j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Q11 17 Q1 18 19 Q2 20 21 22 23 24 25 26 Q4 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Developing an educational video on lung lobectomy for the general surgery resident Emily L. Hayden, BA,a F. Jacob Seagull, PhD,a,b and Rishindra M. Reddy, MDa,c,* a
University of Michigan Medical School, Ann Arbor, Michigan Department of Medical Education, University of Michigan, Ann Arbor, Michigan c Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan b
article info
abstract
Article history:
Background: The educational resources available to general surgery residents preparing for
Received 6 August 2014
complex thoracic surgeries vary greatly in content and target audience. We hypothesized
Received in revised form
that the preparatory resources could be improved in both efficiency of use and targeting.
4 February 2015
Methods: A formal needs analysis was performed to determine residents’ knowledge gaps
Accepted 11 February 2015
and desired format and/or content of an educational tool while preparing for their first lung
Available online xxx
resections. The results of the needs assessment then guided the creation of a 20-min video tool. The video was evaluated by a focus group of experts for appropriateness to the target
Keywords:
audience, ease of use, and relevance.
Resident
Results: The needs assessment illustrated that residents feel there is a paucity of appro-
Education
priate resources available to them while preparing for the lung resection procedure; 82% of
Video
respondents felt that easy-to-use and concise resources on the lobectomy procedure were
Surgery
either “not at all” or “somewhat” accessible. Residents reported that video was their
Cardiothoracic
preferred format for a learning tool overall and identified a broad spectrum of most chal-
Operative competence
lenging procedural aspects. These results were used to guide the creation of a 20-min video tool. A focus group validated the efficacy and appropriateness of the video. Conclusions: Targeted and efficient tools for residents preparing for complex subspecialty procedures are needed and valued. These results clearly encourage further work in the creation of focused educational tools for surgical residents, especially in the format of short video overviews. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
With the advent of the American Council on Graduate Medical Education 80-h workweek rules in 2003, and an increased focus by General Surgery Program Directors on staffing General Surgery services, surgery residents are receiving less exposure to cardiac and thoracic surgery, as well as other subspecialties [1]. Residents may rotate onto thoracic-surgery services for only 1e2 mo of a 5-y program, usually to acquire
American Board of Surgery required thoracotomy cases. Despite minimal exposure to the field, the expectations for trainees rotating on these services remain high. They are usually expected to perform or first assist complex operations including lung cancer resections. To maximize resident learning and skill development given the backdrop of time constraints and productivity demands, effective preparation and directed study outside the operating room (OR) is essential.
* Corresponding author. 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Tel.: þ1 734 763 7337; fax: þ1 734 615 2656. E-mail address: [email protected] (R.M. Reddy). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.02.020
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
Q3
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
Multiple barriers affect resident case preparation. Historically, residents would be second or even third assistants for complicated operations during their first few years. This time would allow the residents to observe operations in a less exacting role (i.e., not being the primary surgeon and/or assistant) and give them time to gain contextual information on surgical techniques. With the institution of the 80-h workweek, this time in the OR as a second assist has been almost completely eliminated. However, reading time has not increased, and most surgical trainees feel dissatisfied with the number of hours they are able to spend studying outside of the hospital [2,3]. The acquisition of foundational knowledge that had been obtained in the OR is now more haphazard and inefficient. There are a number of available resources for residents, including atlases, textbooks, videos, didactics, and written articles, but these resources vary with regard to target audience and are often descriptive in nature. Of these different resources, atlases tend to be used the most overall, followed closely by textbooks [4]. Despite their popularity, atlases have been described as only marginally useful [5]. Pugh et al. have demonstrated that residents often perceive themselves to be unprepared for the technical aspects of surgical case management, and the knowledge gaps that trainees have identified do not tend to be explained or addressed in the most popular surgical atlases and textbooks [2]. It is becoming clear that our current educational resources may be out of touch with the learning needs and time limitations of today’s surgical residents. Among internal medicine residents, focused educational interventions have proven to be an effective stimulus for increasing resident reading and study, as well as resident satisfaction with the efficiency and applicability of time spent in preparation [6e8]. For surgery residents, however, recent research has been devoted to cultivating resident operating skills via simulation training, whereas less attention has been directed to facilitating or standardizing the acquisition of the foundational knowledge and operative competence for complicated procedures [9]. Greater intervention is needed for junior-level residents’ learning complex cardiothoracic (CT) surgeries for the first time, including lobectomies. Residents have shown interest in increasing utilization of video podcasts for studying and preparation for procedures. Videos could improve residents’ overall understanding of the steps and choices involved with the procedure, as well as the efficacy of their time spent studying [8]. We hypothesized that general surgery residents are missing tools to prepare them adequately for lung operations. We describe three phases of a project to evaluate this hypothesis. First, a formal needs analysis was performed to determine the format and content of an educational tool to meet their needs. Second, based on the results of the needs assessment, we developed an instructional video addressing the educational needs. Third, we assess the quality of the tool developed.
