ASE 2024 Abstracts

Podium IIC - Teaching Methods

USING AERONAUTICAL DECISION MAKING TO GUIDE THE DEVELOPMENT OF A NOVEL MODEL FOR 'GOOD SURGICAL JUDGMENT'
Alexander Miles, MD, Brett Mador, MD, Simon Turner, MD, Jonathan White, MD; University of Alberta

Introduction

Despite being considered a core attribute among surgeons, 'good surgical judgment’ remains a poorly defined concept among clinicians. Previous research on surgical judgment has focused on the intraoperative decision-making environment. However, surgical judgement is a skill which surgeons apply to all their decision-making processes and ignoring extraoperative decision-making creates a deficit in our understanding of ‘good surgical judgment’. In contrast to the surgical profession aviators have long had a holistic model of good pilot judgment termed “Aeronautical Decision Making”, which has been highly successful in improving pilot decision making and flight safety. Appling the concept of parallel professions, the Aeronautical Decision Making model was utilized as a guiding framework to support the development of a novel holistic model of ‘good surgical judgment’ addressing both intra and extraoperative environments.

Methods

Using constructivist grounded theory we conducted semi-structured interviews with 24 attending surgeons from 9 surgical specialties affiliated with a single Canadian institution. Interviews focused on how the participants conceptualized the process of ‘good surgical judgment’ and the Aeronautical Decision Making model was used as a framework to guide the creation of the interview guide and anchor the discussion. Snowball and purposive sampling were used to achieve diversity in sampling. Data collection and analysis were iterative and guided by theoretical sampling. A conceptual model was generated from the data.  

Results

A total of 25 surgeons from representative surgical specialties were interviewed at which point theoretical saturation was achieved. Analysis of interview data identified a cyclical model of ‘good surgical judgment’ consisting of three major components (Figure 1): contextual factors, the decision cycle, and post decision evaluation.

Discussion

Surgeons utilize an iterative and holistic approach to surgical judgement both inside and outside of the operating room. This new conceptual model for ‘Good Surgical Judgment’ contributes to understanding surgical decision-making outside of the operating room and may serve as a conceptual framework to support the development of novel instructional and feedback tools to enhance the development of surgical judgment in trainees. 

ASSESSING MICRO-ERRORS AND PREOPERATIVE SELF-REFLECTION TO OPTIMIZE COMPETENCY ACQUISITION IN LAPAROSCOPIC CHOLECYSTECTOMY.
Jose Rui-Wamba, MD, Bernardita Becker, MD, Cristóbal Vildósola, Michelle Grunauer, MD, María Inés Gaete, MD, MSc, Julián Varas, MD, MSc; Pontificia Universidad Católica de Chile

Introduction

Competency-Based Surgical Education (CBSE) emphasizes self-regulated learning and deliberate practice as key drivers of technical mastery. However, traditional tools such as the Objective Structured Assessment of Technical Skill (OSATS) fail to make residents aware of subtle micro-errors (minor technical or cognitive deviations that hinder performance in laparoscopic surgery) such as inefficient use of the non-dominant hand, poor instrument alignment, or improper trocar placement. Identifying these errors is crucial for planning targeted practice. This study aimed to design and validate self-applied tools to enhance metacognitive awareness and deliberate practice in laparoscopic cholecystectomy training.

Methods

A two-phase study was conducted. Phase 1 (retrospective): Expert surgeons analyzed 100 laparoscopic cholecystectomy videos from 20 residents to catalogue recurrent technical micro-errors not captured by OSATS. Based on these findings, two instruments were developed: a preoperative self-reflection checklist and a postoperative self-assessment rubric. Content validity was established by five surgical-education experts who rated item relevance, clarity, and representativeness on a 5-point Likert scale. Face validity was assessed by five residents who evaluated clarity, length, and usability. Both instruments were refined through iterative revisions. Phase 2 (prospective): Residents completed the checklist before surgery and the rubric immediately after surgery. Adherence and perceptions of clarity, usefulness, and feasibility were collected using structured Likert-type surveys.

