Surg Endosc (2013) 27:4429–4438 DOI 10.1007/s00464-013-3263-2
and Other Interventional Techniques
SAGES REPORT
Evolution of practice gaps in gastrointestinal and endoscopic surgery: 2012 report from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee John T. Paige • Timothy M. Farrell • Simon Bergman • Niazy Selim • Alan E. Harzman • Erin Schwarz • Yumi Hori • Jason Levine • Daniel J. Scott
Received: 13 September 2013 / Accepted: 6 October 2013 / Published online: 7 November 2013 Ó Springer Science+Business Media New York 2013
Abstract Background In an effort to fulfill its charge to develop and maintain a comprehensive educational program to serve the members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the SAGES Continuing Education Committee (CEC) reports a summary of findings related to its evaluation of the 2012 SAGES annual meeting. Methods All attendees to the 2012 annual meeting had the opportunity to complete an immediate postmeeting questionnaire as part of their continuing medical education J. T. Paige (&) Department of Surgery, LSU Health New Orleans School of Medicine, 1542 Tulane Ave, Rm 734, New Orleans, LA 70112, USA e-mail: [email protected] T. M. Farrell Department of Surgery, University North Carolina at Chapel Hill, Chapel Hill, NC, USA S. Bergman Department of Surgery, McGill University, Montreal, QC, Canada N. Selim Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA A. E. Harzman Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA E. Schwarz Y. Hori J. Levine SAGES, Los Angeles, CA, USA D. J. Scott University of Texas Southwestern Medical Center, Dallas, TX, USA
(CME) certification in which they identified up to two learning themes, answered questions related to potential practice change items that are based on those learning themes, and complete a needs assessment related to important learning topics for future meetings. In addition, participants in the postgraduate and hands-on courses were asked to complete questions about case volume and comfort levels related to procedures/topics in those courses. All respondents to this initial survey were sent a 3-month follow-up questionnaire in which they were asked how successfully they had implemented the intended practice changes and what, if any, barriers they encountered. Postgraduate and hands-on course participants completed case volume and comfort level questions. Descriptive statistical analysis of this deidentified data was undertaken. Results Response rates were 42 % and 56 % for CMEeligible attendees/respondents for the immediate postmeeting and 3-month follow-up questionnaires, respectively. Top learning themes for respondents were Bariatric, Hernia, Foregut, and Colorectal. Improving minimally invasive surgical (MIS) technique and managing complications related to MIS procedures were top intended practice changes. Partial implementation was common with top barriers including cost restrictions, lack of institutional support, and lack of time. Conclusions The 2012 annual meeting analysis provides insight into educational needs among respondents and will help with planning content for future meetings. Keywords gaps
Education Training Courses Practice
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is accredited by the Accreditation
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Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) credits to physicians. In order to do so, SAGES must follow specific ACCME criteria in the planning and implementation of its educational activities. Central to these requirements is the need to identify professional practice gaps among potential learners in order to address adequately SAGES’ four major CME objectives: (1) improving knowledge of gastrointestinal and related disease; (2) assessing current and emerging surgical therapies; (3) acquiring competence to perform and teach appropriate therapies; and (4) measuring effectiveness of therapies in terms of outcomes [1, 2]. The SAGES Continuing Education Committee (CEC) is charged with ensuring maintenance of ACCME accreditation as well as developing and maintaining a comprehensive educational program to serve the members of the Society related to its educational objectives. As part of this process, SAGES has developed a practice gap data bank to assist with planning educational activities. This data bank draws on many sources, of which a major one is the annual postmeeting survey of attendees of the annual meeting. This survey has two major components: (1) a questionnaire given immediately after the end of the annual meeting targeting perceived practice needs of attendees as well as their gains in knowledge, skills, and attitudes (KSAs) resulting from the meeting, and (2) a 3-month follow-up questionnaire targeting transfer of KSAs to actual practice, as well as barriers that may have prevented or blunted such transfer. For the 2011 annual meeting held in San Antonio, TX, Farrell et al. [3] published, on behalf of the SAGES CEC, the results of this survey. Top learning themes selected by attendees to this meeting included Foregut, Hernia, Bariatric, and Colorectal. All four themes were selected by more than a quarter of participants as one of their top two learning themes at the Meeting. Popular topics within learning themes included patient evaluation and selection as well as application of evidence in selecting procedures. Important barriers to implementation of intended practice changes were cost and institutional support. Finally, top requested topics for future educational content among attendees included reoperative laparoscopic surgery, introduction of new procedures into practice, advanced laparoscopic techniques, and foregut surgery. In an effort to build on the above findings and expand the practice gap data bank for programmatic planning of future annual meetings, the SAGES CEC reports a summary of findings related to this evaluation/needs assessment of the 2012 SAGES annual meeting. In this manner, comparison and contrast can be made with the 2011 published data to identify trends and developments related to
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the learning needs of members, helping to inform future educational content.
Methods Learning theme assignment The Assessment Task Force, a working group of the CEC charged in part with overseeing assessment of the meeting’s effectiveness, developed the survey questionnaires sent out to the attendees of the 2012 annual meeting. During planning for the meeting, this body was responsible for ensuring adequate documentation of linkage of the learning objectives developed for each educational offering to identified practice gaps. They divided the program content into ten learning themes that served as the basis for questions related to evaluation of the educational offerings in the postmeeting questionnaires. These themes were identical to those established for the 2011 Meeting, and one or more themes were assigned to each educational activity on the basis of the course content and/or objectives [3]. Six themes were clinical in character (Bariatric, Hernia, Foregut, Colorectal, Hepatobiliary, Solid Organ), two were technological (Flexible Endoscopy, New Technologies/Skill Acquisition), and two were practice-based [Academic/Educational (e.g., simulation-based education, implementing milestones, fellowship training), Professional/Economic (e.g., health care reform, use of electronic medical record, use of social media)]. Questionnaire development and implementation The immediate postmeeting questionnaire had both learning theme-specific and overall meeting sections. For the learning theme-specific sections, respondents were asked to identify up to two learning themes corresponding to the majority of educational offerings in which they participated (e.g., Bariatric and Colorectal if these were the topics of the majority of the sessions attended). After this selection, the respondents were then prompted to answer questions related to potential practice change items that were based on learning objectives developed for educational content in this category. In particular, the respondents were asked to identify those objectives that they planned to implement in their clinical practice. Additionally, any attendees who participated in a hands-on course and/or a postgraduate (PG) course were also asked to complete a series of precourse case volume (5-point scale with volume range as follows: none, 1–3 cases, 4–10 cases, 11–30 cases, [30 cases) and comfort level responses (Likert-type scale, 1 = very uncomfortable to 5 = very comfortable) related to the procedures taught during the hands-on or PG course.