2.
Methods
2.1.
Needs assessment survey
A needs assessment survey was developed to identify common knowledge gaps for general surgery residents entering
their CT rotations. From JuneeAugust 2012, the survey was sent to junior and senior residents through their residency coordinators at five institutions (University of Michigan, Beaumont Hospital, Washington University, Dallas Methodist Hospital, and Queen’s Medical Center in Hawaii). The needs assessment survey consisted of 11 questions that covered 4 main realms as follows: (1) resident demographics (training level and interest in CT), (2) thoracic rotation and lobectomy experience (postgraduate year [PGY] of rotation, length of rotation, number of lung resections [wedge resections, lobectomies, or pneumonectomies] performed, especially challenging aspects of the procedure), (3) availability and/or appropriateness of current educational resources for learning the lobectomy procedure, and (4) preferences for the creation of an educational tool for learning the lung resection procedure (length and format). This survey was piloted with a small cohort of residents at our institution and edited for clarity and content before dissemination. The results of the needs assessment survey guided the design and creation of our video tutorial, described in the results section.
2.2.
Focus-group survey
To assess the video’s appropriateness and relevance for surgical trainees, the video was distributed via a YouTube link to Q5 senior general- and thoracic-surgery residents (PGY4e7) and attending thoracic surgeons. We distributed a survey link Q6 along with the video that elicited opinions regarding the video’s effectiveness. Surgeons were asked whether the video addressed topics that residents identified as challenging, where it could be improved, when to provide the video to residents, and whether they felt the video would be helpful. The panel was also asked to specifically rank the efficacy of different aspects of the video including the clarity, the thoracoscopic film and pictures, the explanation of the patient positioning/anatomy/procedure, and the troubleshooting explanations. Both surveys were created and distributed using the online survey website Qualtrics. Q7 This study was approved by our Institutional Review Board (HUM00064940).
3.
Results
3.1.
Needs assessment
Survey links were sent to 60 residents, and 17 responses were received for a response rate of 28%. Respondents ranged in experience from PGY 3ePGY 6 (Fig. 1A). Thoracic rotations were either 1- or 2-mo-long for the majority of respondents (47% (8) and 24% (4), respectively) and almost all rotations occur during the PGY1e4 y (Fig. 1B). Only 12% (2) reported rotations lasting >4 mo. Most respondents (70%, 12) were not planning to pursue CT surgery further, with half stating it was “unlikely” and the other half stating “definitely not” regarding their interest in a career in CT. Twenty-five percent (5) of our respondents stated they were “definitely” interested or “considering” a career in CT surgery. Most residents reported spending at least an hour (70%, 12) preparing for their first
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 Q8 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325
3
Fig. 1 e Needs assessment survey, level of clinical training currently and during thoracic rotations (n [ 17). (A) Responders current PGY level. (B) PGY level of all thoracic surgery rotation(s) at the different residencies surveyed (more than one response allowed).
lobectomy, and zero residents reported either no preparation or >2 h of preparation (Fig. 2A). There was a wide range in the number of lung resections performed by respondents, ranging from 3e>20 lung resections during their rotations (Fig. 2B). In terms of the type of resources residents used in preparation for their first case, the most common were textbooks and Web sites; 70% (12) of respondents endorsed textbook use (including: Pearson’s Thoracic Surgery, Mastery of CT Surgery, Shield’s General Thoracic Surgery, Operative Anatomy: General Thoracic Surgery, Greenfield’s, Cameron’s, Schwartz, Zollinger’s, and Sabiston’s), and 63% (11) of respondents reported using Web site resources (Expert Consult, TSRA Review of CT Surgery, Access Surgery, ACS Principles and Practice, YouTube, Web surg, and SCORE ). Thirteen percent (2) also reported use of “other” resources, citing industry-created VATS videos and old operative reports, specifically. Despite this, 35% (6) of respondents felt that “easy-to-use and concise resources on the lobectomy procedure” were “not at all” accessible as they prepared for their first lung resection. Forty-seven percent (8) felt that resources were “somewhat” available, and only 18% (3) of respondents stated that resources were “very” available to them. There was variation in the aspects of the procedure that residents found most challenging, ranging from lateral positioning of the patient (most challenging for 29%, 5), VATS ports placement (18%, 3), and robot docking (13%, 2). Free-text
descriptions of especially challenging aspects of the procedure listed by respondents included “changing spatial recognition from abdominal laparotomy to thoracotomy positioning,” and “understanding when to use open versus VATS versus robotic (approaches).” When asked to rank their interest in a preferred educational tool to provide foundational knowledge for the lung resection procedure, 59% (10) preferred a short video overview, followed by 35% (6) preferring a concise book chapter. There was zero interest in journal articles or study guides. Seventy percent (12) of residents preferred a resource that can be used in under 30 min and even 42% (7) favoring a resource under 20 min. These data guided the creation of the 20-min video tutorial.
