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Background: Efficient utilization of the operating room (OR) is essential. Inefficiencies are thought to cause preventable delays. Our goal was to identify OR incidents causing delays and estimate their impact on the duration of various general surgery procedures., Materials: Three trained observers prospectively collected intraoperative data using the ExplORer Surgical app, a tool that helped capture incidents causing delays. The impact of each incident on case duration was assessed using multivariable analysis., Results: 151 general surgery procedures were observed. The mean number of incidents was 2.7 per each case that averaged 109min. On average, each incident caused a 2.8 ​min delay (p ​< ​0.001), however, some incidents were associated with longer delays. The procedural step of each procedure most susceptible to incidents was also defined., Conclusion: The identification of the type of incidents and the procedural step during which they occur may allow targeted interventions to optimize OR efficiency and decrease operative time., Competing Interests: Declaration of Competing interest Our team is submitting an original research article that has not been published previously and is not under consideration for publication elsewhere. It is also approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: We assessed students' perception of the impact of the pandemic on their well-being, education, academic achievement, and whether grit and resilience alter students' ability to mitigate the stress associated with disruptions in education. We hypothesized that students would report a negative impact, and those with higher grit and resilience scores would be less impacted., Methods: A multidisciplinary team of educators created and distributed a survey to medical students. Survey results were analyzed using descriptive statistics, ANOVA, and multivariate linear regressions. A p-value <.05 was considered statistically significant., Results: A total of 195 students were included in the study. Approximately 92% reported that clinical education was negatively affected, including participants with higher grit scores. Students with higher resilience scores were more optimistic about clinical education. Those with higher resilience scores were less likely to report anxiety, insomnia, and tiredness., Conclusion: More resilient students were able to manage the stress associated with the disruption in their education. Resiliency training should be year-specific, and integrated into the UME curriculum due to the different demands each year presents., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Mental imagery (MI) aids skill acquisition, however, it is unclear to what extend MI is used by experienced surgeons. The purpose of this study was to assess differences in MI of participants with varying surgical expertise in robotic surgery., Methods: Students, residents, and surgeons completed the Mental Imagery Questionnaire to assess MI for robotic suturing. Participants then completed robotic simulator tasks, and imagined performing robotic suturing while being assessed with electroencephalogram (EEG)., Results: Attending surgeons reported higher MI for robotic suturing, and EEG revealed higher neural activation during imagery of robotic suturing than other groups., Conclusions: Experienced surgeons displayed higher MI ability for robotic suturing, and displayed higher cortical activity in the frontal and parietal areas of the brain, which is associated with more advanced motor imagery. MI appears to be a component of robotic surgery expertise., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Poor surgeons' non-technical skills (NTS) and excessive stress and workload are known contributors to surgical errors. Our aim was to examine the relationship between surgeons' stress and workload, and their observed NTS intraoperatively., Methods: Surgeon's NTS were rated in the operating room (OR) by trained observers. Surgeon stress, workload, familiarity with the OR team, prior experience, and case difficulty were captured. Relationships between variables were assessed., Results: Fifteen surgeons participated in our study. Agreement among raters was high for NTS observations (ICC range = 0.56-0.96). Stress was negatively correlated with situation awareness, and workload was negatively correlated with decision making. Less familiarity among the team was correlated with higher stress., Conclusions: Surgeons' stress and workload negatively affected their NTS in the OR. Further, unfamiliarity with the surgical team contributed to surgeon's stress. Methods to reduce surgeons' stress and workload such as mental skills training should be considered., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The position of Vice Chair of Education (VCE) is increasingly common in Surgery Departments. The role remains ill-defined. The purpose of this study was to explore perceptions of Department Chairs (DCs) and Other Education Stakeholders (OESs) regarding the VCE role., Methods: DCs and OESs at institutions with a VCE were surveyed. Descriptive statistics and cross-tabulations were calculated (SAS V9.4)., Results: The overall response rate was 25% (166/666). There were significant differences in whether DCs and OESs agree that the VCE supports others in fulfilling educational roles (95.2% vs 49.5%, p = 0.0002), is critical in achieving education missions (90.5% vs 56.6%, p = 0.0032), enhances the quality of education (95.3% vs 65.7%, p = 0.0174), and is important to education teams (95.0% vs 68.7%, p = 0.0464)., Conclusions: DCs value the VCE role more so than OESs, whom VCEs support. In order for VCEs to be effective educational leaders in Departments of Surgery, the needs of key stakeholders deserve further clarification., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The global COVID-19 pandemic has placed tremendous physical and mental strain on the US healthcare system. Studies examining the effects of outbreaks have demonstrated both an increased prevalence and long-term development of Post-Traumatic Stress Disorder (PTSD) symptoms in healthcare providers. We sought to assess the impact of the COVID-19 pandemic on the psychological well-being of medical providers, medical trainees, and administrators at a large academic center to identify stressors and moderators to guide future mental health and hospital-system interventions., Methods: A 42-item survey examining specific stressors, grit, and resilience was widely distributed to physicians, residents, fellows, and administrators a large academic institution for departmental distribution. Survey results were analyzed using descriptive statistics, ANOVA, and multivariate linear regressions. A p-value <0.05 was considered statistically significant., Results: A total of 785 participants completed the survey. The majority of respondents rated their stress to be significantly increased during the pandemic. Respondents' fear of transmitting the virus to their family members was a significant stressor. Higher resilience was associated with lower stress, anxiety, fatigue, and sleep disturbances. Overall, respondents felt supported by their departments and institution and felt contingency plans and personal protective equipment were adequate., Conclusions: Healthcare workers have increased resilience in the face of heightened stress during a pandemic. Higher resilience and grit were protective factors in managing personal and system-level stressors at the peak of the COVID-19 pandemic in our institution. Implementing an intervention designed to enhance healthcare workers' resilience in response to the COVID-19 pandemic is warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Progressing the field of surgical simulation research cohesively requires organization. The purpose of this study was to establish contemporary research priorities utilizing Delphi methodology., Methods: Surgical researchers with expertise in simulation-based research were invited to submit important questions for the field according to an organized framework. Thematic analysis was used to collapse questions into unique questions. In a second round, experts rated the importance of questions. In a third round, experts re-rated the importance of questions. A prioritized agenda was then created., Results: Eighteen experts submitted 80 questions in round one, which were collapsed into 43. In the final round, experts rated the following question as the most important priority: "Does demonstrated competency in the simulation lab translate to clinical competency (OR etc.)?", Conclusions: Our systematic approach identified multiple important questions to advance the field that may guide researchers and funding agencies alike., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Our objective was to assess the impact of incorporating videos in a behaviorally anchored performance rating scale on the inter-rater reliability (IRR) of expert, intermediate and novice raters., Methods: The Intra-corporeal Suturing Assessment Tool (ISAT) was modified to include short video clips demonstrating poor, average, and expert performances. Blinded raters used this tool to assess videos of trainees performing suturing on a porcine model. Three attending surgeons, 4 residents, and 4 novice raters participated; no rater training was provided. The IRR was then compared among rater groups., Results: The IRR using the modified ISAT was high at 0.80 (p < 0.001). Ratings were significantly correlated with trainee objective suturing scores for all rater groups (experts: R = 0.84, residents: R = 0.81, and novices: R = 0.69; p < 0.001)., Conclusions: Incorporating video anchors (to define performance) in the ISAT led to high IRR and enabled novices to achieve similar consistency in their ratings as experts., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Mental skills limit surgical residents' skill decay resulting from stress. However, optimal mental skills delivery is unknown. We sought to compare the impact of implementing our curriculum in small groups and individually., Methods: At baseline, residents completed assessments of mental skills and laparoscopic suturing. Residents then participated in a comprehensive mental skills curriculum at two institutions. At the first institution, residents completed small group training, whereas residents at the second institution trained individually. Following mental skills training, residents completed FLS training, at which time they completed the Short State Stress Questionnaire detailing their engagement. At post-test, residents completed baseline assessments again., Results: Twenty-one residents completed training. Small groups were less engaged after training than individuals (Group average engagement: 26.4 vs. Individual average engagement: 29.6, p = 0.06)., Conclusions: Delivering mental skills individually facilitates greater engagement than training in small groups, but regardless of delivery method, our