General Surgical Training Research Articles

BS P04 The Legacy of the Adjustable Gastric Band; 5-year study of the presentation and management of gastric band-related complications

Abstract Background Laparoscopic adjustable gastric banding (LAGB), once one of the most popular surgical treatments for obesity, now represents less than 10% of procedures undertaken nationally. No accurate figures exist regarding how many UK patients have undergone LAGB; approximately 5000 procedures were submitted to NBSR between 2013-2015. Alongside procedures undertaken abroad and privately, the total number is likely to be several multiples of this figure over the last 20 years. Currently there is a perception that LAGB-related complications account for a disproportionate volume of non-elective episodes compared to other procedures. This study describes the presentation and management of gastric band dysfunction. Methods This was a retrospective review of all referrals, attendances and admissions to a regional bariatric service with a dedicated bariatric on-call, serving the North West of England between. The study period was January 2018 and April 2023. All elective outpatient (OPC) and non-elective (NE) LAGB-related episodes were included. Patient demographics, band-related data, presentation, investigations, interventions, and related complications were collected and described. Results 375 episodes (212 OPC; 163 NE) accounted for 58% of all OPC and 44% of NE activity. Most patients had LAGB in the independent sector (OPC presentation 73% UK, 18% abroad; NE presentation 80% UK, 20% abroad). Median time from index surgery was 8 years (IQR 5-11, range 0-30 years). Erosions and infections accounted for 4% (14/375) and 5% (20/375) of cases, respectively. LAGB removal was required in 59% of OPC and 60% of NE presentations. LOS for NE presentations was 3 days (IQR 2-6, range 0-41 days). 5 patients required ITU admission (median LOS 2 days). Conclusions Whilst representing only a small proportion of current elective practice, LAGB-related complications represent the majority urgent and non-elective activity in the outpatient and emergency settings. Given that LAGB related complications often present many years after the index procedure, it is likely that this phenomenon will continue to be a challenge for UK surgeons and services for years to come. This has training implications for the future generation of bariatric surgeons and general surgical trainees, many of whom will likely never have seen a gastric band placed, and yet will have to manage complications, a significant proportion of which are complex.

What are heads of department looking for in new general surgeons in Aotearoa New Zealand?

Training pathways vary significantly after completion of the general surgery surgical education and training (SET) program due to increasing sub-specialization. Aotearoa New Zealand requires a diverse range of general surgeons. Appointment of new consultant surgeons can be an opaque process; trainees are often uncertain how to tailor their training to that required by potential employers. Heads of departments (HODs) are influential in new appointments, and their opinions on desirable candidate attributes are valuable. An online survey was conducted in March 2023. All public hospital general surgery HODs were invited to participate. The survey sought opinions on the importance of attributes, skills and experience when appointing a new consultant general surgeon. The response rate was 70% (14/20) including 6 of 7 HODs from tertiary hospitals and 8 of 13 from secondary hospitals. The top three desirable factors were all personal attributes (being a team player, having a strong work ethic, and good interpersonal skills). 10 of 14 respondents disagreed that SET completion alone is sufficient without the need for further training. Most respondents preferred at least 2 years of fellowship training, except for trauma and endocrine surgery, where 1 year was frequently considered sufficient. Only one respondent agreed formal research training is highly valued. Trainees would be wise to obtain training desired by the majority of HODs while building an individualized profile of attributes, skills and experience tailored to hospitals they may wish to work in. The findings should be considered by organizations responsible for general surgical training and workforce planning.

