Surgical Performance

The structure, content, implementation, and outcomes of education during medical school, residency, and ongoing clinical practice have been the subject of extensive debate and discussion since the times of William Halsted and Abraham Flexner, and more recently by influential committees from the Institute of Medicine, the Macy Foundation, and the Association of American Medical Colleges. In January 2005, the American Surgical Association Blue Ribbon Committee published their report in this Journal, concerning the multiple forces for change impacting medical education.1 Workforce issues, medical student and resident education, work-hour restrictions, structure of training programs, research training, faculty education, and continuing professional development were cited as critical strategies at a national level, to define and implement a new surgical education system. In 2012, Lewis and Klingensmith2 considered ongoing concerns in general surgery residency training. Technological advances such as laparoscopic and intraluminal approaches, the impact of cross-sectional imaging on management of trauma patients, outpatient surgery for breast, gallbladder and hernia procedures, continued postresidency training in fellowships, increasing American Board of Surgery examination failure rates, and challenges for autonomy during residency were declared as negative impacts on resident training. Curriculum updates, online learning and self-assessment modules, decreased service responsibilities, pre-residency boot-camps, simulation-based training, earlier specialization tracks, and extended residency training length were considered plausible solutions to the issues at hand. At a broader level, there is a national agenda to implement competency-based medical education, underpinned by competencies, milestones, and entrustable professional activities (EPAs).3 It is the aspiration that this educational structure will ensure trainees are placed under regular scrutiny with regard to their performance, and more importantly, to hold residency programs accountable for outcomes of their graduates. A laudable goal, as indeed there is a defined relationship between where one undertakes residency, and clinical outcomes in independent practice.4 The challenge is how to translate and coalesce all aspects of medical school, residency, and fellowship education into delivery of high-quality surgical care. Ultimately, the intention is to produce physicians who have acquired and can demonstrate their clinical knowledge, the skills to question, examine, investigate, diagnose, and manage patients, and behaviors or attitudes to engage colleagues, nursing and ancillary staff, patients, and their families. In addition, there is a desire to produce surgeons who also excel as educators, scholars, health advocates, and consummate professionals. The current alphabet soup of SCORE, EPAs, FES, OPRS, ATLS, mini-CEX, and so on, perhaps unintentionally, serves to fragment surgical education processes and outcomes, into piecemeal training models. The polar end is continuity of care, being the hallmark of high quality clinical practice, from symptoms, to diagnosis, treatment, and follow-up care. Care should be team based, patient-centered, and enable patient-physician relationships to develop, which are beneficial to both parties. Daly et al5 studied continuity of care for 228 patients undergoing operative procedures involving general surgery residents, and reported frequency of operative resident involvement in the preoperative consultation (9.2%), postoperative clinic visit (9.0%), and the entire course of care (0%). Although this may be ascribed to challenges with regard to rotation length, residents were on service for greater than 40 days, with average total duration of care per patient of 26 days. Indeed, Lewis and Klingensmith2 agreed that ‘…longitudinal experience with patients… have been markedly reduced’ and that ‘…residents have minimal opportunity to evaluate these patients before surgery or to follow them up afterward.’ Again, duty-hour restrictions and increasing outpatient surgical procedures were mentioned as challenges, associated with reduced opportunities for mentoring and apprenticeships. The Halsted-based apprenticeship model comprised long and arduous hours of training, steep hierarchies, subjective feedback of performance, and ambiguous definitions of competence. We cannot and should not hark back to the old days, but there is value in considering how the apprenticeship model enabled an appreciation of the entire surgical care pathway for patients, nuances and intricacies of disease states, their ongoing management, and cure. The aforementioned challenges in surgical education are now ingrained, necessitating novel concepts, and experiences to educate our trainees to deliver high-quality surgical care. Clinical care pathways are commonplace in modern health care, in the context of enhanced recovery programs, or care protocols.6 The charting of all aspects of care, in a multidisciplinary manner, at multiple settings and time points, for all providers, and focused upon the patient are key tenets of this approach. Clinical care pathways are evidence-based, demand team working, reduce variability in care delivery, improve outcomes, and may lower costs of care. This is the contemporary model of clinical care, none more so than in surgical practice. Despite this, training and assessment in surgical residency is focused upon time in program, prerequisite courses such as ATLS, clinical assessments, and operative caseload requirements.7 Although the Accreditation Council for Graduate Medical Education has mandated for graduating residents to demonstrate skills related to multidisciplinary team working, patient engagement, or quality improvement initiatives, this is a recent directive, and not widespread in application worldwide. In 2005, Brewster et al8 reported a pilot project for general surgery residents to participate in pre-, intra-, and postoperative management of a patient with retroperitoneal sarcoma, in a simulated setting. Each resident undertook a simulated clinic visit with a standardized patient and spouse (SPs), then performed part of the operative procedure in the simulated operating room (OR), followed by a discussion with the spouse (SP) of the patient. Evaluations of performance were based upon clinical, technical, and interpersonal skills, and professionalism, undertaken by faculty members and SPs themselves. The residents found the simulations to be