MSC can achieve the same outcomes on surgical performance., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The advanced laparoscopic skills (ALS) curriculum was created to address the need for improved laparoscopic training for senior surgical trainees. It focuses on the domain of laparoscopic suturing and consists of 6 tasks with established proficiency benchmarks. Tasks are performed using a standard laparoscopic box trainer. This study examines whether practicing on the ALS curriculum could translate to improved clinical suturing., Methods: Surgery residents from four institutions participated in the study. Performance of the 6 ALS tasks and performance of a porcine gastrojejunostomy (GJ) and Nissen fundoplication were assessed before and after training. Video-recorded performance was de-identified and scored by three experts using both time and a previously published assessment instrument. Paired t-tests examined performance differences before and after the curriculum. Pearson correlations examined the relationship between performance on the porcine and ALS tasks., Results: Twelve residents (PGY1-8) from 4 institutions completed the study. Average practice time on ALS tasks was 6.25 weeks (range 1-14 weeks) and 254 min (range 140-600min). Combined ALS task time decreased from 2748s ± 603s to 1756s ± 281s (p < 0.001). Each of the 6 task times significantly improved (p < 0.05). Total errors decreased from 5.8 ± 3.2 to 3.7 ± 1.9 (p < 0.05). Average GJ times decreased from 1043s ± 698s to 643s ± 183s (p = 0.055). Average Nissen times decreased from 990s ± 531s to 685s ± 265s (p < 0.05)., Conclusion: Dedicated practice on the six ALS tasks led to decreased suturing time and fewer errors when completing both GJ and Nissen suturing in a porcine model. Further studies will be undertaken to determine the optimal application of the ALS task set in advanced laparoscopic training., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Though the importance of physician non-technical (NT) skills for safe patient care is recognized, NT skills of medical students, our future physicians, has received little attention. This study aims to investigate the relationship of medical student NT skills and clinical performance during acute care team simulation (ACTS)., Methods: Forty-one medical students participated in ACTS. A nurse confederate facilitated and evaluated clinical performance. Two raters assessed participants' NT skills using an adapted NT assessment tool and overall NT skills score was calculated. Regressions predicting clinical performance using NT constructs were conducted., Results: Overall NT skills score significantly predicted students' clinical performance (r 2  = 0.178, p = 0.006). Four of the five individual NT constructs also significantly predicted performance: communication (r 2  = 0.120, p = 0.027), situation awareness (r 2  = 0.323, p < 0.001), leadership (r 2  = 0.133, p = 0.019), and decision making (r 2  = 0.163, p = 0.009)., Conclusions: Medical student NT skills can predict clinical performance during ACTS. NT skills assessments can be used for targeted education for better feedback to students., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Several studies demonstrated that simulator-acquired skill transfer to the operating room is incomplete. Our objective was to identify trainee characteristics that predict the transfer of simulator-acquired skill to the operating room., Methods: Trainees completed baseline assessments including intracorporeal suturing (IS) performance, attentional selectivity, self-reported use of mental skills, and self-reported prior clinical and simulated laparoscopic experience and confidence. Residents then followed proficiency-based laparoscopic skills training, and their skill transfer was assessed on a live-anesthetized porcine model. Predictive characteristics for transfer test performance were assessed using multiple linear regression., Results: Thirty-eight residents completed the study. Automaticity, attentional selectivity, resident perceived ability with laparoscopy and simulators, and post-training IS performance were predictive of IS performance during the transfer test., Conclusions: Promoting automaticity, self-efficacy, and attention selectivity may help improve the transfer of simulator-acquired skill. Mental skills training and training to automaticity may therefore be valuable interventions to achieve this goal., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: This study aimed to identify differences in pattern recognition skill among individuals with varying surgical experience., Methods: Participants reviewed laparoscopic cholecystectomy videos of various difficulty, and paused them when the cystic duct or artery was identified to outline each structure on the monitor. Time taken to identify each structure, accuracy and work load, which was assessed using the NASA-Task Load Index (TLX), were compared among the three groups., Results: Ten students, ten residents and eight attendings participated in the study. Attendings identified the cystic duct and artery significantly faster and more accurately than students, and identified the cystic artery faster than residents. The NASA-TLX score of attendings was significantly lower than that of students and residents., Conclusions: Attendings identified anatomical structures faster, more accurately, and with less effort than students or residents. This platform may be valuable for the assessment and teaching of pattern recognition