104.18 Integrating Provider-Level Practical Trauma Training into Undergraduate Medical Education

Posted on January 31, 2019

A. C. Sayce1, S. Rakhit1,2,3, S. C. Eastham1,2, C. S. Wilson2, L. B. Nanney1,4,5, M. B. Patel1,2,3,6,7  1Vanderbilt University,School Of Medicine,Nashville, TN, USA 2Vanderbilt University Medical Center,Division Of Trauma, Emergency General Surgery, And Surgical Critical Care, Department Of Surgery, Section Of Surgical Sciences,Nashville, TN, USA 3Vanderbilt Critical Illness, Brain Dysfunction, and Survivorship Center,Nashville, TN, USA 4Vanderbilt University Medical Center,Department Of Plastic Surgery, Section Of Surgical Sciences,Nashville, TN, USA 5Vanderbilt University,Department Of Cell And Developmental Biology,Nashville, TN, USA 6US Department of Veterans Affairs,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System,Nashville, TN, USA 7Vanderbilt University Medical Center,Departments Of Neurosurgery And Hearing And Speech Sciences, Vanderbilt Brain Institute,Nashville, TN, USA

Introduction: The American College of Surgeons (ACS) has created trauma curricula for graduate and continuing medical education (i.e. residents, fellows, faculty), including Advanced Trauma Life Support (ATLS) and Advanced Surgical Skills for Exposure in Trauma (ASSET). We used ATLS and ASSET programs as cornerstones for an undergraduate medical education (i.e. medical student) integrated science course in trauma in order to understand attitudes and performance of less-experienced learners. We hypothesized that medical students would be satisfied with the course, possess sufficient knowledge for ATLS certification, and demonstrate knowledge of the theoretical concepts of ASSET training.

Methods: From 2015 to 2018, ATLS (9th and/or 10th editions) and ASSET curricula were embedded in a single institution, four-week, post-core clinical clerkship medical student course containing basic science didactics, laboratory, and clinical experiences across the spectrum of post-injury science. Medical students enrolled in ATLS and ASSET alongside resident, fellow, faculty, and/or allied health providers. Prospective survey data were collected on medical student course satisfaction and clinical performance evaluations including pre-test and post-test ATLS and ASSET scores. Paired survey data and test scores were analyzed by Pratt’s modified method of matched non-parametric rank-sign testing. Change in performance on multiple choice testing was analyzed by ANOVA for level of training.

Results: Fifty-six medical students enrolled in and completed the trauma course. All students were satisfied with the overall learning experience (5/56 satisfied; 51/56 very satisfied) and would recommend the trauma course to their peers (8/56 agree; 48/56 strongly agree). ATLS test scores improved amongst medical students by 6.34 points (95% CI [3.64, 9.04]) and residents by 4.20 points (95% CI [0.06, 8.33]) but not faculty (mean: 0.98; 95% CI [-2.84, 4.81]) or other providers (mean: 1.25; 95% CI [-7.40, 9.90]). Although ATLS pre-test scores differed among groups by level of training (p=0.029), post-test scores did not differ by group (p=0.129). All medical students passed ATLS. In addition, 90 percent (44/49) of medical students achieved a score of at least 70 percent on the ASSET post-course test.

Conclusion: A four-week trauma course based on ATLS and ASSET curricula was well received by medical students. Medical students demonstrated equivalent improvement to residents during ATLS with both groups achieving final performance equivalent to attending faculty. All medical students passed ATLS for official certification on graduation. Medical students also exhibited abilities to synthesize and apply the advanced surgical concepts taught in ASSET. These data demonstrate that medical students can successfully complete postgraduate-level ACS trauma curricula, and suggest a means for increasing the clinical readiness of future residents in care of the injured patient.

104.17 Low Cost Inanimate Models are Useful in Assessing Open and Laparoscopic Skills of GS Residents

Posted on January 31, 2019

Y. N. AlJamal1, N. Prabhakar1, H. Saleem1, M. Baloul1, D. R. Farley1  1Mayo Clinic,General Surgery,Rochester, MN, USA

Introduction: Surgical residents prefer to spend most of their training time doing operations on real patients. Little has been written about training and assessing senior surgical residents on low cost models for both open and laparoscopic surgery. While our simulation education efforts have concentrated on surgical interns, we do assess senior level residents biannually in our simulation center. The cost and educational utility of such an effort to assess open and laparoscopic skills has not been delineated. 

Methods: Surgical residents biannually participate in a 59 minute OSCE (Surgical X-Games) consisting of 6 stations.  Several stations involve open surgery low-cost task trainers (constructed from felt, yarn, cardboard, etc.) and laparoscopic task trainers (laparoscope, monitor, graspers, plastic box containing felt and cloth made to look like abdominal organs). Skills assessed were open inguinal hernia repair, small bowel anastomosis, and portal vein injury management, and laparoscopic abdominal exploration and enterotomy closure. Performance analysis utilized an objective checklist, and residents provided feedback (Likert Scale 1= negative through 5=positive) regarding the utility of the exercises.

