Age at

cepome.au.dk

Age at

May I be so bold? A new

model for surgical training

Færdighedstræningskonference

Richard K. Reznick M.D., M.Ed., FRCSC, FACS

R.S. McLaughlin Professor and Chair

Department of Surgery, University of Toronto

We are accepting the best and the

brightest

• GPA>3.6

• MCAT>11

• Awards

• Sports

• Music

• Volunteerism

• Parted the Red Sea

That’s a lot of years!

Age at Graduating as a Surgical

Specialist

Undergraduate

6 years

37

Residency

5-6 years

36

Fellowship

2-3 years

35

Research Training

2-5 years

34

Age

33

32

31

Residents IMG Advanced

1


Training is too long!

The handshake of the world's oldest

surgeon St. Petersburg's Fyodor Uglov, 99,

who was still doing operations last spring, is

as firm as that of a 30-year-old athlete.

Reduced Work

Week and Sleep

Deprivation

Patient Safety and

Public Expectation

I Did It!

There is a Tension

Call for Generalism

Need for Focused

Training

Training is Already

Too Long

Need for Graduated

Independence

Marital Disharmony,

Substance Abuse,

Depression

United States

Canada

Ireland

Australia

New Zealand

Taiwan

Brazil

Great Britain

The Americans are whining and

Europe has gone crazy!

80 hours

72 hours

70 hours

68-75 hours

72 hours

70 hours

60 hours

54 hours

Switzerland

The Netherlands

Denmark

Germany

Belgium

Sweden

France

Norway

50 hours

48 hours

42 hours

40 hours

40 hours

40 hours

35 hours

35 hours

2


Your current residents?

A) are getting better technical training than you did?

B) are getting the same training as you did?

C) are getting different but equivalent training?

D) are getting inferior training than you did?

Our Residents May be Less

Skilled than Us

• A decreasing level of resident independence

across the board

• Increased attention being paid to patient demands

and the reduction of medical error

• Inadequate opportunities for deliberate practice

• The pressure for speed, often driven by finances

• A working week is reducing

• Core hospitals have skyrocketing complexity

We are not adapting to changing times

Boomers

career

Impressed with

authority

Defend policies and

procedures

Xers

job

Unfazed

Mistrust them

3


What are the ingredients of an expert surgeon?

Focused Training

We have been indoctrinated with the

philosophy that the route to expertise

is the creation of a totipotential

trainee, one with a broad base of

experiences. And that this broad base

is essential to the development of a

surgical specialist

TRAINING IS TOO LONG

AND NOT FOCUSED

ENOUGH

It’s not necessarily axiomatic that all things majestic

have an strong underlying network, that all things

meager lack an extensive foundation

It may well be true, that there is no

such thing as a surgical principle!

Expertise is a matter of being there,

over and over and over again

4


Focused Training

Turn it upside down

Let me be so bold as to

propose to you a new model

of surgical training

A Torontonian Iconoclast

AKA surgical educator gone mad

A Eight Point Plan to Restructure and

Dramatically Shorten Training

1. Tackle Politics and Finances Head On

2. Modular-based training linked to specific

learning objectives

3. Dramatically accelerate the pace of

technical skill acquisition

4. Diminish wasted time

A Eight Point Plan to Restructure and

Dramatically Shorten Training

5. Incorporate meaningful assessment into

day-to-day activities

6. Develop and promote a culture of

collegiality

7. Intelligently address the “if it’s not broken

don’t fix it criticism

8. Serially address a multitude of potentially

adverse by-products of this type of model

5


1. Tackle Politics and Finances Head

On (otherwise it won’t work!)

1. Surgical Teaching is undervalued

2. Surgical Teaching is not properly remunerated

3. Residents are providing low-cost service

4. Dramatic overabundance of regulatory agencies

and governing bodies

5. Who speaks for Canadian academic surgery?

6. Creating a link of faculty compensation to

educational deliverables

2. Modular-based training linked to

specific learning objectives

1. Specific modular objectives form the basis of learning

contracts

2. Objectives must be comprehensive

3. Objectives are learner-based and streamlined to

ultimate career

4. Deploy modern technology, such as web-based

curricular materials, access to point of care (wireless)

information, and a focus on providing data for

evidence based decision making

5. Re-establish anatomy as a backbone of surgical

teaching, and including cadaver dissection,

prosection and the use of VR-based anatomy training

models

3. Dramatically accelerate the

pace of technical skill acquisition

1. Developing a “pre-program” of basic skills

focusing on fundamental technical skills

2. Dramatically ramping up skills laboratory (ex

vivo) practice, using virtual reality, cadavers,

surrogate tissue and inanimate training models

3. Developing programs of structured and

deliberate practice

4. Placing a premium on participatory learning as

opposed to observational learning

5. Maximize the number and focus of real-world

operations performed by residents

3. Dramatically accelerate the

pace of technical skill acquisition

6. Ensuring that all learners are actively engaged in

each real surgical opportunity

7. Maximizing each “real” patient experience by

the use of pre-operative technical sessions, by

videotape review of self and experts, and by

debriefing sessions

8. Developing specific teaching teams

9. Developing programs of faculty development for

teaching surgeons

6


Deliberate Practice

“ . . . we argue that the

difference between expert

performers and normal adults

reflects a life-long period of

deliberate effort to improve

performance in a specific

domain.”