skill to novice surgeons., Short Summary: Accurate anatomical recognition is paramount to proceeding safely in surgery. The assessment platform used in this study differentiated recognition skill among individuals with varing surgical experience., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The role of simulation-based education continues to expand exponentially. To excel in this environment as a surgical simulation leader requires unique knowledge, skills, and abilities that are different from those used in traditional clinically-based education., Methods: Leaders in surgical simulation were invited to participate as discussants in a pre-conference course offered by the Association for Surgical Education. Highlights from their discussions were recorded., Results: Recommendations were provided on topics such as building a simulation team, preparing for accreditation requirements, what to ask for during early stages of development, identifying tools and resources needed to meet educational goals, expanding surgical simulation programming, and building educational curricula., Conclusion: These recommendations provide new leaders in simulation with a unique combination of up-to-date best practices in simulation-based education, as well as valuable advice gained from lessons learned from the personal experiences of national leaders in the field of surgical simulation and education., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Surgical education has seen tremendous changes in the US over the past decade. The Halstedian training model of see one, do one, teach one that governed surgical training for almost 100 years has been replaced by the achievement of the ACGME competencies, milestones, entrustable professional activities (EPAs), and acquisition of surgical skill outside the operating room on simulators. Several of these changes in American medical education have been influenced by educators and training paradigms abroad. In this paper, we review the training paradigms for surgeons in the UK, Japan, and Mexico to allow comparisons with the US training paradigm and promote the exchange of ideas., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Stress can negatively impact surgical performance, but mental skills may help. We hypothesized that a comprehensive mental skills curriculum (MSC) would minimize resident performance deterioration under stress., Methods: Twenty-four residents were stratified then randomized to receive mental skills and FLS training (MSC group), or only FLS training (control group). Laparoscopic suturing skill was assessed on a live porcine model with and without external stressors. Outcomes were compared with t-tests., Results: Twenty-three residents completed the study. The groups were similar at baseline. There were no differences in suturing at posttest or transfer test under normal conditions. Both groups experienced significantly decreased performance when stress was applied, but the MSC group significantly outperformed controls under stress., Conclusions: This MSC enabled residents to perform significantly better than controls in the simulated OR under unexpected stressful conditions. These findings support the use of psychological skills as an integral part of a surgical resident training., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We sought to determine the feasibility of developing a multimedia educational tutorial to teach learners to assess the critical view of safety using input from expert surgeons, non-surgeons and crowd-sourcing. We intended to develop a tutorial that would teach learners how to identify the basic anatomy and physiology of the gallbladder, identify the components of the critical view of safety criteria, and understand its significance for performing a safe gallbladder removal. Using rounds of assessment with experts, laypersons and crowd-workers we developed an educational video with improving comprehension after each round of revision. We demonstrate that the development of a multimedia educational tool to educate learners of various backgrounds is feasible using an iterative review process that incorporates the input of experts and crowd sourcing. When planning the development of an educational tutorial, a step-wise approach as described herein should be considered., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: We hypothesized that the implementation of a novel mental skills curriculum (MSC) during laparoscopic simulator training would improve mental skills and performance, and decrease stress., Methods: Sixty volunteer novices were randomized into intervention and control groups. All participants received FLS training while the intervention group also participated in the MSC. Skill transfer and retention were assessed on a live porcine model after training and 2 months later, respectively. Performance was assessed using the Test of Performance Strategies-2 (TOPS-2) for mental skills, FLS metrics for laparoscopic performance, and the State Trait Anxiety Inventory (STAI-6) and heart rate (HR) for stress., Results: Fifty-five participants (92%) completed training and the transfer test, and 46 (77%) the retention test. There were no significant differences between groups at baseline. Compared to controls the intervention group significantly improved their mental skill use, demonstrated higher laparoscopic skill improvement during retention, and reported less stress during the transfer test., Conclusions: The MSC implemented in this study effectively