283 The Impact of Augmented Reality Laparoscopic Simulator in Improving Performance Metrics in General Surgical Trainees

Abstract Aim To assess the impact of simulated laparoscopic trainers on improving surgical trainees’ technical ability in completing a laparoscopic appendicectomy by measuring effect on completion time and distance travelled with standard instruments. Method Six CT1 (early-stage) trainees with little prior operative exposure were selected from the North-West of England Deanery to perform x10 appendicectomy simulated exercises with the Augmented Reality Laparoscopic Simulator (LapAR™), interspersed by x3 Lapass exercises. Metrics including ‘Time of completion’ and ‘Distance travelled’ were collected by the simulators and analysed. Results Repeated laparoscopic appendicectomies with the LapAR™ improved performance time for 100% of trainees, with an average of 55% (Regression coefficient -0.65) and improved distance travelled for 75% of the trainees with an average improvement of 39% (Coefficient -2.67). Improvement in instrument smoothness, acceleration and ambidexterity were also observed. Conclusions LapAR™ use has improved all performance metrics for most surgical trainees and proves to be an invaluable tool for surgical training.

Creating a sustainable rural general surgery workforce: what enables fellows to return as rural general surgeons?

In the context of shortfalls in rural general surgeon supply, this research aims to explore why rural general surgical Fellows returned and remained after fellowship at a single rural centre in Victoria, Australia. Fellowship positions post achievement of Fellowship of the Australasian College of Surgeons are traditionally not funded by government because they currently fall outside the accredited rural training post funding provided by the federal government. This article aims to explore if fellowship positions can be an important part in sustaining the rural general surgery workforce. Semi-structured interviews were conducted with nine former general surgery Fellows from a single rural Australian institution. Interviews were recorded, transcribed, coded and themed to undertake analysis according to thematic analysis. This research demonstrates that consultant rural general surgeons can be recruited from a fellowship year when emphasis is placed on: (1) creating a positive workplace culture with safe working hours, (2) ensuring diversification of the general surgical case mix, (3) facilitating opportunities for schooling and work for the surgeon's family, and (4) preferentially selecting for those who identify as rural general surgeons. Rural towns can effectively recruit general surgeons when families are supported with career and school opportunities, and the newly qualified surgeon can initially commit to a 12-month position so that opportunities can be assessed by the entire family unit. Fellowship positions (post completion of general surgical training) allow young surgeons to 'try before they buy' prior to moving to a rural area. Ensuring a sustainable general surgical workforce in a rural community requires employee and surgical leadership to ensure a collaborative and progressive culture, which offers work diversity, supports the family lifestyle and petitions for selecting those who embody the rural general surgeon identity. Post-fellowship positions can enable young general surgeons to have exposure to the realities of a rural lifestyle, which is likely to have a positive effect on recruitment. Due to the return investment of the fellowship program, we propose that the federal government should look at funding post-fellowship positions to improve rural recruitment.

Differences in Resident Self-Evaluation and Clinical Competency Committee Evaluation Using ACGME Milestone Versions 1.0 and 2.0

Intentionally self-driven professional development of surgical resident physicians is a hallmark of surgical training and is expected to gain further traction as Entrustable Professional Activities (EPAs) become the new paradigm for surgical education. We aimed to analyze how surgical residents rate themselves as compared to the evaluation of the Clinical Competency Committee using ACGME Milestones Version 1 (M1.0) and Version 2 (M2.0). We asked 22 general surgical trainees for self-evaluation of Milestones (both M1.0 and M2.0) from 2017 semiannually to 2022. ACGME-required Milestone evaluations by the Clinical Competency Committee (CCC) were independently performed after the time window for resident self-evaluation. Neither trainees nor CCC were aware of the other party's evaluations. There were 1552 paired data available for evaluating individual competencies by both trainees and CCC. Paired Wilcoxon signed-rank tests were then performed among the corresponding pairs. MercyOne Des Moines Medical Center, Des Moines, IA; Teaching tertiary referral center. Twenty-two general surgical trainees at this hospital and 28 faculty surgeons participated in this study. The average self-evaluation of surgical residents was lower in the M1.0 cohort compared to the corresponding CCC evaluation (1.96 ± 0.72 vs. 2.11 ± 0.67; p < 0.001). M1.0 self-assessments and CCC-assessments were statistically similar for ICS (p = 0.548) and PROF (p = 0.554) competencies and differed for MK (p < 0.001), PBLI (p < 0.001), PC (p < 0.001), SBP (p = 0.008). On the contrary, the M2.0 cohort demonstrated higher average self-evaluation of surgical residents compared to the corresponding CCC evaluation (2.75 ± 0.87 vs. 2.12 ± 0.97; p < 0.001). Significant differences were observed for all 6 ACGME competencies using M2.0 self-assessments and CCC-assessments (all p < 0.001). Multivariate regression modeling (p < 0.001, R2 = 0.255) predicted the degree of discordance between self-assessment and CCC-assessed achievement of competencies with a significant effect of gender (baseline male: coef = -0.232, p < 0.001), PGY level (-0.083 per year, p < 0.001) and Milestone version (0.831, p < 0.001). A significant interaction exists for all gender/Milestone combinations except for the female trainees with M1.0. The difference between self-evaluated Milestone achievement and faculty-driven CCC evaluation of surgical resident physician performance is more evident in Milestones 2.0 than in Milestones 1.0. Residents self-evaluate higher compared to faculty using Milestones 2.0. This discrepancy is seen among both genders and is more pronounced among male residents overestimating core competencies with M2.0 self-evaluation than formal CCC assessment.

