The Goalposts Have Moved: Can Surgery Residents Meet Updated Quality Benchmarks for Adenoma Detection Rate in Colonoscopy?

The American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology Task Force (ACGTF) on Quality in Endoscopy released updated quality benchmarks for colonoscopy in 2015. Our initial study concluded that surgery residents could perform safe and competent screening colonoscopy within a structured endoscopy curriculum. In this follow-up study, we sought to determine whether surgery residents could achieve the increased adenoma detection rate (ADR) benchmarks endorsed by the ASGE/ACGTF. An Institutional Review Board-approved prospective analysis of colonoscopies performed by five postgraduate year 2 and 3 general surgery residents from 2013 to 2015 was completed. All colonoscopies were performed under the direct supervision of surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following ASGE/ACG quality metrics were recorded: bowel preparation quality; cecal intubation rate; polyp and ADRs; and, complications. Power analysis determined that 108 procedures were required for an 80 per cent probability of data analysis accuracy. About 135 screening and diagnostic colonoscopies were performed. Bowel prep was considered "adequate" in 90 per cent of cases. The cecum was reached independently in 95 per cent of cases. Polyp(s) were visualized and removed in 39 per cent of patients. The overall ADR was 31.8 per cent (>25%). Male ADR was 38.7 per cent (>30%). Female ADR was 26.0 per cent (>20%). Average polyp size was 8.7 mm (range: 1-22 mm). One patient was readmitted for postpolypectomy syndrome, and successfully managed nonoperatively. In conclusion, using our structured endoscopy curriculum, surgery residents achieved ADRs fully consistent with the updated benchmark values endorsed by the ASGE/ACGTF.

Quality Metrics in Surgery Resident Performance of Screening Colonoscopy.

In an attempt to further standardize surgical training, the American Board of Surgery now requires that residents provide evidence that they are certified in flexible endoscopy. This prospective study was designed to determine whether, through a structured curriculum, junior level residents could learn to conduct competent and safe screening colonoscopy (SC). An Institutional Review Board-approved prospective analysis of SC performed by five postgraduate year-2 residents during the 2012-2013 academic year was completed. All SC were performed under direct supervision of one of the two surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following metrics of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology were recorded: bowel prep quality; cecal intubation; withdrawal time; number of visualized polyps; procedural duration; final pathology; adenoma detection rate (ADR); and, complications. Power analysis revealed that 108 procedures were required for an 80 per cent probability of data analysis accuracy. (American Society for Gastrointestinal Endoscopy ASGE/American College of Gastroenterology benchmark values in parentheses): 166 colonoscopies were performed, of which 149 met inclusion criteria. Bowel prep was considered "excellent" or "good" in 90 per cent of cases. The cecum was reached in 96 per cent of cases. Mean withdrawal time was 12 minutes (≥6 minute). Average procedure time was 30 minutes (≤ 30 minute). Polyp(s) were visualized and removed in 30 per cent of patients. The overall adenoma detection rate was 22.8 per cent (>20%). The ADR for males was 29.5 per cent (>25%). The ADR for females was 18.2 per cent (>15%). Average polyp size was 7.7 mm (range: 2-25 mm). No patients were readmitted for bleeding or perforation. Within a structured learning environment, trained surgical endoscopists can teach junior level surgery residents to perform safe and competent screening colonoscopy.

The effect of call on neurosurgery residents' skills: implications for policy regarding resident call periods.

OBJECT: Although fatigue and its effects on surgical proficiency have been an actively researched area, previous studies have not examined the effect of fatigue on neurosurgery residents specifically. This study aims to quantify the effect of fatigue on the psychomotor and cognitive skills of neurosurgery residents. METHODS: Seven neurosurgery residents performed a minimum of 3 and a maximum of 4 sessions of 6 surgical exercises precall and postcall. The simulation exercises were designed to measure a surgeon's cognitive abilities, such as memory and attention, while performing simulated surgical tasks and exercises that have been previously validated in several studies, including studies measuring the impact of fatigue on general surgery residents. Each exercise measured tool-movement smoothness, time elapsed, and cognitive errors. The change in surgical skills in precall and postcall conditions was assessed by means of an ANOVA, with p < 0.05 considered statistically significant. RESULTS: The neurosurgery residents did not show a statistically significant difference in their surgical skills between the pre- and postcall states (p < 0.3, p < 0.4, and p < 0.2 for movement smoothness, time elapsed, and cognitive errors, respectively). The mean decrement for all residents in the postcall condition was 13.1%. CONCLUSIONS: Postcall fatigue is associated with a marginal decrease in proficiency during simulated surgery in neurosurgery residents. In a similar study, general surgery residents showed a statistically significant decrement of 27.3% in the postcall condition. The impact of fatigue on different specialties should be further investigated prior to implementation of a national physician work-hour policy.