enhanced participants' mental skill use, reduced cognitive stress in the operating room with a small impact on laparoscopic performance., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Mental skills training refers to the implementation of cognitive performance-enhancing strategies to promote optimal performance. We aimed to develop a surgery-specific mental skills curriculum (MSC) and obtain initial evidence of efficacy., Methods: The developed MSC consisted of 8 proven performance-enhancing modules. Its efficacy was assessed during laparoscopic simulator-based practice by novices using validated instruments of mental skills, workload, and stress, in addition to a skill transfer test to a porcine model. A paired t test was used to analyze the data., Results: Nine surgical novices completed the curriculum. Compared with baseline assessment, participants improved significantly their laparoscopic performance and mental skills after completion of the MSC. All participants completed the task in the porcine model without an appreciable change in their perceived stress. During the skill transfer test, 8 participants were observed using mental skills taught in the MSC., Conclusions: A surgery-specific simulator-based MSC was developed, and its efficacy in improving mental skills and surgical performance was supported during a surgical skill transfer test., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Intro: The mental workload associated with laparoscopic suturing can be assessed with a secondary task that requires the same visual-spatial attentional resources. The purpose of this study was to use a secondary task to measure the incremental workload demands of single-incision laparoscopic surgery (SILS) procedures versus traditional laparoscopic procedures., Method: 12 surgery residents and surgical assistants who had met FLS criteria on an FLS and SILS simulator performed one trial each of peg transfer, cutting, and intracorporeal suturing tasks simultaneously with the secondary task and provided subjective workload ratings using the NASA-TLX., Results: SILS procedures resulted in lower primary and secondary task scores, p < 0.001 and higher workload ratings, p < 0.0001. Suturing resulted in lower primary (p < 0.003) and secondary task scores (p < 0.017) and higher workload ratings (p < 0.017) compared to the other tasks., Conclusions: SILS procedures were significantly more mentally demanding than traditional laparoscopic procedures corroborated by primary and secondary tasks scores and subjective ratings., Competing Interests: The authors of this study have no conflict of interest to disclose., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Advanced laparoscopic suturing (LS) tasks were developed based on a needs assessment. Initial validity evidence has been shown. The purpose of this multicenter study was to determine expert proficiency benchmarks for these tasks., Methods: 6 tasks were included: needle handling (NH), offset-camera forehand suturing (OF), offset-camera backhand suturing (OB), confined space suturing (CF), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons experienced in LS completed the tasks twice. Mean time and median accuracy scores were used to establish the benchmarks., Results: Seventeen MIS surgeons enrolled, from 7 academic centers. Mean (95% CI) time in seconds to complete each task was: NH 169 (149-189), OF 158 (134-181), OB 189 (154-224), CF 181 (156-205), UT 379 (334-423), and CS 416 (354-477). Very few errors in accuracy were made by experts in each of the tasks., Conclusions: Time- and accuracy-based proficiency benchmarks for 6 advanced LS tasks were established. These benchmarks will be included in an advanced laparoscopic surgery curriculum currently under development., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: A recent survey of fellowship directors suggested significant deficits in the technical laparoscopic skills of graduated general surgery residents. Our aim was to define the need for and possible content of a simulation-based curriculum in advanced laparoscopic skills (ALS)., Methods: An anonymous online survey was distributed to all Fellowship Council program directors (PDs), current fellows, and recent fellowship graduates. The survey was designed to assess the perceived need for, possible content of, and implementation challenges to an ALS curriculum. Recently developed simulation-based advanced laparoscopic tasks included off-angle camera work and restricted space suturing. Images and descriptions of these tasks were evaluated by respondents, and suggestions for modifications or improvements solicited via free text response., Results: Of 186 respondents (response rate: 64%), 40% were current fellows, 22% were fellowship graduates, and 37% were PDs. Respondents primarily self-identified as minimally invasive and/or bariatric surgeons (78%) and hepatobiliary surgeons (12%). Most respondents (73%) identified a need for an ALS curriculum. All 3 respondent groups cited laparoscopic needle positioning and suturing (78%) and bimanual coordination during dissection and retraction (72%) as the skills in most need of improvement. In addition, most of the responding PDs identified "lack of familiarity with anatomy and procedure" (74% of PDs) and "lack of proficiency at laparoscopic bowel anastomosis" (59% of PDs) as problem areas. Respondents felt that successful implementation of an ALS curriculum depended on both overall feasibility and the ability for repeated practice and should