents preferred the static model, possibly due to the ability to do specific procedures with specific implants, while junior residents seemed to benefit most from basic skills exercises with the VR simulator. Further research to determine optimal training methods to facilitate efficient, learner-centered skill acquisition is necessary.
What Is The Operative Work of a Surgery Resident Worth? Laura Ostapenko, MD, Douglas S Smink, MD, MPH, FACS Brigham and Women’s Hospital, Harvard Medical School, Boston, MA INTRODUCTION: General surgery residents both receive education and provide service. We sought to determine the operative work of a general surgery resident by estimating what the average general surgery resident could collect if permitted to bill as a first assistant.
J Am Coll Surg
METHODS: We used Accreditation Coucil for Graduate Medical Education (ACGME) national case log reports for surgery residents graduating in 2015 to 2016. Procedures were included in the analysis if the national resident average was greater or equal to 1, and the procedure allowed billing an assistant fee. CPT codes were assigned to each Residency Review Committee procedure using the ACGME tracked codes report. A national payment amount was assigned to each CPT code using the Centers for Medicare and Mediaid Services (CMS) physician fee schedule. The standard billing rate of 16% for first assistants was used. RESULTS: The average surgery resident graduating in the 2015 to 2016 could bill for 723.8 procedures. This would generate $128,369.80 in first assistant fees over a 5-year surgery residency. Chief residents could bill for 173.3 procedures on average, generating $31,703.18. CONCLUSIONS: As our overall health care system shifts to incentivize value, graduate medical education will need to account for its costs and benefits. Accounting for the operative work of a surgery resident is one part of calculating the value of surgery residents to our health care system.
Scientific Forum Abstracts
S185
RESULTS: We identified 11,230 procedures for this analysis. Operating room (OR) times were shorter for procedures with attendings alone (122.8 mins) when compared with junior (135.3 mins) or senior (146.3 mins) participation (p < 0.001). Hospital stays were marginally longer with senior residents (2.33 vs 2.35 vs 2.51 days, p ¼ 0.050). Resident involvement at any level did not increase the rate of wound-related complications: superficial surgical site infections (SSI, p ¼ 0.276), deep incisional SSI (p ¼ 0.272), organ space SSI (p ¼ 0.188), and wound disruptions (p ¼ 0.502), or the rate of medical complications: pneumonia (p ¼ 0.517), pulmonary embolisms (p ¼ 0.294), urinary tract infections (p ¼ 0.150), bleeding requiring transfusion (p ¼ 0.688), and deep vein thrombosis (p ¼ 0.561). Returns to the operating room did not significantly differ between groups (p ¼ 0.680). CONCLUSIONS: Although resident involvement may increase OR times, there is no evidence of adverse perioperative outcomes. Training outside the OR to improve resident surgical skills should be pursued as well as continued focus on increasing perioperative efficiencies. Variations in Surgical Outcomes: Is it the Residency Program, the Surgeon or the Practice Venue? Rebecca L Hoffman, MD, Rachel R Kelz, MD, FACS, Christopher J Wirtalla, Luke J Keele, PhD, Jon B Morris, MD, FACS, Elizabeth A Bailey, MD, Morgan Sellers, MD University of Pennsylvania, Philadelphia, PA; Georgetown University Washington, DC INTRODUCTION: We aimed to estimate the role of residency program, surgeon, and practice venue in explaining variation in patient outcomes. METHODS: General surgical procedures performed in the ambulatory and inpatient setting in NY, FL, and PA (2012 to 2013) were identified using state datasets. A hybrid dataset was created to link surgeon education and outcomes for surgeons up to 20 years in practice. Generalized linear mixed effects models were used to explain the variation in outcomes using the Intraclass Correlation Coefficient (ICC). Subset analysis was performed by operation type and surgeon experience. RESULTS: A total of 183,283 operations were performed by 1,128 surgeons who trained at 97 residency programs and performed surgery at 601 institutions. The overall complication rate was 10.7% (range by operation type 1.3% to 47.5%), 1.7% died, and procedure-specific prolonged length of stay (pLOS) was 17.8%. In the model including 24 operation types, variation in patient outcomes due to residency was 0.1% (ICC 95% CI <0.01e1.6), the practice venue 1.2% (ICC 95% CI <0.01e4.5), and the surgeon 6.2% (ICC 95% CI 5.4e7.1). The magnitude of the effects varied by operation and experience (Figure).
