Surgical Skills Research Articles

Advancements in surgical skills through short-term training with surgical 3D exoscopes.

Advancements in surgical skills through short-term training with surgical 3D exoscopes.

How to Play a Game Properly – Enhancing Obstetrics and Gynecology Education through Gamification: A Scoping Review

AbstractEffective healthcare relies on well-trained professionals, and the quality of their training is dependent on appropriate learning methods and assessment techniques. Gamification, the use of game mechanics in non-game environments, has emerged as a promising strategy in medical education. This review explores the applicability and effectiveness of gamification in obstetrics and gynecology education.Adhering to PRISMA guidelines, a comprehensive search was conducted on PubMed, Google Scholar, Embase, and Medline databases from January to March 2023. The search terms included “medical students OR residents OR physicians OR midwives AND games OR educational games OR serious games AND gynecology OR obstetrics”. The inclusion criteria encompassed studies published in English or German from 1990 to March 2023, focusing on gamification in gynecology and obstetrics education. Data extraction and analysis were structured using the PICOS framework.The review identified various studies demonstrating the effectiveness of gamification in obstetrics and gynecology education. Gaming shows like Jeopardy significantly boosted knowledge retention and engagement. VR technologies, such as Second Life, enhanced emergency and surgical training. Improvisational games improved empathy skills, though requiring reinforcement. Video games and laparoscopy trainers showed promise in enhancing surgical skills, with gamers performing better in initial tasks. Custom-developed games like Play and Learn for Surgeons significantly improved procedural skills.Gamification in obstetrics and gynecology education boosts learner engagement, knowledge retention, and practical skills. VR technologies and video games are effective for surgical training, while custom games can enhance specific procedural skills. Further research is needed to optimize and integrate gamification strategies into standard curricula, offering a modern approach to equip healthcare professionals with essential skills and knowledge.

Eye-Style Model Using Intelligent Virtual Reality Technology to Promote Surgical Skill Accuracy

Eye-Style Model Using Intelligent Virtual Reality Technology to Promote Surgical Skill Accuracy

Zahra TAATI ASIL The first Iranian Woman Neurosurgeon

It is crucial to promote the role of women in surgery, particularly in the field of neurosurgery, which is still predominantly male-dominated. Without recognition and support, these talented and pioneering women may continue to be overlooked, despite their significant contributions to the field. One such remarkable woman is Professor Zahra Taati Asil, the first female Iranian neurosurgeon. Born in 1954 in Iran, she graduated from medical school in Tehran in 1978 with a degree in General Medicine. After completing her studies at the Medical School of the Melli University in 1983, she became the first female Iranian neurosurgeon and was promoted to assistant professor. She held this position for 14 years and during this time, she operated on numerous war-wounded patients during the Iran-Iraq war. Her exceptional surgical skills earned her the nickname “The Golden Hands Surgeon” at Nirou-y-Entezami Hospital, where she had an impressively low rate of postoperative complications. Despite her professional competence, she was never promoted to associate professor, due to reasons beyond her surgical and academic skills. The dean of the university opposed Zahra’s appointment as an associate professor and told her that if she were to be appointed as a professor, the Ministry of Health would separate men and women. He also warned her that the Islamists would only send women to her. She has retired but remains actively involved in both clinical and academic work.

Impact of Live Tissue Training on Provider Confidence for Operative Trauma Management.

Readiness of military health care providers is essential to maintain a prepared fighting force and remains a central issue for today's military. Maintaining skills regarding operative management of trauma is becoming more difficult if not located at an urban trauma center. Live tissue training may be used to practice skills in a facility that does not have exposure to high acuity trauma. The goal of our live tissue skills course is to train health care providers and ancillary staff in the management of various injury complexes and improve confidence and familiarity with management using a porcine model. A live tissue skills course using a porcine model was offered to surgical residents, attendings, and operating room technicians. Before completing the course, each participant completed a survey assessing comfort level, previous training experiences, and deployments. Operative management was simulated with a standardized sequence of abdominal and thoracic injuries. After the course, each participant then completed a survey assessing comfort level, benefit of the course, and comparison to inanimate simulation training. Survey information was obtained via participant completion of a multiple-choice confidential questionnaire. Responses were collected from 34 participants at our institution. Average abdominal trauma comfort increased from 2.79 to 3.73, with no participants reporting feeling not comfortable at all post-lab. Average thoracic trauma comfort increased from 2.47 to 3.48, with one participant reporting feeling not comfortable at all post-lab. Overall, 85% of participants reported the course to be very beneficial in improving their knowledge, 83% reported the course to be very beneficial compared to inanimate simulators, and 92% reported high fidelity of the live tissue training course. Perceived as highly beneficial, live tissue training increased comfort with operative trauma management by surgical residents, attendings, and technicians supporting continued utilization. Further evaluation of live tissue courses would be advantageous in assessing surgical skill improvement, including comparison with simulation training.

