Preparing Students for Surgical Residency

1. Preparing Students for Surgical Residency Rebecca M. Minter, MD Associate Professor Departments of Surgery and Medical Education APDS Panel Session March 24, 2011

2. Disclosure Slide • Nothing to disclose

3. Current Landscape of Surgical Education in Medical School • 5-8 week (rarely 12 weeks) M3 rotation • Rotate on 1-2 often highly specialized surgical services • Increasing marginalization and “observorship” status • M4 rotations • Surgical “Sub-I(s)” • ICU rotation • “Bootcamp” or “Prep” Courses for Surgery residency

4. End Result • Surgical interns arrive with broad variability in exposure, experience, and skill • Difficult to assess specific deficiencies to provide directed learning until problems surface during the provision of clinical care

5. ACS/APDS/ASE Entering Surgery Resident Prep Curriculum

6. Needs Assessment – Mixed Methods Approach • Query of all relevant “stakeholders” regarding perceived level of preparation of entering surgical interns • Interns • Chief residents • Faculty/Program Directors • Mixed Methods Approach • Survey – with quantitative and qualitative data • Focus Group of Chief Residents

7. Survey Development/Dissemination • Needs assessment survey – extension of the Essentials document to determine perceived level of preparation by surgical interns • Survey distributed to interns at 15 institutions across the country – 158 responses • Response rate of ~40%*

8. Needs Assessment Survey • Likert Scale – Degree of preparation rated 1 (not prepared at all) to 5 (well prepared) • Medical Knowledge and Patient Care • Surgical and Technical Skills • Professionalism • Interpersonal and Communication Skills • Practice-Based Learning and Improvement • Systems Based Practice

9. Needs Assessment Survey • Reflecting back on your first year of Surgery residency, what was the most challenging clinical care scenario you faced, and why did you find it challenging? Specifically, did you feel that you lacked some skill or preparation that would have aided you in addressing it?

10. Intern Survey - Results Medical Knowledge and Patient Care

11. Intern Survey - Results Medical Knowledge and Patient Care: Prescribe the following common peri-operative drugs:

12. Intern Survey Results Surgical and Technical Skills

13. Intern Survey - Results : Professionalism: Interpersonal and Communication Skills:

14. Intern Survey - Results Practice-based Learning and Improvement: Systems-based Practice:

15. Frequency Distributions (N = 158) Intern Survey – Summary Results Frequency Distributions – Total respondents 158

16. Intern Survey – Summary Results

17. Intern Survey – Qualitative Analysis • Single qualitative question • Reflecting back on your first year of Surgery residency, what was the most challenging clinical care scenario you faced, and why did you find it challenging? Specifically, did you feel that you lacked some skill or preparation that would have aided you in addressing it? • 148 responses (out of 158) – some extensive • Cluster analysis to identify themes • Quotes clustered into themes • Reviewers were also asked to identify if sufficient back-up was available and if the issue raised was “amenable to training” or fell into the “Just have to do it” category (80% versus 20% respectively).

18. Cluster Analysis • Anxiety or Lack of Preparation Related to Performance of a Technical Skill or Procedure • “Creating a tension pneumothorax after subclavian CVL placement in the ICU. I felt not only that I lacked skill, but that I am harming my patients because of this. This only ever happened once in my intern year, but it took me a few days to get over it, despite the patient having a decent outcome.” • Managing/Prioritizing Multiple Simultaneous Demands • “Handling respiratory distress with decompensation on the floor at the same time that many other smaller crises were occurring (and I was being paged about them).”

19. Cluster Analysis • First Responders for Critically Ill or Unstable Patients • “Tracheo-innominate fistula on the floor with an ESRD patient in a halo for cervical spine fractures - my backup was readily available, but "put a finger on it" as a warning was not enough advice for day 4 of internship! “ • Clinical Management of (Predictable) Post-Operative Conditions • “POD 3 Evisceration at the bedside with coughing. I did not realize that the patient was supposed to have fascia closed. Did not know that on the ward this was a surgical emergency. ”

20. Cluster Analysis • Difficult Communications • “There was one case where I was concerned about a patients airway, relayed my concern to my more senior residents, but nothing was done. Recommended some therapy, but was told to wait and see. Later patient did have worsening of his airway and eventually was transferred to the ICU. It was challenging not from a medical standpoint, it was obvious he was having trouble. The main problem I see in hindsight is that I should have been more forceful with my seniors to express my concern and act quickly.”

