Scotland's "Incentivised Laparoscopy Practice" programme: Engaging trainees with take-home laparoscopy simulation.

BACKGROUND: The transfer validity of portable laparoscopy simulation is well established. However, attempts to integrate take-home simulation into surgical training have met with inconsistent engagement worldwide, as for example in our 2014-15 study of an Incentivised Laparoscopy Practice programme (ILPv1). Drawing on learning from our subsequent multi-centre study examining barriers and facilitators, we revised the programme for 2018 onwards. We now report on engagement with the 2018-2022 versions of this home-based simulation programme (ILP v2.1-2.3). METHODS: In ILP v2.1-2.3, three consecutive year-groups of new-start Core Surgical Trainees (n = 48, 46 and 53) were loaned portable simulators. The 6-month education programme included induction, technical support, and intermittent feedback. Six tasks were prescribed, with video instruction and charting of metric scores. Video uploads were required and scored by faculty. A pass resulted in an eCertificate, expected at Annual Review (but not mandatory for progression). ILP was set within a wider reform, "Improving Surgical Training". RESULTS: ILP v2.1-2.3 saw pass rates of 94%, 76% and 70% respectively (45/48, 35/46 and 37/53 trainees), compared with only 26% (7/27) in ILP v1, despite now including some trainees not intending careers in laparoscopic specialties. The ILP v2.2 group all reported their engagement with the whole simulation strategy was hampered by the COVID19 pandemic. CONCLUSIONS: Simply providing take-home simulators, no matter how good, is not enough. To achieve trainee engagement, a whole programme is required, with motivated learners, individual and group practice, intermittent feedback, and clear goals and assessments. ILP is a complex intervention, best understood as a "reform within a reform, within a context."

Simulation-based education: understanding the socio-cultural complexity of a surgical training 'boot camp'.

OBJECTIVE: The focus of simulation-based education (SBE) research has been limited to outcome and effectiveness studies. The effect of social and cultural influences on SBE is unclear and empirical work is lacking. Our objective in this study was to explore and understand the complexity of context and social factors at a surgical boot camp (BC). METHODS: A rapid ethnographic study, employing the theoretical lenses of complexity and activity theory and Bourdieu's concept of 'capital', to better understand the socio-cultural influences acting upon, and during, two surgical BCs, and their implications for SBE. Over two 4-day BCs held in Scotland, UK, an observer and two preceptors conducted 81 hours of observations, 14 field interviews and 11 formal interviews with faculty members (n = 10, including the lead faculty member, session leaders and junior faculty members) and participants (n = 19 core surgical trainees and early-stage residents). RESULTS: Data collection and inductive analysis for emergent themes proceeded iteratively. This paper focuses on three analytical themes. First, the complexity of the surgical training system and wider health care education context, and how this influenced the development of the BC. Second, participants' views of the BC as a vehicle not just for learning skills but for gaining 'insider information' on how best to progress in surgical training. Finally, the explicit aim of faculty members to use the Scottish Surgical Bootcamp to welcome trainees and residents into the world of surgery, and how this occurred. CONCLUSIONS: To the best of our knowledge, this is the first empirical study of a surgical BC that takes a socio-cultural approach to exploring and understanding context, complexities, uncertainties and learning associated with one example of SBE. Our findings suggest that a BC is as much about social and cultural processes as it is about individual, cognitive and acquisitive learning. Acknowledging this explicitly will help those planning similar enterprises and open up a new perspective on SBE research.

Incentivising practice with take-home laparoscopic simulators in two UK Core Surgical Training programmes.

