Training Competencies Research Articles

BN SO37 - Upper GI surgical training in the UK: Are there enough training opportunities? 10-year trends in Benign Upper GI index procedures and the impact of COVID-19

Abstract Background Surgical training was adversely impacted during the COVID pandemic, with reports of reduced logbook numbers and challenges in meeting training competencies. Despite a national elective care recovery plan, and interventions aimed at maintaining training opportunities, waiting list expansion has continued and has particularly impacted benign procedures. Upper GI trainees are all required to achieve “Level 4” (independent) competence in Cholecystectomy and Antireflux surgery, however there are anecdotally. fewer opportunities in the post-COVID era to train in these procedures. This study aimed to evaluate trends in these index procedures and to compare the pre- and post- COVID eras. Method The annual Admitted Patient Care (APC) publications draw on Hospital Episode Statistics and summarise activity for each financial year by OPCS4 codes. Codes pertaining to cholecystectomy and antireflux surgery (the “Benign Upper GI” competences on the Joint Committee of Surgical Training New Curriculum Checklist) were screened for inclusion. Data were extracted from APC publications between 2013 and 2023. These data were summarised in a Microsoft Excel Spreadsheet, categorised by index procedure and divided into pre-covid (2013-2019) and post-covid (2019-2023). Trends were evaluated using a Mann-Kendal Non-Seasonal Trend Test. Comparisons were undertaken using a two tailed unpaired t-test. Results Between 2013 and 2023 there was a statistically significant negative annual trend in the number of cholecystectomies from 75934 to 68182 (p=0.02), with a minimum of 47803 in the 2020-2021 financial year and a non-significant positive trend in the subsequent years. There were significantly fewer cholecystectomies in the 4 years following COVID (mean 77357 vs 63882, p=0.015). Antireflux procedures also underwent a significant negative trend from 5467 to 4745 (p=0.02), with a minimum of 2565 in the 2020-2021 financial year and a non-significant positive trend in subsequent years. Mean post-COVID antireflux procedures were also significantly lower (5548 vs 4256, p=0.03). Conclusion The procedures required for training in Benign Upper GI surgery in the UK are occurring with lower frequency than before the COVID pandemic. Whilst this may reflect ongoing operational pressures, or changes in clinical practice, this evidence suggests that training opportunities are now less frequent. This highlights the importance of focussed training and an awareness of training needs amongst both trainees and their mentors.

Synergy Analysis of Pedagogical Competence and Managerial Competence in Fish Preservation Industry Management Training in Maluku Province

This study aims to obtain and analyze data regarding: 1) The effect of pedagogical competence on learning outcomes of fish preservation industry management training in Maluku Province. 2) The effect of managerial competence on learning outcomes of fish preservation industry management training in Maluku Province. 3) The effect of a synergy of pedagogical competence and managerial competence in the process of industrial management training for fish preservation in Maluku Province. With a population of 40 people and a sample of 15 employees. The instrument used to collect data in this study is a questionnaire. This study uses multiple regression analysis. The data were then subjected to descriptive analysis, classical assumption testing, and hypothesis testing. The results showed that: 1) There is an influence of pedagogical competence on learning outcomes of fish preservation industry management training in Maluku Province, meaning H1 is accepted. 2) There is an influence of managerial competence on learning outcomes of fish preservation industry management training in Maluku Province, meaning H2 is accepted. 3) There is an influence of the synergy of pedagogical competence and managerial competence in the process of fish preservation industry management training in Maluku Province, meaning H3 is accepted. Keywords: pedagogical competence, managerial competence, training. Keywords: pedagogical competence, managerial competence, training

Factors influencing the development of STEM competencies in vocational training: an analytical review of international studies

Factors influencing the development of STEM competencies in vocational training: an analytical review of international studies

Penyediaan Pendidik dan Tenaga Kependidikan dalam Pendidikan Islam

Islamic education aims to develop individual potential as a whole, including spiritual, intellectual, emotional and physical aspects, in accordance with Islamic values ​​and principles. Therefore, qualified educators and educational staff are needed. This qualitative research uses a library research method, namely a research method carried out by observing various literature related to the problems in the research, in the form of papers, books or writings, both from print and online media. The results of this research are that the quality of educators and educational staff in Islamic educational institutions is currently still a complex and challenging issue. Even though there are efforts to improve quality standards, there are still various challenges that need to be overcome, such as lack of qualifications and competence of educators, low welfare, minimal training and professional development, and inadequate policy support. To overcome this challenge, collaboration is needed between the government, educational institutions and communities to implement structured training and development programs and improve the welfare of educators.