K. Anders Ericsson et al

Average Number of Pucks Per Year

6000

Manual and video of

fiberoptic intubation

Familiarization

with bronchoscope

5000

4000

3000

Model training (n=12)

Didactic training (n=12)

2000

1000

0

Games Team Individual

Pre-test of fiberoptic manipulation ability

Fiberoptic intubation in OR on healthy,

anesthetized and paralyzed female

patients with “easy” airways

7


Successful Tracheal Intubation

% of Subjects

100

80

60

40

*

Didactic

Model

* p < 0.01

20

We need to use our skills labs smartly!

8


What Kind of Practice Makes Perfect?

Massed Vs Distributed Practice

Schema

Refers to schedule of practice or training

Massed (all at once)

Distributed (interspersed with

rest periods)

T

e

s

t

Distributed

(4 weeks) T

Massed

T

e

s

t

T

r

a

n

s

f

e

r

&

T

e

s

t

(One day)

* Tests pre and post for each session

* Expert microsurgeon for each session

Outcome Measures

30

Microsurgical drill

Rat

Group

Distributed

Microsurgical Drill

• 2 Blinded Expert Ratings

• Hand Motion Analysis

• Time to completion

Rat Anastomosis

•2 Blinded Expert Ratings

•Hand Motion Analysis

•Time to completion

•Clinically Relevant

Outcome Measures

•Patency

•Completion

Global Ratings (max. 25)

20

10

*

*

Massed

*p


Treatment

Group

Randomization of

Residents

Control

Group

Video Instruction &

Equipment

Familiarization

Familiarization Phase

Video Instruction &

Equipment

Familiarization

Pre-test on Simulator

(Case 1)

Simulator Pre-test Phase

Pre-test on Simulator

(Case 1)

Simulator Practice

(Cases 1, 2, 4, 5, 6)

Treatment Phase

No Intervention

Post-test test on Simulator

(Case 3)

Simulator Post-test test Phase

Post-test test on Simulator

(Case 3)

Clinical Post-test

test

Author Purpose Platform Findings Strength

Effects of Simulator Training on Clinical

Colonoscopic Performance

Park, Reznick et al., Unpublished Data

•Otoole Construct Validity VR Suturing Validity Confirmed +++

•Anastakis Transfer Bench to Cadaver Bench=Cadaver >Control ++++

•Grober Durability Bench to Live animal Bench > Control, some decay +++

Mean Global Rating Score

(Expressed as Percentage of Max Score ) .

60

50

40

30

20

Mean +/- 1.0 SE

Controls

*

Treatment

•Grober Fidelity Bench vs. Live Live≥Bench>Control ++++

•Jacomides Effect of Training VR Ureteroscopy Med Students = Residents with training +++

•Matsumoto Fidelity Bench to Simulator Low tech = high tech >control ++++

•Matsumoto Construct validity Simulator Validity Confirmed +++

•Ogan Validation Simulator Good r for novices, poor for residents ++

•Traxer Effect of Traiing Simulator Training→ ↑’s on simulator no ↑’s on cadaver ++

•Watterson Effect of Training Simulator Training > No Training ++

* p = 0.04

•Rossi Construct Validity VR Simulator Validity Confirmed +++

10


•Lentz Reliability Bench models Reliability good +++

Moorthy Construct Validity VR GI Endoscopy Validity Confirmed ++++

•Goff Construct Validity Bench Models Construct validity confirmed for blinded exam ++++

•Mahmood Construct Validity VR GI Endoscopy Validity Confirmed ++++

•Seymour VR to O.R. VR Lap Chole VR training improved operative performance ++++

•Di Giulo VR to Patient VR GI Endoscopy VR training improved procedural performance +++

•Scott Bench to O.R. Bench Lap Chole Training improved operative performance ++++

•Gerson VR to Patient VR GI Endoscopy VR training improved elements of performance ++

•Rosser Training Lap Trainer Practice improves performance ++

•Ferlitsch VR to VR VR GI Endoscopy Practice →Improvement ++++

•Hamilton Effect of Training VT and VR VT transfers to VR; VR (not VT) Tx to O.R. +++