not be dependent on cost. Thematic analysis of free responses revealed the following priorities for possible ALS skills and tasks: (1) difficult dissections and exposures, (2) forehand and/or backhand and suturing under tension, (3) nondominant hand drills, (4) working with an off-set camera, and (5) suturing and handling fragile tissue with properties similar to peritoneum or bowel., Conclusions: We present survey results identifying several specific ALS set deficits among graduating general surgery residents, including advanced suturing, bimanual coordination, and managing difficult anatomy. Next, the results of this needs assessment will be used to develop an advanced laparoscopic curriculum for residents entering minimally invasive surgery fellowships and careers., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Key research priorities for surgical simulation have been identified in recent years. The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved., Methods: Members of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel., Results: Excellent progress has been made in the assessment of individual and teamwork skills in simulation. The best methods of feedback and debriefing have not yet been established. Progress in answering more complex questions related to competence and transfer of training is slower than other questions. A link between simulation training and patient outcomes remains elusive., Conclusions: Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery. The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency., Methods: We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests., Results: Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations., Conclusions: Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to determine sources of intraoperative stress, impact on surgical outcomes, coping strategies, and surgeon interest in stress management training., Methods: An anonymous survey was electronically distributed to surgeons at a tertiary care hospital. Respondents were asked to rate the perceived impact of 9 stressors on operative performance, identify stress coping strategies, list witnessed stress-related complications, and opine on the perceived need for stress management training., Results: Seventy-two responses were received (76% relative risk). Complex or rarely performed cases and poor assistance were associated with the highest stress, while personal life distractions were associated with the least. Importantly, 40% of surgeons indicated that they had witnessed an intraoperative complication directly related to surgeon stress. Respondents (82%) believed that formal stress management training is needed., Conclusions: Several stressors affect surgical performance and contribute to complications. Surgeons use a variety of stress coping strategies. Formal stress management training is needed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Effective teamwork is critical to safety in the operating room; however, implementation of phase III of the American College of Surgeons (ACS) and Association of Program Directors in Surgery (APDS) Curriculum that focuses on team-based skills remains worryingly low. Training and assessing the complexities of teamwork is challenging. The objective of this study was to establish guidelines and recommendations for training faculty in assessing/debriefing team skills., Methods: A multistage survey-based consensus study was completed by 108 experts responsible for training and assessing surgical residents from the ACS Accredited Educational Institutes., Results: Experts agreed that a program to teach faculty to assess team-based skills should include training in the recognition of teamwork skills, practice rating these skills, and training in the provision of feedback/debriefing. Agreement was reached that faculty responsible for conducting team-based skills assessment should be revalidated every 2 years and stringent proficiency criteria should be met., Conclusions: Faculty development is critical to ensure high-quality, standardized training and assessment. Training faculty to assess team-based skills has the potential to facilitate the effective implementation of phase III of the ACS and APDS Curriculum., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Our aim was to report the longitudinal assessment of technical performance of general surgery residents on select tasks from multiple programs over a 2-year period., Methods: An institutional review board-approved, multi-institutional collaborative study was undertaken with yearly resident performance assessments over a 3-year period. General surgery residents (postgraduate year [PGY] 1 to 5) were tested on 3 laparoscopic and 5 open simulated surgical tasks. Resident performance was compared individually over time and among interns and more senior residents., Results: Forty-one residents from 4 residency programs were evaluated. Scores increased in all tasks with each assessment, plateauing at a lower PGY level for open tasks compared with laparoscopic tasks. Change in performance scores between assessments were higher for interns compared with more senior residents (P < .003)., Conclusions: Resident performance on basic open and laparoscopic tasks assessed over time improved the most between the PGY 1 and 2 levels and was dependent on task difficulty. This documented skill evolution may allow tailoring of skills curricula to both meet existing needs and minimize performance