Results: Forty-four GS residents (16 PGY-2s, 8 PGY-3, 10 PGY-4s and 10 PGY-5s) completed the assessment. Performance within and between PGY levels was variable, but PGY 5 trainees outperformed PGY-2s, 3s, and 4s (p<0.05). Although PGY-4 and 3 residents’ skills were comparable (p=NS), they outperformed PGY 2 residents (p<0.05). Material cost for constructing models (IH repair= $3, SB anastomosis=$1.10, PV injury=$1.05, lap abd exploration=$10.50, and lap enterotomy closure=$11.50) was reasonable. Medical student volunteers (free labor) required between 9 minutes (SB anastomosis) and 2 hours (Lap abdominal exploration) for model construction. Models were re-used. Resident feedback suggests the models and activities had utility (Likert scores: range of 3-5, mean=4.5);  PGY-5s unanimously disliked the lap enterotomy closure station.

Conclusions: Low cost inanimate models facilitated assessment of surgical residents’ open and laparoscopic surgical skills. Residents felt the models were useful and realistic, and staff found them inexpensive, easy to set up, and durable. We will plan to look for new ways to use this low cost option in our surgical curriculum and specifically find a lap enterotomy closure model that is not so taxing on PGY-5s.

104.15 Attributes of Medical School Curricula that Promote the Development of Self-Directed Learning Skills

Posted on January 31, 2019

S. Stauder1, N. Kugler1, T. Webb1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA

Introduction:
Self-Directed Learning (SDL) is a critical component of medical education beginning in medical school and continuing throughout the career of physicians. Medical schools are now required to demonstrate evidence of medical student SDL within the curriculum. However, there is no consensus on what constitutes a self-directed learner, nor how medical schools or residencies may better provide SDL opportunities to learners. Our project aimed to develop a consensus on the attributes and behaviors of a self-directed learner and the components of medical education curricula that promote SDL skills in medical students.

Methods:
Surveys were distributed to members of the Society of Teaching Scholars at the Medical College of Wisconsin, which is comprised of 75 full time faculty who have been elected based on demonstrated excellence in educational scholarship and leadership. The initial phase consisted of a survey asking two open-ended questions: 1) What are the observable characteristics (behaviors) of a self-directed learner? 2) What specific components of a medical school course or clerkship do you believe promote self-directed learning? Based on open-ended survey results, a new survey consisting of SDL characteristics and curriculum components was sent to the STS following the Delphi method of surveying, ranking attributes on a Likert scale of 1-7. Using attributes which received a 4+ rating from ≥50% of respondents, a second and final Delphi round was performed, and a consensus of final attributes was compiled using those which received a 5+ rating from >70% of respondents. Afterward, all attributes were classified into core themes to provide an outline of self-directed learners and components of a curriculum that foster SDL skills.

Results:
30 STS members completed the open-ended survey, 37 completed the Delphi 1st round, and 25 completed the Delphi 2nd round. 44 SDL characteristics and 50 curriculum components were used in the Delphi surveys. Final survey results obtained 33 unique SDL characteristics and 36 curriculum components which received a 5+ rating from >70% of respondents. These attributes were subsequently classified into themes with similar attributes. In total, 8 core themes of SDL characteristics and 8 core themes of curriculum components that promote SDL skill development were identified.

Conclusion:
Attributes of SDL related to the learner and educational environment can be classified into core themes that may be used for further curriculum development and demonstration of promotion of SDL. Further studies should analyze validity and reliability of using these themes in student assessment and curricular evaluation.

104.14 BioInnovate: Medical Student Experiential Education in Technology Innovation and Entrepreneurship

Posted on January 31, 2019

B. R. Fogg3, J. T. Langell1,2,3,4  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Department Of Bioengineering,Salt Lake City, UT, USA 3University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 4VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA

 

Introduction: Joint M.D. programs are becoming increasingly popular as more medical students seek additional professional development training. These programs have direct costs (tuition and living expenses) and opportunity costs (delayed training and compensation). Potential benefits include enhancing future career opportunities and knowledge acquisition in additional fields to increase future professional impact.

 

Here we present our 6-year experience with BioInnovate, a combined degree program for medical students and residents focused on medical technology innovation and entrepreneurship. BioInnovate is an accelerated 1-year Master of Science track in bioengineering. Students in the program combine their healthcare background with engineering and business training to identify clinical problems and create technology solutions to improve healthcare delivery. The program focuses on experiential education and interdisciplinary teams composed of graduate students with backgrounds in medicine, engineering, business, design and law. The curriculum is based on the complete product development lifecycle including design inputs, design processes, technology verification and validation and the commercial translation process.

 

Methods: Background and outcomes data was gathered through our program database and an anonymous online survey to assess medical student participant characteristics and program impact, including student academic and entrepreneurial accomplishments. Additional data was collected to assess how the program impacted future career choices and opportunities. 