3.2.
Video development
Based on the results of the needs assessment we created a video tutorial. Aspects of the procedure that residents ranked as most challenging (da Vinci docking, port placement, anatomy and orientation with thoracoscopy, and decision making for surgical approach) were addressed and used to guide video content. The outline of the video is shown in Table 1. It contained three components as follows: schematic representation of the procedure, thoracoscopic video footage, and explanation of techniques. These components were interspersed. Static
Fig. 2 e Needs assessment survey, number of lung resections and time spent preparing for their first lung resection (n [ 17). (A) Lobectomies performed during thoracic rotations as general surgery residents. (B) Time spent preparing by any method for their first lung resection. 5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390
4
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
391 Q9 Table 1 e Video outline. 392 Outline 393 - Introduction 394 - Patient positioning 395 - Incision techniques/placement 396 - Review of anatomy 397 - Procedure (right upper and right lower lobectomy) 398 399 Wedge resection 400 Inferior pulmonary ligament Pulmonary vein 401 Pulmonary artery 402 Bronchus/fissure 403 - Technical pearls and troubleshooting 404 405 406 407 images and thoracoscopic video footage from the OR pro408 cedures as well as whiteboard schematic drawings were used 409 to delineate patient positioning, incision placement, and 410 anatomy (Fig. 3). Thoracoscopic video depicted relevant aspects 411 412 of the procedure, accompanied by voice-over explanations 413 and/or narration. Given our goal of providing foundational in414 formation in the short timeframe preferred by residents, only 415 essential steps were shown, and these were presented in fast416 motion (2e8) thoracoscopic footage. The final segment of 417 the video covered troubleshooting techniques for difficult 418 portions of the procedure. The resulting video was 20 min in 419 duration and was posted on YouTube for viewing. 420 421 422 3.3. Video focus group 423 424 425 The video and survey link were sent to 20 residents and 4 426 surgeons, with 8 residents completing the focus-group survey 427 (40% response rate). Seventy-five percent (6) felt the tutorial 428 would “definitely” have been helpful to them during their CT 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 Fig. 3 e Sample picture of a whiteboard drawing explaining 453 454 lung hilar anatomy from a video tutorial. (Color version of 455 figure is available online.)
rotation, with the remaining 25% (2) stating it would “likely” have been helpful. Comments from resident and faculty respondents about the potential helpfulness of the video included “great, especially for things like positioning and incision mapping,” and “great explanation and correlation with real video.” Regarding the appropriateness for the audience of interest, 75% (6) of respondents considered the tutorial to be “appropriately” or “very appropriately” targeted to junior residents. Respondents recommended that the video link should be provided to residents before rotating onto their CT service, either with the rotation’s orientation materials or a month before beginning their CT service. Residents also ranked the efficacy and execution of the various teaching points (Table 2). Relevant comments about the overall video noted that “the highlights of the procedure and viewing at high speed were helpful” and suggested “an initial orientation shot with a wider view.” Comments about patient positioning stated that it “could be more helpful to see the team actively position the patient” and that “a live demonstration” or “animation” of each step “would be more helpful” than the photo with explanation. Suggested improvements for the anatomy portion included incorporation of a threedimensional lung model, digitalizing whiteboard drawings, and including lung surface landmarks in explanations.
4.
Discussion
We have described a small-scale needs assessment and validation of an educational resource. We have shown that there is a great variability in residents’ exposure to lung resections. Over half of the residents performed more than 10 lung resections, which is double the national average number of liver resections, as per 2013 American Council on Graduate Medical Education logs. Liver resections are a core abdominal operation that is “required” for graduating general surgery residents to be American Board of Surgery eligible [10]. The fact that our cohort performed a higher number of lung resections demonstrates that preparatory resources for complex thoracic surgeries are still pertinent for general surgery residents. In fact, in an era of reduced exposure, there is an increased need for focused educational tools for surgical residents for specialties where they have decreasing exposure but are expected to still assist in technically complex operations. Although the sample size for the needs assessment and validation survey was limited, and the response rates limited, the numbers were adequate to represent a pattern of results consistent with the literature regarding educational resources. Response rates were typical for such studies, and the qualitative information garnered from the open-ended responses provided valuable information to guide further development of such resources [11,12]. As intraoperative exposure to complex procedures decreases, and the acquiring of technical skills and basic cognitive knowledge through traditional resources is limited, it is important to create “just in time” training resources that allow trainees to learn the whole procedure in a short period. This does not replace traditional resources to address the reasons behind performing lung resections, for example, lung cancer, but it does attempt to shorten the time needed in the
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520
5
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586
Table 2 e Focus group survey, evaluation of video by focus group experts (N [ 8).
