Journal of Spinal Disorders and Techniques Publish Ahead of Print DOI:10.1097/BSD.0000000000000211
Title: Outcome of a Resident Spine Surgical Skills Training Program
Authors:
Brian P. Calio, BA1 Christopher K. Kepler, MD, MBA1,2 John D. Koerner, MD1,2 Jeffrey A. Rihn, MD1,2 Paul Millhouse, MD2 Kris E. Radcliff, MD 1,2
Affiliations:
1- Thomas Jefferson University, Philadelphia PA 2- Rothman Institute, Philadelphia PA
Corresponding Author:
Kris E. Radcliff, MD 925 Chestnut St. 5th Floor Philadelphia, PA 19107 [email protected]
Sources of Support:
Cadavers provided by a grant from Depuy to the Rothman Institute
Conflict of Interest:
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Structured Abstract Study Design: Cadaver Training Lab Objective: To determine if a technical cadaver skills training lab for spinal surgery increases resident confidence, satisfaction in training, and perception of operating room safety. Summary of Background Data: Resident training is an important topic in the setting of work hour reform. The use of supplemental materials such as videos, sawbones, and simulators may become important to adequately train orthopedic residents. Currently, there are no established curricula for training orthopedic surgery residents on anatomy and common procedures encountered during a spinal surgery rotation. Methods: Residents were assembled into teams of a PGY-5, and PGY-2 and/or PGY-1 to perform dissection and procedures on 5 fresh frozen spine cadavers. With attending and spine fellow supervision, residents performed anterior cervical, posterior cervical, and posterior thoracolumbar surgical exposure, decompression, and fusion procedures in the operating room using surgical tools and instrumentation. Residents were then queried about their confidence levels, satisfaction in training, and perception of safety using a Likert scale (0-10). Strong agreement (scores > 8) and strong disagreement (scores ≤3) and correlations were evaluated. Results: Seventeen residents completed the training program (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). After the training, the majority of residents strongly agreed that they had an increased confidence of their own abilities (59%). A significant majority (65%) of residents strongly agreed that they were satisfied with the benefits provided by the training program. Compared to other methods of education, residents strongly agreed
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that the training was more helpful than textbook chapters (94%), sawbones (94%), web based training (94%), or a virtual (completely electronic) based training (94%). After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). The vast majority of residents strongly agreed “Before performing surgery on me, I would want a resident to perform this cadaveric training” (88%). Conclusions: These results demonstrate that team-based, cadaveric training with adequate attending supervision, prior to onset of a spine surgical rotation may lead to high resident confidence, satisfaction in training, and perception of patient safety. Key Words: cadaver lab, orthopedic resident, training, simulator, work hours
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Introduction
The publication of the 2000 Institute of Medicine (IOM) report entitled “To Err Is Human: Building a Safer Health System” shed light on the necessity for increased safety protocols in hospital procedures1. In the report, the IOM estimates that between 44,000 and 98,000 patient deaths happen each year in hospitals as a result of medical malpractice1. In response to this alarming data, there has been a push in several medical sectors to first identify the source of the errors2,3, and subsequently establish protocols that correct the established systems that have contributed to patient harm. In the field of orthopedic surgery, the American Academy of Orthopedic Surgeons (AAOS) recently collected responses to a membership survey designed to analyze medical errors in orthopedic practice. Among the orthopedic subspecialties, it was found that there is a legitimate risk of error in spine surgery regarding incorrect identification of the target surgical site prior to surgery, and subsequently a risk of performing the surgery at the wrong vertebral level4.