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Upon completion of this learning theme-specific section of the questionnaire, respondents then completed an overall Program evaluation that included, among other questions, a subsection asking them to select from a list of topics those items which they considered the most important as content for future meetings (5-point Likert scale, 1 = no need to 5 = high need). Respondents could complete this immediate postmeeting questionnaire at a computer kiosk on site at the meeting or via the internet online after returning home. They had 2 weeks from the end of the meeting to respond. Three months after the meeting, the follow-up questionnaire was administered electronically via internet to all respondents who had completed the immediate postmeeting questionnaire. Respondents were asked to describe the extent to which they had implemented proposed changes in practice using a three-point scale (fully implemented, partially implemented, not implemented at all). For respondents indicating partial or failed implementation of an intended practice change, a follow-up question asked them to indicate what barriers, if any, they encountered to implementation from a list of 11 items. These items fell into four broad categories of barriers: (1) no barriers present, (2) environmental/institutional barriers, (3) individual-based/practitioner barriers, and (4) miscellaneous barriers. Additionally, respondents who had participated in the hands-on and/or PG courses at the annual meeting were asked about their case volume and comfort level for performing procedures taught during the hands-on course over the 3 months since attending the annual meeting. Analysis All data were deidentified and underwent descriptive statistical analysis. Response rates for each questionnaire were calculated. Frequency counts were determined for learning themes, intended practice change objectives, degrees of implementation, and case volume ranges. Mean scores were calculated for all comfort level questions as well as for the educational content topics.
Results Response rates, learning theme selection, and future topics Attendees to the 2012 annual meeting held in San Diego, CA from March 7–10 included physicians, nurses, and members of allied health involved in the care of gastrointestinal and endoscopic surgery patients. A total of 2,306 individuals attended, of which 1,505 were ‘‘CME-eligible’’ (i.e., physicians in practice). All attendees were invited to
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complete the immediate postmeeting questionnaire, of which 797 did, a 34.6 % response rate. Of CME-eligible participants, 637 completed the questionnaire, a 42.3 % response rate. The 3-month follow-up questionnaire was sent to all those individuals who had completed the immediate postmeeting questionnaire. Of this entire group, 367 responded, a 46 % response rate, of which 355 were CME-eligible, a 55.7 % response rate. The top four learning themes selected by respondents included Bariatric, Hernia, Foregut, and Colorectal (Fig. 1). In addition, among respondents picking two learning themes, 45 % chose a combination of two of these topics (i.e., Bariatric–Foregut, Foregut–Bariatric, Bariatric–Hernia, Bariatric–Colorectal, and Colorectal–Hernia). The Professional/Economic learning theme was the least commonly chosen theme. Figure 2 lists respondents’ perceived importance of suggested topics for future SAGES meetings. Improving MIS technique defined the top three topics selected, whether for reoperative surgery, introducing new procedures into practice, or developing advanced techniques. The fourth through sixth highest rated topics were subjects related to the Foregut, Hernia, and Colorectal learning themes, respectively. Topics identified as having little need were NOTES, basic training in diagnostic endoscopy, and pediatric issues. Intended practice changes and their implementation Overall, respondents to the immediate postmeeting questionnaire expressed an intention to implement a practice change related to minimally invasive surgery (MIS) technique and/or management of complications of MIS procedures (Table 1). An intended practice change related to improving MIS technique was among the top three most commonly cited in the learning themes for Solid Organ, Colorectal, Bariatric, New Technology/Skill Acquisition, and Hepatobiliary. An intended practice change related to management of complications related to an MIS procedure was among the top three most commonly cited in the learning themes for Foregut, Solid Organ, and Bariatric. The top cited intended practice changes for each learning theme are listed in Table 2. At the 3-month follow-up, implementation rates were variable for the top cited intended practice changes (Table 2). A majority of respondents reported full implementation for the top cited intended practice changes for the Foregut, Hernia, New Technology/Skill Acquisition, and Professional/Economic learning themes. A majority of respondents reported partial implementation of the top cited Colorectal, Bariatric, Academic/Educational, Solid Organ, and Hepatobiliary learning theme intended practice changes. Finally, the highest rates of no implementation
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Fig. 1 Learning theme frequency rates among respondents to the questionnaire immediately after the meeting
Fig. 2 Respondents’ perceived importance of suggested topics for future SAGES meetings. 1 no need, 2 little need, 3 neutral, 4 some need, 5 high need
([10 % of respondents) of the top cited intended practice changes were present in the Professional/Economic, Flexible Endoscopy, and Academic/Educational learning
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themes. The top four most and least successfully implemented intended practice changes are listed in Tables 3 and 4, respectively. Both the Professional/Economic and the
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Table 1 Commonly cited desired practice changes related to MIS technique and/or complication management per learning theme Practice change category
Learning theme (n)
Practice change desired
Frequency/ order
MIS technique
Solid Organ (53)
Increase my use of MIS techniques for abdominal solid organ surgery
63 %/#1 cited
Colorectal (221)
Increase my use of MIS techniques in pelvic surgery
56 %/#1 cited
Increase my use of reduced port or transanal surgical techniques
48 %/#2 cited
Bariatric (292)
Increase or modify my use of MIS techniques in metabolic surgery
49 %/#1 cited
Hernia (285)
Increase my use of endoscopic component separation release
49 %/#2 cited
New Technology/ Skill Acquisition (151)
Increase my use of reduced port surgical techniques
49 %/#1 cited
Increase my use of robotic surgical techniques
44 %/#2 cited
Hepatobiliary (47)
Increase my use of MIS techniques when treating HPB diseases
77 %/#1 cited
Increase use of MIS techniques in the treatment of pancreatitis and its complications
43 %/#2 cited
Increase my use of reduced port surgical techniques
40 %/#3 cited
Foregut (282)
Improve patient safety by applying appropriate measures and techniques to prevent intraoperative complications
48 %/#1 cited
Solid organ (53)
Improve patient safety by applying appropriate measures to prevent intraoperative complications
47 %/#2 cited
Bariatric (292)
Increase my use of MIS or endoscopic techniques to treat complications of metabolic surgery
42 %/#2 cited
Management of complications
enumerated in Table 5. Overall, approximately one fifth of respondents did not perceive any barriers to implementation. This rate (i.e., between 20 and 25 % of respondents) was found in 7 of the 10 learning themes. For respondents perceiving barriers, institutional barriers were most common, in particular cost restrictions and lack of support. They accounted for almost 50 % of the total. Individual-based barriers, especially lack of time, accounted for *25 % of the total. Among the top four learning themes, environmental issues were cited as barriers by over 50 % of respondents in the Foregut and Bariatric themes. In Colorectal, individualbased barriers were cited by 25 % of respondents, the highest for the top four learning themes. Solid organ had the highest rate of perceived environmental barriers, whereas Hepatobiliary had the highest rate of perceived individual-based barriers to implementation of intended practice changes. Postgraduate and hands-on courses Pre- and post-hands-on course procedural comfort level and case volume values are shown in Table 6 and Fig. 3, respectively. In general, less than 50 % of initial respondents filled out the 3-month follow-up data. Comfort levels increased after the hands-on courses except for robotic bariatric and colorectal courses. Changes in procedure volume were variable.