Mental training in general surgery: a qualitative review of Australian trainee perceptions.

Mental training is the cognitive process and pedagogical technique of 'viewing' and 'feeling' a task without physically performing it. Its application is well-established within aviation, elite sports and the arts. While surgical trainees often mentally rehearse prior to operating, this technique is yet to be established for educational and skill acquisition purposes. The aim of this study was to investigate trainee awareness of mental training, the use of mental rehearsal, and explore perceived benefits and barriers to its implementation. An exploratory qualitative study design was employed, with semi-structured interviews of general surgical trainees across Australia. Interviews were transcribed and thematic analysis undertaken to identify common themes. A total of 10 General Surgery trainees were interviewed encompassing each Australian state and territory. A consistent finding was that all teaching of operative skills occurs in the clinical environment, without the adjunct of structured practical or cognitive simulation. All trainees reported mentally rehearsing procedures in some capacity as part of personal preparation, and were supportive of implementing formal mental training for surgical skill development. Themes included standardization of training, enhancing training during times of reduced clinical exposure, minimizing anxiety, and improving communication. Implementation was deemed to be most effective through a bank of online mental training resources. Mental training was supported by General Surgical trainees, with perceived potential benefits in multiple domains. To mitigate the main perceived barrier of time constraints, an online method of delivery was felt to be optimal.

Rural general surgeon confidence with managing vascular emergencies: A national survey.

Life and limb threatening vascular emergencies often present to rural hospitals where only general surgery services are available. It is known that Australian rural general surgical centres encounter 10-20 emergency vascular surgery procedures annually. This study aimed to assess rural general surgeons' confidence managing emergent vascular procedures. A survey was distributed to Australian rural general surgeons to determine their confidence (Yes/No) in performing emergent vascular procedures including limb revascularisation, revising arterio-venous (AV) fistulas, open repair of ruptured abdominal aortic aneurysm (AAA), superior mesenteric artery (SMA)/coeliac embolectomy, limb embolectomy, vascular access catheter insertion and limb amputation (digit, forefoot, below knee and above knee). Confidence level was compared with surgeon demographics and training. Variables were compared using univariate logistic regression. Sixteen per cent (67/410) of all Australian rural general surgeons responded to the survey. Increased age, years since fellowship and training prior to 1995 (when separation of Australian vascular and general surgery occurred) were associated with greater confidence in limb revascularisation, revising AV fistulas, open repair of ruptured AAA, SMA/coeliac embolectomy, and limb embolectomy (p < 0.05). Surgeons who completed >6 months of vascular surgery training were more comfortable with SMA/coeliac embolectomy (49% vs. 17%, p = 0.01) and limb embolectomy (59% vs. 28%, p = 0.02). Confidence in performing limb amputation was similar across surgeon demographics and training (p > 0.05). Recently graduated rural general surgeons do not feel confident in managing vascular emergencies. Additional vascular surgery training should be considered as part of general surgical training and rural general surgical fellowships.