Within orthopedic surgery residency training programs, there is a didactic curriculum as outlined by the Accreditation Council for Graduate Medical Education (ACGME) designed to educate residents about fundamental concepts in basic science and pathophysiology of disease5. The foundation of this portion of education is based on didactic lectures, textbooks, and peer-reviewed journals. As far as surgical techniques, orthopedic surgery residents are educated by direct observation and graduated responsibility and participation in surgical procedures. The use of videos and online
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resources can also provide an understanding of the general steps of a procedure, however, there are limited resources currently available to enable residents to practice surgical procedures on human anatomical structures. Sawbones and models are valuable tools to conceptualize three-dimensional anatomic structures, but there are limits to the application of surgical techniques due to lack of accurate proprioceptive feedback, as well as absence of neural and vascular structures. Surgical simulators have been developed to overcome this deficit, but can be expensive. Cadavers are also expensive, but may provide the most realistic scenario of surgical procedures.
Our objective was to introduce a cadaver-based training program for residents rotating in spine surgery, in which residents participated in procedures under attending supervision, followed by administration of a post-program survey designed to assess residents’ confidence, satisfaction with education, as well as perceptions of patient safety. We hypothesized that after the cadaver-training program, residents would feel more confident in their ability to assist in spinal surgery, be more satisfied with their general knowledge of spinal surgery procedures, and feel safer in participating in the care of spine patients.
Materials and Methods
This study was a prospective assessment of resident confidence, satisfaction, and safety attitudes following a cadaveric spine surgery training program. All residents who rotate on the spine surgical service during the calendar year at an academic medical center were enrolled in the training program. Within our program curriculum, residents rotate on the
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spine service during their PGY-1, PGY-2, and PGY-5 years. Only the residents scheduled to rotate on the spine service during the academic year were eligible to participate. No residents were excluded from the program.
The residents were assembled into five teams based on their rotation schedules and performed dissections on five fresh-frozen spine cadavers. The residents were assigned graduated responsibility such that the PGY-1 and PGY-2 residents performed the surgical dissection and identified critical anatomical structures. The PGY-5 residents performed the instrumentation and decompression, and the PGY-1 and PGY-2 residents performed closure. Current spine surgery clinical fellows participated in a supervisory role. In this manner, the actual team of residents who would work together during the academic year gained experience working together to perform spine procedures. Two fellowshiptrained attendings also supervised the procedures.
Each team of residents performed the following procedures: (1) an anterior cervical exposure, followed by discectomy and fusion, as well as cervical corpectomy; (2) posterior cervical exposure, laminectomy, laminoforaminotomy, laminoplasty, and arthrodesis from C1 to C7; (3) Posterior thoracolumbar exposure, microdiscectomy, laminectomy, facetectomy, pedicle screw instrumentation, interbody fusion, and spinal osteotomy.
Following the training, a previously published safety attitude survey was adapted to assess learners’ responses to the training program6. The survey was specifically designed
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to query confidence levels, satisfaction with the unfolding of the procedures in the operating room and prior knowledge, as well as expectation of safety culture following the training using a Likert scale (0-10). Strong agreement (scores > 8) and strong disagreement (scores ≤3) and correlations between responses were evaluated.
Results Seventeen residents participated in the cadaver training (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). Overall, residents expressed feelings of being adequately prepared for surgical procedures. The majority of residents strongly agreed with the statements that they have “good understanding of spine anatomy and surgical procedures” (59%) (table 1). As expected, fifth year residents reported feeling more confident with their skill set on average than did first and second year residents, most notably in level of strong agreement with “I have a good understanding of the critical aspects of spine surgery” (75% vs. 22%), “I feel safe assisting in spine surgery in the operating room” (63% vs. 22%) and “I feel prepared to step into an operating room and engage in spine surgery” (75% vs. 22%) (table 2). The majority (65%) of residents strongly agreed that they were eager to participate in spine surgery after the training.
Most residents (65%) were satisfied with their current spine training so far. Compared to other methods of education, residents strongly agreed that the team-specific cadaveric training was more helpful than textbook chapters (94% of residents), sawbones (94%), web based training (94%), or a virtual (completely electronic) based training (94%).
