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September 15, 2008

Laboratory-Based Instruction for Skin Closure and Bowel Anastomosis for Surgical Residents

Author Affiliations

Author Affiliations: Department of Surgery (Drs Jensen, Wright, McIntyre, Levy, Foy, Pellegrini, and Horvath) and College of Education (Dr Jensen), University of Washington, Seattle; and Division of Plastic Surgery, University of Toronto, Toronto, Ontario, Canada (Dr Anastakis).

Christian de Virgilio, MD, Torrance, California: The present study is a prospective cohort study conducted over a 1-year period at the Institute for Surgical and Interventional Simulation at the University of Washington. The hypothesis of this study was that multimedia delivery of cognitive content paired with faculty-supervised, partial task simulation would result in improvement in technical skill, time to completion, and end product quality.

The specific tasks, as demonstrated today, included skin excision and closure and hand-sewn bowel anastomosis. The study included first-and second-year residents who took part in this training while rotating on the recently designed innovative rotation at the University of Washington known as EVATS. This rotation is designed to allow residents to fill in for emergency coverage, vacation coverage, academic time, competency training, and technical skills training.

The findings of the study as outlined today were that significant improvements were seen for skin excision and wound closure with respect to time of completion and OSATS global rating scales. For bowel anastomoses, significant improvements were seen again in time to completion, OSATS, and anastomotic leak pressure. The residents on survey found that the value of training was equivalent to OR [operating room] training for skin closure and more valuable than OR training for bowel anastomoses.

As was stated today, simulator training for surgery residents is now being mandated by the ACGME [Accreditation Council for Graduate Medical Education]. More and more, the onus will be on us as surgical educators to be able to demonstrate objective evidence of technical competency of our trainees, not only with laparoscopic training, but with all aspects of open procedures. These increasing requirements for documentation of competency are being placed on us at a time when residents are working fewer hours.

This brings me to my first question. How do we reconcile this dilemma? Do you foresee a future where a significant percentage of technical skills training will be done in the simulator laboratory as opposed to in the operating room? You mentioned that the study was conducted over a year. Presumably residents enrolled in the study later in the year had more operative experience by the time they undertook this educational endeavor. Did you observe any differences in the outcome for residents undertaking the course later in the year?

In the [[ldquo]]Methods[[rdquo]] section, you state that residents were informed in advance of the study procedures. Presumably this meant the residents were aware of the end points of the study[[mdash]]time to completion of tasks, etc. If this was done, do you think this introduced a bias?

You mentioned in the [[ldquo]]Methods[[rdquo]] that the survey items included such things as prior closure or anastomotic experience in operative case volume, but this information is not available in the [[ldquo]]Results.[[rdquo]] Was there any correlation between prior operative experience and outcome?

Also, in the [[ldquo]]Results[[rdquo]] you state that there were 28 first-year residents and 17 second-year residents in the study. Since you only have 7 categorical residents per year, presumably the study also included preliminary surgery residents, and since most of these residents are not going into general surgery, your population appears to be comprised predominantly of residents who are not going into general surgery. Please comment. Did you compare the performance of categorical and preliminary residents? If not, is it possible that most of the improvement in your study was a reflection of the preliminary residents who have less operative experience and are, thus, likely to show the greatest improvement with the tutorials.

On a broader note, do you think that the immense time and effort of dedicated skills training should be offered to preliminary residents who are going to pursue, say, radiology or anesthesiology?

One of your surveys asked to compare the value of skill laboratory with the operating room. You found that the value of skill laboratory was slightly better than training in the OR for bowel anastomosis, but since the study was comprised primarily of R1s [first-year residents] and R2s [second-year residents], and since R1s would typically have little exposure performing an actual bowel anastomosis in the OR, is it fair to compare a skills laboratory experience with an OR experience, when the OR experience is so limited with this skill?

Regarding the use of bursting strength of the bowel anastomosis, did you use fresh tissue? Do you think this makes a difference, and do you think that bursting strength is the best measure of a technically sound anastomosis? Do you think that the skills session will result in long-term improvement in technical skill? Do you plan to study this long-term?

Finally, do you currently utilize a scoring system intraoperatively to determine resident competence with various skills? If not, do you plan to do so in the future?

Dr Horvath: Dr de Virgilio's first question was regarding whether the significant percentage of technical skills training will eventually be done in the simulator laboratory as opposed to the operating room. I think that more will be done than we are doing now and that the release of the ACS/APDS [American College of Surgeons/Association of Program Directors in Surgery] National Technical Skills Curriculum (part of the board's SCORE [Surgical Council on Resident Education] project) will be very much a part of that expansion. But we are also reaching our limit in what we can do outside of actual patient care. With the advent of the 80-hour workweek, most of the surgical training programs in the country lost about 30% of resident hours previously used for patient care. While I think that we have been able to do, in general, an equivalent, and maybe even sometimes better, job in training our residents in 80 hours, we are reaching a limit where we can give up time to non[[ndash]]patient-related educational activities.

In the last year or so, we have had a tidal wave of e-learning platforms and an assortment of other time-consuming requirements from both our hospital and national governing bodies[[mdash]]and now this new National Technical Skills Curriculum. We are going to be reaching a ceiling and are not going to have time to accommodate everything. Otherwise, residents are going to be taken away from patient care too significantly, and it will negatively impact resident education. I don't yet know how we are going to incorporate all of these changes.

Dr de Virgilio also asked about the difference in outcome for residents undertaking the course later in the year. Did we find any differences? Our study was not powered to examine this effect. We had, on average, only 3 to 4 subjects per month, and there was a lot of interresident variability in baseline skills. If there were a difference, we likely would not have been able to detect it. I think the important message is that all residents learned, whether they were R1s or R2s. More importantly, we were able to demonstrate that the trainee's pretraining ability significantly impacts the amount that was learned, with those of lower pretraining performance deriving greater educational gain. However, residents of all levels of pretraining ability did demonstrate improvement with this training.