Results

The preoperative checklist included six Yes/No items addressing cognitive preparation, including anatomical review, identification of critical steps, anticipation of difficulties, and error prevention. The postoperative rubric comprised eight items across two domains: technical (non-dominant hand usage, procedural steps, instrument alignment, tissue handling, ergonomics) and cognitive (situational awareness, anticipation, and decision-making). Each item was rated on a 5-point Likert scale (1 = needs improvement; 5 = expert level). Adherence reached 86% for the checklist and 79% for the rubric. Median satisfaction was 4.7/5, with high perceived usefulness (4.8) and feasibility (4.6).

Discussion

Self-applied metacognitive tools can help residents identify and reflect on their own micro-errors, promoting the self-awareness required for deliberate practice. High adherence and favorable perceptions indicate that these instruments are feasible and valuable complements to faculty-based feedback, supporting reflective learning and autonomy in laparoscopic training.

TRAINEE-FACULTY GENDER CONCORDANCE AND INTRAOPERATIVE ENTRUSTMENT IN CARDIAC SURGERY
Alexandra Theall¹, Megan L Schultz, MD², Rico Ozuna-Harrison³, Diamond Buchanan, MS³, Darrell Tubbs II, MPH³, Julie Evans, MS⁴, Niki Matusko³, Steven F Bolling, MD², Gurjit Sandhu, PhD³; ¹University of Michigan Medical School, ²Department of Cardiac Surgery, University of Michigan, ³Department of Surgery, University of Michigan, ⁴Michigan Medicine

Introduction: Surgical education is predicated on intraoperative entrustment and progressive autonomy to prepare trainees for independent practice. The OpTrust tool has recently been employed in cardiac surgery to measure intraoperative entrustment; however, little is known about what specific factor(s) influence entrustment in this novel setting. This study evaluates trainee-faculty gender concordance as a potential mediator of intraoperative entrustment in cardiac surgery.

Methods: Elective cardiac surgeries were observed from November 2022 to June 2023. Entrustment was assessed using the OpTrust tool, and performance of twelve cardiac-specific surgical benchmarks was observed. “Gender concordant” dyads were defined as pairings of male trainees with male faculty; “gender discordant” dyads consisted of female trainees and male faculty. Entrustment scores and number of trainee-completed benchmarks were compared according to gender concordance using two-sample t-tests and Wilcoxon rank-sum tests, respectively. Chi-squared and Fisher’s exact tests assessed the relationship between gender concordance and specific trainee-completed benchmarks.

Results: 12 trainees (50% male) and 7 male faculty were observed over 49 cases; 25 cases were performed by “gender concordant” trainee-faculty dyads. No significant differences in overall entrustment or total number of trainee-completed benchmarks were identified between “gender concordant” and “gender discordant” dyads (Table 1). Similarly, no differences in entrustment were observed for technical benchmarks, such as internal mammary artery (IMA) harvest (p=0.50) and chest tube placement (p=0.46). However, male trainees in “gender concordant” dyads were significantly more likely to complete benchmarks associated with case leadership, including cardiopulmonary bypass cessation (p=0.01) and cross-clamp removal (p=0.048).

Conclusion: Though gender concordance within faculty-trainee dyads does not significantly impact overall intraoperative entrustment or trainee autonomy in cardiac surgery, male gender may facilitate entrustment with leadership-oriented tasks in the cardiac operating room. Further research should explore drivers of technical and non-technical skill entrustment and the impact of faculty gender on these trends.

FACULTY STRATEGIES TO CREATE AN AUTONOMY-SUPPORTIVE LEARNING ENVIRONMENT
Jonathan D'Angelo, PhD, MAEd¹, Aashna Mehta, MD¹, Oviya Giri, MBBS¹, Mohamed Baloul, MD¹, Mariela Rivera, MD¹, Rebecca Busch, MD², Anne-Lise D'Angelo, MD, MSEd¹; ¹Mayo Clinic - Rochester, ²University of Wisconsin

Introduction

Robust research indicates an autonomy-supportive learning environment fulfills learners’ needs of autonomy, competence, and relatedness and thus promotes learning. Given the focus on autonomy in surgery and assessment via EPAS, this research evaluated faculty perspectives on behaviors that create an autonomy-supportive learning environment, an area currently lacking empirical investigation. 