Discussion
MIS minimally invasive surgery, HPB hepatobiliary
New Technology/Skill Acquisition learning themes had at least one item in the top four of both the most and least successfully implemented intended practice changes. Barriers to implementation of desired practice changes noted by respondents at the 3-month follow-up are
The data presented in this article are a synopsis of information gathered by the SAGES CEC after the 2012 annual meeting in San Diego, CA, as part of its ongoing charge of satisfying ACCME requirements and identifying and targeting practice gaps for educational activities. Taken with the published 2011 data of Farrell et al. [3] for the annual meeting in San Antonio, TX, it can help identify trends related to evolving needs and gaps among attendees of the meetings, including physicians, nurses, allied health professionals, SAGES members, and nonmembers. In this manner, it can help inform the nature of future SAGES’ educational activities, including the annual meeting, SAGES University and the Fundamental programs, in order to provide timely, valuable professional development for members and learners. It represents a needs assessment for educational planning in order to help hone members’ KSAs. It also serves to demonstrate the effectiveness and educational impact of the SAGES annual meeting. In no way does it represent an inability of SAGES members to practice effective, safe surgery. To our knowledge, publication of such in-depth analyses of the educational impact of consecutive annual scientific meetings of a surgical society is novel.
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Table 2 Top desired practice change per learning theme cited by respondents and degree of implementation Learning theme
Desired practice change
Respondents (n) After meeting
Response rate (%)
Degree of implementation (%)
3-month follow-up
None
Partial
Full
Foregut (n = 282)
Prevent intraoperative complications
136
64
47
3
31
66
Colorectal (n = 221)
Increase MIS techniques in pelvic surgery
123
53
43
4
55
42
Bariatric (n = 292)
Increase MIS techniques in metabolic surgery
143
64
45
6
53
41
Hernia (n = 285)
Modify mesh choice
158
82
52
5
44
51
New technology/skill acquisition (n = 151)
Increase reduced port techniques
74
35
47
6
43
51
Academic/educational (n = 81)
Increase use of validated procedural assessment tools
38
24
63
13
58
29
Flexible endoscopy (n = 55)
Increase therapeutic endoscopy
41
23
56
17
35
48
Solid organ (n = 53)
Increase MIS techniques in solid organ surgery
33
17
51
6
59
35
Hepatobiliary (n = 47)
Increase MIS techniques in HPB diseases
36
19
53
11
53
37
Professional/economic (n = 33)
Increase involvement in health care reform
20
8
40
25
13
62
MIS minimally invasive surgery, HPB hepatobiliary
Table 3 Top four most successfully implemented desired practice changes by respondents to 3-month follow-up questionnaire Learning theme
Desired practice change
Respondents (n) After meeting
Professional/Economic
EMR use in practice
Foregut
Prevent intraoperative complications Involvement in health care reform
Professional/Economic New Technology/Skill Acquisition
Energy devices
3-month follow-up
Response rate (%)
Degree of implementation (%) None
Partial
Full
15
9
60
11
22
67
136
64
47
3
31
66
20
8
40
25
13
63
46
22
48
5
41
55
EMR endoscopic mucosal resection
Table 4 Top four least successfully implemented desired practice changes by respondents to 3-month follow-up questionnaire Learning theme
Desired practice change
Respondents (n)
Response rate (%)
Degree of implementation (%) None
Partial
Full
After meeting
3-month follow-up
140
72
51
43
32
25
Hernia
Endoscopic CST
Academic
Milestones
31
22
71
27
41
32
Professional/economic
Involvement in health care reform
20
8
40
25
13
63
Colorectal
Reduced port transanal
105
49
47
24
35
41
New technology/skill acquisition
Robotic surgery
66
29
44
24
45
31
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Table 5 Barriers to desired practice changes reported by respondents in the 3-month follow-up questionnaire Learning theme
Total no. of responses (n)
No reported barriers (%)
Environmental/institutionalbased barriers (%)
Individual/practitionerbased barriers (%)
Miscellaneous barriers (%)
Foregut
175
22
54
19
5
Solid organ
38
5
68
24
3
Colorectal
106
25
44
25
5
Bariatric
149
23
53
17
6
Hernia
164
21
38
32
8
New Technology/skill acquisition
100
25
41
27
7
Academic
56
9
32
48
11
HPB
29
41
21
55
0
Professional/ economic
18
22
44
28
6
Flex endo Total
28
21
46
21
11
863
21
47
26
6
HPB hepatobiliary
Table 6 Comparison of comfort levels immediately after the meeting to 3-month follow-up Category
After meeting (n)
3-month follow-up (n)
Comfort before course (mean)
Comfort at 3-month follow-up (mean)
Change in comfort (post–pre)
APC or RFA
78
5
2.88
4.2
1.32
Bipolar energy
79
5
4.06
4.4
0.34
POEM
81
39
2.09
2.13
0.04
Open component separation
171
75
3.74
3.89
0.15
Laparoscopic component separation
171
74
2.99
3.21
0.22
Ventral hernia
170
75
4.14
4.48
0.34
Band (DM)
167
74
3.66
3.76
0.1
Roux-en-Y (DM)
167
74
3.83
4.19
0.36
Sleeve (DM) ESD
168 139
74 58
3.94 2.17
4.15 2.38
0.21 0.21
Combined endoscopiclaparoscopic
139
58
3.11
3.14
0.03
Single-port colorectal
140
58
2.49
2.79
0.3
Robotic HPB
88
40
2.18
2.23
0.05
Robotic colorectal
84
40
2.46
2.25
-0.21
Robotic bariatrics
85
40
2.22
2.08
-0.145
Robotic foregut
88
40
2.52
2.63
0.11
RFA radiofrequency ablation, POEM peroral endoscopic myotomy, ESD endoscopic submucosal dissection, HPB hepatobiliary
Several summary points may be made regarding the 2012 immediate postmeeting and 3-month follow-up questionnaire findings. First, respondents clearly were most interested in the Bariatric, Hernia, Foregut, and Colorectal learning themes because almost 50 % chose a combination of the two as their preferred learning themes at the meeting. These same four themes were most commonly reported by attendees at the 2011 annual meeting [3]. For these topics, respondents succeeded fairly well in either fully or partially
implementing their most commonly cited intended practice change, with over 90 % attaining full or partial implementation. Full implementation of intended practice changes was more successful within the Foregut and Hernia learning themes compared to Colorectal and Bariatric. Such results suggest that at least some of the annual meeting content related to these learning themes is leading to adoption of practices by attendees, an important goal. The fact that the Colorectal and Hernia learning themes