Another question asked if we introduced bias by letting the residents know up front what metrics were going to be used to assess their performance. This is a valid point. However, rather than calling it bias, we might refer to it as motivation. As much as we tried to keep the scores confidential, the residents were equally intent to share their data with one another. In fact, almost every resident wanted to watch their anastomosis get tested for leaks. It was an environment of a lot of friendly competition, which we think is actually a good thing. Whether we call it bias or motivation, we actually do believe that it's important to inform the residents up front of the metrics used for assessment as this helps them focus on the things that we really think are valuable to show improvement.

The next question was regarding the correlation between prior operative experience and outcome. Unfortunately, our data were too skewed to reliably be used as covariates for this analysis. The resident experience, both for skin closure and bowel anastomosis, was very homogeneous.

The next question was regarding the performance of categorical vs preliminary residents. It's true that most subjects in this study were preliminary residents, and the one group that I would like to exclude from the rest of this answer are the preliminary anesthesia residents, because in our program they only spend 3 months doing a surgical rotation and are not formally in our program for the entire year.

So, along with the general surgery residents, the rest of the study group was either designated preliminary residents going into surgical subspecialties, like plastics and neurosurgery, or nondesignated preliminary residents who headed into general surgery. These residents, although maybe not general surgeons, are still surgeons. We did analyze for the effect of categorical status and found no difference in the degree of improvement between categorical and preliminary residents for skin excision. For bowel anastomosis, there was a small difference. Both sets of residents, however, improved on both tasks.

The next question asked whether it was worth spending the immense time and effort for these preliminary residents who may be going into radiology and anesthesiology. I think that this is a question that may have very different answers depending upon who is asked. Most of the designated and nondesignated preliminary residents are actually going into a surgical subspecialty, and as such they all need to learn basic technical skills. I think it is our job to train them. These 2 exercises, while maybe not directly applicable to every subspecialty, may have many benefits such as hand-eye coordination, use of the needle driver, sewing on delicate tissue, and principles of tension and countertension. So I think that the time and effort are worthwhile.

With regard to the radiology residents, I do think that we should at least offer them this training. The differential amount of time that is required to include them is little, and when they spend a year in our department taking care of our patients and being assessed with the same performance evaluations and metrics as categorical residents, I think that we should be inclusive whenever we can. One of the recent trends we have seen is an increase in radiology preliminaries who are interested in going into interventional radiology. They are spending a preliminary year in surgery, not only for the time in the operating room, but also for basic technical skills acquisition.

The next question was regarding comparing skills laboratory experience with the OR experience when the OR experience was so limited. This may not be a valid comparison, but it reflects a real perception. What it means I am not really sure, but it is a reflection of resident perception.

The next question asked about the bursting strength as a measure of a technically sound anastomosis and the use of frozen tissue. About halfway through our study, Dr Karen Borman's group at the Surgical Education Week presented a study that questioned the validity of the use of frozen tissue for this assessment. And at that time we had already started collecting data for this study. Perhaps if we had not been able to demonstrate a significant difference between groups, then we would have had to question this model. The discriminative ability of using previously frozen tissue model and bursting strength may not really be valid at a higher technical level. However, for very early improvements at the gross level of a junior resident, it seems to have utility. What it means as far as translation to the operating room is unknown.

The next to the last question was regarding retention of technical skill and the long-term improvements in technical skill. Skills retention following the training session is probably the most important question in an investigation like this; however, we don't know the answer to this question. At this point, we are not planning to study retention in this group of residents primarily because such a large percentage of them were preliminary residents. It is difficult to track them over time as they leave us and have other interests. This question does need to be answered, and with the release of the standardized National Technical Skills Curriculum through the SCORE Project, we might finally have the adequate numbers needed to develop a multicenter project.

Arch Surg. 2008;143(9):852-859. doi:10.1001/archsurg.143.9.852

Hypothesis  Multimedia delivery of cognitive content paired with faculty-supervised partial task simulation for both excision of a simulated skin lesion with subsequent wound closure and hand-sewn bowel anastomosis would be an effective method for developing appropriate procedural skills among junior residents.

Design  Prospective cohort study.

Setting  University-based surgical residency.

Participants  First- and second-year surgical residents (n = 45).

Interventions  Surgical residents were given comprehensive instructional materials, including structured curricula with goals and objectives, text, figures, and narrated expert digital video, before the training session. A 4-hour, standardized, laboratory-based instruction session was then performed in small groups, which emphasized faculty-supervised practice. Residents were asked to (1) excise a skin lesion and close the wound and (2) perform hand-sewn bowel anastomosis. These 2 tasks were assessed before and after supervised practice. Performances were video recorded. Residents were surveyed before and after training.

Main Outcome Measures  Time to completion and Objective Structured Assessment of Technical Skill global rating scale score based on video recordings were evaluated by blinded reviewers. Final product quality was measured by anastomotic leak pressure and by wound closure aesthetic quality.

Results  Residents perceived the laboratory training to be equal to training in the operating room for skin closure and superior to training in the operating room for bowel anastomosis. Residents perceived time spent on both tasks to be “perfect.” Mean objective scores improved significantly on 5 of 6 outcome measures.

Conclusions  Junior resident surgical performance improved substantially with 4 hours of laboratory-based, faculty-supervised practice. Both first- and second-year residents benefited from this training. These data show that curriculum-driven, faculty-supervised instruction in a laboratory setting is beneficial in the training of junior surgical residents.