1. Development and Evaluation of an Objective and Simulation-Based Core Curriculum for Surgery Residents Orlando C. Kirton, M.D., F.A.C.S., F.C.C.M., F.C.C.P. Ludwig J. Pyrtek, M.D. Chair in Surgery Director of Surgery, Chief Division of General Surgery Hartford Hospital Professor of Surgery Program Director, Integrated General Surgery Residency Program Vice Chair, Department of Surgery University of Connecticut School of Medicine

2. Essential ACGME Requirement Create a knowledge-based and clinical curriculum based on six educational competencies: - Medical Knowledge - Patient Care - Interpersonal and Communication Skills - Professionalism - Practice-Based Learning and Improvement - Systems-Based Practice

3. The Perfect Storm faced by Program Directors Restricted resident duty hours –I.e.;80 hours; PGY 1- no more than 16hrs Falling reimbursements for hospitals and faculty Less non-clinical time available to the Teaching Faculty An increasing # of educational requisites –The ACGME milestone project, robust simulation curriculum, patient safety and quality objectives

4. The University of Connecticut Integrated General Surgery Residency Program 1 of 8 general surgery residency training programs in Connecticut Integration of 3 separate training programs in 1990 46 Residents ; 6 chiefs 5 Hospital integrated program 110 teaching Faculty –60% private practice

5. The Residents’ Concerns with the Curriculum Program Director (October 2009) Diminished available time for residents Less non-clinical time available to teaching faculty Resident dissatisfaction with the didactic curriculum Regurgitation from textbooks Lack of audience interaction Session taught by resident lacked depth and scope Inadequate simulation exposure Inadequate preparation time (learner & presenter)

6. Methods A core curriculum steering committee of residents and faculty: –Program Director –Incoming 2 Administrative Chief Residents –A peer–elected categorical resident representative (PGY 1-3) –A faculty member from each teaching hospital A simulation curriculum steering committee also created –Similar composition + simulation coordinator and education specialist Starts meeting in February; Curriculum completed by May

7. The Core Curriculum Focuses on specific goals and objectives –2 year bundled curriculum of 85 standing (annual) and 25 bi- annual learning topics Utilizes online teaching materials –SCORE Modules, ACS Fundamentals of Surgery TM Curriculum –Various on-line texts : e.g.; Schwartz, Sabiston, etc Interactive lecture format –An audience response system Compulsory simulation curriculum SCORE system-based practice modules Professionalism in Surgery: Challenges and Choices TM, ACS Division of Education (2008)

8. Chief Resident – Teaching Faculty Moderator Team (Monthly Curriculum) Define content and format Identify and confirm presenters Utilize the ABSITE program report Moderate interactive sessions –Vignettes, case scenarios, question/answer –Focus on critical knowledge; decision making Exhaustive literature review prohibited

9. The Monthly Curriculum Week 1Interactive presentations Week 2Simulation/ skills sessions Week 3Interactive presentations; competency lecture, journal club Week 4Interactive presentation, resident research (11:00 AM) Week 5Dedicated to a 2nd simulation/ skills or competency presentation Fridays; 8:30 AM – 11:00 AM

10. Intern Boot Camp July / August Fluids and electrolytes Cardiac Pulmonary GI MS Wounds Nutrition Pain management Post-op emergencies Fever work -up Hypotension Pre-op evaluation Safety Wednesday 2:00 – 4:30 PM; Friday 8:30 – 11:00 AM - Fundamental of Surgery Curriculum – 25 essential modules - Clinical Skills Lab

11. Simulation / Skills Modules PGY I Asepsis and instrument identification Knot tying; tissue handling Latex allergy; anaphylaxis Chest tube and thoracentesis Basic laparoscopy CVP and foley placement Patient hand-off FLS PGY II-V Sim man Cholecystectomy/ Advanced laparoscopy EGD; colonoscopy Vascular anastomosis Biolab/fresh tissue lab Robotics ACS e-learning site

12. Evaluation Anonymous Survey Questionnaire –Baseline (June, 2010); 6 months (December, 2010); 1 year (June, 2012) –Fifteen, 5-point Likert-type items Conferences in relation to ACGME competencies –PBI, SBP, IC, Professionalism The learning objectives of the curriculum Quality of teaching presentations –Faculty and Residents Quality of the supplementary teaching materials –Chi-square tests of proportions; Kruskal Wallis to compare full distribution of responses

13. Survey Questions I.Conferences Please rate the following aspects of the Friday morning core curriculum for the entire year using the scale below. The core curriculum conferences taught me the value of practice based learning. The core curriculum conferences positively impacted my ability to effectively communicate with patients, families and other health-care professionals. The core curriculum conferences positively impacted my ability to act in a professional and ethical manner. The core curriculum conferences provided knowledge of the healthcare system, beyond the confines of the hospital setting, which enables me to feel comfortable calling on other resources for assistance. II.Learning Objectives & Goals There is the opportunity to suggest curriculum changes with the core curriculum for the Integrated Surgical Residency Program. The ACGME core competencies were adequately addressed during the academic year..