Gender associations with selection into Australian General Surgical Training: 2016-2022.

For those who have maintained an interest in general surgery after medical school and their early post-graduate years, selection is the first step to a career in general surgery. Identifying differences secondary to gender in selection tools and their outcomes should assist the Royal Australasian College of Surgeons and the Australian Board in General Surgery to improve gender equity in the general surgical workforce. Selection tools for general surgery include the curriculum vitae (CV), referee report (RR) and multiple mini-interview (MMI). All applicants' CV, RR and MMI scores achieved in the general surgery selection process were reviewed by gender over a seven-year period. In all years, there were lower numbers of female applicants to selection. There were differences identified between genders in the CV and MMI, with females scoring lower in the CV and higher in the MMI when compared to males. There were no differences identified in the RR or proportion of applicants that were successful in their application based on gender. The CV and MMI utilized for selection into general surgery were associated with gender bias. However, the lower number of females selected into training reflects the lower number of female applicants overall. There was no overall impact from gender found in an applicant's ability to be selected into general surgery in Australia.

Trends in Racial and Gender Diversity Among Complex General Surgical Oncology Fellowship Trainees.

This study examines trends in racial and gender diversity of trainees within Complex General Surgical Oncology Fellowships, and compares the racial and gender proportions of trainees across different fields to assess potential barriers to increasing diversity within surgical oncology training programs. Accredited Council for Graduate Medical Education (ACGME) data were queried to identify surgical trainees between 2013 and 2021. Trainees were identified based on self-reported race and gender and were stratified based on residency type and fellowship program type if applicable. Chi-square tests were used to assess differences between groups and trends. A significantly lower proportion of individuals who are underrepresented in medicine (URMs) trained in surgical oncology fellowships (8.9%) compared with both the overall trainee pool (12.8%) and general surgery residency programs (13.1%) [p<0.05]. There was no significant increase in URM representation in surgical oncology fellowships across the study period. Furthermore, there was a significantly lower proportion of females training in surgical oncology fellowships (38.6%) compared with the overall trainee pool (45.6%) [p<0.05]. Despite a significant increase in female representation in general surgery residency and other surgical fellowships, there was no significant increase in female representation in surgical oncology fellowships across the study period. This study identifies disparities in gender and racial minority representation within ACGME-accredited Complex General Surgical Oncology Fellowship training programs. While steps have been taken to expand diversity, more needs to be done to combat the systemic barriers that both racial minorities and women face during their training.

Gender and Racial Diversity Among Colon and Rectal Surgery Trainees and Leaders.