Important for thoracic rotation Appropriate content for junior resident Adequate review of patient positioning Adequate review of anatomy Adequate review of procedural steps Pearls and troubleshooting helpful
Q10
Strongly agree
Agree
Partially agree
Neutral
Partially disagree/disagree/ strongly disagree
3 2 3 1 2 1
4 4 2 4 4 7
1 2 0 3 1 0
0 0 3 0 1 0
0 0 0 0 0 0
OR learning positioning and anatomy from the second assistant spot. Video is an effective tool that can serve to lay the groundwork for dynamic, relevant, and effective educational resources that empower trainees in the cultivation of operative competence (i.e., the ability to perform the entirety of a procedure) [9]. Focused video tools, which can capture the surgeon’s positioning, timing, and techniques, are best suited to address this realm [1,9,10]. The use of needs assessments to guide the development of video resources addresses a need for more directed surgical subspecialty educational tools. The methodology of creating a video resource based on a needs assessment can be applied to the creation of tutorials for other complex surgeries as well. This methodological template and video-creation process is inexpensive and time efficient. An online video archive for residents can be built, which could also present the variations in surgeon preferences, approaches, and techniques. This would help residents to be more thoroughly prepared for the variations in approach that they inevitably encounter working with different attending surgeons. This foundational preparation will facilitate deeper learning and greater efficiency in the OR and can be reviewed before or even in the OR just before starting the case. Moving forward, this introductory video, and other anatomic based videos, could fill a gap in the resources available to general surgery trainees beginning their CT rotation. It provides the technical and foundational knowledge needed for the procedure that is not readily available in traditional resources, such as atlases, textbooks, and traditional operative videos, and often can only be attained through time spent in the OR. Limitations for our study include the low response rates and the lack of a randomized control trial comparing our video to other educational materials (atlases, and so forth). We have modified our video on a rolling basis, making minor edits, as we have gotten continuous input from residents on a monthly basis. We anticipate regular modifications in the future and the creation of other video tools to assist our residents.
Acknowledgment The authors thank Allison C. Billi for thoughtful comments on the article. Authors’ contributions: E.L.H. and R.M.R. conceived the idea for the project. E.L.H. was involved with the filming and video creation, the creation of the needs assessment and
focus-group survey. E.L.H., R.M.R., and F.J.S. did the writing, revising, and editing of the article. F.J.S. provided his medical education expertise to guide the surveys and validation of the video tool. R.M.R. was involved with guiding, directing, and creating the surveys and video, as well as guiding the article.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[1] Jarmin B, Miller M, Brown S, et al. The 80-hour work week: will we have less-experienced graduating surgeons? Curr Surg 2004;61:612. [2] Edson RS, Beckman TJ, West CP, et al. A multi-institutional survey of internal medicine residents’ learning habits. Med Teach 2010;32:773. [3] Yeh DD, Hwabejire JO, Imam A, et al. Survey of study habits of general surgery residents. J Surg Education 2013;70:15. [4] Pugh CM, DaRosa DA, Bell RH Jr. Residents’ self-reported learning needs for intraoperative knowledge: are we missing the bar? Am J Surg 2010;199:562. [5] Steele RJC, Logie JRC, Munro A. Technical training in surgery: the trainee’s view. Br J Surg 1989;76:1291. [6] Chahla M, Eberlein M, Wright S. The effect of providing a USB syllabus on resident reading of landmark articles. Med Educ Online 2010;15:10. [7] Kabrel C, Liu S, Takayesu JK, Thomas SH. Creation of an online collection of emergency medicine literature. Acad Emerg Med 2005;34:646. [8] Tannery NH, Foust JE, Gregg AL, et al. Use of Web-based library resources by medical students in community and ambulatory settings. J Med Libr Assoc 2002;90:305. [9] Grober ED, Jewett MAS. The concept and trajectory of “operative competence” in surgical training. Can J Surg 2006;49:238. [10] 2013 Accreditation Council for Graduate Medical Education. General surgery case logs national data report, total experience of residents completing programs in 2012-2013. 2013. Available from: https://www.acgme.org/acgmeweb/ Portals/0/GSNatData1213.pdf. Accessed March 8, 2014. [11] Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemology 1997;50:1129. [12] Grava-Gubins I, Scott S. Effects of various methodologic strategies: survey response rates among Canadian physicians and physicians-in-training. Can Fam Physician 2008;54:1424.