variability., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Research in surgical education has seen unprecedented growth but originates from single institutions and remains uncoordinated; this study aimed to generate a list of research priorities in surgical educational topics., Methods: The membership of the Association for Surgical Education was asked to submit up to 5 research questions concerned with multi-institutional collaborative surgical education research and to identify challenges faced by surgical education researchers. A modified Delphi methodology was used to create the research agenda based on these responses., Results: Surgical educators responded to 3 survey rounds. Categories of submitted questions included teaching methods and curriculum development; assessment and competency; simulation; medical student preparation and selection; impact of work hour restrictions; and faculty development. Participants cited institutional culture and practice variability and lack of institutional review board coordination as common barriers to collaborative research, while identifying extensive planning, frequent communication, and availability of dedicated research coordinators as the most important facilitators., Conclusions: Using a Delphi methodology, a prioritized agenda for multi-institutional surgical education research was developed that may help advance surgeon education., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Despite tremendous growth, research in surgical simulation remains uncoordinated and unfocused. The objective of this study was to develop research priorities for surgical simulation., Methods: By using a systematic methodology (Delphi), members of the Association for Surgical Education submitted 5 research questions on surgical simulation. An expert review panel categorized and collapsed the submitted questions and redistributed them to the membership to be ranked using a priority scale from 1 (lowest) to 5 (highest). The results were analyzed and categorized by consensus in distinct topics., Results: Sixty members submitted 226 research questions that were reduced to 74. Ratings ranged from 2.19 to 4.78. Topics included simulation effectiveness and outcomes, performance assessment and credentialing, curriculum development, team training and nontechnical skills, simulation center resources and personnel, simulator validation, and other. The highest ranked question was, "Does simulation training lead to improved quality of patient care, patient outcomes, and safety?"., Conclusions: Research priorities for surgical simulation were developed using a systematic methodology and can be used to focus surgical simulation research in areas most likely to advance the field., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify the ideal interval between training sessions in a proficiency-based laparoscopic suturing simulator curriculum., Methods: We analyzed performance data from 3 randomized controlled trials of novices (n = 66) who followed a similar proficiency-based simulator curriculum in laparoscopic suturing on the Fundamentals of Laparoscopic Surgery model. The change in performance and intertraining interval were correlated., Results: Overall participant performance improved from 530 +/- 58 seconds at baseline to 81 +/- 14 seconds at training completion (P < .001). Intertraining intervals ranged from 1 to 43 days and performance change between training sessions varied widely. There was no correlation of performance change with intertraining interval (r = .05, P = .30). Performance deterioration was similar at different intertraining intervals. Shorter intervals were associated, however, with shorter training duration (r = .35, P = .005)., Conclusions: No association was found between intertraining interval and change in performance during proficiency-based laparoscopic simulator training but shorter intervals were associated with improved skill acquisition. Further study is needed to confirm these findings.

Background: The objective of this study was to investigate whether novices improve their ability to develop multitask (ie, automaticity) with accumulating experience on a simulated laparoscopic task., Methods: In this prospective study, novices (12 premed students) trained for 4 months in laparoscopic suturing. Simultaneously with suturing, participants performed a visual-spatial secondary task to assess their spare attentional capacity. Trainees were required to achieve expert-derived levels in both suturing (520 score) and the secondary task (target 73%). Their performance was assessed with objective scores, and their ability to multitask during training was examined., Results: After 10 +/- 5 hours and 84 +/- 41 repetitions, participants demonstrated improvements in their suturing (70%, P < 0.001) and secondary-task performance (16%, P = 0.08) compared with their baseline scores. During the study period, 11 of 12 participants achieved suturing proficiency, but no one achieved secondary-task proficiency. Longer training times correlated with higher secondary-task scores (r = .68, P < 0.02), and participants who performed >100 repetitions (n = 4) achieved higher secondary-task scores (P < 0.03)., Comments: This study provides evidence for improved automaticity at advanced stages of simulator training. Although novices achieve simulator proficiency after relatively short training durations, the attainment of automaticity requires substantially longer training periods. Further study of this concept is warranted and is currently underway.

