ASE 2024 Abstracts

Introduction:  The position of residency program director has been well defined by governing bodies as an important educational role. Its impact on the individuals themselves has not been studied extensively. We aimed to examine the impact of the role of program director (PD) as seen by former leaders of general surgery residency programs.

Methods:  Qualitative methodology was used to conduct this IRB approved study. Semi structured virtual interviews were conducted from May– September 2023 with invited former PDs of general surgery residencies, so they had each been able to reflect on this phase of their career retrospectively. A research team consisting of five members transcribed responses and conducted a thematic content analysis.  Team members individually coded the responses and an iterative consensus process as per grounded theory was utilized to identify the final themes and subthemes.

Results:  A total of 19 former general surgery residency PDs were interviewed.  Their responses were found to have five recurring themes which were further divided into subthemes (Figure 1). The themes centered on 1) Development as a leader, 2) Relationship building, 3) Proficiencies needed as a program director, 4) Transactional aspects, 5) Transformational aspects. Several key sub-themes came out from these themes (Figure 1).

Conclusion:  Leading a general surgery residency program is an extremely impactful position. The transformational aspects create professional fulfillment not only while one holds the position of program director, but also in subsequent stages of their career.

Introduction

With the initiation of EPAs, focusing on learner progression(growth) has taken center stage, however we have failed to define(and study) language that promotes growth in the surgical learner.  An association between growth mindset(GM) and improved knowledge retention, cognitive load, and well-being has been demonstrated in non-surgical cohorts.  This study aimed to define GM language(GML) in surgical resident feedback and to determine the prevalence of GML used in formative and summative feedback.

Methods

A mixed methods study was performed using written evaluations and transcribed operative feedback dictations from the SIMPL platform delivered to general surgery and urology residents in a single health system over 5 years. An a priori codebook defining both growth and fixed language was adapted from the literature and deductively applied.  Three separate random samples were coded by 4 coders until 80% agreement was achieved. Three parent codes and 7 child codes were established. Feedback statements(FS) received a parent code for overall theme, and child codes were applied to excerpts within the FS.  Descriptive statistics were performed to determine code prevalence.

Results

A total of 450 FS were coded; 185(41.1%) of FS were GM dominant. Effort Language(“came prepared to the OR” or “I appreciate his approach to always looking for a way to improve things”),  occurred 85 times(45.9[HRL1] %), Learning Language(“Keep working on using both hands") 136 times(73.5%), Progress Language(“Progressing nicely” or [I] saw…significant growth over the rotation”) 87 times(47%), and Support Language(“We need to work on the fluidity of our operations together”) 12 times(6.5%). Alternatively, 217 FS (48.2%) were coded as fixed, with Innate Ability/Quality (“Good hands” or “Smart”) occurring 112 times(51.6%) and No Room For Improvement(“Good job. No issues”) occurring 181(83%). FS that were neither amounted to 48(10.6%).  The word “yet” occurred once(0.5%).

Conclusions

Nearly 60% of FS fail to contain GML. A  tremendous opportunity to improve the quality of feedback for the learner exists. With minimal effort, educators can add key phrases to feedback that signify their recognition of a learner’s effort and progress, and a belief in their capacity to improve. This GML, in turn, may positively impact learning outcomes.

Introduction: Junior faculty in the operating room (OR) have many competing priorities, including time, efficiency, cost, patient safety, education, supervision, and, often, a multi-disciplinary health care team. a scarcity of research explores factors contributing to junior faculty feeling underprepared for independent practice, but we hypothesize that cognitive overload from the competing priorities may be one such factor. Our objective was to examine barriers faced by junior faculty members as they transition from trainee to leader in a surgical practice, specifically as they begin teaching in the OR.

Methods: Semi-structured interviews were conducted with junior faculty members (<6 years out of training; n=6currently, 20-25 planned via Zoom: ~30-45 minutes each). Participants were asked to reflect on their experience via prepared questions, including background, training to date, experience with cognitive overload, impact of imposter syndrome, and teaching ability. Qualitative content analysis was conducted to identify relevant themes/sub-themes.

Results: All junior faculty reported feeling overloaded in the OR, particularly in their first few years in this new role. This was often elevated by: complex cases or extremely sick/comorbid patients, the presence of junior trainees, the presence of unfamiliar/less familiar trainees with whom they had not developed sufficient trust, and time constraints. 83.3% of junior faculty reported feelings of imposter syndrome, and stated this affected their cognitive overload in the OR, as well as their teaching competence and confidence. When asked how they deal with this cognitive overload, junior faculty suggested repetition of procedure, the presence of more senior faculty either available to help with the case or on call as back-up, the presence of more practiced residents or support staff (e.g. APPs, nurses), and a developed, internal trust in their own skillset. No junior faculty had received formal training in managing cognitive overload prior to becoming a faculty member.

Conclusions: We report many barriers faced by junior faculty members as they transition into their leadership role in the OR, as they learn to balance teaching with patient safety and case concerns. We suggest mechanisms to deal with cognitive load in the short-term (‘live’) and long-term, which could inform surgical education practices.

Introduction:

Feedback plays a critical role in surgical residents’ development, and end-of-rotation (EOR) evaluations are a ubiquitous form of feedback across residencies. However, we have previously demonstrated significant issues in the quality of narrative feedback in EOR evaluations. We sought to further examine the quality and utility of EOR evaluations through a mixed-methods approach.

Methods:

De-identified EOR evaluations of 26 PGY1-3 residents over a 6-month period at a single institution were obtained, consisting of ACGME 5-point milestone ratings across 9 milestones and narrative comments. 5-point Likert scale-based surveys were utilized to evaluate surgery resident and faculty perceptions of EOR feedback. Descriptive and advanced statistics were performed using SPSS. Narrative comments were deductively coded by two reviewers as “specific,” “constructive,” and/or “actionable.”  