Figure. A, The relative contribution of the residensy program, the practice venue and the surgeon to variation in operation-specific complications. B, by surgeon experience.
CONCLUSIONS: The role of the residency program in explaining variation in outcomes is minimal, except for complex operations performed soon after transition to practice. Practice venue explains an inconsistent amount of the variation, and appears important in specific complex operations. The individual surgeon explains a moderate and consistent amount of variation in outcomes. These patterns should be considered when designing credentialing systems for new surgeons. Virtual Reality Simulator Training for Shoulder Arthroscopy Procedures Anthony E Johnson, MD, FAOA, Christopher J Roach, MD, Travis C Burns, MD, Jessica C Rivera, MD Brooke Army Medical Center, JBSA-Fort Sam, Houston, TX INTRODUCTION: Arthroscopic procedures, as compensatory tracking tasks requiring refined eye-hand coordination, are conducive to virtual reality (VR) simulation. This study tested the efficacy of a VR simulator vs a Sawbones static simulator in training orthopaedic residents to perform specific shoulder arthroscopic tasks. METHODS: Thirty-eight residents were randomized into a training routine on either a VR or static simulator for learning an arthroscopic shoulder stabilization technique. Before and after 4 weeks of prescribed training on their respective simulators, each resident performed shoulder stabilization on cadavers, during which basic skills and ability to perform the specific procedures were graded by a staff surgeon. Regression modeling was used to assess “pre” and “post” training scores, and simulator preference was compared between simulator used for training and baseline resident experience. RESULTS: There was no difference in observed scores or change in scores between residents who trained on the VR vs static simulator (p ¼ 0.3805); however, the whole group experienced an increase in score regardless of training simulator (20.8 18 vs 24.3 6.3 points, p ¼ 0.0424). Majority (89%) of residents requested more simulator training during residency. Junior
S186
Scientific Forum Abstracts
arthroscopists preferred the VR simulator, while senior arthroscopists preferred the static simulator (p ¼ 0.043). CONCLUSIONS: All participants improved after 4 weeks of prescribed training regardless of simulator model. Senior residents preferred the static model, possibly due to the ability to do specific procedures with specific implants, while junior residents seemed to benefit most from basic skills exercises with the VR simulator. Further research to determine optimal training methods to facilitate efficient, learner-centered skill acquisition is necessary.
What Is The Operative Work of a Surgery Resident Worth? Laura Ostapenko, MD, Douglas S Smink, MD, MPH, FACS Brigham and Women’s Hospital, Harvard Medical School, Boston, MA INTRODUCTION: General surgery residents both receive education and provide service. We sought to determine the operative work of a general surgery resident by estimating what the average general surgery resident could collect if permitted to bill as a first assistant.
J Am Coll Surg
METHODS: We used Accreditation Coucil for Graduate Medical Education (ACGME) national case log reports for surgery residents graduating in 2015 to 2016. Procedures were included in the analysis if the national resident average was greater or equal to 1, and the procedure allowed billing an assistant fee. CPT codes were assigned to each Residency Review Committee procedure using the ACGME tracked codes report. A national payment amount was assigned to each CPT code using the Centers for Medicare and Mediaid Services (CMS) physician fee schedule. The standard billing rate of 16% for first assistants was used. RESULTS: The average surgery resident graduating in the 2015 to 2016 could bill for 723.8 procedures. This would generate $128,369.80 in first assistant fees over a 5-year surgery residency. Chief residents could bill for 173.3 procedures on average, generating $31,703.18. CONCLUSIONS: As our overall health care system shifts to incentivize value, graduate medical education will need to account for its costs and benefits. Accounting for the operative work of a surgery resident is one part of calculating the value of surgery residents to our health care system.