Methods

A survey was distributed to surgical faculty at three institutions. Items assessed the perceived autonomy-supportive operative learning environment (12-item Learning Climate Questionnaire(LCQ)); behaviors impacting this environment (open-ended questions); locus of control; and demographics. Qualitative responses were deductively coded with focus on faculty strategies to support resident autonomy, competence, and relatedness. Frequency of codes was tabulated.

Results

Fifty-six surgeons responded to the survey (52% female; M=9.48±8.07 practice years). 

The LCQ scale (α=.87) indicated that faculty firmly believe they foster autonomy-supportive learning environments (M=4.33/5, SD=.56). Perception of autonomy-supportive teaching was not associated with gender, practice years, or locus of control. Qualitative responses indicated faculty engaged in autonomy-supportive behavior via specific actions (Table 1). Faculty most frequently emphasized strategies enhancing relatedness (75%) and competence (72%), with fewer references to autonomy (35%).

Conclusion

While faculty identified specific and repeatable behaviors to enhance the autonomy-supportive learning environment, fewer faculty were able to describe explicit techniques to enhance autonomy itself, compared to competence and relatedness. This can serve as a focus for faculty education and future research on entrustment decisions related to EPAs. 

REFRAMING THE CLERKSHIP OR EXPERIENCE: SIMULATING AN INTRAOPERATIVE EMERGENCY AS PREPARATION FOR PATIENT-CENTERED LEARNING
Alexis Korman, MD¹, Magdalena Robak Scheer, MD, MHPE¹, Rachel Sibley, MD², Georgia Westbrook Bressner¹, Shannon Kahen¹, Meg Anderson¹, Pablo Heredia¹, Mahino Talib, MD¹, Isabelle Le Leannec, MD¹, Johana Oviedo, MD, MPH¹, Deepak Pradhan, MD, MHPE¹, Verity Schaye, MD, MHPE¹, Leandra Krowsoski, MD¹; ¹NYU Langone, ²Keck School of Medicine of USC

Background:

Operating room (OR) emergencies create abrupt tonal shifts, transforming the environment from learner-centered to patient-centered. Many students first encounter these dynamics during the surgical clerkship, often misinterpreting them as negative learning environments. End-of-surgery-clerkship feedback cited dissatisfaction with limited learner-centered OR education and negative impressions of faculty professionalism and teaching. We hypothesized that safely simulating intense OR experiences better prepares students for patient-centered learning. Our innovative simulation reframes direct communication and hyperfocus as essential components of patient-centered care rather than an inhospitable learning environment.

Methods:

A multidisciplinary OR simulation was implemented for students entering the clerkship year to develop learning strategies during dynamic OR changes. First, a pre-brief on psychological safety and roles occurs. During the case, intraoperative hemorrhage with hemodynamic instability triggered a sudden shift from a calm teaching environment to one entirely focused on patient care, placing learners outside their comfort zone. The debrief explored strategies for continued learning during high-stress, patient-centered moments. 

Efficacy was evaluated using immediate post-session feedback and quarterly end-of-clerkship evaluations comparing faculty teaching, learning environment ratings, and the number of role model and positive learning environment fallout reports before and after simulation implementation.

Results:

342 students have participated from October 2023-July 2025.  Feedback consistently highlights the realism and value of experiencing these dynamics before rotations. Among 2025 participants, 88% reported improved preparedness for the OR. 

The clerkship learning environment report from the quarter before implementation was compared with the two subsequent quarters. Faculty teaching rated as fair/poor/terrible decreased from 21% pre-introduction to 8% and 7% post-introduction. Learning environment ratings in those categories was 12% pre- and 12% and 0% post-introduction. Five faculty previously fell below institutional thresholds for role model ratings and four for positive learning environment scores; post-simulation, these declined to one and zero for both categories.

Conclusion:

This well-received, innovative simulation provides an effective, psychologically safe introduction to the OR and is highly adaptable for other institutions. Although causation cannot be inferred, post-intervention feedback demonstrated improved perceptions of faculty teaching and the learning environment. Ongoing clerkship evaluation surveys will further assess the impact on students’ perceptions of the OR environment.