realistic, immersive, and beneficial. Comparable work published more recently has regarded the development of simulation care pathways (SCPs) for biliary disease, foregut surgery, and trauma care.9–11 Each pathway involved management of a patient in multiple settings, comprising preoperative clinic with an SP, interaction in simulated OR with a synthetic/animal surgical model and team of anesthesiologist, scrub nurse, and assistant, and postoperative encounter either in the postanesthesia care unit, emergency room, or outpatient clinic, again with SPs (Fig. 1).FIGURE 1: A simulation care pathway, outlining pre-, intra-, and postoperative phases of care, mapped to knowledge, skills, attitudes and behaviors, and resulting outcome measures.The strategic educational framework for each SCP was based upon Bloom's taxonomy of cognitive, psychomotor and affective domains, mapped to ACGME competencies, aligned with the SCORE clinical syllabus. Clinical conditions incorporated were deemed appropriate for PGY training level and then translated into learning objectives. The SCPs were then mapped onto clinical care pathways—for example, with regard to biliary disease, SCPs were developed for biliary colic, acute cholecystitis, biliary pancreatitis, and choledocholithiasis, and similarly for postoperative simulations that consisted of uncomplicated course, bile leak, postoperative hemorrhage, or obstructive jaundice. Resident assessment of performance utilized forms approved by the American Board of Surgery—that is, CAMEO, OPRS, and mini-CEX, which were completed by faculty members and SPs in pre- and postoperative scenarios. In addition to the SCP, modules included didactic sessions built upon case-based learning, hands-on technical skills sessions, and peer-engaged learning sessions, whereby residents would observe each other undergo pre- and postoperative encounters with SPs—for residents to learn through observation of their colleagues, to debrief, and provide feedback. Over 1 year, a series of six 3-day modules were developed and implemented for 18 PGY1 residents at an academic health care system in the United States, comprising 2272 learner hours, and 29 faculty for 536 hours, encompassing biliary disease, acute care surgery, trauma and critical care, foregut surgery, colorectal disease, and cardiovascular disease. All residents undertook the SCP at commencement and conclusion of the 3-day module, which enabled residents to receive feedback of their performance at an individual level, and areas for improvement. Furthermore, the surgical education program to evaluated performance of the group, and areas for global improvement, aligned with Department or Health System initiatives for resident education. Although the simulation paradigm was based upon clinical care pathways, the focus is upon multiple care settings and inter-disciplinary care, rather than a prerequisite to have predefined comprehensive clinical care pathways. This model of simulation-based training, directly aligned with clinical practice, is novel and impactful. Powell et al12 have coined the term sequential simulation to bring together a series of key events, such as an adolescent (SP) with asthma in the family practice clinic, followed by an ambulance, and then in the emergency room. Beyond a concept for multidisciplinary team-training, this tool was used for public health education, to engage high school students. The development of pre- and postoperative cases for management of patients with acute appendicitis has been developed in the virtual world of Second Life, whereby the same encounters as per the SCPs in the simulation center occur on screen-based simulations, leading to better accessibility and reduced cost.13 Cross contamination between simulation and clinical worlds is more facile, when one considers the concept of SCPs. The pathways are context-specific and directly applicable to the clinical setting for the learner, more so than piecemeal simulation-based education for central line insertion, breaking bad news, or crisis management in the OR. The learner-based assessment tools are transferable between clinical and simulation settings, enabling a continuity of assessment processes, with focus upon the simulation center as a training environment, complementary (in time and space) to performance in real life settings. The pathways enable relationships between simulation-based curricula and clinically relevant outcome measures to be derived, such as simulation initiatives for enhanced quality and safety. The complexity and extent of SCPs can be aligned to learner needs, such that senior residents could not only engage in complex operative scenarios, but also participate in simulated morbidity and mortality rounds, tumor board presentations, and family meetings to discuss organ donation. The SCPs can be used to recreate real clinical scenarios that were rare, unusual, or of high importance—such as management of an abusive patient, or patient refusal for curative therapy. The concept of SCPs can be used to engage and educate clinical faculty, perhaps during disclosure of an adverse event to a patient, or identification and management of an under-performing trainee or other health care professional.14 Although new treatment paradigms continue to emerge, our patients become more complex, older and obese, chronic diseases more prevalent, and our health systems continue to evolve, the central tenet is to engage multiple disciplines of expertise to deliver patient-focused, effective, accessible and affordable care. Social determinants and their impact on the health of populations are key concerns; health care spending is based around acute episodes of care, with an urgent need to consider how to keep healthy people healthy, and identify those at risk or with early symptoms. The goal is to develop an outcomes-based surgical education system, underpinned by the structure, content and implementation of tools such as simulation, assessments, curricula, program requirements, and work hour regulations, to enable surgical experts to deliver patient-centered care as members of an inter-disciplinary team across acute and community-based settings, emphasizing evidence-based practice, quality improvement initiatives and informatics. Clinical care pathways are considered the gold standard for management of surgical disease; it is time for simulation to adapt to the emerging needs of students, residents, independent clinical practitioners, and most of all, our patients.

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