Matthew Schill, BS, Debbie Tiemann, RN, Mary Klingensmith, MD, L. Michael Brunt, MD Department of Surgery and Institute for Minimally Invasive Surgery Washington University School of Medicine St. Louis, MO

Disclosures  Matthew Schill: No relevant financial interests  L. Michael Brunt, MD: MIS Fellowship Grant Support: ○ Ethicon Endosurgery Honorarium/Speaking: ○ Lifecell Corp

Background  Simulation is increasingly important in surgical education  Surgical residents may suffer in skills acquisition for many reasons: Work hour restrictions OR time constraints Patient safety concerns Increasing complexity of surgical patients and surgical technology

Background  Basic suturing and knot tying are essential for surgical skills development  Technical skills of incoming PGY-1 residents may vary widely due to prior experiences  Suturing and knot tying skills sessions are commonly taught but without further formal instruction, specified practice or assessment  Development of these skills progresses primarily along a Halstedian model of training in the OR

Background  Since 2001 our Department has held an introductory suturing and knot tying skills session for beginning surgical interns  In 2009, we restructured this program to include further instruction, defined goals and proficiency targets, and assessment of performance  Goal to develop cohort of trainees who have undergone the same training and performance template (“Masters” Program)

Hypothesis  Feedback, remediation and further practice would be necessary to meet the desired performance levels

Specific Aims 1. Describe elements of this “Masters” program 2. Report year one outcomes data 3. Correlate skills performance with conventional performance measures (case volumes, intern rotation evaluations, and ABSITE scores)

Masters Program Structure: Skills Training Template  2-hour skills training session Lecture and hands-on  Materials for practice Suture pad and tying board Instrument set  Online videos available for self-study  Follow-up skills training session at 2.5 months

Tasks  Suturing tasks: Simple interrupted Subcuticular Vertical mattress  Tying tasks: One-handed Two-handed Tie on a pass

Assessment  Timed and video taped technical performance (TP) of six tasks  Pre-course, 4 months post-course and thereafter as needed  All videos reviewed and scored by one senior surgeon (LMB) blinded to the intern using OSATS format

Masters Program Structure Baseline Assessment Introductory Training Session Independent Practice Refresher Session (2.5 months) Independent Practice Assessment (4 months) Feedback and Remediation Independent Practice Repeated Assessments

Other Performance Measures  Case numbers at 4 and 10 months  Technical skill comments from resident rotation evaluations graded on 1-5 scale  ABSITE scores PGY-1 year

Participants  9 surgical interns (8 categorical and 1 non- designated) at Washington University Medical Center participated in the program  6 end of PGY-2 Categorical General Surgery residents were assessed for comparison  Washington University School of Medicine Human Studies Committee approved protocol

Data Analysis  All data are mean ± SD  Statistical analysis: Task completion time: ANOVA with Tukey post-hoc tests Technical proficiency: Kruskal-Wallis test Comparison with other measures: Pearson correlation p-value of < 0.05 was considered significant

Results: Demographics  Mean age: 27 ± 2.4 years  Gender: male – 6, female – 3  Handedness: right – 8, left – 1  None had participated in an intern preparedness skills course as 4 th year medical students

Suturing Task Times * * *

Tying Task Times ** * * p < 0.05 ** p < relative to baseline

Total Combined Task Time * *p < vs baseline 8½ minutes!

Suturing Technical Proficiency * * * p < 0.05 vs baseline

Tying Technical Proficiency *** * p < 0.05 vs baseline

Time to Proficiency  All interns reached proficiency targets on 6/6 tasks  Mean time to proficiency: 10.1 months (4-12 months)  Mean # assessments post-training: 2.4 (range 1-3)  Proficiency rates at 4 mos: Suturing tasks: 44-55% Tying tasks: 11-22% Only one intern proficient on all 6 tasks at 4 month assessment

Conventional Performance Measures  Case counts at 4 and 10 months, and ABSITE did not correlate with time or TP  Coded rotation comments pertaining to technical skills were inversely correlated with total combined task time (not TP scores)

Study Limitations  Small sample size  Absence of control intern group  Technical proficiency assessment by one evaluator  Impact on operative technical performance unknown

Summary  Feedback, remediation, and repetitive practice are necessary for surgical interns to reach proficiency levels on basic suturing and knot tying tasks  Performance levels on these fundamentals upon completion of this program are comparable to that of end of R-2 year residents  Most traditional measures of intern performance correlate poorly with formal technical skills assessment

Conclusions  Proficiency based training and objective assessment of performance should be more widely utilized early in residency training for these fundamental surgical skills

Acknowledgements  M Schill was supported by NIH grant T35 DK