Honing a surgeon's decision making skills in the presence of mechanical tasks.

BACKGROUND: Although surgeons perform procedures and tasks under a significant amount of cognitive load, current simulators focus on training psychomotor skills in isolation. This may limit the transfer of learned skills to actual surgical environments. METHODS: Visuohaptic simulations were created that required participants to hone psychomotor skills in the presence of cognitive load. A control group (n = 7) trained on conventional skills simulator and their performance was compared with the experimental group (n = 7) in terms of learning curves and performance on a transfer task. RESULTS: The experimental group performed significantly better than the control group in terms of both learning curves and performance on the transfer task. CONCLUSIONS: Simulations that combine psychomotor and cognitive skills training are more effective than simulators that focus on psychomotor skills in isolation.

Impact of fatigue on neurophysiologic measures of surgical residents.

BACKGROUND: To gain additional insight into the impact of fatigue on surgery resident proficiency, we set out to quantify its impact on behavioral and neurophysiologic measures. STUDY DESIGN: Simulations were first created using a visio-haptic joystick attached to a surgical instrument (tool) that allows realistic interactions. Before baseline (pre-call) and after call, 7 PGY1 surgery residents performed simulation tasks that required varying levels of psychomotor and cognitive skill. Residents completed 3 sessions per week for 4 weeks. Surgical proficiency was established using 5 metrics: hand movement smoothness; instrument movement smoothness; time to task completion; gesture level proficiency and cognitive errors. Data (percent change from baseline, pre-call) were analyzed using repeated measures ANOVA. While performing these tasks, the residents also wore an EEG cap (B-Alert; Advanced Brain Monitoring), the data from which provided second to second insight into the effects of workload, distraction, and attention on task performance. Mean (±SD) pre-call and post-call values for each were analyzed using repeated measures ANOVA. RESULTS: Residents experienced significant (p < 0.014) post-call erosions in surgical proficiency, punctuated by dramatic increases in cognitive errors. EEG-based attention scores showed a significant (p < 0.014) concomitant decrement of 40%; distraction/drowsiness scores increased by 91%; and workload score increased by 51%. CONCLUSIONS: Fatigue adversely affects PGY1 resident surgical proficiency and neurophysiologic performance.

Toward effective pediatric minimally invasive surgical simulation.

BACKGROUND/PURPOSE: Simulation is increasingly being recognized as an important tool in the training and evaluation of surgeons. Currently, there is no simulator that is specific to pediatric minimally invasive surgery (MIS). A fundamental technical difference between adult and pediatric MIS is the degree of motion scaling. Smaller instruments and areas of dissection under greater optical magnification require finer, more precise hand movements. We hypothesized that this can be used to detect differences in skills proficiency between pediatric and general surgeons. METHODS: We programmed a virtual reality simulation of intracorporeal suturing with modes that used motion scaling to mimic conditions of either adult or pediatric MIS. The participants consisted of pediatric and general surgeons who wore motion-sensing gloves. Metrics included time elapsed, penetration errors, tool movement smoothness, hand movement smoothness, and gesture level proficiency. RESULTS: For all measures, pediatric surgeons demonstrated superior proficiency on exercises conducted in pediatric conditions (P < .05). Performance in adult conditions was similar between the 2 groups. CONCLUSION: Pediatric surgeons possess unique skills compared with general surgeons that relate to the technical challenges they routinely face, reinforcing the need for a surgical simulator specific to pediatric MIS. This validates our simulator and the manipulation of motion scaling as a useful training tool.

Initial experiences in embedding core competency education in entry-level surgery residents through a nonclinical rotation.

