Podium IIB Global Surgical Education
(S036) RESPONSIBLE PROGRAM ENGAGEMENT IN EXTERNAL INTERNATIONAL CLINICAL ROTATIONS FOR RESIDENTS
Helen W Li, MD, Catherine N Zivanov, MD, Colleen Witty, MD, Paul Wise, MD; Washington University in St Louis School of Medicine
Introduction
In 2023, the ACGME proposed expanding resident exposure to resource-limited clinical environments including international sites. This parallels an increasing interest within US residency programs in international clinical rotations (ICR), though the number of institutions hosting formal global surgery programs remains limited. To meet this interest, residency programs without an internal global surgery partnership can engage with other US institutions who have existing longitudinal international relationships to establish ICR opportunities for their own residents. We sought to explore the strengths and weaknesses of this training model.
Methods
We performed a retrospective interview study enrolling general surgery residents (n=7) at our academic institution who have participated in an ICR partnership established at another US institution. Interviews were coded by two independent researchers and analyzed through rapid qualitative analysis techniques, utilizing a matrix template organized by domains mirroring the interview guide. Emerging themes were identified through thematic analysis of the matrix.
Results
Institutional responsibility for residents engaging in ICR at external institutions varies across the timeline of the ICR process. Home institutions sending residents for ICR at partner institutions manage residents during pre- and post-rotation periods, whereas external institutions manage resident experiences during the ICR itself (Figure 1). Emerging themes showed that residents are highly motivated to be prepared for the ICR, but efforts are mostly guided by their own initiative with limited formal guidance. The rotation experience was highly impactful and pushed residents to grow in their role as surgeons and leaders. However, upon return, residents had limited opportunities to debrief or further explore global surgery at their home institution.
Conclusion
Institutions without global surgery programs may increasingly leverage external, established global surgery collaborations as ICR opportunities for their own residents. However, the complex nature of global surgery engagements creates the need for additional trainee support. Thus, it is important for all institutions sending residents for ICR to work with collaborating institutions to establish baseline global health knowledge and practices approved by all partners, particularly during pre-departure and post-rotation periods when external institutions are less involved, to ensure appropriate trainee preparation to work in a global space.
Figure 1.
(S037) SHORT-TERM SURGICAL MISSIONS VERSUS LONGER INTERNATIONAL SURGICAL ROTATIONS: A RAPID QUALITATIVE ANALYSIS COMPARING THE IMPACT OF GLOBAL SURGERY MODELS ON TRAINEE EXPERIENCES
Catherine Zivanov, MD, MPHS, Helen Li, MD, Colleen Witty, MD, MPH, Paul E Wise, MD; Washington University in St. Louis
Introduction: Influenced by growing interest among trainees and supportive policy changes from the ACGME, many US surgical residency programs offer international surgical experiences (ISEs) in resource-limited settings. ISEs are highly variable in structure, objectives, and impact. Our program is unique in that we facilitate two structurally distinct ISEs for residents: a 1-week mission trip to Central America with a non-profit organization and an 8-week RRC-approved surgical rotation in East Africa. We performed a needs assessment of these ISEs to explore their impact on trainees and identify opportunities for improvement.
Methods: Current and former trainees who participated in at least one ISE during residency were purposively sampled for participation in semi-structured focus group discussions (FGDs) stratified by ISE. FGD recordings were summarized independently by two research team members using an iteratively refined template of domains mirroring the FGD guide. Reconciled summaries were aggregated into a matrix, and rapid qualitative analysis was used to triangulate salient themes across FGDs.
Results: Rapid analysis of four FGDs revealed distinct strengths and weakness of each ISE. The non-profit organization offered robust cultural sensitivity training for the 1-week mission trip, but short duration and high operative volume limited time for patient interaction and cultural exchange. While a high-resource standard of care was maintained on the 1-week trip, trainees expressed concerns about postoperative follow-up. The 8-week rotation had less cultural preparation but allowed more time for on-the-ground cultural immersion and exchange. The 8-week rotation also afforded more time for longitudinal apprenticeship, graduated autonomy, and improved surgical decision-making. However, trainees reflected on moral injury related to disparities in surgical outcomes that resulted from insufficient resources. Both experiences broadened trainees’ perspectives and inspired further learning about global surgical equity. Trainees expressed a desire for longitudinal engagements, supplemental curricula, and increased exposure to multisectoral aspects of establishing international partnerships.
Conclusion: As surgery residency programs continue to offer ISEs, they should, provide pre- and post-ISE support to address cultural and ethical challenges inherent to these experiences, encourage longitudinal engagements when possible, and offer supplementary curricula to maximize the impact of these experiences on trainees.