Results:

A total of 169 individual evaluations completed by faculty were analyzed. An average milestone score (AMS) was calculated for each resident, which significantly correlated with each of the 9 milestones (R=0.989-0.997, p<0.001). AMSs significantly differed between PGY level (1.5 vs 2.3 vs 3.2, p<0.001), negatively correlated with the number of specific comments (R= -0.49, p<0.05), but had no significant relationship to constructive or actionable comments. 31 PGY1-5 residents and 50 faculty completed the survey with 35.8% of faculty (29/50) agreeing that lack of anonymity influences how they evaluate residents. There were significant differences in resident vs faculty perceptions on usefulness of ACGME milestones (2.6 vs 3.5, p<0.05). However, residents and faculty agreed that EOR evaluations are a less useful form of feedback (2.7 vs 3.1, p=0.2) than intraoperative (4.5 vs 4.3, p=0.4) or on-the-job verbal feedback (4.2 vs 4.3, p=0.8).

Conclusion:

This study demonstrates issues surrounding the quality and utility of EOR evaluations in surgical residency. Residents do not find ACGME milestone ratings useful and milestone ratings do not correlate with higher order feedback quality metrics, suggesting that residents are not given adequate feedback to address lower milestone scores. Residents and faculty find EOR evaluations much less useful than other forms of feedback. Overall, our findings question the utility and effectiveness of EOR evaluations, suggesting that emphasis may need to be placed on other feedback mechanisms.

Introduction

Medical student mistreatment is a persistently unwelcome issue on surgery clerkships. Neither a comprehensive description of mistreatment nor best practices in mitigation have been developed. The aim of this study was to explore the perspectives of surgical education leaders related to the forms of student mistreatment and subsequent mitigation efforts. 

Methods

A phenomenological approach was used to develop study methodology, including initial snowball recruitment to identify participants and purposive sampling to include a variety of class sizes and geographical regions in the United States. A single interviewer was trained to use a content-expert developed semi-structured script. Via phone or video calls, participants were contacted, consented, and interviewed. Conversations were transcribed (Ottr®) and independently coded (Dedoose® 2022) by two research team members to identify emerging themes. The developed codebook was iteratively updated. All coding disagreements were resolved by consensus meetings with all team members.

Results

A total of 15 current and recent surgery clerkship directors were contacted and 14 interviewed between July and October 2022 (1 declined participation due to desire for absolute confidentiality). Types of mistreatment were categorized which ranged from verbal berating to neglect. A primary theme underpinning participant understanding of student mistreatment was the concept of perspective misalignment: the lack of alignment between students and non-students in perception and understanding of a given clinical or educational interaction. Analysis of participant understanding of solutions revealed two fundamentally different approaches: proactive and reactive. Proactive solutions were more common and involved strategies such as increasing faculty awareness of the problem and empowering and orienting students in the learning environment.  Reactive solutions were less common but highly visible and included concepts such as prompt management of complaints and early leadership involvement.

Discussion

Mistreatment of medical students on surgery clerkships remains a pervasive challenge.  This study describes the shared understanding of clerkship directors regarding the importance of perspective misalignment. The majority of existing efforts to mitigate mistreatment have been geared towards anticipatory proactive strategies, in part designed to diminish this misalignment. Next steps must include contrasting these findings with student perspectives of mistreatment on surgery clerkships and the impact of existing solutions.

INTRODUCTION:

Many simulation centers are challenged in securing well-trained faculty who are able to teach learners using simulation despite competing professional priorities. Also, surgeon educators interested in teaching simulation may need additional training to improve their teaching and assessment skills. We aimed to fill this gap by creating an “Introduction to Simulation Based Teaching” course that leveraged the cobranded American College of Surgeons (ACS)/Association for Surgical Education (ASE) Medical Student Simulation-Based Surgical Skills Curriculum and the resources of an ACS-Accredited Education Institute.

METHODS:

This national two-day experiential train-the-trainer course utilized seven core skills applicable to all medical students undergoing their surgical clerkship. Modules included suturing, knot-tying, nasogastric tube, Foley catheter, central line with ultrasound, intraosseous line, and basic airway. No previous simulation experience was necessary. Senior surgeons were encouraged to apply but other surgical faculty interested in simulation were also invited. Hands-on skills training with feedback from nationally-recognized simulation experts was supplemented with didactics on deliberate practice, types of simulators and simulations, briefing and debriefing, and assessment tools. Participants taught and assessed medical students and received student, peer and expert feedback regarding their newly acquired teaching and assessment skills. Course evaluations addressed the value and quality of didactics and simulation stations (scale of 1-5).

RESULTS:

The course was fully subscribed with 28 participants, including fourteen senior surgeons (> 25 years in practice) as well as clerkship and program directors, simulation champions, and surgical faculty. Fourteen medical students participated as subjects. Twenty-five participants completed course evaluations. Overall score for meeting course objectives was 4.88. Didactics received ratings of ≥ 4.62 with enhancing feedback (4.87) and deliberate practice (4.85) being highest-rated. All simulation station activities received a score of ≥ 4.54.

CONCLUSIONS:

The highly-rated course was successful in training surgeons at various stages of their careers in teaching and assessing skills for the ACS/ASE skills curriculum and provided evidence for its high quality. The importance of experiential train-the-trainer courses to assure high-quality implementation of the curriculum was underscored. Future plans include evaluating participant success using simulation at their institutions and scaling the course to address the needs of additional surgeon educators.