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A
B
Fig. 3 Reported case volume of hands-on course procedures (A) 3 months before and (B) 3 months after course
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each had two of the top four least successfully implemented intended practice changes indicates that more work can be done to assist learners in overcoming barriers to change. Causes for such failure to implement intended practice changes could be the result of either ineffective teaching in these areas, something that can be addressed in courses at future meetings, or to the presence of local institutional barriers. Sharing of successful strategies in overcoming common barriers to implementation during future courses could address such an issue. The three highest rated desired topics for future educational activities were unchanged from what Farrell et al. [3] described for 2011: reoperative laparoscopic surgery, introducing new procedures into practice, and advanced laparoscopic techniques. Additionally, the fourth through sixth topics included Foregut, Colorectal, and Hernia learning theme subject matter. Continued focus on educational content related to these topics appropriately aligns our educational content to our attendees’ scope of practice. Reoperative laparoscopy can be one of the most technically challenging forms of MIS [4, 5], and as such, it is not surprising that attendees to the annual meeting show a desire to have more content for refining KSAs. The introduction of new procedures is also a particularly challenging endeavor for a surgeon in practice. Learning the new technique or procedure, undergoing preceptorships, determining when one is ready to perform it independently, obtaining the appropriate credentials, and overcoming barriers to implementation within their home institutions can be challenging [6], and these issues continue to be considered by our learners as priorities to address in future meetings. Other areas in which SAGES may focus educational content include MIS techniques and management of complications because variations of these two topics were among the top cited intended practice changes for seven of the ten meeting learning themes. In addition, 2012 meeting topics dealing with the innovative techniques of reducedport colorectal surgery, endoscopic component-separation hernia techniques, and robotic surgery had some of the highest rates of nonadoption at the 3-month follow-up. As such, revisiting these topics in future educational activities and attempting a different teaching approach may be warranted. The same comments are true for promoting the adoption of milestones in residencies and the involvement of individuals in health care reform, two other intended practice changes with low adoption rates. Barriers to implementing changes in practice were perceived by almost 80 % of respondents. These were mainly environmental/institutional-based in character, but individual/practitioner-based barriers were present in about a quarter of responses. Cost, lack of support, and lack of time were major factors selected by respondents, similar to the
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findings of Farrell et al. [3]. Given these facts, addressing how to overcome possible cost constraints related to these issues in the implementation of intended practice changes by attendees may improve the impact of the educational offerings. Additionally, noneducational strategies such as targeted advocacy by SAGES may help in overcoming the barriers in certain situations. Limitations to this data set include its self-reported nature leading to potential inaccurate recall by respondents. In addition, the hands-on precourse questions were completed by participants during the immediate postmeeting questionnaire, creating the possibility of bias in responses. Although response rates were fairly good for a survey of this character, the number of respondents to the 3-month follow-up questionnaire was lower than immediately after the meeting, potentially skewing results. For example, some of the follow-up response rates for hands-on courses and/or learning themes were accounted for by 40 individuals or fewer. Finally, the 3-month follow-up could have been too short to document practice change among many surgeons. In conclusion, analysis of the 2012 annual meeting survey data set identifies important practice gaps among attendees, some of which are similar to those reported by Farrell et al. [3]. Such analyses are one aspect of a multipronged approach by the SAGES CEC to creating a robust practice gap data bank which can serve as a resource for educators developing content for members. Other targeted sources of information for this Gap Bank include material from SAGES University, SAGES course surveys, SAGES evidence-based guidelines, outcomes data banks, and case volumes of residents and MIS fellows. In this manner, SAGES will continue to lead educational curricular development, providing timely, useful, effective offerings to its membership. In addition, these data can help inform the curricular content of other educators and provide direction for educational research. Acknowledgments In preparing this report, the authors would like to recognize the support and input of the other members of the CEC; SAGES past president, W. Scott Melvin; SAGES president, Gerald Fried; SAGES president-elect, L. Michael Brunt; and SAGES executive director, Sallie Matthews. Disclosures Dr. Paige is coeditor of Simulation in Radiology and receives royalties from Oxford University Press. Dr. Farrell is a consultant for New Wave Surgical and Teleflex Medical and receives consulting fees from both. Dr. Selim is a speaker/teacher for Covidien and has received honoraria for these services. Erin Swartz is a consultant for BSC Management which manages SAGES and receives consulting fees. Yumi Hori is a salaried employee of BSC Management. Jason Levine is a salaried employee of BSC Management. Dr. Scott is coinventor and has intellectual property rights on magnetically anchored instruments. He has done sponsored research support and/or received lab equipment from Ethicon, Karl Storz Endoscopy, and Covidien. He is a consultant for Neat Stitch Inc. and Accelerated
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4438 Technologies Inc., for which he receives consulting fees. He is also on an advisory panel and teaches for Covidien. Drs. Bergman and Harzman have no conflicts of interest or financial ties to disclose.