 

Results:69% of BioInnovate medical students had no previous experience with technology development and only 2 had minor experience with business start-ups. No student had experience with FDA regulations or medical technology reimbursement pathways. On average during their BioInnovate year, students filed 2 patents (range 0-3), raised $37.5k in funding (range $6k-$120k), completed 4 peer-reviewed publications or national academic presentations on their BioInnovate work (range 1-6) and all filed at least 1 IRB clinical trial applications. Additionally, 100% of BioInnovate students later matched in one of their top-3 residency choices (national average 78%), 69% are currently engaged in healthcare technology development, 90% plan to conduct medical technology innovation and development as part of their professional careers and 90% recommend this training for all medical students and residents.

 

Conclusions:The BioInnovate program has been effective in providing medical students with an experience in comprehensive medical technology innovation and commercialization. It has impacted students’ future career decisions and their academic and entrepreneurial success metrics. Over the first 6-years, the program has trained 13 medical students who developed 21 medical technologies, filed 22 patents and launched 14 startup companies.

104.13 Feasibility and Impact of Stop the Bleed Training of an Entire Medical School Class

Posted on January 31, 2019

R. L. Schocke1, T. P. Webb1, L. B. Somberg1, C. S. Davis1  1Medical College Of Wisconsin,Trauma/Acute Care Surgery, Department Of Surgery,Milwaukee, WI, USA

Introduction:  Injury is the leading cause of death before the age of 45, and hemorrhage from penetrating extremity injury is the most preventable cause of death from trauma. Answering the call that all citizens learn the basic techniques of hemorrhage control, the American College of Surgeons has spearheaded the national Stop the Bleed campaign. Medical students can now be associate Stop the Bleed instructors, and many instructors are required to meet the objectives set forth by the Hartford Consensus. Thus, we sought to train an entire incoming medical school class while simultaneously measuring the success of the course in this engaging group.

Methods:  One hour during the first-year orientation week was utilized to teach the Stop the Bleed B-Con course to 197 medical students. A survey was administered to assess pre- and post-course comfort with wound compression, wound packing, and tourniquet use. Students were also asked if they were interested in later participating in the Stop the Bleed program. The Fisher’s exact test was used for statistical analysis.

Results: Of the study cohort, only 21 (11%) had previously heard of the Stop the Bleed program. Before the course, those who rated themselves as comfortable or somewhat comfortable with the basic tenants of hemorrhage control were: 113 (57%) for compression, 69 (44%) for wound packing, and 69 (35%) tourniquet use. After the course, those who rated the same levels of comfort were significantly greater, being: 194 (98%) for compression, 190 (96%) for wound packing, and 193 (98%) for tourniquet use (p < 0.0001 for all comparisons). Nearly 60% of students (n=115) indicated that they would like to become instructors, and the overall survey response rate was 100%. Many students stated that the training was their favorite part of medical school orientation.

Conclusion: Stop the Bleed training was enthusiastically received by an entire incoming medical school class. Comfort with the techniques of basic hemorrhage control was significantly improved, and many students indicated they desired to participate further in the program. Engaging large numbers of medical students in Stop the Bleed is feasible. Most importantly, medical students may serve as an important resource as we redouble our efforts of primary injury prevention and aim to achieve zero preventable deaths from injury.

104.12 Assessment of Dexterity on Suturing Boards Predicts Open and Laparoscopic Ability

Posted on January 31, 2019

H. Mohamadipanah1, K. H. Perrone1, J. Nathwani2, K. Peterson2, A. Witt1, A. Garren2, C. Pugh1  1Stanford University,General Surgery,Palo Alto, CA, USA 2University Of Wisconsin,General Surgery,Madison, WI, USA

Introduction:
A range of simulators with varying fidelity have been devoloped for surgical training. As the number and type of available simulators continues to increase, it is critically important to properly match simulator fidelity to trainee task and skill level to achieve cost and learning goals. We hypothesize that a sensor-based dexterity assessment during a suturing board task can accurately predict dexterity level during the performance of both open and laparoscopic simulated scenarios.

Methods:
Participants (N=45) completed three tasks: 1) securing six surgical knots on a suturing board, 2) completing a simulated open small bowel repair, and 3) performing a task during a simulated laparoscopic ventral hernia (LVH) repair. Participants’ hand movements were recorded using electromagnetic sensors and quantified using common motion metrics. A parametric correlational analysis was performed to assess the relationship between dexterity on the suture board and dexterity during the two simulated procedures.

Results:
There were multiple significant relationships between motion metrics on the suture board and motion metrics during simulated small bowel repair and the LVH task. The strongest correlations between the suturing task and open small bowel repair were seen in the “idle time” (r = +0.546, p<0.01) and “jerk magnitude” (r = +0.431, p<0.01) metrics. For the suturing task and the LVH task, the strongest correlations were seen in the “bimanual dexterity” (r = +0.326, p < 0.05) and “working volume” (r = +0.367, p<0.05) metrics.