•Datta Validity of metrics VR GI Endoscopy 3 of 4 metrics showed construct validity ++++

•Grantcherov VR to O.R. MIST VR VR training improved operative performance ++++

•Blum VR to Patient VR Bronchoscopy VR training improved procedural performance +++

•Gallagher Construct Validity MIST VR Validity Confirmed +++

•Colt VR to Patient VR Bronchoscopy Practice →Improvement +++

•Tuggy VR to Patient VR GI Endoscopy Early positive effect eliminated by practice +++

•Moorthy Construct Validity VR Bronchoscopy Validity Confirmed +++

•Sedlack VR tp Patient VR GI Endoscopy Early positive effect; no effect after 30 +++

•Naik Bench to Patient Bench Bronchoscopy Training improved operative performance ++++

•Sedlack Metrics of VR VR GI Endoscopy Only 3/14 metrics valid +++

•Ost VR to patient VR Bronchoscopy Training improved operative performance ++

•Ritter Construct Validity VR GI Endoscopy Only limited validity of Internal metrics ++

•Rowe VR to Patient VR Bronchoscopy Practice →Improvement ++++

Summarizing the Simulation

Literature

Number

Of Studies

35

Number

Positive

29

Number

Negative

6

4. Diminish Wasted Time

1. Eliminating or minimizing time wasted

secondary to a hierarchical model

2. Eliminating or minimizing time wasted doing

non-educational activities

3. Increasing support services, increasing nurse

autonomy, rationalizing calls, and optimizing

technological solutions to service problems

4. Critically assessing the need for and the context

of night call

5. Seriously addressing the issue of sleep

deprivation

11


STUDY

Friedman et al., 1973

Christensen et al, 1977

Poulton et al., 1978

Engel et al., 1978

Reznick and Folse, 1987

Storer et al., 1989

Lingenfelser et al., 1994

Haynes et al, 2003

Howard et al., 2003

Ellman et al., 2004

Stone et al., 2004

Uchal, 2005

Jakubowicz, 2005

Clinical Effects of

Sleep Deprivation

TASK

EKG interpretation

X-ray Interpretation

Review lab results

Simulated patients

Suturing task

ETT, IV insertion

EKG interpretation

Surgery outcomes

Anesthesia simulator

Surgery outcomes

AMSITE examination

Laparoscopic simulator

Simulated endoscopic

sinus surgery

STUDY

Goldman et al., 1972

Friedman et al., 1973

Beatty et al., 1977

Storer et al., 1989

Denisco at al., 1987

Bertram, 1988

Jaques at al., 1990

Gottleib et al., 1991

Mann and Danz, 1993

Lingenfelser et al., 1994

Taffinder et al., 1998

Grantcharov et al., 2001

Landrigen et al., 2004

Jensen et al., 2004

Eastridge, 2004

TASK

Videotape:performance

EKG interpretation

Patient monitoring

arterial catheterization

Patient monitoring

Review resident notes

In-training examination

Medication errors, LOS

X-ray Interpretation

EKG interpretation

VR lap. simulator

MIST-VR

Medical errors

laparoscopic simulator

MIST-VR

Sitting and Reading

Watching TV

Epworth Sleepiness Scale

How likely would you be to doze

off in the following situations?

Sitting inactive in a public place

Passenger in a car for 1 hour

Lying down to rest

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car stopped for a few minutes in traffic

TOTAL EPWORTH SCORE

Surgery (SD)

2.22 (.84)**

2.13 (.93)**

1.74 (.89)**

2.03 (.93)*

2.41 (.85)*

.52 (.70)**

1.21 (.94)*

.56 (.85)

12.84 (4.7)**

Non - Surgery (SD)

1.53 (.97)

1.39 (.98)

0.91 (.92)

1.72 (1.06)

2.14 (.92)

0.16 (.42)

0.92 (.92)

0.39 (.76)

9.17 (4.8)

0 = never, 1 = slight chance, 2 = moderate chance, 3 = high chance

** p < 0.01 * p < 0.05

Patient Care

Professionalism

Sleep Deprivation Impact (SDI) Scale

Surgery (SD) Non-Surgery (SD)

Less concentration during patient rounds 3.76 (1.11)** 4.54 (0.78)

Unable to retain new patient information 3.67 (1.03)** 4.32 (0.80)

Less effective clinical judgment

3.70 (1.12)** 4.18 (0.91)

Inappropriate discharge orders

2.93 (1.28)** 3.75 (1.09)

More irritable

4.20 (0.92)** 4.50 (0.79)

Decreased empathy towards patients 3.55 (1.34)** 4.08 (1.04)