(S038) LONG-TERM EFFICACY OF A LOW-COST LAPAROSCOPIC TRAINING CURRICULUM FOR NIGERIAN SURGEONS: 8-MONTH POST-COURSE SURVEY
Rija Awan1, Andrea Orji1, Erin Kim1, Joy Obayemi2, Deb Rooney3, Peter Ekeh4, Grace Kim2; 1University of Michigan Medical School, 2Michigan Medicine, Department of Surgery, 3University of Michigan Medical School, Department of Learning Health Sciences, 4Wright State University, Department of Surgery
Introduction: The surgical workforce in Africa is 50 times smaller than what is recommended by the World Health Organization, resulting in a critical need for enhanced surgical education and training across the continent. To accompany its open-source laparoscopic training system, ALL-SAFE facilitated a 2-day educational course in Abuja, Nigeria. This study aims to assess the impact of this in-person training program over time by evaluating participant engagement, knowledge and skill acquisition, and future use of laparoscopy eight months after training.
Methods: A two-day in-person course was facilitated in October 2023 consisting of didactic lectures and basic skills training in laparoscopic surgery for 34 surgeons from Nigeria. After the course, participants were given sample box trainers and laparoscopic instruments for continued practice and engagement using the ALL-SAFE system. An 8-month post-course survey was created by a team consisting of surgeons, residents, and researchers from varied backgrounds and distributed online to participants. Survey questions focused on engagement in laparoscopic practice, perceived translation of skills to the operating room, and improvements in surgical skills.
Results: Sixteen participants (16/34 = 47%) completed the survey. Post-course, 63% built their own box trainers, and 70% continued using the ALL-SAFE modules, with cognitive learning (50%) and surgical skills training (100%) being the most accessed. Sixty-eight percent anticipated continuing to use the modules weekly, and 69% reported increased confidence in performing laparoscopic procedures, with 56% feeling “highly competent.” Additionally, 82% of participants taught laparoscopic skills to colleagues, and 94% noted improvement in their surgical skills, particularly in knot-tying and hand-eye coordination. Seventy-five percent were “highly satisfied” with the course.
Conclusion: Eight months after its completion, the in-person ALL-SAFE educational course in Abuja, Nigeria, demonstrated significant and durable positive outcomes in participant engagement, knowledge expansion, skill acquisition, and sustained use of the training resources. These findings suggest that following the ALL-SAFE course, participants continue to engage in surgical skill development and proficiency, which supports the potential for successful skill acquisition to enhance clinical outcomes.
(S039) HOW TO BOOST RETENTION IN SIMULATION-BASED LAPAROSCOPIC TRAINING PLATFORMS: INSIGHTS FROM PILOT SITES
Erin Kim1, Phillip Hsu, MD, PhD1, Joy Obayemi, MD1, Luke Rettig, MD2, Blessing N Ngoin, MD3, Christopher Reynolds, MD1, Rija Awan1, Deborah M Rooney, PhD1, David R Jeffcoach, MD4, Kevin El-Hayek, MD, MBA5, Melanie Barnard, MD6, Grace J Kim1; 1University of Michigan, 2University of California San Francisco, 3Mbingo Baptist Hospital, 4University of California San Francisco Fresno, 5MetroHealth, 6Southern Illinois University
Introduction: Open-source web-based educational platforms provide critical opportunities for surgical skill acquisition, especially in resource-limited settings that may lack instructors for traditional surgical training. However, sustaining usage beyond initial exposure is challenging, often requiring structured support for learner retention. We evaluated the impact of supportive measures on usage of a simulation-based laparoscopic training platform piloted in the US and 10 countries in Africa.
Methods: We analyzed learner usage of six educational modules, each comprising a case scenario and psychomotor training with video upload. Learner retention was assessed on interaction with the module (case scenario completion) and module completion (simulated video upload). We assessed learner demographics (age, gender, laparoscopic experience, training level), training program requirement, designation as an official pilot site (institutional resources, availability of pre-assumbled DIY box trainer), educational course (>24 hours), and educational seminar (< 24 hours). Additionally, we examined the impact of surgeon champions and regional spillover effects on training engagement.
Results: Of the 307 learners using the platform, 63.2% (113/307) interacted with >1 module and were considered retained learners. Learner retention was associated with 12 pilot sites, 3 courses, 2 programs with formal requirements, and 2 seminars, with 92.0% (104/113) of retained learners being supported by one or more measure. However, only 11.1% (34/307) of learners completed more than one module, with completion primarily occurring at pilot sites (91.1%; 31/34) that featured surgeon champions and pre-assembled box trainers. A strict program requirement at one institution resulted in 62.1% (18/29) of learners interacting with multiple modules and 17.2% (5/29) completing all six. Conversely, a soft program requirement at another site saw only 20% (5/20) of learners interacting with multiple modules, with no completions. A course in Nigeria led to adoption in four additional institutions in Nigeria. Both courses and seminars enhanced interaction, but not completion.
Conclusion: While the responsibility for learning on online platforms ultimately lies with the individual learner, implementing program requirements and supportive testing infrastructure can enhance usership. Dedicated in-person courses not only improve learner retention but also facilitate spillover effects.