Conclusion:
The correlation in motion metrics identified in this study between simple suturing board tasks and more complex open and laparoscopic simulation scenarios reflects a consistency in performance across simulators due to the participant’s level of dexterity and supports the utility of suturing boards in surgical training and assessment. The correlation between “idle time” and “jerk magnitude” for the suture board and small bowel repair may result from the pauses that take place when planning subsequent actions and the stop/start nature of placing each stitch during these two tasks. The correlation between “bimanual dexterity” and “working volume” for the suture board and LVH tasks may relate to use of the non-dominant hand as an effective assistant in both tasks. To decrease cost and prevent cognitive load distractions when learning fundamental psychomotor skills such as suturing and effective non-dominate hand use, trainees should demonstrate proficiency on low cost suture boards before training on higher fidelity, higher cost trainers.
 

104.11 Do Words Matter? The "Chair" Title and Gender Gaps in Academic Surgery

Posted on January 31, 2019

C. Peck1, S. J. Schmidt2, D. A. Latimore1, M. I. O’Connor1  1Yale University School Of Medicine,New Haven, CT, USA 2Yale Law School,New Haven, CT, USA

Introduction:  Gender-marked titles have shown to be exclusionary of women in a variety of professional settings. The purpose of this study was to analyze and compare the use of the words "chair" and "chairman" on academic websites for both surgical and non-surgical departments in the US. 

Methods:
Orthopedics, Neurosurgery, Obstetrics and Gynecology, and Pediatrics departments from 139 US allopathic medical schools were reviewed. Official websites were screened for use of the word chair or chairman. Any use of the word chairman was classified according to type of use and location on the website. Patterns of chair use were compared by specialty, region, and gender of the current chair. 

Results:
Overall, 59.8% of all academic departments used only the gender-neutral term chair. In surgical specialties, this number was significantly lower (p<.001)—40.3% in Orthopedics and 42.5% in Neurosurgery, compared to 70.1% and 64.0% in Obstetrics/Gynecology and Pediatrics respectively. Departments with female chairs used gender-neutral titles 89% of the time, compared to 53.1% in departments led by males. Gender-neutral title use was highest in the West across specialties (p<.01). The proportion of female chairs was highest in Obstetrics and Gynecology at 32.5%, compared to 26.0% in Pediatrics, 4.3% in Neurosurgery, and 0.8% in Orthopedics. Use of the word chair correlated with a 437% increase in the likelihood of having a female chair (p<.01).

Conclusion:
Our studies show persistence of the gender-marked title "chair" across academic specialties—particularly in surgical specialties—and suggest a association between title use and overall gender diversity. Increasing the use of gender-neutral titles may be a simple way to promote gender parity in academic surgery. 

104.10 Assessing Knowledge and Skills of Surgical Leaders in Optimizing Organizational Culture

Posted on January 31, 2019

K. Brown1, P. Angelos8, A. Banerjee10, R. Britt4, K. B. Dunn7, G. Kennedy9, R. Kim2, J. Lau5, V. Nfonsam3, R. Radhakrishnan6, K. Brown1  1University of Texas Austin Dell Medical School,Surgery And Perioperative Care,Austin, TX, USA 2Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 3University Of Arizona,Surgery,Tucson, AZ, USA 4Eastern Virginia Medical School,Surgery,Norfolk, VA, USA 5Stanford University,Surgery,Palo Alto, CA, USA 6University Of Texas Medical Branch,Surgery,Galveston, TX, USA 7University Of Louisville,Surgery,Louisville, KY, USA 8University Of Chicago,Surgery,Chicago, IL, USA 9University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA 10Roosevelt University,Industrial-Organizational Psychology,Chicago, IL, USA

Introduction:  Leadership skills have become an important competency for successful academic surgeons. Informed by research in Industrial-Organizational Psychology across multiple business settings, analyzing and optimizing the culture of an organization can significantly impact the effectiveness of the unit. These concepts have begun to influence leaders in academic medicine, but there are few data on leaders’ use of these tools or their impact. The purpose of this study is to explore SUS members’ knowledge and use of leadership skills relating to optimizing the culture of the units they lead, as a needs assessment for future educational activities.

Methods:  Survey questions were constructed in collaboration with a PhD Industrial-Organizational Psychologist and piloted on a sample of members of the SUS. The revised survey was distributed to the members of the SUS via email, with one follow-up reminder email. Responses were analyzed with descriptive statistics.

Results: Our response rate was 20% (98/492 members contacted). Respondents’ leadership units included academic divisions or sections (n=49), clinical programs (n=14), training programs (n=15), and research programs (n=7). There were 14 Vice Chairs and 4 Department Chairs. Nine respondents had more than 1 leadership role. The number of faculty and staff led by respondents was 10 or less for 37%, 11-25 for 37% and >26 for 26%. Only 8% of respondents reported “a good working knowledge” of selection science and organizational psychology (figure). Respondents learned about organizational culture most often through self-directed study, followed by learning from colleagues and through non-degree courses. Six percent of leaders routinely use formal culture assessment; 15% routinely assess potential hires for cultural fit, and 15% routinely use interventions aimed at cultural change. 73% of respondents reported “a great deal of interest” in learning about interventions to change culture; 56% in developing an aspirational culture, and 54% in assessment tools for potential hires. When asked about preferred methods for learning, attending workshop at a national meeting was strongly preferred by 35% and 51% would use that if available. Dedicated workshops and targeted reading materials were strongly preferred by 30% and 19% respectively.