Despite recent changes in women and underrepresented minorities in medicine, there still exists large gender and racial gaps in surgical training and leadership. We hypothesize that gender and racial representation have improved among general and colorectal surgical trainees and leadership over the past 20 years. This cross-sectional study examines gender and racial representation of general and colorectal surgery residents, colorectal faculty members, and the American Society of Colon and Rectal Surgeons Executive Council. We extracted data from the Journal of the American Medical Association Graduate Medical Education yearly reports for information on surgical residents. We used the American Society of Colon and Rectal Surgeons website and publicly available practice websites to obtain information regarding colon and rectal surgery residents, faculty members, and the American Society of Colon and Rectal Surgeons Executive Council. We primarily focused on the gender and underrepresented minority breakdowns of general surgery residents, colorectal surgery residents, and the American Society of Colon and Rectal Surgeons Executive Council. We found that between 2001 and 2021, the number of women and people identifying as underrepresented minorities increased within general surgery programs. In addition, there has been a similar increase in underrepresented minorities and women entering colorectal surgery residency programs. Finally, there has been a steady, significant increase in women representation in the American Society of Colon and Rectal Surgeons Executive Council, with a slower increase in underrepresented minorities on the council. The study is limited by using previously collected data and relying on publicly available profiles for gender and race information. General and colon and rectal surgery have significantly increased gender and racial diversity at the training and leadership levels. ANTECEDENTES: A pesar de los cambios recientes en las mujeres y las minorías subrepresentadas en la medicina, todavía existen grandes brechas de género y raza en la capacitación y el liderazgo quirúrgico.OBJETIVO: Presumimos que la representación racial y de género ha mejorado entre los pasantes y el liderazgo en cirugía general y colorrectal en los últimos 20 años.DISEÑO: Este es un estudio transversal que examina la representación racial y de género de los residentes de cirugía general y colorrectal, miembros de la facultad colorrectal y el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto.CONFIGURACIÓN: Extrajimos datos de los informes anuales de Educación Médica para Graduados del Journal of the American Medical Association para obtener información sobre los residentes quirúrgicos. Utilizamos el sitio web de la Sociedad Estadounidense de Cirujanos de Colon y Recto, así como los sitios web de práctica disponibles públicamente para obtener información sobre los residentes de cirugía de colon y recto, miembros de la facultad y el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto.MEDIDAS PRINCIPALES DE RESULTADO: Nos enfocamos principalmente en los desgloses de género y minorías subrepresentadas de residentes de cirugía general, residentes de cirugía colorrectal y el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto.RESULTADOS: Encontramos que entre 2001 y 2021, la cantidad de mujeres y personas que se identificaron como minorías subrepresentadas aumentó dentro de los programas de cirugía general. Además, ha habido un aumento similar en minorías subrepresentadas y mujeres que ingresan a programas de residencia en cirugía colorrectal. Finalmente, ha habido un aumento constante y significativo en la representación de mujeres en el Consejo Ejecutivo de la Sociedad Estadounidense de Cirujanos de Colon y Recto con un aumento más lento en las minorías subrepresentadas en el consejo.LIMITACIONES: El estudio está limitado por el uso de datos recopilados previamente y por confiar en perfiles disponibles públicamente para la información de género y raza.CONCLUSIONES: La cirugía general y de colon y recto han hecho algunos avances significativos en el aumento de la diversidad racial y de género en los niveles de formación y liderazgo. (Traducción-Yesenia.Rojas-Khalil ).

Learning Curves in Establishing a New Minimally Invasive Pancreas Program.

Robotic pancreaticoduodenectomy (rPD) is a complex operation with a reported learning curve of 80 cases. Two recent graduates of a formal robotic complex general surgical oncology training program have been performing rPD at our institution since 2016, which had no previous institutional experience with rPD. To evaluate the learning curve associated with developing a new robotic pancreaticoduodenectomy (rPD) program by fellowship trained surgeons with institutional support. Sixty patients undergoing rPD from 2016 to 2022 were reviewed for and compared with proficiency benchmarks set by the University of Pittsburg experience. By 30 cases, operative time met the proficiency benchmark of 391minutes. Additionally, the entire cohort had comparable rates of clinically relevant postoperative pancreatic fistula (6.7% vs 3%, P = .6), 30-day mortality (0% vs 3%, P = .18), major complications (Clavien >2; 23% vs 17%, P = .14), and length of stay (6 vs 7days, P = .49) when compared to the benchmark. Perioperative outcomes were comparable to proficiency benchmarks from initiation of the new rPD program, and operative time reached proficiency benchmark by 30 cases. This data suggests that graduates of formal rPD training programs can safely establish new minimally invasive pancreas programs at sites with no previous institutional rPD experience.

ASO Visual Abstract: Assessing the Complex General Surgical Oncology Pipeline-Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees.

ASO Visual Abstract: Assessing the Complex General Surgical Oncology Pipeline-Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees.

Assessing the Complex General Surgical Oncology Pipeline: Trends in Race and Ethnicity Among US Medical Students, General Surgery Residents, and Complex General Surgical Oncology Trainees.

