A Prospective Multicenter Standard of Care Study of Outpatient Laparoscopic Sleeve Gastrectomy.

A global shift is occurring as hospital procedures move to ambulatory surgical settings. Surgeons have performed outpatient sleeve gastrectomy (SG) in bariatric surgery since 2010. However, prospective trials are needed to ensure its safety before widespread adoption. PURPOSE: The study aimed to present a comprehensive report on the prospective data collection of 30-day outcomes of outpatient primary laparoscopic SG (LSG). This trial seeks to assess whether outpatient LSG is non-inferior to hospital-based surgery in selected patients who meet the outpatient surgery criteria set by the American Society for Metabolic and Bariatric Surgery. MATERIALS AND METHODS: This study is funded by the Society of American Gastrointestinal and Endoscopic Surgeons and has been approved by the Advarra Institutional Review Board (Pro00055990). Cognizant of the necessity for a prospective approach, data collection commenced after patients underwent primary LSG procedures, spanning from August 2021 to September 2022, at six medical centers across the USA. Data centralization was facilitated through ArborMetrix. Each center has its own enhanced recovery protocols, and no attempt was made to standardize the protocols. RESULTS: The analysis included 365 patients with a mean preoperative BMI of 43.7 ± 5.7 kg/m2. Rates for 30-day complications, reoperations, readmissions, emergency department visits, and urgent care visits were low: 1.6%, .5%, .2%, .2%, and 0%, respectively. Two patients (0.5%) experienced grade IIIb complications. There were no mortalities or leaks reported. CONCLUSION: The prospective cohort study suggests that same-day discharge following LSG seems safe in highly selected patients at experienced US centers.

Finding Themselves, Their Place, Their Way: Uncertainties Identified by Medical Students.

Phenomenon: Navigating uncertainty is a core skill when practicing medicine. Increasingly, the need to better prepare medical students for uncertainty has been recognized. Our current understanding of medical students' perspectives on uncertainty is primarily based on quantitative studies with limited qualitative research having been performed to date. We need to know from where and how sources of uncertainty can arise so that educators can better support medical students learning to respond to uncertainty. This research's aim was to describe the sources of uncertainty that medical students identify in their education. Approach: Informed by our previously published framework of clinical uncertainty, we designed and distributed a survey to second, fourth-, and sixth-year medical students at the University of Otago, Aotearoa New Zealand. Between February and May 2019, 716 medical students were invited to identify sources of uncertainty encountered in their education to date. We used reflexive thematic analysis to analyze responses. Findings: Four-hundred-sixty-five participants completed the survey (65% response rate). We identified three major sources of uncertainty: insecurities, role confusion, and navigating learning environments. Insecurities related to students' doubts about knowledge and capabilities, which were magnified by comparing themselves to peers. Role confusion impacted upon students' ability to learn, meet the expectations of others, and contribute to patient care. Navigating the educational, social, and cultural features of clinical and non-clinical learning environments resulted in uncertainty as students faced new environments, hierarchies, and identified challenges with speaking up. Insights: This study provides an in-depth understanding of the wide range of sources of medical students' uncertainties, encompassing how they see themselves, their roles, and their interactions with their learning environments. These results enhance our theoretical understanding of the complexity of uncertainty in medical education. Insights from this research can be applied by educators to better support students develop the skills to respond to a core element of medical practice.

Medical students' responses to uncertainty: a cross-sectional study using a new self-efficacy questionnaire in Aotearoa New Zealand.