Assessment of the efficiency of functioning of the environmental management system of enterprises

Purpose. A multifactor model is developed to assess the efficiency level of an enterprise’s environmental management system, depending on the effectiveness of organizational environmental measures. Methodology. The authors’ method for determining a comprehensive criterion for monitoring the effectiveness of the environmental management system, which characterizes the efficiency of operation and determines the level of environmental safety of enterprises, is proposed and used. To solve the tasks, a complex research method was also used, which included the analysis and generalization of literary and patent sources, and analytical, experimental research using computer and mathematical modeling methods. Findings. According to the studies and calculations of the generalized environmental quality indicator – 0.64, 0.66 and 0.66, the largest negative impact on the environment is caused by the activities of enterprises in the Pecherskyi, Podilskyi, and Solomianskyi districts of Kyiv, respectively. The obtained data testify to the relationship between the effectiveness of the implemented environmental measures (saving and rational use of resources, application of environmental technologies, advanced training, and environmental competence of employees) and the level of efficiency of the environmental management system of enterprises. Originality. As a result of the studies conducted using actual data, a system of indicators of the generalized environmental quality indicator has been proposed for the first time, which allows determining the environmental efficiency and effectiveness of the implemented environmental measures to assess the effectiveness of the functioning of the implemented environmental management system of the enterprise. Practical value. Based on the research results, a technique is proposed to assess the effectiveness of the environmental management system of enterprises by determining a generalized environmental quality indicator in terms of reducing the negative impact of the enterprise’s activities on the environment. Such an assessment system will help the management of the enterprise to promptly introduce corrective actions to improve the efficiency of the environmental management system and increase the level of environmental safety.

Enhancing cardiology trainee competence through simulation-based pericardiocentesis training: a pilot programme evaluation

Abstract Introduction Cardiology training requires trainees to manage clinical duties whilst developing practical skills. Changes to the UK curriculum have resulted in reduced time available for procedural teaching. Pericardiocentesis is one of many required competencies. The Joint Royal College of Physicians Training Board cardiology curriculum cites the importance of simulation-based education to teach procedures. Procedural training encompasses the development of clinical reasoning alongside motor skills. Gange (1962) and Carless (2010) emphasized the importance of expert-guided practice, interactive teaching, and instant feedback in motor skills teaching to maximize the educational experience. Aim Develop a simulation teaching programme to enhance trainees' confidence and competency in pericardiocentesis. Procedures form part of a summative Direct Observation of Procedural Skills, enabling trainees to learn in a safe environment and use as evidence at their Annual Review of Competence Progression (ARCP). Method We developed a pilot programme for pericardiocentesis facilitated through high-fidelity equipment between February 2023 and February 2024. Participants were recruited through medical education departments. The sessions were delivered on a one-to-one basis by a cardiology consultant to facilitate discussion and interactivity. The teaching involved a core knowledge presentation, discussion of trainee experiences, case studies as examples, including review of echocardiography features. This was followed by clinical skills teaching of pericardiocentesis, utilizing a model, and transthoracic echocardiography. Trainees were sent anonymous feedback forms after the session. Results 46 cardiology registrars participated; 48% were within their first few years of training. 87% reported difficulty in practicing this skill in clinical practice due to: lack of exposure, other clinical responsibilities taking priority, and the need for consultant-delivered care on patients requiring an urgent or emergency procedure. Mean trainee confidence before teaching was 3.24 out of 5 (SD = 1.14), with a significant improvement to 4.48 (SD = 0.59 p<0.001). 52% improved in confidence by 1 unit and, 31% improved in confidence by 2 or more units. Trainees reported the following themes regarding the session: knowledgeable trainer, high fidelity equipment, instant feedback to predict, prevent, and overcome challenges, and a multi-modal approach to teaching, incorporating presentation and discussion on pericardial effusion, tamponade, and drainage. Conclusion Our programme offers a unique multi-modal teaching approach, with dedicated time with an expert. We supported the progress of 46 trainees and enhanced their training competencies. We aim to expand the programme to incorporate more procedures in line with growing curriculum requirements. Tracking trainee progress until ARCP outcomes will reveal the impact of simulation teaching on their experience and professional development.

Endocrine surgery fellowship is necessary for competent endocrine surgical practice: perspectives from Australia and New Zealand.