Cancer incidence is expected to increase in coming decades, disproportionately so among minoritized communities. Racially and ethnically concordant care is essential to addressing disparities in cancer outcomes within at-risk groups. Here, we assess trends in racial and ethnic representation of medical students (MS), general surgery (GS) residents, and complex general surgical oncology (CGSO) fellows. This is a retrospective review of data from the American Association of Medical Colleges and the Accreditation Council of Medical Education (ACGME) from 2015 to 2020. Self-reported race and ethnicity was obtained for MS, GS, and CGSO trainees. Race and ethnicity proportions were compared with respective representation in the 2020 US Census. Mann-Kendall, Wilcoxon rank sum, and linear regression were used to assess trends, as appropriate. A total of 316,448 MS applicants, 128,729 MS matriculants, 27,574 GS applicants, 46,927 active GS residents, 710 CGSO applicants, and 659 active CGSO fellows were included. With every progressive stage in training, there was a smaller proportion of URM active trainees than applicants. Further, URM, Hispanic/Latino, and Black/African American trainees were significantly underrepresented compared with 2020 Census data. While the proportion of White CGSO fellows increased over time (54.5-69.2%, p = 0.009), the proportion of Black/African American and Hispanic/Latino (URM) CGSO fellows did not significantly change over the study period, though URM representation was lower in 2020 as compared with 2015. From 2015 to 2020, minority representation decreased at every advancing stage in surgical oncology training. Efforts to address barriers for URM applicants to CGSO fellowships are needed.

Addressing Surgeon Burnout Through a Multi-level Approach: A National Call to Action.

Physician burnout is an epidemic and there are unique aspects of surgery that dictate rates of burnout among general surgeons and surgical trainees. This review characterizes the scope of burnout and its drivers within the field of surgery and advocates for strategies to address burnout at the individual, institutional, and national levels. Rates of burnout in surgery are increasing with higher numbers of young and female surgeons affected. Contributing factors are generally related to work-life balance, longer hours, and mistreatment in the workplace. Attempts have been made at implementing structured initiatives in an effort to combat work dissatisfaction and emotional exhaustion. Still, rates of burnout continue to increase. General surgeons and trainees are at high risk for burnout with resulting attrition, depression, and suicidal ideation. The solution to burnout must be addressed at individual, institutional, and national levels. Further research into the factors leading to surgeon burnout and enactment of effective strategies to mitigate burnout must be pursued.

ASO Author Reflections: Is the Future Ripe for Integrated Complex General Surgical Oncology Residency Training?

ASO Author Reflections: Is the Future Ripe for Integrated Complex General Surgical Oncology Residency Training?

HPB P62 Is it time to introduce intraoperative ultrasound into surgical training?

Abstract Background Gallstone disease is one of the most common causes of abdominal pain and emergency hospital admissions in the UK. Those patients that have symptomatic gallstones in the gallbladder will be offered a laparoscopic cholecystectomy (LC) as treatment and therefore reduce the risk of developing further complications. Confirmation of bile duct stones before or at the time of LC is essential in order to prevent complications. There are three main ways to identify bile duct stones intraoperatively: x-ray cholangiography, fluoroscopic cholangiography and intraoperative ultrasound (IOUS). X-ray cholangiography is the most commonly used method intraoperatively as it is effective in identifying biliary anatomy and bile duct stones, can be repeated and has good deep tissue penetration. However, it is an invasive procedure that requires the use of ionising radiation. IOUS on the other hand is non-invasive, does not involve ionising radiation, is able to detect vascular anatomy and arguably has a shorter learning curve compared to the other two methods. Methods IOUS is not currently taught on the surgical curriculum. In response to this, we have set up the Laparoscopic Hands-on Intra-operative Ultrasound (L-HOUS) course which takes place over a two-day period. The first day is delivered through interactive seminars and practice on phantom models. The topics covered are: the basic principles of the technique; the relevant anatomy; the role of IOUS in gallstone disease; and the role of IOUS in biliary surgery and various other non-HPB conditions. The afternoon is dedicated to demonstrating how to set up the equipment, the step-wise approach to IOUS of the biliary system, and hands-on practice using phantom models. The second day takes place in the operating theatre and offers delegates the opportunity to perform IOUS of the bile duct in real clinical cases. Delegates rotate around to practice their IOUS skills under the supervision of the operating surgeon, while un-scrubbed delegates are able to watch the surgery via a video link from the seminar room. Results The course has been run on four occasions and attracted 21 delegates since its inception in 2017. The vast majority of delegates have been senior general surgical trainees or post-CCT fellows, in addition to one consultant. The feedback received was overwhelmingly positive and the course has evolved at each iteration to reflect the comments from delegates. Conclusions This is the only course in Europe that offers delegates hands-on experience in developing IOUS skills under specialist guidance. Crucially, hands-on experience has been shown to have better outcomes in relation to ultrasound training when compared to simulation or classroom-based methods. This concept fits in unity with Edgar Dale's pyramid of learning whereby students are more likely to retain information that they have practiced ‘doing’ compared to other visual or auditory methods of teaching. Given the benefits of IOUS in terms of cost, and reduction in additional procedures or investigations, we argue that the technique should be included in the surgical training curriculum. One of the main reasons for poor uptake of a one-stage approach to bile duct stones using IOUS is lack of formal training. Given there will likely be an increase in the adoption of the IOUS technique in coming years, it is vital to equip current trainees with the necessary skills within their training pathway. However, prior to this it is imperative that trainees have access to high-fidelity training opportunities to develop skills that will be used routinely in future practice.