References 1. ACCME professional practice gaps (2013). http://education. accme.org/tags/professional-practice-gaps. Accessed 5 Aug 2013 2. SAGES (2013). http://www.sages.org/. Accessed 5 Aug 2013 3. Farrell TM, Bergman S, Selim N, Paige JT, Harzman A, Schwarz E, Hori Y, Levine J, Scott DJ (2012) Practice gaps in
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Surg Endosc (2013) 27:4429–4438 gastrointestinal and endoscopic surgery (2011): a report from the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee. Surg Endosc 26:3367–3381 4. Brody F, Holzman M, Tarnoff M, Oleynikov D, Marks J, Ramshaw B, Ponsky T (2008) Summaries of the SAGES 2007 reoperative minimally invasive surgery symposium. Surg Endosc 22:232–244 5. Van Beck DB, Auyang ED, Soper NJ (2011) A comprehensive review of laparoscopic redo fundoplication. Surg Endosc 25:706–712 6. Ellison EC, Carey LC (2008) Lessons learned from the evolution of the laparoscopic revolution. Surg Clin N Am 88:927–941
and Other Interventional Techniques
SAGES REPORT
Evolution of practice gaps in gastrointestinal and endoscopic surgery: 2012 report from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee John T. Paige • Timothy M. Farrell • Simon Bergman • Niazy Selim • Alan E. Harzman • Erin Schwarz • Yumi Hori • Jason Levine • Daniel J. Scott
Received: 13 September 2013 / Accepted: 6 October 2013 / Published online: 7 November 2013 Ó Springer Science+Business Media New York 2013
Abstract Background In an effort to fulfill its charge to develop and maintain a comprehensive educational program to serve the members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the SAGES Continuing Education Committee (CEC) reports a summary of findings related to its evaluation of the 2012 SAGES annual meeting. Methods All attendees to the 2012 annual meeting had the opportunity to complete an immediate postmeeting questionnaire as part of their continuing medical education J. T. Paige (&) Department of Surgery, LSU Health New Orleans School of Medicine, 1542 Tulane Ave, Rm 734, New Orleans, LA 70112, USA e-mail: [email protected] T. M. Farrell Department of Surgery, University North Carolina at Chapel Hill, Chapel Hill, NC, USA S. Bergman Department of Surgery, McGill University, Montreal, QC, Canada N. Selim Department of Surgery, University of Kansas Medical Center, Kansas, KS, USA A. E. Harzman Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA E. Schwarz Y. Hori J. Levine SAGES, Los Angeles, CA, USA D. J. Scott University of Texas Southwestern Medical Center, Dallas, TX, USA
(CME) certification in which they identified up to two learning themes, answered questions related to potential practice change items that are based on those learning themes, and complete a needs assessment related to important learning topics for future meetings. In addition, participants in the postgraduate and hands-on courses were asked to complete questions about case volume and comfort levels related to procedures/topics in those courses. All respondents to this initial survey were sent a 3-month follow-up questionnaire in which they were asked how successfully they had implemented the intended practice changes and what, if any, barriers they encountered. Postgraduate and hands-on course participants completed case volume and comfort level questions. Descriptive statistical analysis of this deidentified data was undertaken. Results Response rates were 42 % and 56 % for CMEeligible attendees/respondents for the immediate postmeeting and 3-month follow-up questionnaires, respectively. Top learning themes for respondents were Bariatric, Hernia, Foregut, and Colorectal. Improving minimally invasive surgical (MIS) technique and managing complications related to MIS procedures were top intended practice changes. Partial implementation was common with top barriers including cost restrictions, lack of institutional support, and lack of time. Conclusions The 2012 annual meeting analysis provides insight into educational needs among respondents and will help with planning content for future meetings. Keywords gaps
Education Training Courses Practice
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is accredited by the Accreditation
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Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) credits to physicians. In order to do so, SAGES must follow specific ACCME criteria in the planning and implementation of its educational activities. Central to these requirements is the need to identify professional practice gaps among potential learners in order to address adequately SAGES’ four major CME objectives: (1) improving knowledge of gastrointestinal and related disease; (2) assessing current and emerging surgical therapies; (3) acquiring competence to perform and teach appropriate therapies; and (4) measuring effectiveness of therapies in terms of outcomes [1, 2]. The SAGES Continuing Education Committee (CEC) is charged with ensuring maintenance of ACCME accreditation as well as developing and maintaining a comprehensive educational program to serve the members of the Society related to its educational objectives. As part of this process, SAGES has developed a practice gap data bank to assist with planning educational activities. This data bank draws on many sources, of which a major one is the annual postmeeting survey of attendees of the annual meeting. This survey has two major components: (1) a questionnaire given immediately after the end of the annual meeting targeting perceived practice needs of attendees as well as their gains in knowledge, skills, and attitudes (KSAs) resulting from the meeting, and (2) a 3-month follow-up questionnaire targeting transfer of KSAs to actual practice, as well as barriers that may have prevented or blunted such transfer. For the 2011 annual meeting held in San Antonio, TX, Farrell et al. [3] published, on behalf of the SAGES CEC, the results of this survey. Top learning themes selected by attendees to this meeting included Foregut, Hernia, Bariatric, and Colorectal. All four themes were selected by more than a quarter of participants as one of their top two learning themes at the Meeting. Popular topics within learning themes included patient evaluation and selection as well as application of evidence in selecting procedures. Important barriers to implementation of intended practice changes were cost and institutional support. Finally, top requested topics for future educational content among attendees included reoperative laparoscopic surgery, introduction of new procedures into practice, advanced laparoscopic techniques, and foregut surgery. In an effort to build on the above findings and expand the practice gap data bank for programmatic planning of future annual meetings, the SAGES CEC reports a summary of findings related to this evaluation/needs assessment of the 2012 SAGES annual meeting. In this manner, comparison and contrast can be made with the 2011 published data to identify trends and developments related to
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the learning needs of members, helping to inform future educational content.
Methods Learning theme assignment The Assessment Task Force, a working group of the CEC charged in part with overseeing assessment of the meeting’s effectiveness, developed the survey questionnaires sent out to the attendees of the 2012 annual meeting. During planning for the meeting, this body was responsible for ensuring adequate documentation of linkage of the learning objectives developed for each educational offering to identified practice gaps. They divided the program content into ten learning themes that served as the basis for questions related to evaluation of the educational offerings in the postmeeting questionnaires. These themes were identical to those established for the 2011 Meeting, and one or more themes were assigned to each educational activity on the basis of the course content and/or objectives [3]. Six themes were clinical in character (Bariatric, Hernia, Foregut, Colorectal, Hepatobiliary, Solid Organ), two were technological (Flexible Endoscopy, New Technologies/Skill Acquisition), and two were practice-based [Academic/Educational (e.g., simulation-based education, implementing milestones, fellowship training), Professional/Economic (e.g., health care reform, use of electronic medical record, use of social media)]. Questionnaire development and implementation The immediate postmeeting questionnaire had both learning theme-specific and overall meeting sections. For the learning theme-specific sections, respondents were asked to identify up to two learning themes corresponding to the majority of educational offerings in which they participated (e.g., Bariatric and Colorectal if these were the topics of the majority of the sessions attended). After this selection, the respondents were then prompted to answer questions related to potential practice change items that were based on learning objectives developed for educational content in this category. In particular, the respondents were asked to identify those objectives that they planned to implement in their clinical practice. Additionally, any attendees who participated in a hands-on course and/or a postgraduate (PG) course were also asked to complete a series of precourse case volume (5-point scale with volume range as follows: none, 1–3 cases, 4–10 cases, 11–30 cases, [30 cases) and comfort level responses (Likert-type scale, 1 = very uncomfortable to 5 = very comfortable) related to the procedures taught during the hands-on or PG course.