Currently pathways to practice in endocrine surgery vary based on location and surgical training programme. International data highlights the impact of surgeon volume on outcomes, and the importance of understanding the learning curve in developing minimum training competencies. This study aims to explore how surgeons obtain competence in endocrine surgery in Australia and New Zealand, and perceptions around competence and scope of practice. A web-based survey was distributed to fellows practicing endocrine surgery. Participants were invited to complete a semi-structured interview to explore key themes around competence. Thematic analysis was performed. Responses from 87 surgeons, with 30% practicing primarily in a regional or rural area, showed 94% emphasized post-fellowship training to be competent in endocrine surgery. Median primary operator procedural volume learning curves were 50 thyroid, 30 parathyroid and 20 laparoscopic adrenalectomy procedures. Semi-structured interviews with 12 participants identified four major themes: (1) learning opportunities during general surgical education and training programmes alone are insufficient for consultant-level competence; (2) the importance of sufficient training to develop clinical decision-making, insight and judgement to appropriately select patients in the management of endocrine disease; (3) expected standards of clinical and technical performance are independent of practice location or context; (4) the importance of multi-disciplinary teams for complex cases including advanced cancers. Practicing endocrine surgeons acknowledge formal fellowship training is required to achieve competence across technical and non-technical domains. The definition of competence and expectations regarding technical outcomes are independent of practice location or context.

Interprofessional In Situ Simulation’s Impact on Healthcare Personnel’s Competence and Reported Need for Training in Cardiopulmonary Resuscitation—A Pilot Study in Norway

Background/objectives: International guidelines recommend cardiopulmonary resuscitation [CPR] training every sixth month. However, research indicates that more training is needed to maintain CPR competence. The objectives of this pilot study were (a) to assess health personnel’s self-reported competence and need for more training in CPR before and after interprofessional in situ CPR simulation and (b) to assess time since the last CPR course and respondent’s reported need for more training. Also, we wanted a pilot to assess areas of improvement in a future, larger study. Methods: A questionnaire was administered to healthcare personnel in hospital wards receiving CPR training using a purposeful sampling strategy. Results: In total, 311 respondents answered the pre-intervention and 45 respondents answered the post-intervention survey. The respondents believed they had good knowledge, skills, and training in CPR, and about 2/3 of the respondents reported a need for more knowledge, skills, and training. There was a weak positive correlation between the time since the last CPR course and the perceived need for more training [p < 0.05]. There were no significant differences in self-reported competence or perceived need for more training pre- and post-intervention. The pilot detected several limitations that need improvement in a future study. Conclusions: The authors suggest that regular training is important for maintaining competence in CPR. Also, in a future study, comparisons at an individual level, as well as assessments by experts and of non-technical skills, should be included.

Involvement of competence in comprehensive training of future dentists

Involvement of competence in comprehensive training of future dentists

Telerehabilitation as a Teaching–Learning Tool in Physical Medicine and Rehabilitation Residency Training in the Philippines

Background:Prepandemic, Physical Medicine and Rehabilitation (PM&R) residency training curricula in the Philippines did not include telerehabilitation. The impact of virtual care on residents’ competencies during the pandemic has not been evaluated locally.Objective:The objective of the study is to determine residents’ ability to achieve PM&R competencies through telerehabilitation.Methods:This mixed-methods study included an original survey among residents and a focus group discussion with training/administrative staff.Findings:Residents reported professionalism, interpersonal/communication skills, and medical ethics/public health as the top three competencies facilitated by telerehabilitation, while procedural skills were the least facilitated. Training/administrative staff perceived telerehabilitation could be incorporated into PM&R training curricula.Conclusions:Telerehabilitation contributed to residents’ achievement of training competencies and learning of PM&R topics/skills.

Proposed Nutrition Competencies for Medical Students and Physician Trainees: A Consensus Statement.

In 2022, the US House of Representatives passed a bipartisan resolution (House of Representatives Resolution 1118 at the 117th Congress [2021-2022]) calling for meaningful nutrition education for medical trainees. This was prompted by increasing health care spending attributed to the growing prevalence of nutrition-related diseases and the substantial federal funding via Medicare that supports graduate medical education. In March 2023, medical education professional organizations agreed to identify nutrition competencies for medical education. To recommend nutrition competencies for inclusion in medical education to improve patient and population health. The research team conducted a rapid literature review to identify existing nutrition-related competencies published between July 2013 and July 2023. Additional competencies were identified from learning objectives in selected nutrition, culinary medicine, and teaching kitchen curricula; dietetic core competencies; and research team-generated de novo competencies. An expert panel of 22 nutrition subject matter experts and 15 residency program directors participated in a modified Delphi process and completed 4 rounds of voting to reach consensus on recommended nutrition competencies, the level of medical education at which they should be included, and recommendations for monitoring implementation and evaluation of these competencies. A total of 15 articles met inclusion criteria for competency extraction and yielded 187 competencies. Through review of gray literature and other sources, researchers identified 167 additional competencies for a total of 354 competencies. These competencies were compiled and refined prior to voting. After 4 rounds of voting, 36 competencies were identified for recommendation: 30 at both undergraduate and graduate levels, 2 at the undergraduate level only, and 4 at the graduate level only. Competencies fell into the following nutrition-related themes: foundational nutrition knowledge, assessment and diagnosis, communication skills, public health, collaborative support and treatment for specific conditions, and indications for referral. A total of 36 panelists (97%) recommended nutrition competencies be assessed as part of licensing and board certification examinations. These competencies represent a US-based effort to use a modified Delphi process to establish consensus on nutrition competencies for medical students and physician trainees. These competencies will require an iterative process of institutional prioritization, refinement, and inclusion in current and future educational curricula as well as licensure and certification examinations.