Sustainable Targeted Intervention Models for Stepwise Capacity Development in Surgical Service Delivery in Low- and Middle-Income Countries: A Systematic Map of the Literature

INTRODUCTION: A variety of surgical, obstetric, and anesthetic (SOA) training intervention models have been implemented over the last 10 years to increase SOA service delivery in low- and middle-income countries (LMICs). This systematic map describes the literature on existing models to inform future intervention and evaluation design. METHODS: A comprehensive systematic map methodology was applied to identify studies published after 2010 describing scale-up of SOA in LMICs. Data were extracted and analyzed to assess the type, scale, scope, and impact of various models of surgical skill and capacity development, including tools used for evaluation. RESULTS: A total of 52 studies were identified for extraction; 37 (71%) described training models implemented in Africa. Only 5 used an experimental design with control. The models primarily focused on general surgical skills training (n = 11) and obstetrics and perinatal care (n = 11). Training components included a combination of didactics (45 of 52, 87%), simulation (21 of 52, 40%) and on-the-job instruction (33 of 52, 63%), with limited formal mentorship (8 of 52, 15%; Figure). Outcomes were evaluated on trainee, patient, and organizational levels. Only 2 studies report patient satisfaction scores.FigureCONCLUSION: A wide variety of capacity development interventions and evaluation methodologies are reported, but few describe their work in sufficient detail to allow reproducibility. Furthermore, few study methodologies support causal links between the intervention and recorded impact. Patients are infrequently included in study design and evaluation. This systematic map highlights the need for improved reporting and evaluation design that might inform continued efforts addressing the urgent need for patient-centered surgical care capacity building in LMICs.