Introduction: Practice using simulators has been validated as a mean for surgical trainees to improve basic laparoscopic skills and free their attention for higher cognitive functions. However, mere provision of equipment does not result in frequent practice. This study assesses one approach to incentivising practice within core surgical training programmes and leads to further recommendations. Methods: 30 core surgical trainees (CST) starting laparoscopic-based specialties were recruited from East and West of Scotland CST programmes and given take-home laparoscopic simulators, with six training modules. Attainment of target metric scores generated an eCertificate, to be rewarded by progression in the live theatre. Questionnaires assessed confounding variables and explored CSTs' anxieties about laparoscopy. Results: 27 trainees (90%) agreed to participate (mean age 28 years, range 24-25; 17 males). 13 CSTs (48%) were in the first year of surgical training. 11 (41%) had no previous simulation experience and 7 (32%) CSTs played video games >3 hours/week. 12 of 27 trainees (44%) completed ≥1 task and 7 completed all (26%).Performances improved in some participants, but overall engagement with the programme was poor. Reasons given included poor internet connectivity, busy rotations and examinations. CSTs who engaged in the study significantly reduced their anxiety (mean 4.96 vs 3.56, p<0.05). Conclusions: The provision of take-home laparoscopic simulators with accompanying targets did not successfully incentivise CSTs to practise. However, the subgroup who did engage with the project reported performance improvements and significantly reduced anxiety. Proposals to overcome barriers to practising in simulation, including obligatory simulation-based assessments, are discussed.

Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students.

BACKGROUND: Distraction and interruption are endemic in the clinical environment and contribute to error. This study assesses whether simulation-based training with targeted feedback can improve undergraduate management of distractions and interruptions to reduce error-making. DESIGN: A prospective non-randomised controlled study. METHODS: 28 final year medical students undertook a simulated baseline ward round. 14 students formed an intervention group and received immediate feedback on distractor management and error. 14 students in a control group received no feedback. After 4 weeks, students participated in a post-intervention ward round of comparable rigour. Changes in medical error and distractor management between simulations were assessed with Mann-Whitney U tests using SPSS V.21. RESULTS: At baseline, error rates were high. The intervention group committed 72 total baseline errors (mean of 5.1 errors/student; median 5; range 3-7). The control group exhibited a comparable number of errors-with a total of 76 observed (mean of 5.4 errors/student; median 6; range 4-7). Many of these errors were life-threatening. At baseline distractions and interruptions were poorly managed by both groups. All forms of simulation training reduced error-making. In the intervention group the total number of errors post-intervention fell from 72 to 17 (mean 1.2 errors/student; median 1; range 0-3), representing a 76.4% fall (p<0.0001). In the control group the total number of errors also fell-from 76 to 44 (mean of 3.1 errors/student; median 3; range 1-5), representing a 42.1% reduction (p=0.0003). CONCLUSIONS: Medical students are not inherently equipped to manage common ward-based distractions to mitigate error. These skills can be taught-with simulation and feedback conferring the greatest benefit. Curricular integration of simulated ward round experiences is recommended.

Providing a specialty trainee teaching programme over long distances.

BACKGROUND: Today's teaching programmes must be interesting, relevant to the surgical curriculum, as defined in the UK by the Intercollegiate Surgical Curriculum Programme (ISCP), and attractive enough to the trainee so that they encourage attendance without compromising operative experience. METHODS: Our aim was to achieve the objectives of the ISCP and to provide high-quality teaching to the trainees. We devised a 2-year rolling programme of events to cover the knowledge and skills required for general surgical training for both the Membership of the Royal College of Surgeons (MRCS) and Fellowship of the Royal College of Surgeons (FRCS) examinations. For the trainees unable to attend because of on-call commitments, we developed online course material, creating our own virtual learning environment (VLE). Attendance at training days, website use and exam pass rates were monitored. We surveyed trainees annually to identify whether the teaching was meeting their needs. RESULTS: There were 100 per cent pass rates for FRCS clinical and viva examinations, with 16 out of the 16 candidates passing on their first attempt and one gold medal awarded. DISCUSSION: Our attendance rates show that it is possible to provide well-attended sessions despite modern working patterns. The production of a yearly teaching plan with identified topics and dates allowed trainees to maximise their attendance.

Complications of stomas: their aetiology and management.

The formation of a stoma is an essential part of many colorectal operations. Despite the frequency with which these surgeries are performed and the number of specialists involved in stoma care, complications are still common. This article investigates the most common complications, explains the reasons for their occurrence and suggests potential management options. Common stoma complications were identified by the colorectal/ stoma clinical nurse specialist (CSCNS) and a literature search was performed using a variety of online databases, including Medline and CINAHL using the keywords stoma, complications, prolapse, ischaemia, retraction, hernia and stenosis. Articles used were selected on the basis of relevance to the topic. The commonest complications of stomas included skin irritation, prolapse, retraction, ischaemia, hernia and stenosis.