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Q11 17 Q1 18 19 Q2 20 21 22 23 24 25 26 Q4 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Developing an educational video on lung lobectomy for the general surgery resident Emily L. Hayden, BA,a F. Jacob Seagull, PhD,a,b and Rishindra M. Reddy, MDa,c,* a
University of Michigan Medical School, Ann Arbor, Michigan Department of Medical Education, University of Michigan, Ann Arbor, Michigan c Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan b
article info
abstract
Article history:
Background: The educational resources available to general surgery residents preparing for
Received 6 August 2014
complex thoracic surgeries vary greatly in content and target audience. We hypothesized
Received in revised form
that the preparatory resources could be improved in both efficiency of use and targeting.
4 February 2015
Methods: A formal needs analysis was performed to determine residents’ knowledge gaps
Accepted 11 February 2015
and desired format and/or content of an educational tool while preparing for their first lung
Available online xxx
resections. The results of the needs assessment then guided the creation of a 20-min video tool. The video was evaluated by a focus group of experts for appropriateness to the target
Keywords:
audience, ease of use, and relevance.
Resident
Results: The needs assessment illustrated that residents feel there is a paucity of appro-
Education
priate resources available to them while preparing for the lung resection procedure; 82% of
Video
respondents felt that easy-to-use and concise resources on the lobectomy procedure were
Surgery
either “not at all” or “somewhat” accessible. Residents reported that video was their
Cardiothoracic
preferred format for a learning tool overall and identified a broad spectrum of most chal-
Operative competence
lenging procedural aspects. These results were used to guide the creation of a 20-min video tool. A focus group validated the efficacy and appropriateness of the video. Conclusions: Targeted and efficient tools for residents preparing for complex subspecialty procedures are needed and valued. These results clearly encourage further work in the creation of focused educational tools for surgical residents, especially in the format of short video overviews. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
With the advent of the American Council on Graduate Medical Education 80-h workweek rules in 2003, and an increased focus by General Surgery Program Directors on staffing General Surgery services, surgery residents are receiving less exposure to cardiac and thoracic surgery, as well as other subspecialties [1]. Residents may rotate onto thoracic-surgery services for only 1e2 mo of a 5-y program, usually to acquire
American Board of Surgery required thoracotomy cases. Despite minimal exposure to the field, the expectations for trainees rotating on these services remain high. They are usually expected to perform or first assist complex operations including lung cancer resections. To maximize resident learning and skill development given the backdrop of time constraints and productivity demands, effective preparation and directed study outside the operating room (OR) is essential.
* Corresponding author. 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Tel.: þ1 734 763 7337; fax: þ1 734 615 2656. E-mail address: [email protected] (R.M. Reddy). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.02.020
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
Q3
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
Multiple barriers affect resident case preparation. Historically, residents would be second or even third assistants for complicated operations during their first few years. This time would allow the residents to observe operations in a less exacting role (i.e., not being the primary surgeon and/or assistant) and give them time to gain contextual information on surgical techniques. With the institution of the 80-h workweek, this time in the OR as a second assist has been almost completely eliminated. However, reading time has not increased, and most surgical trainees feel dissatisfied with the number of hours they are able to spend studying outside of the hospital [2,3]. The acquisition of foundational knowledge that had been obtained in the OR is now more haphazard and inefficient. There are a number of available resources for residents, including atlases, textbooks, videos, didactics, and written articles, but these resources vary with regard to target audience and are often descriptive in nature. Of these different resources, atlases tend to be used the most overall, followed closely by textbooks [4]. Despite their popularity, atlases have been described as only marginally useful [5]. Pugh et al. have demonstrated that residents often perceive themselves to be unprepared for the technical aspects of surgical case management, and the knowledge gaps that trainees have identified do not tend to be explained or addressed in the most popular surgical atlases and textbooks [2]. It is becoming clear that our current educational resources may be out of touch with the learning needs and time limitations of today’s surgical residents. Among internal medicine residents, focused educational interventions have proven to be an effective stimulus for increasing resident reading and study, as well as resident satisfaction with the efficiency and applicability of time spent in preparation [6e8]. For surgery residents, however, recent research has been devoted to cultivating resident operating skills via simulation training, whereas less attention has been directed to facilitating or standardizing the acquisition of the foundational knowledge and operative competence for complicated procedures [9]. Greater intervention is needed for junior-level residents’ learning complex cardiothoracic (CT) surgeries for the first time, including lobectomies. Residents have shown interest in increasing utilization of video podcasts for studying and preparation for procedures. Videos could improve residents’ overall understanding of the steps and choices involved with the procedure, as well as the efficacy of their time spent studying [8]. We hypothesized that general surgery residents are missing tools to prepare them adequately for lung operations. We describe three phases of a project to evaluate this hypothesis. First, a formal needs analysis was performed to determine the format and content of an educational tool to meet their needs. Second, based on the results of the needs assessment, we developed an instructional video addressing the educational needs. Third, we assess the quality of the tool developed.
