ASE 2024 Abstracts

What problem in education is addressed by this work? Near-peer teaching in surgery has a storied reputation and is exemplified by the mantra, “see one, do one, teach one.” Balanced against its pitfalls, peer teaching and learning offer a number of advantages over the hierarchical model of master teacher-novice learner, such as increased engagement, collaboration, confidence, and ultimately, effectiveness. We sought to leverage near-peer teaching methodology over a remote digital platform to strengthen nontechnical skills of medical students and junior residents at two non-US medical schools. Virtual Resident-as-Teachers workshops (vRATw) conducted by US-based bilingual general surgery trainees over Zoom Meetings for international colleagues in Ecuador were evaluated. Describe the intervention: The vRATw was designed and led by residents to facilitate the four domains within the curricula: finding time to teach and teaching in the OR, giving feedback, and utilizing leadership style effectively. All workshops were successfully adapted to an online learning format; we included bilingual US surgery residents to expand accessibility and impact by involving international institutions. Slides were created in English with automatic Spanish captions provided by Zoom software (version 5.4.4.) and most content was discussed in Spanish; small breakout rooms were created to facilitate the exchange of ideas. A self-reported performance questionnaire was used to measure its sustainability Describe the improvement/outcome of the intervention. Deans, RAT instructors, and RAT advisors were continuously included in feedback sessions to polish details and guide ongoing workshops, that were modified on the following sessions. A full translation of slides to Spanish was performed and a constant update of the content by the RAT Committee. By offering these online bilingual workshops, we overcome distance barriers ensuring valuable educational resources that are globally accessible. Describe how this intervention could be applied at other institutions. Please specifically comment on identified barriers that could exist and how they could be overcome. After successful results and positive feedback from the local authorities, more students within the same institution were recruited; additionally, a second medical school located in a different city was also included. Despite the feasibility of global vRATw and the reported positive impact, the design still has some limitations regarding the small sample size, the restrictions in data collection, and technology requirements; in order to deal with functionality issues and distractions, small groups were created to facilitate interactions with the participants. Furthermore, thanks to the virtual implementation of these workshops, we aim to further expand these workshops to more countries, provide a more objective assessment of each domain, and settle the means for accessible surgical education.

What problem in education is addressed by this work? Recognizing the need for deliberate practice as a potential solution to the present challenges in surgical education, we performed a survey of Duke General Surgery residents, which identified that only 36% are practicing skills outside of the operating room on a minimum of a weekly basis. Additionally, 30% of residents noted that they were unable to consistently attend simulation labs, and 60% reported not teaching others outside the operating room. A lack of (1) time and (2) materials/models were reported as the greatest barriers to independent practice. Within this context, we have developed a curriculum focused on "micro-skills" -- the individual processes and steps that constitute a broader surgical skill. Describe the intervention: To address the changing skill development paradigm, we developed a micro-skills curriculum for residents to practice autonomously, beyond traditional surgical simulation environments. Materials from our larger Surgical Education Activities Lab (SEAL), which included an Ethicon box trainer, suture materials, practice models, and open and laparoscopic instruments, were distributed to each of the resident work rooms at four hospital locations. Every two weeks, residents were provided with a three-slide PowerPoint introducing the purpose of deliberately practicing a particular micro-skill with an embedded YouTube® link to Duke Faculty performing and instructing on the micro-skill. Describe the improvement/outcome of the intervention. By bringing a sampling of simulated tasks and introducing micro-skills to the residents, we instill a culture of deliberate practice, fostering long-term learning and skill improvement. A surrogate of participation can be assessed with video viewership over time on a private YouTube account, and the residents are assessed on their performance of the micro-skills at a Skills Assessment Day. Describe how this intervention could be applied at other institutions. Please specifically comment on identified barriers that could exist and how they could be overcome. Many institutions have successful simulation labs for resident training, but our survey revealed persistent barriers to independent practice despite 24-hour access to a simulation lab. Implementing this curriculum requires noteworthy coordination and support. We created the teaching materials with our simulation fellow and distributed them with the help of our SEAL team staff and funds.

