Department of Surgery Development of PGY-1 Surgery Preparatory Course Curricula: Identification of Key Curricular Components Mara B. Antonoff MD Jonathan D’Cunha MD, PhD

Department of Surgery Problem New PGY-1 surgical residents are underprepared

Department of Surgery Background Specific training during fourth year of medical school is highly variable Impaired patient care –Inefficient –Poor quality –Unsafe Stevens, Acad Med 2010 Antonoff et al, Surgery 2010

Department of Surgery Background Importance of preparing senior medical students is clear Initiatives to standardize curricula are of national interest

Department of Surgery Solution: PGY-1 Prep Course Most existing courses focus on technical skills Additional areas of potential value: –Cognitive tasks for daily patient care –Professionalism, interpersonal skills

Department of Surgery Aim To identify key curricular components in the design of a PGY-1 surgery preparatory course

Department of Surgery Aim Determine topics –Most valued by students –Most needed by students –Potential for improvement through instruction

Department of Surgery Methods: Course Design Elective 4-week course Variety of teaching modalities: –Interactive didactics –Simulation of postoperative emergencies –Small group discussions –Procedural instruction with skills practice

Department of Surgery Methods: Course Design 55 sessions Instruction in 3 main areas: –19 Ward Management Tasks (WMT) –12 Operative and Technical Skills (OTS) –4 Professionalism Skillsets (PS)

Department of Surgery Methods: Course Design Ward Management Tasks (WMT) Patient tracking Responding to pages Preop eval and informed consent Prescribing medications Ordering IV fluids and electrolyte replacement Managing nutrition Making transfusion decisions Managing common postop issues Chart documentation Patient discharge process & counseling Handling emergent situations in postop patients Management of arrhythmias, pacers, VADs Indications and interpretations of arterial blood gases Indications and interpretation of imaging Trauma systems and initial management Managing postoperative cardiothoracic patients Managing postoperative transplant patients Signouts/handoffs Cross covering other surgical services Operative and Technical Skills (OTS) Understanding steps/caveats of operations Asepsis and skin preparation Suturing, knot tying, local anesthetic General critical care management General management of ventilators Chest tubes, arterial lines, and central lines Conducting a Doppler examination Endoscopy/bronchoscopy Professionalism Skillsets (PS) Describing expectations of residents Emotional shifting/stress management Effective & empathetic communication Professionalism in surgery residency

Department of Surgery Methods: Course Design Ward Management Tasks (WMT) Patient tracking Responding to pages Preop eval and informed consent Prescribing medications Ordering IV fluids and electrolyte replacement Managing nutrition Making transfusion decisions Managing common postop issues Chart documentation Patient discharge process & counseling Handling emergent situations in postop patients Management of arrhythmias, pacers, VADs Indications and interpretations of arterial blood gases Indications and interpretation of imaging Trauma systems and initial management Managing postoperative cardiothoracic patients Managing postoperative transplant patients Signouts/handoffs Cross covering other surgical services Operative and Technical Skills (OTS) Understanding steps/caveats of operations Asepsis and skin preparation Suturing, knot tying, local anesthetic General critical care management General management of ventilators Chest tubes, arterial lines, and central lines Conducting a Doppler examination Endoscopy/bronchoscopy Professionalism Skillsets (PS) Describing expectations of residents Emotional shifting/stress management Effective & empathetic communication Professionalism in surgery residency

Department of Surgery Methods: Course Design Ward Management Tasks (WMT) Patient tracking Responding to pages Preop eval and informed consent Prescribing medications Ordering IV fluids and electrolyte replacement Managing nutrition Making transfusion decisions Managing common postop issues Chart documentation Patient discharge process & counseling Handling emergent situations in postop patients Management of arrhythmias, pacers, VADs Indications and interpretations of arterial blood gases Indications and interpretation of imaging Trauma systems and initial management Managing postoperative cardiothoracic patients Managing postoperative transplant patients Signouts/handoffs Cross covering other surgical services Operative and Technical Skills (OTS) Understanding steps/caveats of operations Asepsis and skin preparation Suturing, knot tying, local anesthetic General critical care management General management of ventilators Chest tubes, arterial lines, and central lines Conducting a Doppler examination Endoscopy/bronchoscopy Professionalism Skillsets (PS) Describing expectations of residents Emotional shifting/stress management Effective & empathetic communication Professionalism in surgery residency