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Upon completion of this learning theme-specific section of the questionnaire, respondents then completed an overall Program evaluation that included, among other questions, a subsection asking them to select from a list of topics those items which they considered the most important as content for future meetings (5-point Likert scale, 1 = no need to 5 = high need). Respondents could complete this immediate postmeeting questionnaire at a computer kiosk on site at the meeting or via the internet online after returning home. They had 2 weeks from the end of the meeting to respond. Three months after the meeting, the follow-up questionnaire was administered electronically via internet to all respondents who had completed the immediate postmeeting questionnaire. Respondents were asked to describe the extent to which they had implemented proposed changes in practice using a three-point scale (fully implemented, partially implemented, not implemented at all). For respondents indicating partial or failed implementation of an intended practice change, a follow-up question asked them to indicate what barriers, if any, they encountered to implementation from a list of 11 items. These items fell into four broad categories of barriers: (1) no barriers present, (2) environmental/institutional barriers, (3) individual-based/practitioner barriers, and (4) miscellaneous barriers. Additionally, respondents who had participated in the hands-on and/or PG courses at the annual meeting were asked about their case volume and comfort level for performing procedures taught during the hands-on course over the 3 months since attending the annual meeting. Analysis All data were deidentified and underwent descriptive statistical analysis. Response rates for each questionnaire were calculated. Frequency counts were determined for learning themes, intended practice change objectives, degrees of implementation, and case volume ranges. Mean scores were calculated for all comfort level questions as well as for the educational content topics.
Results Response rates, learning theme selection, and future topics Attendees to the 2012 annual meeting held in San Diego, CA from March 7–10 included physicians, nurses, and members of allied health involved in the care of gastrointestinal and endoscopic surgery patients. A total of 2,306 individuals attended, of which 1,505 were ‘‘CME-eligible’’ (i.e., physicians in practice). All attendees were invited to
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complete the immediate postmeeting questionnaire, of which 797 did, a 34.6 % response rate. Of CME-eligible participants, 637 completed the questionnaire, a 42.3 % response rate. The 3-month follow-up questionnaire was sent to all those individuals who had completed the immediate postmeeting questionnaire. Of this entire group, 367 responded, a 46 % response rate, of which 355 were CME-eligible, a 55.7 % response rate. The top four learning themes selected by respondents included Bariatric, Hernia, Foregut, and Colorectal (Fig. 1). In addition, among respondents picking two learning themes, 45 % chose a combination of two of these topics (i.e., Bariatric–Foregut, Foregut–Bariatric, Bariatric–Hernia, Bariatric–Colorectal, and Colorectal–Hernia). The Professional/Economic learning theme was the least commonly chosen theme. Figure 2 lists respondents’ perceived importance of suggested topics for future SAGES meetings. Improving MIS technique defined the top three topics selected, whether for reoperative surgery, introducing new procedures into practice, or developing advanced techniques. The fourth through sixth highest rated topics were subjects related to the Foregut, Hernia, and Colorectal learning themes, respectively. Topics identified as having little need were NOTES, basic training in diagnostic endoscopy, and pediatric issues. Intended practice changes and their implementation Overall, respondents to the immediate postmeeting questionnaire expressed an intention to implement a practice change related to minimally invasive surgery (MIS) technique and/or management of complications of MIS procedures (Table 1). An intended practice change related to improving MIS technique was among the top three most commonly cited in the learning themes for Solid Organ, Colorectal, Bariatric, New Technology/Skill Acquisition, and Hepatobiliary. An intended practice change related to management of complications related to an MIS procedure was among the top three most commonly cited in the learning themes for Foregut, Solid Organ, and Bariatric. The top cited intended practice changes for each learning theme are listed in Table 2. At the 3-month follow-up, implementation rates were variable for the top cited intended practice changes (Table 2). A majority of respondents reported full implementation for the top cited intended practice changes for the Foregut, Hernia, New Technology/Skill Acquisition, and Professional/Economic learning themes. A majority of respondents reported partial implementation of the top cited Colorectal, Bariatric, Academic/Educational, Solid Organ, and Hepatobiliary learning theme intended practice changes. Finally, the highest rates of no implementation
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Fig. 1 Learning theme frequency rates among respondents to the questionnaire immediately after the meeting
Fig. 2 Respondents’ perceived importance of suggested topics for future SAGES meetings. 1 no need, 2 little need, 3 neutral, 4 some need, 5 high need
([10 % of respondents) of the top cited intended practice changes were present in the Professional/Economic, Flexible Endoscopy, and Academic/Educational learning
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themes. The top four most and least successfully implemented intended practice changes are listed in Tables 3 and 4, respectively. Both the Professional/Economic and the
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Table 1 Commonly cited desired practice changes related to MIS technique and/or complication management per learning theme Practice change category
Learning theme (n)
Practice change desired
Frequency/ order
MIS technique
Solid Organ (53)
Increase my use of MIS techniques for abdominal solid organ surgery
63 %/#1 cited
Colorectal (221)
Increase my use of MIS techniques in pelvic surgery
56 %/#1 cited
Increase my use of reduced port or transanal surgical techniques
48 %/#2 cited
Bariatric (292)
Increase or modify my use of MIS techniques in metabolic surgery
49 %/#1 cited
Hernia (285)
Increase my use of endoscopic component separation release
49 %/#2 cited
New Technology/ Skill Acquisition (151)
Increase my use of reduced port surgical techniques
49 %/#1 cited
Increase my use of robotic surgical techniques
44 %/#2 cited
Hepatobiliary (47)
Increase my use of MIS techniques when treating HPB diseases
77 %/#1 cited
Increase use of MIS techniques in the treatment of pancreatitis and its complications
43 %/#2 cited
Increase my use of reduced port surgical techniques
40 %/#3 cited
Foregut (282)
Improve patient safety by applying appropriate measures and techniques to prevent intraoperative complications
48 %/#1 cited
Solid organ (53)
Improve patient safety by applying appropriate measures to prevent intraoperative complications
47 %/#2 cited
Bariatric (292)
Increase my use of MIS or endoscopic techniques to treat complications of metabolic surgery
42 %/#2 cited
Management of complications
enumerated in Table 5. Overall, approximately one fifth of respondents did not perceive any barriers to implementation. This rate (i.e., between 20 and 25 % of respondents) was found in 7 of the 10 learning themes. For respondents perceiving barriers, institutional barriers were most common, in particular cost restrictions and lack of support. They accounted for almost 50 % of the total. Individual-based barriers, especially lack of time, accounted for *25 % of the total. Among the top four learning themes, environmental issues were cited as barriers by over 50 % of respondents in the Foregut and Bariatric themes. In Colorectal, individualbased barriers were cited by 25 % of respondents, the highest for the top four learning themes. Solid organ had the highest rate of perceived environmental barriers, whereas Hepatobiliary had the highest rate of perceived individual-based barriers to implementation of intended practice changes. Postgraduate and hands-on courses Pre- and post-hands-on course procedural comfort level and case volume values are shown in Table 6 and Fig. 3, respectively. In general, less than 50 % of initial respondents filled out the 3-month follow-up data. Comfort levels increased after the hands-on courses except for robotic bariatric and colorectal courses. Changes in procedure volume were variable.