Conclusion: SUS survey respondents serve significant leadership roles in academic and clinical units. These leaders have notable knowledge gaps in leadership skills used in high-performing organizations in industries outside of medicine. Targeted education to develop knowledge and skills may benefit surgical leaders in improving the performance of their clinical, administrative, research and educational units.

 

104.09 5-Year Follow-up of a Leadership Development Program: Impact on Culture in a Surgery Department

Posted on January 31, 2019

C. A. Vitous1, S. Shubeck1,2, A. Kanters1,2,3, M. Mulholland1,2, J. B. Dimick1  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program At The Institute For Healthcare Policy & Innovation,Ann Arbor, MI, USA

Introduction: Although a growing body of literature has been focused on the impacts of Leadership Development Programs on individual surgeons, little effort has been focused on understanding the long-term impact these programs can have on surgical culture. The purpose of this study was to explore the impact of implementing a Leadership Development Program on the culture of the Department of Surgery at the University of Michigan.

Methods: Qualitative interviews were conducted with 14 surgical faculty in the first cohort of a Leadership Development Program at the University of Michigan, 5 years after completion of the program. Using NVivo (version 11.4.3), thematic analysis was used to locate, analyze, and report patterns within the data.

Results: Thematic analysis demonstrated that participation in the Leadership Development Program influenced surgical culture in the following ways: 1) promoted a more participative leadership style, providing tools for surgeons to create a more collaborative environment; 2) increased the culture of diversity, with leaders in the department valuing a more inclusive and wide range of skill sets; and 3) strengthened the collegial environment as evidenced by improved morale and relationships within the department. Additionally, several participants expressed difficulty in teasing out what was a direct benefit of the Leadership Development Program versus what could be attributable to other factors, referred to here as the chicken or egg argument.

Conclusion: Reflecting on the past 5 years, almost all of the participants expressed experiencing at least some long-term changes that they thought were related to the Leadership Development Program. This research may provide insight into the broader implications that programs like these have on surgical culture.

 

104.08 Skills Retention after REBOA Training: Assessing the Staying Power

Posted on January 31, 2019

S. S. Raza1, J. Sikoutris1, B. P. Smith1, R. Dumas1, M. A. Vella1, Z. A. Qasim2, J. Guzman1, J. J. Gallagher1, P. M. Reilly1, J. W. Cannon1  1Hospital Of The University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery, Department Of Surgery,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Department Of Emergency Medicine,Philadelphia, PA, USA

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a low-frequency, high-acuity intervention. A formal skills training course remains the cornerstone of operator training and certification for REBOA placement. We hypothesize that REBOA-specific knowledge and comfort with placement deteriorate significantly within 6 months of this training if REBOA is not performed clinically in the interim.

Methods:  A formal REBOA course was administered to train trauma faculty and fellows on REBOA indications and technique. This 4-hour course included a pre-course test and subjective self-assessment, followed by interactive didactics with hands-on practical training on a manikin, and concluded with a post-course test and self-reassessment. 6 months after the initial course, knowledge retention was retested and procedural comfort and number of REBOA cases reassessed for performance improvement with IRB approval. Trends in these repeated measures were evaluated with the Wilcoxon rank-sum test.

Results: A total of thirteen course participants were evaluated. Test scores improved significantly from pre-course (median 76% correct, IQR 64%-80%) to post-course (88% correct, IQR 84%-92%, p=0.002). At 6 months, retest scores (84% correct, IQR 76%-88%) remained higher than pre-course baseline scores (p=0.007) and were not significantly different than post-course scores (p=0.208) (Fig 1). At 6-month subjective assessment, comfort with femoral A-line placement and REBOA-specific knowledge also remained high with no significant difference from post-course levels. However, subjective comfort with REBOA placement at 6 months decreased significantly from post-course levels, driven primarily by participants with no clinical REBOA cases in the interim (p=0.046) (Fig 2).

Conclusion: There was no detectable deterioration in REBOA knowledge gains in the 6 months following a formal REBOA course. However, subjective comfort with REBOA placement skills decreased among participants who had not placed REBOA clinically during this time. Further longitudinal assessment is warranted to determine the appropriate interval for refresher skills training if REBOA insertion is not performed routinely.

104.07 Cumulative Sum as a Method for Tracking Learning Progress in Robotic Surgery Fundamentals

Posted on January 31, 2019

B. J. Goudreau1, Y. Hu1, H. Kim1, E. Mace1, N. S. Schenkman1, L. A. Cantrell1, P. W. Smith1, S. K. Rasmussen1, P. T. Hallowell1  1University Of Virginia,Charlottesville, VA, USA

Introduction: Robotic surgery is becoming a fundamental component of general surgery practice and training. Although a sophisticated virtual reality trainer exists for the da Vinci robot, adaptive methods of measuring proficiency are lacking. The objective of this study was to use cumulative sum (Cusum) to characterize the learning curves of surgical novices and experts using the dV-Trainer robotic virtual simulation system. 