2.
Methods
2.1.
Needs assessment survey
A needs assessment survey was developed to identify common knowledge gaps for general surgery residents entering
their CT rotations. From JuneeAugust 2012, the survey was sent to junior and senior residents through their residency coordinators at five institutions (University of Michigan, Beaumont Hospital, Washington University, Dallas Methodist Hospital, and Queen’s Medical Center in Hawaii). The needs assessment survey consisted of 11 questions that covered 4 main realms as follows: (1) resident demographics (training level and interest in CT), (2) thoracic rotation and lobectomy experience (postgraduate year [PGY] of rotation, length of rotation, number of lung resections [wedge resections, lobectomies, or pneumonectomies] performed, especially challenging aspects of the procedure), (3) availability and/or appropriateness of current educational resources for learning the lobectomy procedure, and (4) preferences for the creation of an educational tool for learning the lung resection procedure (length and format). This survey was piloted with a small cohort of residents at our institution and edited for clarity and content before dissemination. The results of the needs assessment survey guided the design and creation of our video tutorial, described in the results section.
2.2.
Focus-group survey
To assess the video’s appropriateness and relevance for surgical trainees, the video was distributed via a YouTube link to Q5 senior general- and thoracic-surgery residents (PGY4e7) and attending thoracic surgeons. We distributed a survey link Q6 along with the video that elicited opinions regarding the video’s effectiveness. Surgeons were asked whether the video addressed topics that residents identified as challenging, where it could be improved, when to provide the video to residents, and whether they felt the video would be helpful. The panel was also asked to specifically rank the efficacy of different aspects of the video including the clarity, the thoracoscopic film and pictures, the explanation of the patient positioning/anatomy/procedure, and the troubleshooting explanations. Both surveys were created and distributed using the online survey website Qualtrics. Q7 This study was approved by our Institutional Review Board (HUM00064940).
3.
Results
3.1.
Needs assessment
Survey links were sent to 60 residents, and 17 responses were received for a response rate of 28%. Respondents ranged in experience from PGY 3ePGY 6 (Fig. 1A). Thoracic rotations were either 1- or 2-mo-long for the majority of respondents (47% (8) and 24% (4), respectively) and almost all rotations occur during the PGY1e4 y (Fig. 1B). Only 12% (2) reported rotations lasting >4 mo. Most respondents (70%, 12) were not planning to pursue CT surgery further, with half stating it was “unlikely” and the other half stating “definitely not” regarding their interest in a career in CT. Twenty-five percent (5) of our respondents stated they were “definitely” interested or “considering” a career in CT surgery. Most residents reported spending at least an hour (70%, 12) preparing for their first
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 Q8 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325
3
Fig. 1 e Needs assessment survey, level of clinical training currently and during thoracic rotations (n [ 17). (A) Responders current PGY level. (B) PGY level of all thoracic surgery rotation(s) at the different residencies surveyed (more than one response allowed).
lobectomy, and zero residents reported either no preparation or >2 h of preparation (Fig. 2A). There was a wide range in the number of lung resections performed by respondents, ranging from 3e>20 lung resections during their rotations (Fig. 2B). In terms of the type of resources residents used in preparation for their first case, the most common were textbooks and Web sites; 70% (12) of respondents endorsed textbook use (including: Pearson’s Thoracic Surgery, Mastery of CT Surgery, Shield’s General Thoracic Surgery, Operative Anatomy: General Thoracic Surgery, Greenfield’s, Cameron’s, Schwartz, Zollinger’s, and Sabiston’s), and 63% (11) of respondents reported using Web site resources (Expert Consult, TSRA Review of CT Surgery, Access Surgery, ACS Principles and Practice, YouTube, Web surg, and SCORE ). Thirteen percent (2) also reported use of “other” resources, citing industry-created VATS videos and old operative reports, specifically. Despite this, 35% (6) of respondents felt that “easy-to-use and concise resources on the lobectomy procedure” were “not at all” accessible as they prepared for their first lung resection. Forty-seven percent (8) felt that resources were “somewhat” available, and only 18% (3) of respondents stated that resources were “very” available to them. There was variation in the aspects of the procedure that residents found most challenging, ranging from lateral positioning of the patient (most challenging for 29%, 5), VATS ports placement (18%, 3), and robot docking (13%, 2). Free-text
descriptions of especially challenging aspects of the procedure listed by respondents included “changing spatial recognition from abdominal laparotomy to thoracotomy positioning,” and “understanding when to use open versus VATS versus robotic (approaches).” When asked to rank their interest in a preferred educational tool to provide foundational knowledge for the lung resection procedure, 59% (10) preferred a short video overview, followed by 35% (6) preferring a concise book chapter. There was zero interest in journal articles or study guides. Seventy percent (12) of residents preferred a resource that can be used in under 30 min and even 42% (7) favoring a resource under 20 min. These data guided the creation of the 20-min video tutorial.