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After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). A significant majority of residents strongly agreed that “Before performing surgery on me, I would want a resident to perform this cadaveric training” (88%).
Discussion
This study expands upon the traditional methods of cadaver-based training for surgical residents by using cadavers as mock patients and emphasizing specific approaches, techniques, and procedures, as opposed to the more commonly instituted method emphasizing anatomical dissection. Results from this study were overwhelmingly positive, and demonstrate that prior to the onset of a spine surgery rotation, a team based, cadaveric training with adequate attending supervision, may lead to high resident satisfaction, confidence, and perception of patient safety. The vast majority (88%) of residents strongly agreed with the statement: “Before performing surgery on me, I would want a resident to perform this cadaveric training”. This statement is broad, but it sums up the generalized confidence gained after undertaking the program, as well as the value of the program for future patients as perceived by the trainees. Residents strongly agreed that this training was more helpful than other methods of learning, which suggests that integration of similar cadaver-based programs into orthopedic surgery residency training programs as part of the standardized curriculum would be met with positive resident feedback. Integration of such programs in the future would provide residents with a level of engagement in spinal procedures that perhaps may not be as successfully replicated in
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other non-cadaver simulation programs. Almost all residents were eager to participate in spine surgery after the training, which may create a better learning environment and resident morale for an upcoming rotation.
Simulation curriculums have been evaluated for implementation into neurosurgical residency training programs, specifically comparing simulators to cadaveric-based training programs7. One study found that the highest benefit to residents was with cadaver simulations, compared to physical simulators and haptic/computerized simulators7. Model-based simulators may be more beneficial for residents early in their training8. Currently, the ACGME has no established protocols of simulated surgery for resident training in orthopedic surgery9. Among their didactic curriculum requirements are trainings in basic sciences, anatomical dissection and review of pathologies encountered in the field. An incorporation of a surgical simulation program such as the one introduced in the current study may be appropriate under the curriculum requirement of “basic motor skills” training (outlined in section IV.A.3.d).(7).(a)), which is designed to enhance the resident’s application of basic motor skills used in the clinical setting and operating room5. There is “formal instruction in basic surgical skills” outlined in the ACGME guidelines (section IV.A.6.a).(2))5, however the current system relies on residents to gain their surgical skills while operating on patients; if a surgical simulation training program were implemented, it would allow residents to practice and gain surgical skill without endangering the patients prior to mastery of such skills. Simulatorbased educational curricula are being developed in the neurosurgical community9, with specific procedural based simulators10-13, which have the potential to be a valuable
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educational tool.
As reported by the AAOS, the most likely spinal surgery error to occur is a result of incorrect identification of target spinal level on the patient4. Performing spinal procedures on cadavers in a training operating room may increase situational awareness and direct visualization of anatomical landmarks in a surgical exposure. We believe that familiarity with such anatomy will reduce wrong level surgery going forward. Team based surgical goal driven cadaveric training allows the resident to gain an increased sense of physical orientation in the actual operating room, a benefit not gained from virtual experiences, textbooks, or simulators. In this way, cadaver training integration into residency programs would be a logical adjustment to prevent surgery being performed at the wrong spinal level, a leading source of spinal surgery errors. Implementing training with fluoroscopic or radiographic localization of level to the cadaver training may also be beneficial in the future.
Future studies may focus on the potential of cadaver-based trainings in preventing complications and medical errors by following and comparing residents that complete a training program, with those that do not. Performing such a study would be difficult, due to the small sample size of residents in each program, as well as potential ethical dilemmas of providing residents with different levels of training. However, increased experience and education may not necessarily decrease complication rate in training programs. One study found no difference in estimated blood loss, operative time, length of stay, or complication rate in adolescents undergoing posterior spinal surgery between
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the four quarters of a fellowship year14. For now, resident satisfaction surveys can provide important preliminary data as to the perceived benefit of cadaver-based training program. Surveys of attending surgeons’ perception of resident skills for those who undergo such a training would also provide insight into the benefits of this program.