(S040) THE RELIABILITY OF TASK-SPECIFIC METRICS TO ASSESS RESIDENT PERFORMANCE ON A MULTICENTER ROBOTIC HERNIA CURRICULUM
Amr A Abbas, MD1, Sofia Garces Palacios, MD1, Emile Farah, MD1, Andres Abreu, MD1, Zein S Eddin, MD1, Aram E Rojas, MD2, Patricio M Polanco, MD, FACS1, Melissa E Hogg, MD, MS, FACS2, Herbert J Zeh III, MD, FACS1, Ganesh Sankaranarayanan, PhD1; 1University of Texas Southwestern Medical Center, 2NorthShore University Health System
Introduction
Inguinal hernia repairs are common procedures in general surgery, with robotic techniques being increasingly adopted. Proficiency-based curriculum with formative assessment for feedback is essential for training in this procedure. Task-specific metrics (TSM) can offer more detailed and actionable feedback compared to traditional global metrics such as the Objective Structured Assessment of Technical Skills (OSATS). This study aims to evaluate the reliability of TSM for the assessment of surgical performance within a proficiency-based robotic hernia curriculum.
Methods
Surgery residents and expert surgeons from two tertiary medical centers participated in this study. A validated inanimate hernia drill performed using the Da Vinci Xi robot was used in this study. Expert surgeons performed the task once to establish the benchmark score. Each resident repeated the task four times. The performance was videotaped and graded using both TSM and OSATS by two trained graders. Detailed feedback based on TSM was provided after each attempt. Messick’s unitary framework was used to establish the reliability of TSM. Inter-rater reliability was assessed using the Intraclass Correlation Coefficient (ICC) (internal structure). Spearman’s Rank correlation assessed the correlation between TSM and OSATS (relations to other variables). Paired t-tests were used to assess improvement in performance between the first and the fourth trial (construct).
Results
A total of 24 surgery residents along with five attending surgeons participated in the study. Benchmark proficiency scores for OSATS and TSM were 31.8 and 23.4 respectively. ICC was high between the two graders for both TSM (ICC = 0.89, P < 0.001) and OSATS (ICC = 0.87, p < 0.001). All residents achieved expert level performance by their fourth attempt. When comparing the fourth to the first attempts for residents, their total scores for OSATS (30.58 vs 21.41, p < 0.05) and TSM (21.75 vs 12.83, P < 0.05) improved significantly. The TSM exhibited a strong positive correlation to OSATS (R= 0.88, p<0.05).
Conclusion
By establishing internal structure and relations to other variables, we demonstrated the reliability of TSM for assessing surgical skills in a robotic hernia curriculum. Our results further highlight the utility of TSM in providing more targeted and actionable feedback.
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(S041) MULTICULTURAL COMPETENCE EDUCATION IMPROVES CARE: AN INTERNATIONAL COMMUNICATION COURSE FOR MEDICAL STUDENTS
Anna B Newcomb, PhD, MSW, LCSW1, Hassan Mashbari, MD, DABS2, Reem Abbaker, BA3, Khalid Elhadi, BS3, Seba Muzaiiadi2, Erin March, BA4, Rachel D Appelbaum, MD5, Kristen Wells, PhD, MPH3, Denise Mohess, MD6; 1Inova Fairfax Medical Campus, 2Jazan University, 3University of Virginia, 4Eastern Association for the Surgery of Trauma, 5Vanderbilt University Medical Center, 6Yale Medical School
Background
The diversity of our nation presents a prime opportunity to ensure educators deliver culturally competent education. To effectively deliver health care that meets patients’ diverse needs, medical students must be taught how to explore patients’ culture, values, and preferences.
The Eastern Association for the Surgery of Trauma has partnered with communication experts to offer a virtual communication course to medical students from the United States and Saudi Arabia (SA). Students engage in culturally and emotionally challenging conversations with simulated patients under the guidance of an international faculty, filling a gap in both US and SA medical student curricula.
Methods
SA and US students shared reflections of their multicultural experience of the communication course in three focus groups and surveys collected during class. The first focus group was conducted in Arabic and translated into English for analysis; the second and third were conducted in English. We developed a codebook following initial data review, which allowed the data to be organized, refined, and ultimately compiled into a final data set for analysis.
Results
Twenty-four students and 10 faculty from 17 medical schools in the SA and US participated in the 5-week virtual course and were supported by 19 volunteer actors. SA students participated in additional weekly practice sessions with actors and select US students. Seven SA students and five US students participated in the focus groups. Themes emerging from the data included enthusiasm for the course for its realistic experience (“Those actors weren't shying away from the hard stuff!”), insight into diverse patient and provider perspectives (“I appreciated their perspective on the different situations because we’re going to see patients from those backgrounds.”), and highlights of specific communication skills obtained from simulation practice (“This class has taken away a lot of the fear about not knowing things or saying the wrong thing,” and “sometimes we're there just to listen and be another advocate for our patients.”).
Conclusion
This course prepares students to respond respectfully and sensitively to patients from diverse cultures. Medical schools, hospital administrators, and curriculum developers can draw from our experience and collaborate internationally to enhance student multicultural competence.