Surgical skill analysis focused on tissue traction in laparoscopic wet lab training

BackgroundTissue handling is one of the pivotal parts of surgical procedures. We aimed to elucidate the characteristics of experts' left-hand during laparoscopic tissue dissection. MethodsParticipants performed tissue dissection around the porcine aorta. The grasping force/point of the grasping forceps were measured using custom-made sensor forceps, and the forceps location was also recorded by motion capture system (Mocap). According to the global operative assessment of laparoscopic skills (GOALS), two experts scored the recorded movies, and based on the mean scores, participants were divided into three groups: novice (<10), intermediate (10≤ to <20), and expert (≤20). Force-based metrics were compared among the three groups using the Kruskal-Wallis test. Principal component analysis (PCA) using significant metrics was also performed. ResultsA total of 42 trainings were successfully recorded. The statistical test revealed that novices frequently regrasped a tissue (median total number of grasps, novices: 268.0 times, intermediates: 89.5, experts: 52.0, p < 0.0001), the traction angle became stable against the aorta (median weighted standard deviation of traction angle, novices: 30.74°, intermediates: 26.80, experts: 23.75, p = 0.0285), and the grasping point moved away from the aorta according to skill competency [median percentage of grasping force applied in close zone (0 to 2.0 cm from aorta), novices: 34.96 %, intermediates: 21.61 %, experts: 10.91 %, p = 0.0032]. PCA showed that the efficiency-related (total number of grasps) and effective tissue traction-related (weighted average grasping position in Y-axis and distribution of grasping area) metrics mainly contributed to the skill difference (proportion of variance of first principal component: 60.83 %). ConclusionThe present results revealed experts' left-hand characteristics, including correct tissue grasping, sufficient tissue traction from the aorta, and stable traction angle. Our next challenge is the provision of immediate and visual feedback onsite after the present wet-lab training, and shortening the learning curve of trainees.

Designing, Implementing, and Evaluating a Basic Surgical Skills Bootcamp: An Effective Approach to Enhance Competency in Surgical Residency Training

IntroductionRecent technological advances have facilitated the development of new educational methods, such as simulation-based learning, in specialized bootcamps to enhance the learning of surgical residents. This study aimed to design, implement, and evaluate a basic surgical skills bootcamp for residents in general surgery, orthopedics, neurosurgery, and gynecology based on the learning gap in the current educational program. MethodsThis intervention study focused on the design, implementation, and evaluation of a basic surgical skills bootcamp in a simulated operating room for first-year surgical residents in general surgery, orthopedics, neurosurgery, and gynecology. ResultsThe study resulted in the creation of a comprehensive course plan and the execution of a 6-day training program. Evaluation of educational outcomes confirmed high learner satisfaction, improvement in Multiple Choice Questions (MCQ) exam scores, and acceptable scores in the Objective Structured Clinical Examination (OSCE). ConclusionThe findings of this study suggest that surgical bootcamps, when designed based on needs assessment and in line with scientific bootcamp design principles, play a crucial role in enhancing the satisfaction, knowledge, and skills of surgical residents.