Results of this study were primarily limited by the small sample size of 17 residents, all from one training program. The addition of a control group of residents not completing the training would provide important information for comparison. Another limitation is in the lack of available long-term data to support the residents’ reported confidences after attending the training program. Future study should investigate the longevity of this program and the sustained effectiveness with repeated surveys performed throughout the academic year. Furthermore, while less than a majority of residents strongly agreed that with statements regarding preventing intraoperative errors, feeling safe assisting in the operating room, and feeling prepared to step in the operating room (41%, 41% and 47% respectively), this is mostly explained by resident experience by post-graduate year. This training may help residents feel more confident in the operating room, but the experience gained from years of residency are most valuable.
Surgical data assessing residents’ abilities to successfully (or unsuccessfully) take part in spinal surgeries will be needed in order to accurately view the effect of the cadaver training program on residents’ performance. For now, it is encouraging that the cadaver trainings were well received by the residents, and therefore the potential for expansion into actual residency training is possible. One barrier to broad implementation of the
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training program described is cost, which could be prohibitive for some training programs, preventing this type of training from becoming part of a mandatory curriculum. The described training program used five cadavers for a group of 17 residents, which was supplied by a grant from Depuy (Raynham, MA) to the Rothman Institute. Industry funding may be an option as many companies see value in resident education and residents becoming familiar with surgical tools and devices in a relaxed setting. The group sizes were adequate for each resident to participate and be engaged throughout each procedure. However, the optimal number of cadavers needed to complete this training based on residency program size is unknown.
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Kohn L. To err is human: an interview with the Institute of Medicine's Linda Kohn. The Joint Commission journal on quality improvement. Apr 2000;26(4):227-234.
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Matsen FA, 3rd, Stephens L, Jette JL, Warme WJ, Posner KL. Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims. The Journal of bone and joint surgery. American volume. Feb 20 2013;95(4):e201-208.
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Wong DA, Watters WC, 3rd. To err is human: quality and safety issues in spine care. Spine. May 15 2007;32(11 Suppl):S2-8.
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ACGME Program Requirements for Graduate Medical Education in Orthopaedic Surgery. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQPIF/260_orthopaedic_surgery_07012013.pdf.Access date: 3/23/2014.
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Gasco J, Holbrook TJ, Patel A, et al. Neurosurgery simulation in residency training: feasibility, cost, and educational benefit. Neurosurgery. Oct 2013;73 Suppl 1:39-45.
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Selden NR, Origitano TC, Hadjipanayis C, Byrne R. Model-based simulation for early neurosurgical learners. Neurosurgery. Oct 2013;73 Suppl 1:15-24.
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Table 1: Responses of residents with percent strong disagreement, percent neutral, percent strong agreement
Question
Comparison to Other Methods of Learning This training was more helpful to me than a textbook chapter on anatomical approaches This training was better than a simulated (sawbones) surgical experience This training was better than a virtual (completely electronic) surgical experience. This training was better than a web based spine surgical training (e.g. Vumedi or Orthopedic Knowledge Online). Satisfaction with Education I am satisfied with my spine training thus far I have a good understanding of patient anatomy and surgical procedures. I have a good understanding of the critical aspects of spine surgery. My spine surgical technique is adequate. I am eager to participate in spine surgery. Perception of Patient Safety Before performing surgery on me, I would want a resident to perform this cadaveric training. I feel that my current training will prevent me from making intraoperative errors. I feel safe assisting in spine surgery in the operating room. I feel prepared to step into an operating room and engage in spine surgery.