3.2.
Video development
Based on the results of the needs assessment we created a video tutorial. Aspects of the procedure that residents ranked as most challenging (da Vinci docking, port placement, anatomy and orientation with thoracoscopy, and decision making for surgical approach) were addressed and used to guide video content. The outline of the video is shown in Table 1. It contained three components as follows: schematic representation of the procedure, thoracoscopic video footage, and explanation of techniques. These components were interspersed. Static
Fig. 2 e Needs assessment survey, number of lung resections and time spent preparing for their first lung resection (n [ 17). (A) Lobectomies performed during thoracic rotations as general surgery residents. (B) Time spent preparing by any method for their first lung resection. 5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390
4
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
391 Q9 Table 1 e Video outline. 392 Outline 393 - Introduction 394 - Patient positioning 395 - Incision techniques/placement 396 - Review of anatomy 397 - Procedure (right upper and right lower lobectomy) 398 399 Wedge resection 400 Inferior pulmonary ligament Pulmonary vein 401 Pulmonary artery 402 Bronchus/fissure 403 - Technical pearls and troubleshooting 404 405 406 407 images and thoracoscopic video footage from the OR pro408 cedures as well as whiteboard schematic drawings were used 409 to delineate patient positioning, incision placement, and 410 anatomy (Fig. 3). Thoracoscopic video depicted relevant aspects 411 412 of the procedure, accompanied by voice-over explanations 413 and/or narration. Given our goal of providing foundational in414 formation in the short timeframe preferred by residents, only 415 essential steps were shown, and these were presented in fast416 motion (2e8) thoracoscopic footage. The final segment of 417 the video covered troubleshooting techniques for difficult 418 portions of the procedure. The resulting video was 20 min in 419 duration and was posted on YouTube for viewing. 420 421 422 3.3. Video focus group 423 424 425 The video and survey link were sent to 20 residents and 4 426 surgeons, with 8 residents completing the focus-group survey 427 (40% response rate). Seventy-five percent (6) felt the tutorial 428 would “definitely” have been helpful to them during their CT 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 Fig. 3 e Sample picture of a whiteboard drawing explaining 453 454 lung hilar anatomy from a video tutorial. (Color version of 455 figure is available online.)
rotation, with the remaining 25% (2) stating it would “likely” have been helpful. Comments from resident and faculty respondents about the potential helpfulness of the video included “great, especially for things like positioning and incision mapping,” and “great explanation and correlation with real video.” Regarding the appropriateness for the audience of interest, 75% (6) of respondents considered the tutorial to be “appropriately” or “very appropriately” targeted to junior residents. Respondents recommended that the video link should be provided to residents before rotating onto their CT service, either with the rotation’s orientation materials or a month before beginning their CT service. Residents also ranked the efficacy and execution of the various teaching points (Table 2). Relevant comments about the overall video noted that “the highlights of the procedure and viewing at high speed were helpful” and suggested “an initial orientation shot with a wider view.” Comments about patient positioning stated that it “could be more helpful to see the team actively position the patient” and that “a live demonstration” or “animation” of each step “would be more helpful” than the photo with explanation. Suggested improvements for the anatomy portion included incorporation of a threedimensional lung model, digitalizing whiteboard drawings, and including lung surface landmarks in explanations.
4.
Discussion
We have described a small-scale needs assessment and validation of an educational resource. We have shown that there is a great variability in residents’ exposure to lung resections. Over half of the residents performed more than 10 lung resections, which is double the national average number of liver resections, as per 2013 American Council on Graduate Medical Education logs. Liver resections are a core abdominal operation that is “required” for graduating general surgery residents to be American Board of Surgery eligible [10]. The fact that our cohort performed a higher number of lung resections demonstrates that preparatory resources for complex thoracic surgeries are still pertinent for general surgery residents. In fact, in an era of reduced exposure, there is an increased need for focused educational tools for surgical residents for specialties where they have decreasing exposure but are expected to still assist in technically complex operations. Although the sample size for the needs assessment and validation survey was limited, and the response rates limited, the numbers were adequate to represent a pattern of results consistent with the literature regarding educational resources. Response rates were typical for such studies, and the qualitative information garnered from the open-ended responses provided valuable information to guide further development of such resources [11,12]. As intraoperative exposure to complex procedures decreases, and the acquiring of technical skills and basic cognitive knowledge through traditional resources is limited, it is important to create “just in time” training resources that allow trainees to learn the whole procedure in a short period. This does not replace traditional resources to address the reasons behind performing lung resections, for example, lung cancer, but it does attempt to shorten the time needed in the
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520
5
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e5
521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586
Table 2 e Focus group survey, evaluation of video by focus group experts (N [ 8).