CWT-ViT: A time–frequency representation and vision transformer-based framework for automated robotic surgical skill assessment

Surgical skill assessment currently hinges on the manual observations of senior surgeons, and the assessment process is inherently time-consuming and subjective. Hence, there is a need to develop machine learning-based automated robotic surgical skill assessment. However, the existing machine learning-based works are only built in either the time domain or frequency domain but have never considered the investigation on the time–frequency domain. To fill the research gap, we explore the representation of the surgery motion data in the time–frequency domain. In this study, we propose a novel automated robotic surgical skill assessment framework called Continuous Wavelet Transform-Vision Transformer (CWT-ViT). We apply continuous wavelet transform, i.e., a time–frequency representation method, to convert robotic surgery kinematic data to synthesis images. Furthermore, by taking advantage of the prior knowledge of the da Vinci surgical system, we design a four branches-based architecture, each branch representing a robotic manipulator. We have conducted extensive experiments and achieved comparable results on the benchmark robotic surgical skill dataset JHU-ISI Gesture and Skill Assessment Working Set (JIGSAWS). Our proposed CWT-ViT framework has demonstrated the feasibility of applying time–frequency representation for automated robotic surgical skill assessment using kinematic data. The code is available at https://github.com/yiming95/CWT-ViT-Surgery.

THE EVALUATION OF TOTAL HIP ARTHROPLASTY IN THE MANAGEMENT OF SPASTIC PAINFUL HIP DISLOCATION IN CEREBRAL PALSY

Spasticity used to be considered a contraindication for total hip replacement (THR) procedures. Due to the development of implants as well as surgical skills, THR became an option for the treatment of painful dislocation of the hip joint in patients with spastic plegia. The aim of this study was an evaluation of mid-term results of THR in spastic CP adolescent patients with painful hips with hip joint subluxation or dislocation.In 2014–2022, 18 pts (19 hips) with CP aged 16 to 20 years underwent THR in our department. The mean follow-up was 4 years (range: 1 – 9 years). Results were evaluated using the Gross Motor Function Scale, VAS scale in accordance with the Ashworth scale, types of implants used (dual mobility cup and not dual mobility cup), and radiological assessment (Crowe scale). Complications have been thoroughly analyzed.In 10 pts there has been an improvement in the GMFSC scale average from 1 to 2 points observed after the surgery. All pts have improved in the VAS scale average of 8 points (from 10 to 7). According to the Crowe scale repositioning of preoperative dislocation to primary acetabulum was achieved in all cases. Complications occurred in 4 cases: dislocations of 2 THR with dual mobility cup and 2 THR with non-dual mobility cup requiring revision surgery with good final result. No statistical significance was noted according to the type of cup (Mann-Whitney U Test).The most important risk factor for complications is severe spasticity. We believe, that CP pts with painful hips should be treated using THR. We didn't observe any significant differences between the types of implants.These findings may serve as a basis for the prediction of outcomes of THR treatment in this specific group of pts.Level of evidence: Case-control or retrospective comparative study-Level III

Artificial intelligence facilitates the potential of simulator training: An innovative laparoscopic surgical skill validation system using artificial intelligence technology.

The development of innovative solutions, such as simulator training and artificial intelligence (AI)-powered tutoring systems, has significantly changed surgical trainees' environments to receive the intraoperative instruction necessary for skill acquisition. In this study, we developed a new objective assessment system using AI for forceps manipulation in a surgical training simulator. Laparoscopic exercises were recorded using an iPad®, which provided top and side views. Top-view movies were used for AI learning of forceps trajectory. Side-view movies were used as supplementary information to assess the situation. We used an AI-based posture estimation method, DeepLabCut (DLC), to recognize and positionally measure the forceps in the operating field. Tracking accuracy was quantitatively evaluated by calculating the pixel differences between the annotation points and the points predicted by the AI model. Tracking stability at specified key points was verified to assess the AI model. We selected a random sample to evaluate tracking accuracy quantitatively. This sample comprised 5% of the frames not used for AI training from the complete set of video frames. We compared the AI detection positions and correct positions and found an average pixel discrepancy of 9.2. The qualitative evaluation of the tracking stability was good at the forceps hinge; however, forceps tip tracking was unstable during rotation. The AI-based forceps tracking system can visualize and evaluate laparoscopic surgical skills. Improvements in the proposed system and AI self-learning are expected to enable it to distinguish the techniques of expert and novice surgeons accurately. This system is a useful tool for surgeon training and assessment.

Surgical Skill Decay as a Result of the COVID-19 Pandemic.