What problem in education is addressed by this work? Proficiency in open and minimally invasive inguinal hernia repair (IHR) is a key competency for graduating general surgery residents, but the surgical anatomy of the inguinal canal is challenging and must be mastered from intra-abdominal and open approaches. Junior residents benefit from low-fidelity IHR models utilized for simulation in order to practice these anatomic and spatial relationships in a setting optimized for learning. We adapted previously published low-fidelity open IHR and totally extraperitoneal (TEP) IHR models built out of cardboard, cloth, and laparoscopic trainer boxes to better meet the need for simulation of these anatomic relationships. Describe the intervention: We enhanced the models by including a wider variety of easily available materials including foam to simulate excessively deep bites on the pubic tubercle, Penrose drains as femoral vessels, and spray glue, which markedly improves the fidelity of dissection. These novel models were additionally modified to now allow for management of an indirect inguinal hernia with the experience of dissecting the hernia sac off the spermatic cord, reducing the hernia contents, and ligating the hernia sac, all of which has increased the educational value of the model. We conducted an IHR simulation lab with 28 PGY 1-2 residents in which residents performed an open IHR and a TEP IHR on these low-fidelity models, aided by faculty preceptors and self-directed learning supports. Describe the improvement/outcome of the intervention. Feedback on the models from trainees was overwhelmingly positive with an emphasis on the usefulness of practicing two approaches during one simulation. Repeated themes in lab evaluations included the detailed nature of the models, a greatly improved understanding of anatomy, and improved ability to understand and dissect the relevant planes. Residents also commented on the value of being challenged to take a PGY-1 through the operations and teach them both cognitively and technically, and several called it a favorite lab. Describe how this intervention could be applied at other institutions. Please specifically comment on identified barriers that could exist and how they could be overcome. A step-by-step pictorial guide to constructing the models is available upon request and may be implemented in any program that seeks to teach IHR, including in resource-conscious training centers around the world. The materials cost for the models is modest at $11 per resident; the TEP model may be reused many times, but the open model is single-use with a time-cost of approximately 1.25 person-hours per model. Recruitment of a team of trainees interested in education and simulation to build the models improves the efficiency of construction.

What problem in education is addressed by this work? The formative educational value of mock oral examinations has been repeatedly demonstrated; however, they are prohibitively costly in time and faculty effort. Social robots (SRs) and artificial intelligence (AI) technology offer a novel means to conduct a mock oral-style examination in a manner not previously available. Here we present an application of this technology to formatively assess surgical decision-making in a low-pressure environment, simulating the American Board of Surgery Certifying Examination (ABS-CE). Describe the intervention: For this application, we used a SR equipped with speech recognition, speech synthesis, and natural language processing AI, and provided it with reference material regarding specific ABS-CE-style cases, instruction to act as a master surgeon examiner, time limits, and a case-specific rubric to assess examinee performance. We held a series of pilot mock oral examination sessions, in which the SR prompted resident examinees to articulate their surgical decisions and justifications in the test cases provided, and then perform an assessment of their performance. Describe the improvement/outcome of the intervention. We hypothesize that repetition of this simulation exercise will prepare surgical trainees for success in the ABS-CE. Scores at faculty-led standardized mock oral examinations and first-time pass rates on the ABS-CE will be primary outcome measures for future studies. Potential secondary outcomes of interest include examinee attitudes, SR system and maintenance needs, financial and time costs of mock oral examinations, duration of SR use, and training program utilization. Describe how this intervention could be applied at other institutions. Please specifically comment on identified barriers that could exist and how they could be overcome. Training programs may implement AI-based mock oral examinations without specialized technical computing nor coding expertise, and assessment data may be automatically compiled using unique rubrics set by training programs. The AI software’s open-source platform will allow the examination interface to be reproduced, edited, and shared seamlessly among participating programs. SRs are somewhat costly as an upfront expense, and initial AI iterative learning requires time and effort; however, there is little anticipated cost of maintenance, and AI training needs decrease with each iteration of the application.