Knowledge Mapping and Global Trends in the Field of the Objective Structured Clinical Examination: Bibliometric and Visual Analysis (2004-2023).

The Objective Structured Clinical Examination (OSCE) is a pivotal tool for assessing health care professionals and plays an integral role in medical education. This study aims to map the bibliometric landscape of OSCE research, highlighting trends and key influencers. A comprehensive literature search was conducted for materials related to OSCE from January 2004 to December 2023, using the Web of Science Core Collection database. Bibliometric analysis and visualization were performed with VOSviewer and CiteSpace software tools. Our analysis indicates a consistent increase in OSCE-related publications over the study period, with a notable surge after 2019, culminating in a peak of activity in 2021. The United States emerged as a significant contributor, responsible for 30.86% (1626/5268) of total publications and amassing 44,051 citations. Coauthorship network analysis highlighted robust collaborations, particularly between the United States and the United Kingdom. Leading journals in this domain-BMC Medical Education, Medical Education, Academic Medicine, and Medical Teacher-featured the highest volume of papers, while The Lancet garnered substantial citations, reflecting its high impact factor (to be verified for accuracy). Prominent authors in the field include Sondra Zabar, Debra Pugh, Timothy J Wood, and Susan Humphrey-Murto, with Ronaldo M Harden, Brian D Hodges, and George E Miller being the most cited. The analysis of key research terms revealed a focus on "education," "performance," "competence," and "skills," indicating these are central themes in OSCE research. The study underscores a dynamic expansion in OSCE research and international collaboration, spotlighting influential countries, institutions, authors, and journals. These elements are instrumental in steering the evolution of medical education assessment practices and suggest a trajectory for future research endeavors. Future work should consider the implications of these findings for medical education and the potential areas for further investigation, particularly in underrepresented regions or emerging competencies in health care training.

How New Competencies in Medical Training Can Elevate Nutrition Care—Bridging the Gap

How New Competencies in Medical Training Can Elevate Nutrition Care—Bridging the Gap

The capacity of primary school inclusive teachers meets the requirements of the 2018 general education program

The profession of integration teaching is currently receiving considerable attention. The competency framework for teachers is assessed based on the 2018 General Education Program (GEP), which emphasizes the development of students' personal competencies and sets new competency requirements for teachers. This program provides detailed guidelines for teaching and learning in the modern era. The objective of this study is to evaluate the extent to which teachers' training and teaching competencies align with the 2018 GEP. The present study surveyed 611 primary school integration teachers across 32 schools serving disabled students in five provinces and cities within Vietnam. In this study, an assessment of teachers' competencies in various aspects of education and teaching was conducted. The results revealed high levels of proficiency among teachers in assessing and nurturing students' qualities and competencies, as well as in devising pedagogical strategies to enhance students' inherent capabilities. The limited language proficiency, particularly in local and foreign languages, has significant implications for ethnic minority students, who rely on native language instruction for effective learning. This limitation hinders the implementation of the 2018 GEP, especially in regions with a high density of ethnic minority populations. Additionally, teachers showed proficiency in creating safe and culturally educational environments and establishing relationships among students, teachers, and parents. Nevertheless, collaboration with families and communities to achieve educational goals exhibited lower competency levels. Furthermore, teachers demonstrated capabilities in researching and updating subject knowledge, along with supporting colleagues in developing professional competencies. The study also explored stakeholders' perceptions regarding educational practices, indicating varying levels of correctness in responses. This study significantly contributes to the evaluation of current primary school teacher competencies and offers valuable data for school managers, administrators, and teachers to gain a more holistic understanding of this matter.