21. Chief Resident Focus Group • Focus Group conducted at the ACS Clinical Congress 2009 • 11 Chief residents from across the country • Asked to respond to essentially same questions as interns in survey – but with binary response options – prepared or not prepared? • Answered a number of open-ended questions captured on flip charts

22. Chief Resident Focus Group

23. Chief Resident Focus Group

24. Chief Resident Focus Group

25. Chief Resident Focus Group

26. Chief Resident Focus Group

27. Chief Resident Focus Group

28. Chief Resident Focus Group

29. Chief Resident Focus Group

30. Chief Resident Focus Group – Open-ended responses • Describe the domains in which interns generally arrive well prepared for surgical internship? • Can perform a history and physical • Are thorough • Are professional • Are willing to learn

31. Chief Resident Focus Group – Open-ended responses • Describe the domains in which interns generally arrive ill prepared for surgical internship? • Ability to apply book knowledge to patients – “putting A & B together” • Ability to differentiate the “sick” from the “not sick” • Ability to work up a critically ill patient • Ability to prioritize and manage multiple demands • Writing orders – have never done • Writing notes – copy and paste phenomena • Ability to concisely present a patient • Ability to interpret radiologic images

32. National Preparatory Surgery Curriculum Initiative • Goal is development of a modular curriculum designed for easy adoption at any medical school • Curriculum will be designed around competency based goals and objectives focused on the critical skills an intern should possess upon entry to internship • Sample curricula provided with a 4 week elective format as the structure, but could be adopted in a different format • Core content will be identified which should be included and the rest of the content can fill in around the core components based upon available resources and interest

33. National Preparatory Surgery Curriculum Initiative • Course content: • Focused on critical skills needed at the bedside • Technical skills/Simulation heavy • Provide hands-on training particularly in domains where experience is limited in the M3 and other M4 rotations – e.g. mock page program, writing orders • Will NOT provide comprehensive exposure within all competency domains or skills

34. National Preparatory Surgery Curriculum Initiative • Each module will: • Be linked to a specific goal/objective within the relevant competency domain • Provide the following information needed for planning/implementation: • Faculty requirements • Necessary equipment • Component costs • Assessment instruments • Evaluation data • References (when available)

35. Timeline for Development • Goals and Objectives currently being finalized by sub-committees – complete by April 15, 2011 • Sub-committee members will then begin identifying and linking content to each objective • Content will be solicited, evaluated, packaged, and in some cases developed • Web-based platform for building curricula and downloading content – “beta version” available for evaluation in spring of 2012

36. ACS/APDS/ASE Entering Surgery Resident Prep Curriculum Committee • Rebecca M. Minter, MD • Keith D. Amos, MD • Michael L. Bentz. MD • Christopher P. Brandt, MD • Jonathan D'Cunha, MD, PhD • Keith A. Delman, MD • Ellen S. Deutsch, MD • Celia M. Divino, MD • Rebecca Evangelista, MD • Diana L. Farmer, MD • Nancy L. Gantt, MD • Stanley J. Hamstra, PhD • Darra D. Kingsley, MD • Mary Klingensmith, MD • Sarkis H. Meterissian, MD • Thomas S. Riles, MD • Robert M. Sweet, MD • Paula M. Termuhlen, MD • Noel N. Williams, MB, BCh, MCh, FRCSI, FRCS(Gen) • Kyla Terhune, MD (Resident member) • Barbara Pettit, MD • Melissa Brunsvold, MD • Travis Webb, MD • Alan Ladd, MD • Melissa Times, MD • Michael Brunt, MD • Ted James • Matthew Sideman • Maggie Boehler, RN

37. Future Michigan Medical Students