RESIDENT TRAINING IN THE 80 HOUR WORK WEEK ERA-Objective Assessment of Surgical Ability

At the Annual meeting of the AVAS we were treated to a panel discussion highlighting RESIDENT TRAINING IN THE 80 HOUR WORK WEEK ERA.

Dr. Lygia Stewart, MD presented her thoughts on an Objective Assessment of Surgical Ability. While the other presentations focused on the positive and negative aspects of the mandatory abbreviation of resident work week hours, Dr. Stewart approached this utilizing a different tactic. She explored the concept of measuring success in training residents.

She reminded us why surgical training is quite unique from the training experience in the majority of other medical fields. On the one hand, surgeons must learn disease recognition and treatment similar to other fields. On the other hand, unlike most other medical fields, an equal amount of time must be partitioned off to acquire motor (procedural) skills. In of itself, learning procedural steps is not that difficult. Complexity arises as we begin to pick up visual and tactile pattern recognition (surgical planes, subtle findings, anatomical variations).

Acquiring a level of knowledge and skills to become an expert takes considerable time and energy. Exactly which is the most reliable method to accomplish this has been debated for some time. Observation and practice seems to be the most successful technique. Learning from an expert through observing them allows one to acquire motor and cognitive skills (more effective for novice learners than learning by solving the equivalent problems). Repeating these observations of visual patterns, trains the brain’s imaging system.

In the past, measuring the success or failure of technical skill development was highly subjective. Newer scales such as the OSATS (Objective Structured Assessment of Technical Skill) seem to be more consistent in rating performance. The global rating aspect also includes non-technical components such as use of assistants, flow of operation and forward planning similar to the NOTECHS scoring system. Non-Technical skills for Surgeons (NOTSS initially described by Rhona Flin and Dr Steven Yule’s group at the University of Aberdeen group in 2006) comprises cognitive (decision making and situational awareness) and interpersonal (teamwork and leadership) skills.

Newer computer assessment based tests are slowly taking hold that appear to enhance the more subjective assessment processes. Fundamentals of laparoscopic surgery (FLS) is one such area that allows trainee technical function during laparoscopy to be evaluated objectively.

At the end of her discussion Dr. Stewart reminded us that surgical ability is multifaceted.

Evaluation of surgical skills requires measures of cognitive skills / knowledge, technical / psychomotor skills unique to the surgical domain, and complex patient management.

Dr. Stewart was kind enough to answer some of my questions on this topic:

My original question was “in regards to surgical duty hours, should our overall focus be on the number of hours we are providing resident education or on the actual educational process? That is how do we know that the surgical attendings responsible for surgical education are properly educating the residents?

ANSWER: while we complain that 80 hours a week does not afford the time needed to train residents effectively, other countries are looking at 50 and 40 hours. Those places report that duty hour restrictions in their country have been a failure. The real problem is that it is not easy to define exactly what is success and failure in residency training programs. For the most part we use the Pass/Fail aspect of parts I and II of the ABS exam, resident case numbers (and complexity) and autonomy at graduation from the residency program. If we start with the knowledge component, it was clear that from 2008 to 2012 there was a free fall in exam pass rates but that appears to be on the rise since 2013. Therefore it appears that the transmittal of knowledge may be successful in light of reduced duty hours. Some complain that residents do not perform enough cases but data over the past several years indicate that residents do perform enough cases. However, on raw numbers of cases may not be the answer. The residents may not be getting the immersion of all aspects of care they really need during duty hour restrictions. They may be missing the critical decisions being made while they are off duty. We need to assure there is a focus on complex decision making as the subtlety of clinical decision making is important. The question of resident autonomy after graduation is one of the more difficult ones to answer. It appears that residents may opt to become fellows because they have autonomy as an attending during their fellowship but still have more oversight to potentially prevent lapses or misteps. This autonomy issue is more difficult than we consider. We were used to getting up to speed and fast! We knew that we must be on top of the latest care for the diseases we care for. We had to keep everything in our heads. No so much the case anymore where everyone relies on their handheld device to look up any clinical care questions. We need to be asking if the residents even know how to teach themselves. We need to be sure that we teach the residents how to teach themselves. Some residents seem to feel that they should be spoon-fed. Unfortunately, it is not infrequent that one will say: “the attendings should provide us 10 relevant articles on this topic”.

What is best way to teach?

ANSWER: Contextual and immersion.

Do we need a Master’s Degree in education to be fully armed to teach?

ANSWER: I am not sure that a Master’s Degree in education is desirable. For one PhD’s tend to focus on the learner’s learning and not necessarily if the learner can fend for themselves.

We need residents to be self-sufficient when they are done. It’s the old Baby bird vs shark analogy- Sharks are born alive and fend for themselves. We often don’t know what we don’t know. We don’t know how to ask “How do you teach? what I am seeing? What am I thinking?” of ourselves so we can be sure to pass that knowledge along appropriately. That is life of course: you start out that you don’t know what you don’t know…. then you know what you know…. then you don’t know what you know…. It is an ongoing learning process within which you MUST be self-motivated and self-sufficient.

What are the best method of measuring technical skills?

ANSWER: I will start by stating that surgical mentors believe that if they can do a case, then obviously they are qualified to teach that procedure. However, just because we teach a resident to do something does not mean they do it well. We need measures of success. I believe that the OSAT is very good. In addition, the ABS is incorporating the OSATS and some elements of the Zwisch but Zwisch is not useful in of itself. I believe it is a good thing they changed it.

One matter we tend to forget is that most cases are two person cases- that is, you have a partner. The resident should be YOUR PARTNER. Their job is to keep you out of trouble and vice versa. Your attitude and the resident’s attitude is vitally important. Surgery should be a perfect dance. You should not try to control everything with your partner. Surgery is not an isolated sport but a team sport.

What is that the best methodology for building autonomy?

ANSWER: As a chief I always appreciated the Autonomy without Neglect--- Chief of surgery believed in “give ‘em rope but don’t let them hang themselves”. Service is a major part of the learning process. Most organizations have built an infrastructure to adapt to the absence of resident manpower. I think that building the infrastructure so you don’t need the residents may push the residents out of the loop and that is where they begin to lose autonomy.

Do have anything else to add?

ANSWER: We need to be aware of valuable features lost with diminishing work hours and not focus solely on the lost hours.

We should query the membership on: How do you teach problem solving? What is the path towards independence?

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