Percent Percent Strong Neutral Disagree ment
Percent Strong Agreem ent
0
6
94
0
6
94
0
6
94
0
6
94
6 0
41 41
65 59
12
41
47
41 0
30 35
29 65
0
12
88
12
47
41
18
41
41
18
35
47
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Table 2: Resident responses based on post graduate year
Question
I have a good understanding of the critical aspects of spine surgery I feel that my current training will prevent me from making intraoperative errors. I feel safe assisting in spine surgery in the operating room. I feel prepared to step into an operating room and engage in spine surgery
Percent Strong Agreement PGY-1/2 (n= 9) 22
Percent Strong Agreement PGY-5 (n=8) 75
P value
22
62.5
0.453
22
62.5
0.274
22
75
0.148
0.055
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Title: Outcome of a Resident Spine Surgical Skills Training Program
Authors:
Brian P. Calio, BA1 Christopher K. Kepler, MD, MBA1,2 John D. Koerner, MD1,2 Jeffrey A. Rihn, MD1,2 Paul Millhouse, MD2 Kris E. Radcliff, MD 1,2
Affiliations:
1- Thomas Jefferson University, Philadelphia PA 2- Rothman Institute, Philadelphia PA
Corresponding Author:
Kris E. Radcliff, MD 925 Chestnut St. 5th Floor Philadelphia, PA 19107 [email protected]
Sources of Support:
Cadavers provided by a grant from Depuy to the Rothman Institute
Conflict of Interest:
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Structured Abstract Study Design: Cadaver Training Lab Objective: To determine if a technical cadaver skills training lab for spinal surgery increases resident confidence, satisfaction in training, and perception of operating room safety. Summary of Background Data: Resident training is an important topic in the setting of work hour reform. The use of supplemental materials such as videos, sawbones, and simulators may become important to adequately train orthopedic residents. Currently, there are no established curricula for training orthopedic surgery residents on anatomy and common procedures encountered during a spinal surgery rotation. Methods: Residents were assembled into teams of a PGY-5, and PGY-2 and/or PGY-1 to perform dissection and procedures on 5 fresh frozen spine cadavers. With attending and spine fellow supervision, residents performed anterior cervical, posterior cervical, and posterior thoracolumbar surgical exposure, decompression, and fusion procedures in the operating room using surgical tools and instrumentation. Residents were then queried about their confidence levels, satisfaction in training, and perception of safety using a Likert scale (0-10). Strong agreement (scores > 8) and strong disagreement (scores ≤3) and correlations were evaluated. Results: Seventeen residents completed the training program (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). After the training, the majority of residents strongly agreed that they had an increased confidence of their own abilities (59%). A significant majority (65%) of residents strongly agreed that they were satisfied with the benefits provided by the training program. Compared to other methods of education, residents strongly agreed
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that the training was more helpful than textbook chapters (94%), sawbones (94%), web based training (94%), or a virtual (completely electronic) based training (94%). After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). The vast majority of residents strongly agreed “Before performing surgery on me, I would want a resident to perform this cadaveric training” (88%). Conclusions: These results demonstrate that team-based, cadaveric training with adequate attending supervision, prior to onset of a spine surgical rotation may lead to high resident confidence, satisfaction in training, and perception of patient safety. Key Words: cadaver lab, orthopedic resident, training, simulator, work hours
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Introduction
The publication of the 2000 Institute of Medicine (IOM) report entitled “To Err Is Human: Building a Safer Health System” shed light on the necessity for increased safety protocols in hospital procedures1. In the report, the IOM estimates that between 44,000 and 98,000 patient deaths happen each year in hospitals as a result of medical malpractice1. In response to this alarming data, there has been a push in several medical sectors to first identify the source of the errors2,3, and subsequently establish protocols that correct the established systems that have contributed to patient harm. In the field of orthopedic surgery, the American Academy of Orthopedic Surgeons (AAOS) recently collected responses to a membership survey designed to analyze medical errors in orthopedic practice. Among the orthopedic subspecialties, it was found that there is a legitimate risk of error in spine surgery regarding incorrect identification of the target surgical site prior to surgery, and subsequently a risk of performing the surgery at the wrong vertebral level4.