This study aimed to objectively evaluate the impact of the gap in surgical practice caused by COVID-19 on surgical skill decay. This retrospective cohort study enrolled 148 cases of adult patients who were qualified for elective or urgent laparoscopic cholecystectomy. This study compared the period of nine months before the pandemic outbreak and nine months after the end of the pandemic. We analyzed the duration of surgery, the number of intraoperative adverse events (IAEs), postoperative complications (PCs), and differences between the surgeries performed by residents and those performed by specialists. The number of IAEs did not differ significantly between groups (after COVID-19 (AC) and before COVID-19 (BC)). A difficult gallbladder (DGB) was associated with an increased risk of IAEs during surgery in both groups (BC:OR = 2.94, p = 0.049; AC:OR = 2.81, p = 0.35). The multivariate analyses showed no significant differences in IAEs or PCs when the residents performed surgeries compared to specialists. The average duration of surgery was significantly longer in the post-pandemic group (BC-102.4 min vs. AC-119.9 min, p = 0.024). Measurable determinants of surgical skills are the duration of surgery and the number of intraoperative adverse events. By defining this indicators, our study objectively shows that the reduction in the volume of surgeries during COVID-19 resulted in a phenomenon known as surgical skill decay.

Teaching With the GlobalSurgBox: Trainer Perceptions of a Portable Surgical Simulator

Evaluate the utility of a low cost, portable surgical simulator (GlobalSurgBox) for surgical teaching and its ability to dismantle barriers faced by trainers when attempting to use surgical simulation. An anonymous survey was administered to surgical trainers who were involved in leading simulation events using the GlobalSurgBox in the past 2 years. The survey was designed to understand current barriers to using simulation as a trainer, and the utility of the GlobalSurgBox in overcoming these barriers. Academic medical training centers or conferences in the United States, Rwanda and Kenya. 10 practicing surgeons, 3 practicing physicians, 11 surgical residents, 15 medical students and 1 anesthesia resident. The top 3 barriers for effective teaching were lack of convenient access to the simulator (50%), lack of trainer time (43%) and cost (28%). After using the GlobalSurgBox, 100% and 98% of respondents felt that it encourages more practice and offers significant advantages over current simulators in their program. About 90%, 88% and 70% of respondents believed that the GlobalSurgBox makes surgical simulation more convenient, affordable, and compatible with trainer time limitations, respectively. 83% of trainers agreed that it is a good replica of the operating room experience, and 85% practicing physicians were more likely to give autonomy to trainees after demonstrating competence on the GlobalSurgBox. The GlobalSurgBox mitigates several barriers surgical educators experience when practicing surgical skills with trainees. The convenience of the GlobalSurgBox can help facilitate the development of foundational surgical skills outside of the operating room.

"Evaluating surgical approaches for Rathke's cleft cysts and sellar meningiomas: factors influencing treatment of choice".

This study reviews recent progress in the surgical treatment of Rathke's cleft cysts (RCCs) and Sellar region meningiomas, based on findings from three key studies. RCCs are benign, fluid-filled remnants from pituitary gland development that are usually asymptomatic and found by chance. However, surgical intervention is needed when they become symptomatic or increase in size. Research by Stefan Linsler et al. and others examines various surgical methods, including transcranial keyhole and transsphenoidal techniques for RCCs, and endoscopic endonasal and supraorbital keyhole approaches for Sellar meningiomas. The results show that both transcranial keyhole and transsphenoidal surgeries for RCCs have high success rates with no recurrences over 5.7 years, although the keyhole approach has fewer complications. For Sellar meningiomas, the choice between endoscopic endonasal and supraorbital keyhole techniques should be based on tumor characteristics, highlighting the importance of surgeon proficiency in both methods. These studies emphasize the need for personalized treatment strategies tailored to patient and tumor characteristics and highlight the importance of ongoing surgical skill development and further research to refine minimally invasive techniques. This study highlights the crucial role of personalized surgical approaches in improving outcomes for patients with RCCs and Sellar region meningiomas.

Low-cost do-it-yourself (DIY) kit for glaucoma procedures.

Surgical skill training in ophthalmology is pivotal for ensuring optimal and safe patient outcomes. Access to traditional training resources such as cadaveric or animal eyes, as well as modern alternatives such as silicone eyeballs and simulators, remains limited, especially in resource-constrained settings. We present a series of innovative and low-cost do-it-yourself (DIY) models for glaucoma training using readily available hospital waste materials. These models allow ophthalmic assistants, fellows, and junior consultants to practice various procedures before transitioning to live patients, thereby enhancing surgical proficiency and minimizing the financial burden on both trainees and training institutions. We were able to practice procedures such as tonometry, central corneal thickness measurement, laser suture lysis, laser iridotomy, anterior chamber decompression, bleb needling, trabeculectomy flap construction, and suturing. By providing a practical and easy training solution, these models have the potential to boost confidence among glaucoma trainees and thus address the growing demand for skilled glaucoma surgeons.