BACKGROUND: Health care continues to expand in scope and in complexity. In this changing environment, residents are challenged with understanding its intricacies and the impact it will have on their professional activities and careers. AIM: Embedding each of the competency elements in residents in a meaningful way remains a challenge for many surgery residency program directors. METHODS: We established a nonclinical rotation to provide surgery postgraduate year-1 (PGY-1) residents with a structured, multifaceted, largely self-directed curriculum into which each of the 6 core competencies are woven. Posttesting strategies were established for most curricular experiences to ensure to the greatest possible extent that each resident will have achieved an acceptable level of understanding of each of the competency areas before being given credit for the rotation. RESULTS: By uniformly exceeding satisfactory scores on respective objective analyses, residents demonstrated an increased (at least short-term) understanding of each of the assessed competency areas. CONCLUSION: Our project sought to address a prior lack of opportunity for our residents to develop a sound foundation for our residents in systems-based practice. Our new rotation addresses systems-based practice in several different learning environments, including emergency medical service ride-along, sentinel event participation, and hospice visits. Several research projects have enhanced the overall learning program. Our experience shows that a rotation dedicated to competency training can provide an innovative and engaging means of teaching residents the value of each element.

Quantitative evaluation of retention of surgical skills learned in simulation.

BACKGROUND: While initial results suggest that simulation does promote learning, there is a dearth of studies that define the extent to which skills learned through simulation are retained. METHODS: Residents skills were measured upon completion of an initial simulation training (baseline scores) and then every month for 6 months. Analysis was also performed to identify the number of iterations of practice required to regain baseline scores. RESULTS: While skill scores did not deteriorate from baseline after the first 3 months (p = 0.61, p = 0.44, p = 0.2, respectively), all scores (except time elapsed) reflected significant deterioration from the fourth month onward (p < 0.05, p < 0.032, p < 0.02). However the number of practice sessions required to regain baseline scores was significantly less than that required to achieve the baseline skill set (p < 0.0003). CONCLUSIONS: Skills learned through simulation show significant deterioration over long periods of time, suggesting that periodic retraining of skills may be necessary to maintain surgical proficiency.

Effects of duty hours and time of day on surgery resident proficiency.

BACKGROUND: Night floats have evolved in the era of limited resident work hours. This study was designed to define the effect of restricted nighttime duty hours on the psychomotor and cognitive skills of surgery residents. METHODS: To quantify the effect of fatigue on the skills of residents on day-shift and night-float rotations, residents were asked to complete visuohaptic simulations before and after 12-hour duty periods and to rate their fatigue level with questionnaires. RESULTS: Both groups showed significant decrements in proficiency measures after their shifts compared with baseline. The night-float group showed more significant declines (P < .05) in all areas assessed than the day-shift group. The night-float group was significantly less proficient in cognitive tasks after their shifts compared with the day-shift group. CONCLUSIONS: The deterioration of surgical proficiency is to a degree dependent on the time of day during which call occurs, not solely on the length of call.

Distractions and surgical proficiency: an educational perspective.

BACKGROUND: Surgery training requires residents to focus on tasks while minimizing the effect of distractions. There is a need to develop training methodologies that can enable surgical residents to hone this ability. METHODS: Fourteen surgical residents were divided into 2 groups. They were trained to perform simulated tasks in a noiseless environment and subsequently performed these tasks in a distractive one. In a follow-up experiment, an experimental group was trained in noisy and distractive conditions and was compared with a control group trained in noiseless conditions. RESULTS: Residents who trained in noiseless environments possessed decreased surgical proficiency when performing the identical tasks in realistic environments (P < .05). Pretraining in a noisy environment improves surgical proficiency. CONCLUSIONS: Noise and distractions can significantly impede performance of surgical residents, but this effect can be nullified by introduction of noise and distractions in the training environment.

Trauma: the impact of repeat imaging.