Methods: Ten medical students enrolled in a robotic surgery training course completed 10 practice attempts on three tasks using dV-Trainer: Peg-Transfer 2, Ring-Walk 2, and Needle-Driving 1. Simulation proficiency was tracked using Cusum. The students were evaluated via pre- and post-tests using the da Vinci Si robot and two inanimate models: peg-transfer and ring-and-rail. For comparison, Cusum proficiency curves were generated for 7 surgical faculty and 9 surgery residents as they performed repetitions on the same three dV-Trainer tasks. 

Results:Students’ scores on peg-transfer (87.3 vs 66.1, p = 0.004) and ring-and-rail (93.4 vs 77.4, p = 0.002) significantly improved following virtual training. Participants who remained sub-proficient by Cusum criteria at the Peg-Transfer 2 and Ring-Walk 2 virtual tasks were ranked 8thand 10thon post-testing for the corresponding inanimate models. Among residents, only one was sub-proficient on Peg-Transfer 2, while half were sub-proficient on Ring-Walk 2 and Needle-Driving 1. Experienced surgeons were Cusum-proficient on all tasks except for one surgeon who was sub-proficient on Needle-Driving 1.

Conclusion:Inherent variability exists in robotic surgery aptitude. Using Cusum to track training progress on basic technical skills can identify learners who are in need of more rigorous training. 

 

104.06 Impact of Simulation-Based Education on the Volume of MIS Cases Performed by our Division Over Time

Posted on January 31, 2019

J. Balaban1, L. Burkhalter3, D. Diesen2,3  1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 3Children’s Medical Center,Dallas, Tx, USA

Introduction:
Evidence shows simulation in surgical education improves laparoscopic and thoracascopic skills in a safe environment, while increasing physician competency and efficiency. Additionally, studies demonstrate simulation-based education improves patient safety and outcomes. Despite enhancing the learning curve and technical skill of the fellows, there is minimal data to show how the addition of a simulation curriculum changes practice patterns. The purpose of this study was to evaluate the impact of a simulation-based education curriculum on the volume of minimally invasive surgery (MIS) cases performed within a division.

Methods:

After IRB approval, we performed a retrospective review of MIS cases performed in children less than one year of age. Inclusion criteria were thoracascopic and laparoscopic cases performed in the 2 years pre (6/2013-6/2015) and post (6/2016-6/2018) implementation of a simulation-based education curriculum for fellows. Patients were identified by billing codes and verified in EPIC.  Data points included demographics and outcome variables. For both groups, any thoracoscopic or laparoscopic case was considered MIS, while complex MIS cases excluded isolated inguinal hernia repairs, gastrostomy tube placements, and pyloromyotomies.

Designed to improve technical and nontechnical skills, this curriculum consisted of 8-10 simulation sessions covering different complex MIS procedures, all of which were proctored by two clinical faculty. The curriculum has since been integrated into the fellowship curriculum.

Results:

Between 2013- 2015, 1,407 children less than one year of age had operations. 261 (18.6%) of those were MIS. 51 (3.6%) were complex MIS. Between 2016 -2018, 1,348 children less than one year of age had procedures. 441 (32.7% of total) of those were MIS. 125 (9.3%) were complex MIS. Following the implementation of the curriculum, the amount of total MIS cases increased by 1.76-fold, while the amount of complex cases increased by 2.56-fold.

Conclusion:

Implementation of a simulation curriculum corresponded with an increase percentage of cases being performed minimally invasively in infants with a corresponding increase in the percentage of complex cases done minimally invasively. This suggests that SBE curriculum may have advantages to divisions, departments and hospitals, in addition to the educational benefits to the trainee

104.05 Near real time prediction of eye-gaze using deep neural network in endoscopic surgeries

Posted on January 31, 2019

S. Holla2, N. Lau2, S. E. Parker3, S. D. Safford1  1Virginia Tech Carilion School of Medicine,Surgery,Roanoke, VA, USA 2Virginia Polytechnic Institute and State University,Blacksburg, VA, USA 3Carilion Clinic,Human Factors,Roanoke, VA, USA

Introduction:  

Deliberately training novice surgeons on where to attend during an operation has the potential to rapidly improve surgical performance.  Eye-tracking enables the use of machine learning to simulate or predict where surgeons would look during surgical procedures. The capability to predict where surgeons look could have important applications. First, this capability can inform instructors where learners tend to look by simulating their eye movements in real time. Second, this capability can help instruct learners on where experts look for any given operation, thereby providing immediate guidance on visual attention. Finally, this capability can provide visual assistance (i.e., “a second pair of eyes”) to alert the physicians performing the operations on where additional attention appears warranted.

Methods:  

To advance the application of machine learning for surgical training, we conducted an exploratory study developing and evaluating a computer vision deep neural network (DNN) that adapted the ADNet algorithm and employed data from our previous experiment which involved eye-tracking of an expert, attendings and residents viewing laparoscopic surgery videos. Using a subset of 13 videos incorporated with eye-gaze data from several attendings and residents, we trained the DNN to predict the eye gaze of the attending and resident surgeons separately. We evaluated the DNN by testing whether the DNN predicted eye gaze could produce significant findings similar to our previous experiment.