Discussion
MIS minimally invasive surgery, HPB hepatobiliary
New Technology/Skill Acquisition learning themes had at least one item in the top four of both the most and least successfully implemented intended practice changes. Barriers to implementation of desired practice changes noted by respondents at the 3-month follow-up are
The data presented in this article are a synopsis of information gathered by the SAGES CEC after the 2012 annual meeting in San Diego, CA, as part of its ongoing charge of satisfying ACCME requirements and identifying and targeting practice gaps for educational activities. Taken with the published 2011 data of Farrell et al. [3] for the annual meeting in San Antonio, TX, it can help identify trends related to evolving needs and gaps among attendees of the meetings, including physicians, nurses, allied health professionals, SAGES members, and nonmembers. In this manner, it can help inform the nature of future SAGES’ educational activities, including the annual meeting, SAGES University and the Fundamental programs, in order to provide timely, valuable professional development for members and learners. It represents a needs assessment for educational planning in order to help hone members’ KSAs. It also serves to demonstrate the effectiveness and educational impact of the SAGES annual meeting. In no way does it represent an inability of SAGES members to practice effective, safe surgery. To our knowledge, publication of such in-depth analyses of the educational impact of consecutive annual scientific meetings of a surgical society is novel.
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Table 2 Top desired practice change per learning theme cited by respondents and degree of implementation Learning theme
Desired practice change
Respondents (n) After meeting
Response rate (%)
Degree of implementation (%)
3-month follow-up
None
Partial
Full
Foregut (n = 282)
Prevent intraoperative complications
136
64
47
3
31
66
Colorectal (n = 221)
Increase MIS techniques in pelvic surgery
123
53
43
4
55
42
Bariatric (n = 292)
Increase MIS techniques in metabolic surgery
143
64
45
6
53
41
Hernia (n = 285)
Modify mesh choice
158
82
52
5
44
51
New technology/skill acquisition (n = 151)
Increase reduced port techniques
74
35
47
6
43
51
Academic/educational (n = 81)
Increase use of validated procedural assessment tools
38
24
63
13
58
29
Flexible endoscopy (n = 55)
Increase therapeutic endoscopy
41
23
56
17
35
48
Solid organ (n = 53)
Increase MIS techniques in solid organ surgery
33
17
51
6
59
35
Hepatobiliary (n = 47)
Increase MIS techniques in HPB diseases
36
19
53
11
53
37
Professional/economic (n = 33)
Increase involvement in health care reform
20
8
40
25
13
62
MIS minimally invasive surgery, HPB hepatobiliary
Table 3 Top four most successfully implemented desired practice changes by respondents to 3-month follow-up questionnaire Learning theme
Desired practice change
Respondents (n) After meeting
Professional/Economic
EMR use in practice
Foregut
Prevent intraoperative complications Involvement in health care reform
Professional/Economic New Technology/Skill Acquisition
Energy devices
3-month follow-up
Response rate (%)
Degree of implementation (%) None
Partial
Full
15
9
60
11
22
67
136
64
47
3
31
66
20
8
40
25
13
63
46
22
48
5
41
55
EMR endoscopic mucosal resection
Table 4 Top four least successfully implemented desired practice changes by respondents to 3-month follow-up questionnaire Learning theme
Desired practice change
Respondents (n)
Response rate (%)
Degree of implementation (%) None
Partial
Full
After meeting
3-month follow-up
140
72
51
43
32
25
Hernia
Endoscopic CST
Academic
Milestones
31
22
71
27
41
32
Professional/economic
Involvement in health care reform
20
8
40
25
13
63
Colorectal
Reduced port transanal
105
49
47
24
35
41
New technology/skill acquisition
Robotic surgery
66
29
44
24
45
31
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Table 5 Barriers to desired practice changes reported by respondents in the 3-month follow-up questionnaire Learning theme
Total no. of responses (n)
No reported barriers (%)
Environmental/institutionalbased barriers (%)
Individual/practitionerbased barriers (%)
Miscellaneous barriers (%)
Foregut
175
22
54
19
5
Solid organ
38
5
68
24
3
Colorectal
106
25
44
25
5
Bariatric
149
23
53
17
6
Hernia
164
21
38
32
8
New Technology/skill acquisition
100
25
41
27
7
Academic
56
9
32
48
11
HPB
29
41
21
55
0
Professional/ economic
18
22
44
28
6
Flex endo Total
28
21
46
21
11
863
21
47
26
6
HPB hepatobiliary
Table 6 Comparison of comfort levels immediately after the meeting to 3-month follow-up Category
After meeting (n)
3-month follow-up (n)
Comfort before course (mean)
Comfort at 3-month follow-up (mean)
Change in comfort (post–pre)
APC or RFA
78
5
2.88
4.2
1.32
Bipolar energy
79
5
4.06
4.4
0.34
POEM
81
39
2.09
2.13
0.04
Open component separation
171
75
3.74
3.89
0.15
Laparoscopic component separation
171
74
2.99
3.21
0.22
Ventral hernia
170
75
4.14
4.48
0.34
Band (DM)
167
74
3.66
3.76
0.1
Roux-en-Y (DM)
167
74
3.83
4.19
0.36
Sleeve (DM) ESD
168 139
74 58
3.94 2.17
4.15 2.38
0.21 0.21
Combined endoscopiclaparoscopic
139
58
3.11
3.14
0.03
Single-port colorectal
140
58
2.49
2.79
0.3
Robotic HPB
88
40
2.18
2.23
0.05
Robotic colorectal
84
40
2.46
2.25
-0.21
Robotic bariatrics
85
40
2.22
2.08
-0.145
Robotic foregut
88
40
2.52
2.63
0.11
RFA radiofrequency ablation, POEM peroral endoscopic myotomy, ESD endoscopic submucosal dissection, HPB hepatobiliary
Several summary points may be made regarding the 2012 immediate postmeeting and 3-month follow-up questionnaire findings. First, respondents clearly were most interested in the Bariatric, Hernia, Foregut, and Colorectal learning themes because almost 50 % chose a combination of the two as their preferred learning themes at the meeting. These same four themes were most commonly reported by attendees at the 2011 annual meeting [3]. For these topics, respondents succeeded fairly well in either fully or partially
implementing their most commonly cited intended practice change, with over 90 % attaining full or partial implementation. Full implementation of intended practice changes was more successful within the Foregut and Hernia learning themes compared to Colorectal and Bariatric. Such results suggest that at least some of the annual meeting content related to these learning themes is leading to adoption of practices by attendees, an important goal. The fact that the Colorectal and Hernia learning themes
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A
B
Fig. 3 Reported case volume of hands-on course procedures (A) 3 months before and (B) 3 months after course