Background: Automaticity is a characteristic of expertise defined by the ability to perform a task without significant demands on attention. Our objective was to assess whether a visual-spatial task that measures spare attentional capacity would distinguish among individuals with different levels of laparoscopic expertise., Methods: The performance of novices (n = 10), surgery residents (n = 9), laparoscopy experts (n = 3), and individuals previously trained (n = 7) to proficiency in laparoscopic suturing on simulators but without operative experience (trained individuals) was measured under dual-task conditions. Participants performed laparoscopic suturing for 10 minutes on a video trainer simulator using the Fundamentals of Laparoscopic Surgery suturing model (primary task) while at the same time they responded to a visual-spatial secondary task., Results: Experts and trained individuals outperformed both residents and novices on the suturing task (P < .001). Although the performance of experts and trained individuals did not differ significantly based on suturing scores, experts achieved higher secondary-task scores (P < .05)., Conclusions: A visual-spatial secondary task that assesses spare attentional capacity may help distinguish among individuals of variable laparoscopic expertise when standard performance measures fail to do so. Such automaticity metrics may improve current simulator training and assessment methods and warrants further investigation.

Background: Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach., Methods: A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded., Results: Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study., Conclusion: Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.

Background: Numerous protocols for laparoscopic skills training using simulator-based laboratories have proven effective. However, little is known about the availability and uniformity of such facilities. The purpose of this study was to evaluate the prevalence, utilization, and costs of skills laboratories currently in use., Methods: A survey was mailed to 253 general surgery program directors to determine the perceived value, prevalence, equipment, types of training, supervision, and costs of the labs., Results: One hundred sixty-two (64%) programs completed the survey. Eighty-eight percent of responders consider skills labs effective in improving operating room performance; however, only 55% have skills labs. Of 89 programs with skills labs, 99% have videotrainer equipment (mean 3.8 trainers per lab, range 1 to 15); 46% have virtual reality trainer equipment (mean 1.7 trainers per lab, range 1 to 7). Eighty-two percent of programs teach basic skills using a variety of tasks (Rosser/Southwestern stations, MIST-VR, MISTELS, department-created); 96% teach suturing (intracorporeal, extracorporeal, suture devices). On average, residents train 0.8 hours per week (range 0 to 6). Training is mandatory in 55% and supervised in 73% of the programs. The mean development cost was 133,000 dollars (range 300 dollars to 1,000,000 dollars)., Conclusions: While a large majority of program directors consider skills labs important, 45% of programs have no such facilities. Moreover, significant variability of equipment and training practices exist in currently available labs. Strategies are needed for more widespread implementation of skills labs, and standards should be developed to facilitate uniform adoption of validated curricula that reliably maximize training efficiency and educational benefit.

Background: The purpose of this study was to determine the feasibility and effectiveness of implementing a validated suturing curriculum as a free-standing continuing medical education (CME) course., Methods: Eighteen participants (9 practicing surgeons, 9 surgery residents) attended a 4-hour laparoscopic suturing CME course. After viewing an instructional videotape all participants had their baseline performance measured on a fundamentals of laparoscopic surgery-type videotrainer suture model. Participants then practiced on the model with active instruction from 6 proctors until a previously reported proficiency level was achieved or until the course ended. Performance was scored objectively based on time and errors. Precourse and postcourse questionnaires were collected., Results: Participants trained for 2.6 +/- .8 hours and performed 37 +/- 11 repetitions. Although no participant was proficient at baseline, 72% achieved the proficiency level by the end of the course. Participants showed 44% improvement in objective scores and 34% improvement according to subjective self-rating., Conclusions: Although 4 hours may be insufficient for some trainees, an intensive half-day CME course is feasible and effective in significantly improving performance and allowing the majority of participants to achieve proficiency.