Department of Surgery Methods: Course Design Ward Management Tasks (WMT) Patient tracking Responding to pages Preop eval and informed consent Prescribing medications Ordering IV fluids and electrolyte replacement Managing nutrition Making transfusion decisions Managing common postop issues Chart documentation Patient discharge process & counseling Handling emergent situations in postop patients Management of arrhythmias, pacers, VADs Indications and interpretations of arterial blood gases Indications and interpretation of imaging Trauma systems and initial management Managing postoperative cardiothoracic patients Managing postoperative transplant patients Signouts/handoffs Cross covering other surgical services Operative and Technical Skills (OTS) Understanding steps/caveats of operations Asepsis and skin preparation Suturing, knot tying, local anesthetic General critical care management General management of ventilators Chest tubes, arterial lines, and central lines Conducting a Doppler examination Endoscopy/bronchoscopy Professionalism Skillsets (PS) Describing expectations of residents Emotional shifting/stress management Effective & empathetic communication Professionalism in surgery residency

Department of Surgery Methods: Data Collection IRB approval Multiple assessment tools –Surveys –Knowledge tests –Performance exams

Department of Surgery Methods: Survey 46 items For each topic –Perceived importance –Pre/post confidence –Extent to which course contributed to confidence levels

Department of Surgery Methods: Survey 5-point Likert scales Pre/post comparison –Student’s t-tests –P < 0.05 significant

Department of Surgery Topic Importance Which topics are most valued by the students?

Department of Surgery Methods: Importance Indicate the level of importance placed on acquiring each skill Likert scale –1 = “not at all important” –5 = “very important”

Department of Surgery Results: Topic Importance RangeMean WMT / OTS /- 0.06* PS /- 0.15* *P<0.05 vs WMT N=22

Department of Surgery Task-Specific Confidence In which areas do the students lack confidence, and can it be improved with instruction?

Department of Surgery Results: Confidence Rank confidence level for each skill 2 time points Likert scale –1 = “extremely nervous” –5 = “quite confident”

Department of Surgery Results: Confidence PrecoursePostcourseGain WMT2.28 +/ /- 0.10*1.25 OTS2.41 +/ /- 0.24*1.27 PS / / *P<0.05 vs Precourse N=22

Department of Surgery Results: Confidence *P < 0.05 vs Precourse * * N=22

Department of Surgery Results: Confidence Greatest impact seen in WMT –Lowest precourse confidence –Greatest gains in confidence

Department of Surgery Results: Confidence Greatest gains seen in WMT PrePostGain Management of arrhythmias, pacers, VADs / /- 0.15*1.55 +/ Handling emergent situations in postoperative patients / /- 0.18*2.09 +/ *P < 0.005

Department of Surgery Results: Confidence Quantify extent of course contribution to graduation confidence levels Likert scale –1 = “not helpful” –5 = “completely responsible”

Department of Surgery Results: Confidence Course Contribution WMT3.85 +/ OTS3.65 +/ PS3.59 +/- 0.21

Department of Surgery Results: Confidence Students more frequently attributed confidence in WMT to course participation Individual topics with highest scores: 1.Responding to pages (4.85 +/- 0.07) 2.Handling emergent situations in postoperative patients (4.36 +/- 0.15)

Department of Surgery Measured Knowledge and Skills In which topics are the students’ measured weaknesses, and are they modifiable with instruction?

Department of Surgery Knowledge/Skill Assessments Written knowledge test OSATS Pre/post administration –T-test comparisons –P < 0.05 significant

Department of Surgery Methods: Knowledge Test Measured WMT –Baseline knowledge –Impact of course on improvement 9 representative domains –50-point, multiple-choice –Everyday patient care –Emergent situations on surgical ward

Department of Surgery Methods: OSATS Measured OTS –Assess baseline skill level –Track improvement Realistic scenario testing multiple procedural skills Scoring via itemized checklists & global scores

Department of Surgery Results: Test Performance *P < 0.05 vs Precourse * * N=22

Department of Surgery Results: Knowledge/Skills PrecoursePostcourse WMT54.8 +/- 2.1%82.2 +/- 1.9%* OTS82.7 +/- 2.5%93.2 +/- 1.3%* *P<0.05

Department of Surgery Summary Reviewed data from surveys and exams administered during PGY-1 surgery prep course Compared relative value of topics in 3 categories –WMT –OTS –PS

Department of Surgery Summary WMT identified as most important topics Precourse confidence lowest in WMT, with most dramatic postcourse gain Poor precourse performance in WMT with clear potential for improvement Managing emergent situations in postop patients has surfaced as topic of utmost importance

Department of Surgery Conclusion There is a substantial need for instruction in ward management tasks, and these topics merit emphasis in the development of national, standardized curricula