OBJECTIVES: Responding well to clinical uncertainty is a crucial skill for any doctor. To better understand how medical students develop this skill, Social Cognitive Theory can be used to explore students' perceived capability to respond to situations of uncertainty. This study aimed to construct a self-efficacy questionnaire and use it to measure medical students' responses to clinical uncertainty. DESIGN: A 29-item questionnaire was constructed. For each item, participants rated their confidence in responding to uncertain situations using a scale of 0-100. Data were analysed with descriptive and inferential statistics. SETTING: Aotearoa New Zealand. PARTICIPANTS: The questionnaire was distributed to 716 of 852 medical students in second, fourth and sixth year, at the three campuses of the Otago Medical School. RESULTS: The Self-Efficacy to Respond to Clinical Uncertainty (SERCU) questionnaire was completed by 495 participants (69% response rate) and found to be highly reliable (α=0.93). Exploratory factor analysis confirmed a unidimensional scale. A multiple linear regression model predicted self-efficacy scores from year of study, age, mode of entry, gender and ethnicity, F(11,470) = 4.252, p<0.001 adj. R²=0.069. Male students and those admitted to the programme 3 years postdegree or with significant allied health experience were predicted to have significantly higher self-efficacy scores. Year of study was not a significant predictor of average efficacy scores. CONCLUSIONS: Our research contributes a novel, highly reliable questionnaire that uses self-efficacy to measure medical student responses to uncertainty. The questionnaire revealed that students' confidence in responding to uncertainty may be more related to their background and life experience than to progression through the curriculum. Medical educators and researchers can use the SERCU questionnaire to obtain a new perspective on how their students respond to uncertainty, inform future research and tailor teaching about uncertainty.

Revealing the impact of the hidden curriculum on faculty teaching: A qualitative study.

INTRODUCTION: In health professions education, faculty may feel frustrated or challenged by aspects of their teaching. The concept of a hidden curriculum for students describes the expectations and assumptions enacted in educational programmes that tacitly impact students' learning experiences. A hidden curriculum has been suggested as a possible influence on faculty but has not been well explored. The aim of this study was to explain how a hidden curriculum might operate for faculty in health professions education. METHODS: An interpretivist perspective was used to frame this qualitative study that examined one-on-one interview data generated with 16 faculty members from six different health care professions. Participants were asked to describe teaching experiences that they perceived as demanding. Using a hidden curriculum framework, descriptions of demanding teaching experiences were analysed inductively to identify relationships between a teacher's intended practice and what they could accomplish. These relationships were interpreted as the possible ways that a hidden curriculum was operating for faculty. RESULTS: A hidden curriculum for faculty was found to operate in three ways by undervaluing the importance of having teaching expertise, undermining teaching goals through institutional conventions and perpetuating feelings of isolation. DISCUSSION: A hidden curriculum for faculty can be represented as multiple overlapping domains and shape how faculty experience their teaching roles. The results provide examples that reveal how a hidden curriculum may operate for faculty. Faculty developers may find the insights provided by this study useful to make the hidden curriculum visible and help their faculty make sense of and navigate demanding teaching experiences.

Advice for Constructing a Productive Supervisory Relationship in Education Research.

Practical advice is offered for a positive and productive supervisory relationship. Tips to get started include suggestions to consider about possible reasons, assumptions, and expectations for engaging in education research. Once a relationship is established, we emphasise the importance of constructing appropriate research questions, understanding the use of theory, and developing time management strategies. We consider the practicalities of initiating a research project and the reflexivity required to maintain shared expectations. We address potential challenges which may disrupt the research process. Finally, we present a set of reflective prompts for supervisors and students to consider before starting a project together.

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

PURPOSE: The hope that reliably testing clinicians' competencies would improve patient safety is unfulfilled and clinicians' psychosocial safety is deteriorating. Our purpose was to conceptualise 'mutual safety', which could increase benefit as well as reduce harm. METHODS: A cultural-historical analysis of how medical education has positioned the patient as an object of benefit guided implementation research into how mutual safety could be achieved. RESULTS: Educating doctors to abide by moral principles and use rigorous habits of mind and scientific technologies made medicine a profession. Doctors' complex attributes addressed patients' complex diseases and personal circumstances, from which doctors benefited too. The patient safety movement drove reforms, which reorientated medical education from complexity to simplicity: clinicians' competencies should be standardised and measurable, and clinicians whose 'incompetence' caused harm remediated. Applying simple standards to an increasingly complex, and therefore inescapably risky, practice could, however, explain clinicians' declining psychosocial health. We conducted a formative intervention to examine how 'acting wisely' could help clinicians benefit patients amidst complexity. We chose the everyday task of insulin therapy, where benefit and harm are precariously balanced. 247 students, doctors, and pharmacists used a thought tool to plan how best to perform this risky task, given their current clinical capabilities, and in the sometimes-hostile clinical milieus where they practised. Analysis of 1000 commitments to behaviour change and 600 learning points showed that addressing complexity called for a skills-set that defied standardisation. Clinicians gained confidence, intrinsic motivation, satisfaction, capability, and a sense of legitimacy from finding new ways of benefiting patients. CONCLUSION: Medical education needs urgently to acknowledge the complexity of practice and synergise doctors' and patients' safety. We have shown how this is possible.