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each had two of the top four least successfully implemented intended practice changes indicates that more work can be done to assist learners in overcoming barriers to change. Causes for such failure to implement intended practice changes could be the result of either ineffective teaching in these areas, something that can be addressed in courses at future meetings, or to the presence of local institutional barriers. Sharing of successful strategies in overcoming common barriers to implementation during future courses could address such an issue. The three highest rated desired topics for future educational activities were unchanged from what Farrell et al. [3] described for 2011: reoperative laparoscopic surgery, introducing new procedures into practice, and advanced laparoscopic techniques. Additionally, the fourth through sixth topics included Foregut, Colorectal, and Hernia learning theme subject matter. Continued focus on educational content related to these topics appropriately aligns our educational content to our attendees’ scope of practice. Reoperative laparoscopy can be one of the most technically challenging forms of MIS [4, 5], and as such, it is not surprising that attendees to the annual meeting show a desire to have more content for refining KSAs. The introduction of new procedures is also a particularly challenging endeavor for a surgeon in practice. Learning the new technique or procedure, undergoing preceptorships, determining when one is ready to perform it independently, obtaining the appropriate credentials, and overcoming barriers to implementation within their home institutions can be challenging [6], and these issues continue to be considered by our learners as priorities to address in future meetings. Other areas in which SAGES may focus educational content include MIS techniques and management of complications because variations of these two topics were among the top cited intended practice changes for seven of the ten meeting learning themes. In addition, 2012 meeting topics dealing with the innovative techniques of reducedport colorectal surgery, endoscopic component-separation hernia techniques, and robotic surgery had some of the highest rates of nonadoption at the 3-month follow-up. As such, revisiting these topics in future educational activities and attempting a different teaching approach may be warranted. The same comments are true for promoting the adoption of milestones in residencies and the involvement of individuals in health care reform, two other intended practice changes with low adoption rates. Barriers to implementing changes in practice were perceived by almost 80 % of respondents. These were mainly environmental/institutional-based in character, but individual/practitioner-based barriers were present in about a quarter of responses. Cost, lack of support, and lack of time were major factors selected by respondents, similar to the
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findings of Farrell et al. [3]. Given these facts, addressing how to overcome possible cost constraints related to these issues in the implementation of intended practice changes by attendees may improve the impact of the educational offerings. Additionally, noneducational strategies such as targeted advocacy by SAGES may help in overcoming the barriers in certain situations. Limitations to this data set include its self-reported nature leading to potential inaccurate recall by respondents. In addition, the hands-on precourse questions were completed by participants during the immediate postmeeting questionnaire, creating the possibility of bias in responses. Although response rates were fairly good for a survey of this character, the number of respondents to the 3-month follow-up questionnaire was lower than immediately after the meeting, potentially skewing results. For example, some of the follow-up response rates for hands-on courses and/or learning themes were accounted for by 40 individuals or fewer. Finally, the 3-month follow-up could have been too short to document practice change among many surgeons. In conclusion, analysis of the 2012 annual meeting survey data set identifies important practice gaps among attendees, some of which are similar to those reported by Farrell et al. [3]. Such analyses are one aspect of a multipronged approach by the SAGES CEC to creating a robust practice gap data bank which can serve as a resource for educators developing content for members. Other targeted sources of information for this Gap Bank include material from SAGES University, SAGES course surveys, SAGES evidence-based guidelines, outcomes data banks, and case volumes of residents and MIS fellows. In this manner, SAGES will continue to lead educational curricular development, providing timely, useful, effective offerings to its membership. In addition, these data can help inform the curricular content of other educators and provide direction for educational research. Acknowledgments In preparing this report, the authors would like to recognize the support and input of the other members of the CEC; SAGES past president, W. Scott Melvin; SAGES president, Gerald Fried; SAGES president-elect, L. Michael Brunt; and SAGES executive director, Sallie Matthews. Disclosures Dr. Paige is coeditor of Simulation in Radiology and receives royalties from Oxford University Press. Dr. Farrell is a consultant for New Wave Surgical and Teleflex Medical and receives consulting fees from both. Dr. Selim is a speaker/teacher for Covidien and has received honoraria for these services. Erin Swartz is a consultant for BSC Management which manages SAGES and receives consulting fees. Yumi Hori is a salaried employee of BSC Management. Jason Levine is a salaried employee of BSC Management. Dr. Scott is coinventor and has intellectual property rights on magnetically anchored instruments. He has done sponsored research support and/or received lab equipment from Ethicon, Karl Storz Endoscopy, and Covidien. He is a consultant for Neat Stitch Inc. and Accelerated
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4438 Technologies Inc., for which he receives consulting fees. He is also on an advisory panel and teaches for Covidien. Drs. Bergman and Harzman have no conflicts of interest or financial ties to disclose.
References 1. ACCME professional practice gaps (2013). http://education. accme.org/tags/professional-practice-gaps. Accessed 5 Aug 2013 2. SAGES (2013). http://www.sages.org/. Accessed 5 Aug 2013 3. Farrell TM, Bergman S, Selim N, Paige JT, Harzman A, Schwarz E, Hori Y, Levine J, Scott DJ (2012) Practice gaps in
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Surg Endosc (2013) 27:4429–4438 gastrointestinal and endoscopic surgery (2011): a report from the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee. Surg Endosc 26:3367–3381 4. Brody F, Holzman M, Tarnoff M, Oleynikov D, Marks J, Ramshaw B, Ponsky T (2008) Summaries of the SAGES 2007 reoperative minimally invasive surgery symposium. Surg Endosc 22:232–244 5. Van Beck DB, Auyang ED, Soper NJ (2011) A comprehensive review of laparoscopic redo fundoplication. Surg Endosc 25:706–712 6. Ellison EC, Carey LC (2008) Lessons learned from the evolution of the laparoscopic revolution. Surg Clin N Am 88:927–941