Results:
The DNN predicted eye gaze yielded two significant findings similar to our empirical experiment. In our prior experiment, one significant finding is that eye-gaze of the expert agreed less with those of attendings than residents and thus implied a greater field of gaze and possibly awareness. In this study, the expert eye-gaze was marginally further away from the DNN predicted eye-gaze of the attendings than the predicted one of the residents (F(1,14)=3.68, p=.076). In addition, we also observed that the DNN predicted eye-gaze was more closely matched to those of residents than the attendings (F(1,14)=6.48, p=.023), indicating that resident eye-gaze was more predictable or learnable.

Figure: A video frame indicating location of the DNN predicted eye-gaze in the (bigger) blue rectangle in comparison to the actual eye gaze of a participant in the (smaller) green rectangle.

Conclusion: 

By confirming a prior significant finding, these two preliminary results highlight the potential of machine learning in mimicking eye gaze behaviors of different medical professionals viewing laparoscopic surgery without excessive data collection. Future work entails improving the DNN algorithm and utilizing the remaining portion

 

104.04 The Utility of an Open-Access Surgical Simulator to Train Surgeons in Developing Countries

Posted on January 31, 2019

A. S. Volk1, B. S. Eisemann2, R. P. Dibbs1, A. T. Perdanasari2, T. L. Braun2, K. P. Marsack1,2  1Texas Children’s Hospital,Department Of Plastic Surgery,Houston, TX, USA 2Baylor College Of Medicine,Division of Plastic Surgery, Michael E. DeBakey Department of Surgery,Houston, TX, USA

Introduction:  
Smile Train is an international children’s charity committed to improving cleft care around the world by empowering local medical professionals in developing countries to provide quality comprehensive cleft care in their own communities. This organization builds surgical capacity in developing countries by partnering with local hospitals and providing training opportunities for local surgeons and other medical professionals. As part of their sustainable model, Smile Train has developed a web-based, interactive virtual simulator to help improve the surgical training of cleft procedures for surgeons around the world.  The simulator replicates the anatomical and technical steps involved in cleft lip and palate surgery. The purpose of this study was to evaluate this simulator as a tool for enhancing surgical training.

Methods:
Physicians in training at an academic institution were recruited to study the educational benefits of the surgical simulator. A pre-test and questionnaire with questions addressing cleft care, surgical knowledge, and confidence level was developed and administered to all participants. Participants were then instructed to complete three simulator modules followed by a post-test and questionnaire to measure changes in knowledge and confidence levels. 

Results:
Sixteen surgeons-in-training participated in this study. The mean score on the knowledge exam improved after reviewing the modules. Junior resident scores increased from 33.1% to 64.4%, and senior resident scores increased from 46.9% to 70.8%. Survey results demonstrated that reviewing the module increased participants’ confidence in the knowledge of cleft anatomy, understanding of the surgical procedures, and ability to follow along meaningfully while assisting in surgical procedures. 

Conclusion:
This study demonstrates that the Smile Train Virtual Surgery Simulator increased knowledge and reported surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons in training. Virtual simulation may become a valuable resource for improving understanding and competence of the craniofacial surgeon while also serving as an educational resource to other members of the comprehensive cleft care team, patients, and families. 
 

104.03 National Study Identifies Surgeons and Medical Students Under-Reporting Sharp Injury

Posted on January 31, 2019

J. Yun1, D. Berera1, D. Vyas1  1San Joaquin General Hospital,General Surgery,French Camp, CA, USA

Introduction:

A majority of sharps-related injuries in U.S. hospitals are not reported. Even with the passage of the Needle-stick Safety and Prevention Act, estimates suggest that the underreporting rate remains unchanged. Few studies have quantified the incidence of underreporting and even fewer studies have evaluated the underlying reasons for not reporting sharps-related injuries. The primary objective of this study was to quantify the incidence of sharps-related injuries, reporting behaviors, and reasons for not reporting sharps-related injuries by healthcare practitioners (HCPs) in U.S. hospitals.

Methods:

An online, anonymous survey consisting of 15 questions was designed and distributed to attending physicians, residents and fellows, medical students and nurses; 3500 emails were sent to residency programs, hospitals, and medical schools across the U.S.

Results:

Data from a total of 434 respondents were evaluated; 57% (n=247) of total respondents indicated they have experienced at least one sharps injury during their career. When asked about their most recent sharps injury, only 56% (n=139) reported the injury. Among those experiencing a sharps-related injury, medical students had the lowest incidence of reporting the injury (40%, n=12), followed by attending physicians (54%, n=53), residents (62%, n=63). Stratification by medical specialty revealed that HCPs from general surgery had the lowest incidence of reporting a sharps-related injury (49%, n=31) compared to other medical specialties. The three most common reasons for not reporting an injury were: (1) the HCP perceived no or minimal risk based on the patient’s medical history (2) excessive time required to report injuries, and (3) the perception that reporting offered no benefit.