The Sinatra Doctrine: bespoke approaches to academic research in surgery

Introduction Academic scholarly credentials are now obtained in two broad ways: out of programme research (OOPR) experience via bespoke funding (BF) or a higher degree (HD) funded by run-through fellowships (academic clinical fellow/lecturer in England or Wales Clinical Academic Track [WCAT]). The aim of this study was to determine the relative academic credentials achieved related to HD route, surgical specialty and topic. Methods Fifty-four postgraduate trainees engaged in HD study were followed and the primary outcome measures were HD completion, publication number and Hirsch index (HI). Results There were 38 BF trainees and 16 WCAT trainees. General surgical trainees were more likely to choose postgraduate research (n = 37, 68.5%) than other specialties (n = 17, 31.5%). Similarly, trainees in general surgery were more likely to choose the BF route than the WCAT pathway (94.6% vs 12.5%, (p &lt; 0.001), with ethnic minorities also more likely to choose WCAT (56.3% vs 18.4%, p = 0.005). HD completion rates were 82.1% in the BF cohort and 88.9% in the WCAT group (p = 0.409). The median number of publications was 17 versus 18 respectively (p = 0.894) and the median HI was 7 in both groups (p = 0.690). OOPR experience during phase 1 of surgical training was associated with a higher HI (11 vs 0, p = 0.011). Degree type (MD vs PhD) was not associated with HD completion (80.0% vs 91.7%, p = 0.374), publication number (15 vs 19, p = 0.958) or HI (7 vs 5, p = 0.107). Conclusions HD routes appear equivalent although specialty related HI outcomes varied over fourfold. Trainees and training programme directors alike should be aware of these outcomes when planning OOPR training. Surgical training is multifaceted and should result in a competent clinician, able scholar, first class communicator, health advocate and well rounded professional. 1 Surgical research has served as the foundation for evidence-based clinical practice as long ago as Galen. 2 Nevertheless, in the UK and since the inception of Modernising Medical Careers, out of programme research (OOPR) experience has lost its allure. 3 , 4 Indeed, other distinguishing credentials are available, such as subspecialty clinical attachments, and qualifications in management, education and leadership.

YouTube as a source of information and education on endometriosis

Many patients seek information online, including on social media, regarding various health topics. This study aimed to investigate whether YouTube videos on endometriosis could be a useful source for the general population, surgical trainees, and specialists. A YouTube search was conducted on December 26, 2021, using the search terms “endometriosis,” “endometrioma,” and “endometriotic cyst.” Videos were sorted by view count, and the 100 videos with the highest view counts were chosen. After excluding 48 videos for various reasons, 52 were included in the final analysis. The number of views, duration, likes and dislikes, content type, and source of each video were recorded. We referred to a previous study to evaluate video quality. The 52 videos related to endometriosis had a total of 35,220,141 views (median 233,688, range 48,874–10,452,366). Based on authorship, the videos were categorized into videos uploaded by the medical group and the nonmedical group. The medical group mainly uploaded videos directly related to endometriosis, such as explanations or detailed surgical procedures for endometriosis (26/27, 96%), whereas the nonmedical group mainly uploaded videos about personal experiences and others (24/25, 96%; P <.001). Evaluating the score by each type of content, videos containing personal experiences (median score 6, range 3–10) scored significantly lower than videos containing other content such as explanations of the disease (median score 14, range 7–18; P < .001) and surgical procedures (median score 9, range 5–17; P < .001). Analysis according to the source, the number of views and video power index was significantly higher in the videos uploaded by the nonmedical group (P < .05). YouTube is currently not an appropriate source for patients to gain information on endometriosis. Credible videos with accurate information and clear, high-quality operative clips with proper scientific commentary should be uploaded by medical professionals and medical institutions to critically and rapidly appraise the quality of online video-disseminated information on endometriosis. In addition, advanced filtering using categories by YouTube’s staff appears to be necessary.

29 The Surgical Trainee Personality: Selected or Shaped?

Abstract Aim This study aims to describe the personality differences between trainees at different stages prior to and during surgical training. Method The Mental Muscle Diagram Indicator was distributed electronically to doctors in training in South West London. A total of 553 trainees completed the personality questionnaire. Specifically, there were general surgery specialty (n = 53), core surgical (n = 254), and foundation trainees (n = 246). 52% of trainees were female. Results Women scored significantly higher in the Extraversion, Sensing and Judging personality domains (p &amp;lt; 0.0001), there were no significant differences between genders for ‘Thinking’. One-way ANOVA only showed a significant difference in the ‘Judging’ domain between grades. Tukey's test was performed showing the difference arose from FT to CST (p = 0.008). Two-way ANOVA showed an interaction between gender and grade for ‘Judging’ and as such simple main effects were performed, with alpha = 0.017 to control for type 1 errors. Significant differences were found in the Judging domain between genders during in FT (p=0.002) and CST (p=0.002), and there was no significant difference for SpRs (p=0.15). Conclusions This study demonstrated differences in personality types between trainee stages and gender. These differences appear to decrease as trainees progress through their training, although the cause of this is unclear.