Fostering young talents for surgery : Laparoscopy in preclinical education-Too early or exactly right?

Due to the declining interest among medical students in pursuing asurgical career, the impact of demographic changes and the technical challenges, there is an increasing need to attract medical students to the surgical profession. Against this backdrop, ateaching project was developed to familiarize medical students with minimally invasive surgical techniques early in the preclinical education, thereby increasing the interest in surgery. Within the framework of the regular anatomical dissection course the following modules on laparoscopic surgery were integrated: (1)clinical lecture on the technique and application of laparoscopy, (2)exploratory live laparoscopy on abody donor and (3)practical exercises on laparoscopic trainers. The impact of this teaching project on the interest in asurgical career and on the clinical anatomical understanding was evaluated among 295 participating medical students. The evaluation revealed apronounced gender-independent interest in learning surgical skills early in the preclinical study phase. The teaching project led to asignificantly increased interest in pursuing asurgical career. Moreover, the incorporation of laparoscopic teaching modules into the preclinical anatomy course enhanced the learning motivation and understanding of clinically relevant topographic anatomy. The integration of practical surgical content into preclinical anatomical education can increase the attractiveness of surgical disciplines and simultaneously optimize teaching of anatomy. Longitudinal studies are required to examine the sustainability of these clinical teaching modules in career decisions of medical students.

Defining minimum work priorities in emergency general surgery in a national cohort

IntroductionEmergency general surgery is typically delivered in addition to routine elective care. Models such as acute surgical assessment units and reduced elective working have been explored to reduce the conflict between these competing demands. We aim to identify the models used, the cohorts of patients seen, and the staffing levels in each system. MethodsData on general surgery activities were obtained from the National Quality Assurance and Improvement System (NQAIS) and previously published data. The mode of delivery of acute services in other countries was collated from national surgical bodies and published position statements. ResultsNational on-call services are supra-elective or parallel to elective streams with little dedicated on-call. Internationally, many similar countries are moving to separate acute and elective care to ensure both are performing optimally. Staff in Model 3 hospitals are frequently on call with variable but small operative numbers but represent a combination of high and low acuity. These consultants need a wider breadth of surgical skills than Model 4 hospitals due to a lack of local specialists. ConclusionThe majority of national hospitals still work a traditional on-call model, with limited adoption of separate on-call and elective workstreams. Preserving the elective workload is likely to require separation of these priorities, which is difficult with current staffing levels. The use of Acute Surgical Assessment Units (ASAUs) within emergency surgical networks may improve patient outcomes by regionalising the delivery of higher acuity care.

Surgical Aortic Valve Replacement Using a Porcine Model: A Low-Cost Simulation for Surgical Trainees.

Simulation experiences are valuable to the training of future successful surgeons. These experiences introduce trainees to operational concepts through hands-on engagement within a low-stress environment to promote skill, information retention, and increased competency for future success in real-life scenarios. The study aimed to develop a low-cost, reproducible surgical simulation for teaching aortic valve replacement using porcine models. This study employed a single-center educational workshop design to provide trainees with a comprehensive wet laboratory experience in surgical aortic valve replacement using a porcine model. The simulation involved step-by-step procedures using porcine hearts in a wet lab environment, emphasizing specific surgical techniques such as suturing, knot tying, and valve replacement. Simulated valves were created using insulation foaming and aluminum wiring. The study was conducted at a southeastern medical school's wet lab. Thirty-eight preclinical medical students participated. The simulation was designed to provide a comprehensive overview of the steps involved in aortic valve replacement using porcine models. It emphasized the importance of teamwork, fundamental surgical skills, and effective communication within a surgical setting. The low-cost surgical simulation allowed trainees to learn technical skills that could be tailored to their proficiency level. Simulation for cardiothoracic procedures is limited by monetary spending and the availability of adequate materials to create a beneficial learning experience. This low-cost simulation allows resource-limited institutions to provide their students an additional opportunity to practice fundamental surgical principles such as suturing.