Within orthopedic surgery residency training programs, there is a didactic curriculum as outlined by the Accreditation Council for Graduate Medical Education (ACGME) designed to educate residents about fundamental concepts in basic science and pathophysiology of disease5. The foundation of this portion of education is based on didactic lectures, textbooks, and peer-reviewed journals. As far as surgical techniques, orthopedic surgery residents are educated by direct observation and graduated responsibility and participation in surgical procedures. The use of videos and online
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of the article is prohibited.
resources can also provide an understanding of the general steps of a procedure, however, there are limited resources currently available to enable residents to practice surgical procedures on human anatomical structures. Sawbones and models are valuable tools to conceptualize three-dimensional anatomic structures, but there are limits to the application of surgical techniques due to lack of accurate proprioceptive feedback, as well as absence of neural and vascular structures. Surgical simulators have been developed to overcome this deficit, but can be expensive. Cadavers are also expensive, but may provide the most realistic scenario of surgical procedures.
Our objective was to introduce a cadaver-based training program for residents rotating in spine surgery, in which residents participated in procedures under attending supervision, followed by administration of a post-program survey designed to assess residents’ confidence, satisfaction with education, as well as perceptions of patient safety. We hypothesized that after the cadaver-training program, residents would feel more confident in their ability to assist in spinal surgery, be more satisfied with their general knowledge of spinal surgery procedures, and feel safer in participating in the care of spine patients.
Materials and Methods
This study was a prospective assessment of resident confidence, satisfaction, and safety attitudes following a cadaveric spine surgery training program. All residents who rotate on the spine surgical service during the calendar year at an academic medical center were enrolled in the training program. Within our program curriculum, residents rotate on the
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spine service during their PGY-1, PGY-2, and PGY-5 years. Only the residents scheduled to rotate on the spine service during the academic year were eligible to participate. No residents were excluded from the program.
The residents were assembled into five teams based on their rotation schedules and performed dissections on five fresh-frozen spine cadavers. The residents were assigned graduated responsibility such that the PGY-1 and PGY-2 residents performed the surgical dissection and identified critical anatomical structures. The PGY-5 residents performed the instrumentation and decompression, and the PGY-1 and PGY-2 residents performed closure. Current spine surgery clinical fellows participated in a supervisory role. In this manner, the actual team of residents who would work together during the academic year gained experience working together to perform spine procedures. Two fellowshiptrained attendings also supervised the procedures.
Each team of residents performed the following procedures: (1) an anterior cervical exposure, followed by discectomy and fusion, as well as cervical corpectomy; (2) posterior cervical exposure, laminectomy, laminoforaminotomy, laminoplasty, and arthrodesis from C1 to C7; (3) Posterior thoracolumbar exposure, microdiscectomy, laminectomy, facetectomy, pedicle screw instrumentation, interbody fusion, and spinal osteotomy.
Following the training, a previously published safety attitude survey was adapted to assess learners’ responses to the training program6. The survey was specifically designed
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to query confidence levels, satisfaction with the unfolding of the procedures in the operating room and prior knowledge, as well as expectation of safety culture following the training using a Likert scale (0-10). Strong agreement (scores > 8) and strong disagreement (scores ≤3) and correlations between responses were evaluated.
Results Seventeen residents participated in the cadaver training (7 PGY-1s, 2 PGY-2s, and 8 PGY-5s). Overall, residents expressed feelings of being adequately prepared for surgical procedures. The majority of residents strongly agreed with the statements that they have “good understanding of spine anatomy and surgical procedures” (59%) (table 1). As expected, fifth year residents reported feeling more confident with their skill set on average than did first and second year residents, most notably in level of strong agreement with “I have a good understanding of the critical aspects of spine surgery” (75% vs. 22%), “I feel safe assisting in spine surgery in the operating room” (63% vs. 22%) and “I feel prepared to step into an operating room and engage in spine surgery” (75% vs. 22%) (table 2). The majority (65%) of residents strongly agreed that they were eager to participate in spine surgery after the training.