Poor interaction with colleagues

3.76 (1.04)* 4.09 (1.00)

Poor communication with patients 3.62 (1.20)** 4.16 (0.92)

Decreased motivation to learn

4.07 (0.99)** 4.56 (0.75)

Diminished desire to teach

4.16 (0.89)* 4.51 (0.84)

Slower

4.14 (0.80)** 4.54 (0.78)

Unsafe Driving

3.59 (1.21)* 3.95 (1.14)

TOTAL SDI SCORE

45.2 (8.54)** 51.5 (5.97)

1 = strongly disagree, 2 = somewhat disagree, 3 = no opinion, 4 = somewhat agree, 5 = strongly agree

The surgical “machismo”

• Surgery residents work longer hours

• Surgery residents perceive less impact of sleep

deprivation on their own clinical performance

• Surgery residents report increased sleepiness

ESS Surgery: 12.84 ESS Non-surgery: 9.17

Normal

Obstructive Sleep Apnea

8 (


5. Incorporate Meaningful

Assessment on a Day by Day Basis

1. Rigorous, reliable and regular assessment of the

multitude of competencies with a special focus

on technical achievement

2. Liberal use of formative assessment

3. Linking evaluation instruments to goals,

objectives and desired competencies

4. Training the evaluators

5. Focusing effort on performance-based

evaluation systems, such as PAME, OSATS,

6. Using a diverse array of assessors, including

self, other health professionals, patients, peers,

and faculty

Summary of OSATS Experiments:

Five Years of Research

• Inter-rater and Inter-station reliability

• Construct valid (PGY6>5>4>3>2>1)

• Concurrent validity (r=.81 with faculty)

• Not just Toronto (across Ontario)

• Central preparation and peripheral delivery

(Chicago and Los Angeles)

• Used now in RACS, RCS and GMC

13


Distribution of OSATS Scores for PGY 2, 3, 4 & 5

with Crosspoints between PGY Levels

and Scores for 5 Candidates

6. Develop and Promote a Culture of

Collegiality

1

0.8

0.6

0.4

0.2

0

0.5 0.6 0.7 0.8 0.9

Candidate 1 >

Candidate 2 >

Candidate 3 >

Candidate 4 >

Candidate 5 >

PGY2

PGY3

PGY4

PGY5

Crosspoints

1. Embraces a multi-professional and patient

centered approach to patient care

2. Focuses on patient safety

3. Focuses on professionalism as a distinct

enabler of learning

Frequency Histogram:

# of failures per procedure

Number of procedures

Number of failures per procedure

14


Frequency Histogram:

# of failures per procedure

Number of procedures

Number of failures per procedure

What do team members hear?

Surgeons: “Surgeons are the only ones who really

care if all the patients get done – the nurse is a shift

worker.”

Anesthetists: “Surgeons have a distorted sense of

operative time – it’s all about their time.”

7. Intelligently address the “if it’s

not broken don’t fix it criticism

1. We did it and we’re OK

2. Rights of passage

3. Hard work during residency is preparatory

for real-world pressures

Nurses: “Surgeons are just worried about money – if a

case gets cancelled it’s less money for them.”

15


8. Serially address a multitude of

potentially adverse by-products of

this type of model

1. Potential loss of continuity of care

2. Loss of the special relationship between a

surgeon and his/her patient

3. Highly focused training may be unduly limiting

4. The need for itinerant surgery in this model is

controversial

5. Over-focus on the technical may turn

professional training into vocational training

Continuity of Care and

Professionalism

• Two Departments of Surgery

• 43 semi-structured interviews

• 25 residents, 18 faculty

• 700 pages of transcript

Responsibilities

Patient Care

Self

Education

Colleagues

Principle

Family &

Relationships

Value

Obligation

Continuity

Lifestyle

Inculcation

Obedience

Safety

Health

Gatekeepers

Patient

Relationships

Affect

16


If we want to

avoid everyone’s

favorite sport

35 Hours a Week: Laudable or Lunacy?

We Can’t Afford To Go Backwards

2100 2070 2040 2 010 1980

We have used the same model of training for

over a century!

• We can improve on time wasted- non

educational activities

• We can improve on the inefficiencies of

a higher-archical system

• We can improve on time wasted by

learning by a model based on available

opportunity

In 1964, before all of our trainees

were born!

We didn’t listen very

well then, we better

start listening now!

A Graduating

Resident

17


What can a Canadian bring to Denmark?

A Goalies Dream

It started a long long time ago

Seven Years and 50,000 pucks later

18


Practice with the team

The Game: Our Operation

Average Number of Pucks Per Year

6000

5000

4000

3000

2000

1000

0

Games Team Individual

19

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