Conclusion:

This national survey indicates that sharps-related injuries are underreported in U.S. hospitals. Sharps-related injury education and improved reporting processes may be beneficial to all practitioners, which may help reduce the risk of injury and infection.
 

104.02 The National Science Foundation I-Corps Program: A Tool to Promote Technology Innovation in Surgery

Posted on January 31, 2019

J. Whittle2, T. Petelenz2,4, T. D’Ambrosio2,5, J. Langell1,2,3,4  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 3VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA 4University Of Utah,Department Of Bioengineering,Salt Lake City, UT, USA 5University Of Utah,Lassonde Entrepreneurship Institute,Salt Lake City, UT, USA

Introduction: Many universities have embraced the concept of faculty-driven innovation, invigorating a new generation of physician entrepreneurs focused on translating discoveries to commercial products. New federal funding programs have been created that are designed to support faculty commercialization of academic research. Innovation Corps (I-Corps) a program developed by the National Science Foundation (NSF) provides educational support and seed funding to educate research faculty on business principles of technology commercialization. 

Our university is a funded I-Corps training site focused on healthcare technology. Our curriculum teaches Lean Start-up and Business Model Canvas principles, customer discovery and elements focused on unique aspects of health technology commercialization. Annual faculty cohorts are selected to participate in a 20-week I-Corps program and assigned entrepreneurial partners to create interdisciplinary teams. Teams attend the I-Corps training program composed of didactic lectures and workshops (table 1) and assigned an industry mentor.  Teams also receive $3000 seed grants and conduct market assessments. At the end of the program teams with viable commercial technologies concepts are provided ongoing support. Here we present our I-Corps experience, curriculum and the impact it had in educating faculty and supporting entrepreneurial activities over our first 4-years of implementation.

Methods: Team data was collected to assess participant characteristics, faculty assessment of program quality and program impact.  Data was acquired through our I-Corps program database, participant objective self-reporting of commercialization metrics and subjective quality surveys.

Results: During the first 4-years, we trained 102 faculty-led entrepreneurial teams in the I-Corps program. This included 81 physicians (34 Surgeons), 22 medical students, 37 engineering faculty and 41 engineering graduate student. 21 of 102 teams responded to our commercialization progress surveys.  Of these, 20 continue to pursue technology commercialization forming 14 companies and filing 22 patents.  These companies have generated 30 employees, 5 federal SBIR grants, 7 licensing agreements and >$11.5M in funding. Eight team faculty leads reported publishing their efforts in peer-reviewed journals and 11 presented their work at national academic conferences.

Conclusions: Our NSF I-Corps program tailored to healthcare technologies has successfully promoted physician innovation and entrepreneurship. Interdisciplinary programs like I-Corps designed to educate and support faculty innovation and entrepreneurship are important tools to promote the translation of research into clinical solutions.

104.01 Beyond Cross-Sectional Assessments: Can Virtual Reality Serve as a Longitudinal Skills Assessment?

Posted on January 31, 2019

K. H. Perrone1, H. Mohamadipanah1, F. C. Huang2, M. Garren2, A. Witt1, C. Pugh1  1Stanford University,Palo Alto, CA, USA 2University Of Wisconsin,Madison, WI, USA

Introduction:

Research supports the use of virtual reality (VR) as a screening tool for stratifying novices from experts based on psychomotor skills. However, little is known about the ability of VR to predict psychomotor skills longitudinally with one learner group as most studies focus on cross-sectional assessments of extremes of expertise. We hypothesize that VR will be able to serve as a valid longitudinal assessment for psychomotor skills in surgery residents.

Methods:
Surgical residents (N=26) participated in two consecutive years of data collection during their research time. Each year, participants placed a subclavian central line on a mannequin simulator and performed a path steering task in VR. During subclavian central line placement, hand movement data were collected from electromagnetic sensors and the number of clinical performance errors were tabulated. Central line data were then compared to the hand movement data calculated from the path steering task in the VR environment using parametric correlation analysis.

Results:
In the first year of participation, higher deviation of the hand from the desired path (steering error) in VR correlated positively to more time spent inserting the needle(r = +0.553, p<0.01), and more dominant hand jerkiness (r = +0.518, p<0.01) during subclavian central line placement (Table 1). In addition, more time spent (r = +0.466, p<0.05) and more dominant hand jerkiness (r = + 0.575, p<0.01) in VR also correlated significantly to a higher number of clinical performance errors during central line placement. In the second year of participation, however, we found that there were no correlations between VR metrics, motion metrics, and clinical performance errors during subclavian central line placement.

Conclusion:
Although there was a strong correlation during the first year, VR motion metrics did not sustainably correlate with motion metrics or clinical performance errors during central line placement in the second year. Of note, there was a small improvement in subclavian central line placement in year two, which suggests that the loss of correlation might be a result of participants learning through mental rehearsal and self-assessment during the interval between assessment year one and two. In addition, these VR tasks may simply have low sensitivity as a longitudinal screening tool for psychomotor skills.

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