Most residents (65%) were satisfied with their current spine training so far. Compared to other methods of education, residents strongly agreed that the team-specific cadaveric training was more helpful than textbook chapters (94% of residents), sawbones (94%), web based training (94%), or a virtual (completely electronic) based training (94%).
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After the training, residents strongly agreed that the training improved feelings of preparation (47%), safety (41%), and ability to prevent intraoperative errors (41%). A significant majority of residents strongly agreed that “Before performing surgery on me, I would want a resident to perform this cadaveric training” (88%).
Discussion
This study expands upon the traditional methods of cadaver-based training for surgical residents by using cadavers as mock patients and emphasizing specific approaches, techniques, and procedures, as opposed to the more commonly instituted method emphasizing anatomical dissection. Results from this study were overwhelmingly positive, and demonstrate that prior to the onset of a spine surgery rotation, a team based, cadaveric training with adequate attending supervision, may lead to high resident satisfaction, confidence, and perception of patient safety. The vast majority (88%) of residents strongly agreed with the statement: “Before performing surgery on me, I would want a resident to perform this cadaveric training”. This statement is broad, but it sums up the generalized confidence gained after undertaking the program, as well as the value of the program for future patients as perceived by the trainees. Residents strongly agreed that this training was more helpful than other methods of learning, which suggests that integration of similar cadaver-based programs into orthopedic surgery residency training programs as part of the standardized curriculum would be met with positive resident feedback. Integration of such programs in the future would provide residents with a level of engagement in spinal procedures that perhaps may not be as successfully replicated in
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of the article is prohibited.
other non-cadaver simulation programs. Almost all residents were eager to participate in spine surgery after the training, which may create a better learning environment and resident morale for an upcoming rotation.
Simulation curriculums have been evaluated for implementation into neurosurgical residency training programs, specifically comparing simulators to cadaveric-based training programs7. One study found that the highest benefit to residents was with cadaver simulations, compared to physical simulators and haptic/computerized simulators7. Model-based simulators may be more beneficial for residents early in their training8. Currently, the ACGME has no established protocols of simulated surgery for resident training in orthopedic surgery9. Among their didactic curriculum requirements are trainings in basic sciences, anatomical dissection and review of pathologies encountered in the field. An incorporation of a surgical simulation program such as the one introduced in the current study may be appropriate under the curriculum requirement of “basic motor skills” training (outlined in section IV.A.3.d).(7).(a)), which is designed to enhance the resident’s application of basic motor skills used in the clinical setting and operating room5. There is “formal instruction in basic surgical skills” outlined in the ACGME guidelines (section IV.A.6.a).(2))5, however the current system relies on residents to gain their surgical skills while operating on patients; if a surgical simulation training program were implemented, it would allow residents to practice and gain surgical skill without endangering the patients prior to mastery of such skills. Simulatorbased educational curricula are being developed in the neurosurgical community9, with specific procedural based simulators10-13, which have the potential to be a valuable
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educational tool.
As reported by the AAOS, the most likely spinal surgery error to occur is a result of incorrect identification of target spinal level on the patient4. Performing spinal procedures on cadavers in a training operating room may increase situational awareness and direct visualization of anatomical landmarks in a surgical exposure. We believe that familiarity with such anatomy will reduce wrong level surgery going forward. Team based surgical goal driven cadaveric training allows the resident to gain an increased sense of physical orientation in the actual operating room, a benefit not gained from virtual experiences, textbooks, or simulators. In this way, cadaver training integration into residency programs would be a logical adjustment to prevent surgery being performed at the wrong spinal level, a leading source of spinal surgery errors. Implementing training with fluoroscopic or radiographic localization of level to the cadaver training may also be beneficial in the future.