Towards a new understanding of uncertainty in medical education.

RATIONALE, AIMS, AND OBJECTIVES: Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. METHOD: A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty. RESULTS: Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education. CONCLUSION: The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.

Readiness to prescribe: Using educational design to untie the Gordian Knot.

INTRODUCTION: Junior residents routinely prescribe medications for hospitalised patients with only arms-length supervision, which compromises patient safety. A cardinal example is insulin prescribing, which is commonplace, routinely delegated to very junior doctors, difficult, potentially very dangerous, and getting no better. Our aim was to operationalise the concept of 'readiness to prescribe' by validating an instrument to quality-improve residents' workplace prescribing education. METHODS: Guided by theories of behaviour change, implementation, and error, and by empirical evidence, we developed and refined a mixed-methods 24-item evaluation instrument, and analysed numerical responses from Foundation Trainees (junior residents) in Northern Ireland, UK using principal axis factoring, and conducted a framework analysis of participants' free-text responses. RESULTS: 255 trainees participated, 54% women and 46% men, 80% of whom were in the second foundation year. The analysis converged on a 4-factor solution explaining 57% of the variance. Participants rated their capability to prescribe higher (79%) than their capability to learn to prescribe (69%; p<0.001) and rated the support to their prescribing education lower still (43%; p<0.001). The findings were similar in men and women, first and second year trainees, and in different hospitals. Free text responses described an unreflective type of learning from experience in which participants tended to 'get by' when faced with complex problems. DISCUSSION: Operationalising readiness to prescribe as a duality, comprising residents' capability and the fitness of their educational environments, demonstrated room for improvement in both. We offer the instrument to help clinical educators improve the two in tandem.

Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure that can be performed as an outpatient procedure. OBJECTIVES: The aim of the study was to determine whether same-day discharge LSG is safe when performed in an outpatient surgery center. SETTING: Outpatient surgery centers. METHODS: The medical records of 3162 patients who underwent primary LSG procedure by 21 surgeons at 9 outpatient surgery centers from January 2010 through February 2018 were retrospectively reviewed. RESULTS: Three thousand one hundred sixty-two patients were managed with enhanced recovery after surgery protocol and were included in this analysis. The mean age and preoperative body mass index were 43.1 ± 10.8 years and 42.1 ± 7.1 kg/m2, respectively. Sleep apnea, type 2 diabetes, gastroesophageal reflux disease, hypertension, and hyperlipidemia were seen in 14.4%, 13.5%, 24.7%, 30.4%, and 17.6% patients, respectively. The mean total operative time was 56.4 ± 16.9 minutes (skin to skin). One intraoperative complication (.03%) occurred. The hospital transfer rate was .2%. The 30-day follow-up rate was 85%. The postoperative outcomes were analyzed based on the available data. The 30-day readmission, reoperation, reintervention, and emergency room visit rates were .6%, .6%, .2%, and .1%, respectively. The 30-day mortality rate was 0%. The total short-term complication rate was 2.5%. CONCLUSIONS: Same-day discharge seems to be safe when performed in an outpatient surgery center in selected patients. It would appear that outpatient surgery centers are a viable option for patients with minimal surgical risks.