EFEKTIFITAS IMPLEMENTASI PENGEMBANGAN SDM PADA PRODUKTIVITAS KARYAWAN BAGIAN PENJUALAN

This research aims to evaluate the effectiveness of the implementation of human resource development (HR) on the productivity of sales employees at PT. Sophie Cosmetic Cirebon. HR development includes various training programs, skills improvement and competency development aimed at improving employee capabilities and performance. The research method used is qualitative with a case study approach. Data was obtained through in-depth interviews with 20 sales employees and 1 HR manager at PT. Sophie Cosmetic Cirebon. The research results show that the implementation of HR development at PT. Sophie Cosmetic Cirebon is generally effective in increasing the productivity of sales employees. Employees involved in HR development programs report significant improvements in sales skills, communication and product understanding. The implications of this research highlight the importance of planning and implementing a structured and sustainable HR development program to achieve optimal results.Keywords: Effectiveness, HR Development, Employee Productivity, Sales.

Demand for digital competencies in professional training of the EMERCOM of Russia employees

Nowadays, digital competencies have become a necessary component of professional training for a specialist in any industry, including EMERCOM. Digital technologies and digital tools are important not only in the work of all systems of the EMERCOM of Russia, but also in the process of training specialists of this industry. Digitalization of education in EMERCOM universities, despite the emerging problems and difficulties, continues to expand. The article is devoted to the study of the demand for digital competencies in the professional training of the EMERCOM of Russia employees. For this purpose, a survey across on­campus and correspondence students of The State Fire Academy of the Ministry of Russian Federation for Civil Defence, Emergencies and Elimination of Consequences of Natural Disasters was conducted. Based on the results of the survey, a rating of competencies required for an EMERCOM employee was compiled, the analysis of the demand for competencies was carried out, the place of digital competencies among the professional competencies of EMERCOM employees was determined, and the difference in the demand for digital competencies depending on the specialization of students (e. g., fire and rescue service and forensic expertise) was noted. The data obtained in the course of the study indicates the importance and demand for digital competencies in the professional activities of employees of various the EMERCOM of Russia departments, which determines the need to modernize professional training in the context of new means of labor (digital technologies and digital tools).

The development of information and analytical competencies in the professional training of master's students in the "State and municipal management" direction

Information and analytical competencies are an integral part of the professional skills of state and municipal authorities, as they allow to effectively process and analyze large amounts of information, make informed decisions, and forecast the consequences of the actions taken. Such skills are especially relevant in the conditions of the modern information society, where access to the information has become wider and data volumes are growing every day. The development of information and analytical competencies is a necessary condition for the successful professional activity of graduates of the direction 38.04.04 “State and Municipal Management”. To form and improve these competencies in students it is necessary to use modern methods and tools for working with big data, such as data analysis, information visualization, with databases, and others. It is important to develop the critical thinking and self­control ability when working with information. Using the example of teaching the discipline “Information and analytical technologies in the state and municipal management” at the Peter the Great St. Petersburg Polytechnic University, the author proves the necessity of using B. Bloom’s taxonomy as the basis of the course methodology: thanks to the hierarchy of learning and research objectives, it is possible to effectively form information and analytical competencies and their consistent consolidation in the professional activities of master’s students.

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.

Project-Based Learning Model: Its Implication in The Initial Training of Mathematics Teachers

Objective: The objective of the study was to analyze the benefits of a study curriculum under the competency-based approach and to analyze the implications of the implementation of the project-based learning model in the initial training of mathematics teachers in the context of university higher education. Theoretical Framework: The concepts related to the project-based learning model, its characteristics, its phases and educational competencies in the twenty-first century are systematically addressed. The relevance of the curriculum under the competency approach in university education is also analyzed from a critical perspective. Method: The research approach was mixed, non-experimental design, 30 teachers and 54 students in initial training for mathematics teachers participated in the study; the data were collected through a Likert questionnaire, the analysis and interpretation of the results was carried out with the Minitab software, complemented with the information from the semi-structured interview applied to the teachers. Results and Discussion: On average, more than 77% of teachers and more than 72% of students who attended the study have a favorable opinion about the implementation of project-based learning (PBL) in university education; therefore, it favors and strengthens the development of mathematical skills and competencies in the initial training of mathematics teachers based on the realization of mathematicsof tasks and problem solving through collaborative activities for efficient learning of mathematical concepts and procedures. Research Implications: This research highlights the importance of the project-based learning model from the theoretical and practical perspective of competency-based curricular implementation. Theoretically, the concepts of project-based learning are deepened and contextualized, while the practical implication translates into collaborative work between students and the teacher in problem solving. Originality/Value: The findings value the PBL model as a viable alternative for the efficient initial training of secondary school mathematics teachers, with a broad mastery of conceptual, procedural and digital technology knowledge in problem solving.

Current status of resident simulation training curricula: pearls and pitfalls.

Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected. Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding. While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.