BACKGROUND: Patients referred to trauma centers often undergo an extensive diagnostic work-up before transfer. The purpose of our study was to quantify and examine the effects of repeat imaging in this population. METHODS: A prospective cohort study of 410 patient transfers was performed. Repeat imaging was conducted at the discretion of the accepting surgeon for multiple reasons. Two groups were compared, those who did and those who did not require repeat imaging. RESULTS: Overall, 53% of referrals received repeat imaging, at an average cost of $2,985 per patient. This group was older (42 vs 37 y; P < .05), more severely injured (injury severity score, 12 vs 9; P < .05), and experienced longer delays before transfer (244 vs 192 min; P < .05). By using logistic regression analysis, injury severity score was found to be an independent predictor of the need for repeat imaging (P = .003). CONCLUSIONS: Severely injured trauma patients often receive films that ultimately require duplication, resulting in transfer delay, unnecessary morbidity, and increased resource use. Targeted education and development of centralized radiology systems could alleviate some of the burden of unnecessary imaging.

Jack Barney award: the effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons.

BACKGROUND: Fatigue and sleep deprivation and their effects on surgical proficiency have been actively researched areas. Past studies that have focused solely on residents have provided an important insight into how fatigue affects residents' ability to perform. This study aims to quantify the effect of fatigue on attending surgeons. METHODS: To quantify the effect of fatigue on psychomotor and cognitive skills of surgical residents and attending surgeons, visiohaptic simulations were created to mimic realistic interactions. RESULTS: Both groups showed a significant decrement in proficiency measures postcall. When tasks were separated based on psychomotor versus cognitive-dominated skills, attending surgeons made 25% fewer (P < .05) cognitive errors than residents postcall. Psychomotor skills were equally affected in both groups. CONCLUSIONS: Call-associated fatigue is associated with increased error rates in the cognitive skill domain, although less so in attending surgeons compared with their resident counterparts.

Effect of fatigue on psychomotor and cognitive skills.

BACKGROUND: Previous studies have explored the effect of fatigue on general psychomotor proficiency. However, studies specifically addressing the effect of fatigue on surgical residents' cognitive skills during simulated surgical exercises are lacking. METHODS: Thirty-seven surgical residents in both the precall and the postcall condition were tested for psychomotor and cognitive skill evaluation on a virtual-reality simulator with haptic feedback and hand-motion recording. To evaluate surgical skills, hand- and tool-movement smoothness, cognitive errors, and time to completion for specific tasks were analyzed. RESULTS: In addition increased cognitive errors, a significant decrease (P < .01) was recorded in the proficiency variables of memory, attention, and intermodal coordination tasks when residents were in the postcall condition. CONCLUSIONS: Fatigue and sleep deprivation cause a significant deterioration in the surgical residents' cognitive skills as measured by virtual reality simulation. Psychomotor skills are also negatively impacted during tasks that require a combination of psychomotor and cognitive skills.

Causes for the undertreatment of elderly breast cancer patients: tailoring treatments to individual patients.

BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer patients. The purpose of this study was to determine the rate and causes of elderly patients not receiving standard therapy. STUDY DESIGN: A random sample of 500 patients was reviewed for age, cancer stage, surgical, radiation, cytotoxic or hormonal chemotherapy, number and type of comorbidities, type of therapeutic deficiencies, and their causes. RESULTS: The average age was 59.9+/-13.6 years. Of the patients less than 65 years old, 6.0% did not receive standard treatment, compared with 22.2% of patients 65 years or older. Treatment omitted in the less than 65-year-old group: 16.7%, no tumor extirpation; 38.9%, no axillary dissection; 33.3%, no radiation therapy; and 33.3% no chemotherapy. Treatment omitted in the 65-year and older group: 11.4%, no tumor extirpation; 39.1%, no axillary dissection; 47.7%, no radiation therapy; and 18.2%, no chemotherapy. Causes in the less than 65-year-old group were: prohibitive associated medical conditions, 27.8%; favorable primary tumor pathology, 16.7%; and patient treatment refusal, 55.6%. Causes in the 65-year and older group were: prohibitive associated medical conditions, 40.9%; favorable tumor pathology, 13.6%; patient treatment refusal, 31.8%; and unexplainable, 13.6%. The median number of concomitant medical conditions in patients receiving standard therapy was one compared with three in the undertreated patients from prohibitive associated medical conditions or unexplained causes. CONCLUSION: Population-based studies of breast cancer treatment do not adequately assess the complex decision making associated with breast cancer in the elderly. Patients do not receive standard care for specific reasons.