Important for thoracic rotation Appropriate content for junior resident Adequate review of patient positioning Adequate review of anatomy Adequate review of procedural steps Pearls and troubleshooting helpful
Q10
Strongly agree
Agree
Partially agree
Neutral
Partially disagree/disagree/ strongly disagree
3 2 3 1 2 1
4 4 2 4 4 7
1 2 0 3 1 0
0 0 3 0 1 0
0 0 0 0 0 0
OR learning positioning and anatomy from the second assistant spot. Video is an effective tool that can serve to lay the groundwork for dynamic, relevant, and effective educational resources that empower trainees in the cultivation of operative competence (i.e., the ability to perform the entirety of a procedure) [9]. Focused video tools, which can capture the surgeon’s positioning, timing, and techniques, are best suited to address this realm [1,9,10]. The use of needs assessments to guide the development of video resources addresses a need for more directed surgical subspecialty educational tools. The methodology of creating a video resource based on a needs assessment can be applied to the creation of tutorials for other complex surgeries as well. This methodological template and video-creation process is inexpensive and time efficient. An online video archive for residents can be built, which could also present the variations in surgeon preferences, approaches, and techniques. This would help residents to be more thoroughly prepared for the variations in approach that they inevitably encounter working with different attending surgeons. This foundational preparation will facilitate deeper learning and greater efficiency in the OR and can be reviewed before or even in the OR just before starting the case. Moving forward, this introductory video, and other anatomic based videos, could fill a gap in the resources available to general surgery trainees beginning their CT rotation. It provides the technical and foundational knowledge needed for the procedure that is not readily available in traditional resources, such as atlases, textbooks, and traditional operative videos, and often can only be attained through time spent in the OR. Limitations for our study include the low response rates and the lack of a randomized control trial comparing our video to other educational materials (atlases, and so forth). We have modified our video on a rolling basis, making minor edits, as we have gotten continuous input from residents on a monthly basis. We anticipate regular modifications in the future and the creation of other video tools to assist our residents.
Acknowledgment The authors thank Allison C. Billi for thoughtful comments on the article. Authors’ contributions: E.L.H. and R.M.R. conceived the idea for the project. E.L.H. was involved with the filming and video creation, the creation of the needs assessment and
focus-group survey. E.L.H., R.M.R., and F.J.S. did the writing, revising, and editing of the article. F.J.S. provided his medical education expertise to guide the surveys and validation of the video tool. R.M.R. was involved with guiding, directing, and creating the surveys and video, as well as guiding the article.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[1] Jarmin B, Miller M, Brown S, et al. The 80-hour work week: will we have less-experienced graduating surgeons? Curr Surg 2004;61:612. [2] Edson RS, Beckman TJ, West CP, et al. A multi-institutional survey of internal medicine residents’ learning habits. Med Teach 2010;32:773. [3] Yeh DD, Hwabejire JO, Imam A, et al. Survey of study habits of general surgery residents. J Surg Education 2013;70:15. [4] Pugh CM, DaRosa DA, Bell RH Jr. Residents’ self-reported learning needs for intraoperative knowledge: are we missing the bar? Am J Surg 2010;199:562. [5] Steele RJC, Logie JRC, Munro A. Technical training in surgery: the trainee’s view. Br J Surg 1989;76:1291. [6] Chahla M, Eberlein M, Wright S. The effect of providing a USB syllabus on resident reading of landmark articles. Med Educ Online 2010;15:10. [7] Kabrel C, Liu S, Takayesu JK, Thomas SH. Creation of an online collection of emergency medicine literature. Acad Emerg Med 2005;34:646. [8] Tannery NH, Foust JE, Gregg AL, et al. Use of Web-based library resources by medical students in community and ambulatory settings. J Med Libr Assoc 2002;90:305. [9] Grober ED, Jewett MAS. The concept and trajectory of “operative competence” in surgical training. Can J Surg 2006;49:238. [10] 2013 Accreditation Council for Graduate Medical Education. General surgery case logs national data report, total experience of residents completing programs in 2012-2013. 2013. Available from: https://www.acgme.org/acgmeweb/ Portals/0/GSNatData1213.pdf. Accessed March 8, 2014. [11] Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemology 1997;50:1129. [12] Grava-Gubins I, Scott S. Effects of various methodologic strategies: survey response rates among Canadian physicians and physicians-in-training. Can Fam Physician 2008;54:1424.
5.2.0 DTD YJSRE13137_proof 5 March 2015 1:35 pm ce
587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652