Future studies may focus on the potential of cadaver-based trainings in preventing complications and medical errors by following and comparing residents that complete a training program, with those that do not. Performing such a study would be difficult, due to the small sample size of residents in each program, as well as potential ethical dilemmas of providing residents with different levels of training. However, increased experience and education may not necessarily decrease complication rate in training programs. One study found no difference in estimated blood loss, operative time, length of stay, or complication rate in adolescents undergoing posterior spinal surgery between
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the four quarters of a fellowship year14. For now, resident satisfaction surveys can provide important preliminary data as to the perceived benefit of cadaver-based training program. Surveys of attending surgeons’ perception of resident skills for those who undergo such a training would also provide insight into the benefits of this program.
Results of this study were primarily limited by the small sample size of 17 residents, all from one training program. The addition of a control group of residents not completing the training would provide important information for comparison. Another limitation is in the lack of available long-term data to support the residents’ reported confidences after attending the training program. Future study should investigate the longevity of this program and the sustained effectiveness with repeated surveys performed throughout the academic year. Furthermore, while less than a majority of residents strongly agreed that with statements regarding preventing intraoperative errors, feeling safe assisting in the operating room, and feeling prepared to step in the operating room (41%, 41% and 47% respectively), this is mostly explained by resident experience by post-graduate year. This training may help residents feel more confident in the operating room, but the experience gained from years of residency are most valuable.
Surgical data assessing residents’ abilities to successfully (or unsuccessfully) take part in spinal surgeries will be needed in order to accurately view the effect of the cadaver training program on residents’ performance. For now, it is encouraging that the cadaver trainings were well received by the residents, and therefore the potential for expansion into actual residency training is possible. One barrier to broad implementation of the
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training program described is cost, which could be prohibitive for some training programs, preventing this type of training from becoming part of a mandatory curriculum. The described training program used five cadavers for a group of 17 residents, which was supplied by a grant from Depuy (Raynham, MA) to the Rothman Institute. Industry funding may be an option as many companies see value in resident education and residents becoming familiar with surgical tools and devices in a relaxed setting. The group sizes were adequate for each resident to participate and be engaged throughout each procedure. However, the optimal number of cadavers needed to complete this training based on residency program size is unknown.
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Table 1: Responses of residents with percent strong disagreement, percent neutral, percent strong agreement
Question
Comparison to Other Methods of Learning This training was more helpful to me than a textbook chapter on anatomical approaches This training was better than a simulated (sawbones) surgical experience This training was better than a virtual (completely electronic) surgical experience. This training was better than a web based spine surgical training (e.g. Vumedi or Orthopedic Knowledge Online). Satisfaction with Education I am satisfied with my spine training thus far I have a good understanding of patient anatomy and surgical procedures. I have a good understanding of the critical aspects of spine surgery. My spine surgical technique is adequate. I am eager to participate in spine surgery. Perception of Patient Safety Before performing surgery on me, I would want a resident to perform this cadaveric training. I feel that my current training will prevent me from making intraoperative errors. I feel safe assisting in spine surgery in the operating room. I feel prepared to step into an operating room and engage in spine surgery.
Percent Percent Strong Neutral Disagree ment
Percent Strong Agreem ent
0
6
94
0
6
94
0
6
94
0
6
94
6 0
41 41
65 59
12
41
47
41 0
30 35
29 65
0
12
88
12
47
41
18
41
41
18
35
47
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Table 2: Resident responses based on post graduate year
Question
I have a good understanding of the critical aspects of spine surgery I feel that my current training will prevent me from making intraoperative errors. I feel safe assisting in spine surgery in the operating room. I feel prepared to step into an operating room and engage in spine surgery
Percent Strong Agreement PGY-1/2 (n= 9) 22
Percent Strong Agreement PGY-5 (n=8) 75
P value
22
62.5
0.453
22
62.5
0.274
22
75
0.148
0.055
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