Virtually Augmented Surgical Navigation in Endoscopic Sinus Surgery Simulation Training: A Prospective Trial of Repeated Measures.

The objective of this study was to explore the educational utility of virtually augmented surgical navigation (VASN) in simulation training for endoscopic sinus surgery. Prospective trial using within-subjects design. Single academic institution. Otolaryngology trainees (n = 15) were enrolled in a prospective trial of repeated measures. Participants performed unilateral functional endoscopic sinus surgery (FESS) on a 3-dimensional-printed sinus model without instruction. Participants then underwent educational intervention incorporating VASNtools-featuring anatomic overlay delineations, virtual planning points, proximity alerts, digital measurements, as well as artificial intelligence-generated endoscopic viewpoints. With the VASN tools activated, participants then performed FESS on the contralateral side of the model. Primary outcomes of interest included number of major complications, time to complete anterior fess, steps completed, and technical skills score. Descriptive statistics were performed to describe participant characteristics and bivariate analysis were used to evaluate differences in subjective and objective outcome measures. A majority (93%) of residents strongly agreed that simulation intervention improved their confidence in surgical skills related to FESS. Complications decreased from 13 instances to 3 following interventions. Initial technical skills score of 45.2 increased to 54.4 postintervention (P < .0001) and global score also improved by 4.6 points on average (P < .001). Time to anterior FESS decreased from 1356 to 915seconds (P = .006) and average number of completed surgical steps increased from 3.3 to 4.6 (P < .001). This simulation study contributes to growing evidence supporting utility of advanced technology in surgical education. Results suggest that VASN serves as a beneficial adjunct in FESS simulation training.

Efficacy evaluation of a high-precision simulator of posterior pharyngeal flap pharyngoplasty

BackgroundIn order to improve medical students' preclinical skills and enable them to quickly comprehend the procedure of posterior pharyngeal flap surgery, our teaching team developed a surgical simulator specifically for pharyngeal flap surgery. MethodsThirteen undergraduate students and eight first-year residents trained from March to May 2023, participated in simulated surgical training. Initially, multimedia was used to explain and demonstrate relevant anatomy, surgical principles, and procedural steps to them. This was followed by independent simulated surgeries by the students, culminating in the completion of a questionnaire. Independent samples t-test was used for statistical analysis. Results: Before the simulated surgery, the residents had a greater understanding of the surgical design compared to the undergraduate students. After the simulated surgery, the residents showed not only significantly higher levels of understanding of the surgical design, but also increased familiarity with the surgical process, and enhanced confidence in independent surgery compared to the undergraduate students. Both groups showed a notable increase in familiarity with the surgical process and confidence in independent surgery after the simulated surgery. ConclusionThe surgical simulator demonstrates high clinical fidelity and provides tactile feedback that closely resembles reality. It significantly enhances the understanding and mastery of surgical techniques for young doctors, ultimately improving their surgical skills.

Surgical training; destination unknown?

Background A surgical fellowship allows both additional training as well as maintenance of surgical skills while searching for a steady job. As the presence of fellows usually does not results in a measurably higher productivity, fellowshipsmay be considered a form of disguised unemployment. The aim of this study is to evaluate the career flow of a surgical trainee to a staff position and to determine the number of surgeons working on temporary basis within the general surgery workforce in Flanders. Methods All surgeons graduated in Flanders between 2000 and 2022 were invited to fill out a web-based survey concerning their current and past employment. Reminders were sent out after 2 and 4 weeks. Statistical analysis was performed with SPSS version 27.0 (IBM Inc., Chicago, IL, USA.) Results Response rate was 64% (292/457) with 76% of respondents currently working as surgeons, 14% (38) as fellows and 10% working outside the surgical domain. Eighty-two percent of current fellows graduated in 2019 or later. Thirty-one percent of surgeons graduated in 2019 are still working as fellows. For surgeons graduated in 2020, 2021 and 2022 this is 45%, 80% and 90% respectively. Compared to staff surgeons the number of additional training years (2,8 ± 1,0 vs 2,2 ± 1,3; p = 0,009). and the number of applications (6,6 ± 5 vs 3,3 ± 3; p < 0,001) is significantly higher for current fellows Conclusion This study shows that disguised unemployment is present in the general surgical community in Flanders. The status of “fellow” should be incorporated in calculations concerning future needs of the surgical workforce in order to prevent open unemployment.