14. Survey Questions (con’t) III. Supervision & Training – Attending Presentations Preparedness of the faculty speakers. Quality of the presentations by faculty speakers. Do faculty regularly assigns specific reading at least 2 weeks prior to the presentations? Do faculty presenters ask residents in the audience about key content? IV. Supervision & Training – Resident Presentations Preparedness of the resident speakers? Quality of the presentations by resident speakers. Were the weekly assigned reading and video materials relevant to the topics presented? Do the assigned reading and video materials prepare you sufficiently for the weekly topics?

15. Survey Questions (con’t) V.Materials Weekly reading and videos relevant. Weekly reading and videos sufficient preparation.

16. The Following Likert-Scales Were Used for Survey Questions I.Conferences 0 – Not Applicable 1 – Strongly Disagree 2 – Disagree 3 – Neutral 4 – Agree 5 – Strongly Agree II.Learning Objectives & Goals 0 – No Interaction 1 – Never 2 – Infrequently 3 – Sometimes 4 – Most of the time 5 – Always

17. The Following Likert-Scales Were Used for Survey Questions (con’t) III. Supervision & Training (Attending & Resident Presentations) 0 – No Interaction 1 – Not at All 2 – Not Usually 3 – Usually 4 – Most Always 5 – Always IV. Material 0 – Not Applicable 1 – Not Valuable 2 – A Little Valuable 3 – Valuable 4 – Very Valuable 5 – Extremely Valuable

18. Results

19. Percent of Residents Responding: Two Most Positive Categories ConferencesJune 2010 1 Year December 2011 6 months June 2011 1 Year X 2 (p) Taught value of practice based learning52.578.893.3.005 Positively impacted ability to communicate37.572.786.7.001 Positively impacted ability to act professionally/ethically45.060.673.3n.s. Provided knowledge of health care system42.560.680.0.034 Learning Objectives and Goals Opportunity to suggest curriculum changes70.078.887.5n.s. ACGME core competencies were adequately addressed72.587.993.3n.s. Supervision and Training - Attendings Faculty speakers prepared87.593.9100n.s. Quality of the faculty presentations50.078.873.3.028 Sufficient lead time for reading assignments12.566.773.3.001 Faculty identifies key required content50.075.886.7.012 Faculty ask residents about key content37.572.773.3.004 6/10 – 42 respondents; 12/10 – 38 respondents; 6/11 – 22 respondents

20. Percent of Residents Responding: Two Most Positive Categories (con’t) Conferences June 2010 1 Year December 2011 6 months June 2011 1 Year X 2 (p) Supervision and Training – Resident Moderators Resident speakers prepared80.084.8100n.s. Quality resident presentations25.051.540.0n.s. Materials Weekly reading and videos relevant34.663.666.7.046 Weekly reading and videos sufficient preparation32.054.553.3n.s 6/10 – 42 respondents; 12/10 – 38 respondents; 6/11 – 22 respondents

21. American Board of Training Inservice Examination [ABSITE] Percentage Scores (Lower Quartiles; Top Quartile) Exam Level Lower Quartiles (0-75%) Top Quartiles (76-100%) JuniorABSITEYear200989.5%10.5% (PGY I, II)201089.5%10.5% 201181.0%19.0% 201257.1%42.9% SeniorABSITEYear200995.0%5.0% (PGY III, IV, V)201090.9%9.1% 201188.9%11.1% 201284.2%15.8%

22. American Board Of Surgery Intraining- Examamination Proportion of Residents in Top Quartile (76-100%) Introduction of new curriculum

23. Study Limitations Unequal # of respondents at the 3 times of the survey Unable to separate the survey data by PGY years or categoricals vs. preliminaries ? Factor of survey fatigue

24. The Residents’ Concerns prior to the new approach to Core Curriculum Development Diminished available time for residents Less non-clinical time available to teaching faculty Resident dissatisfaction with the didactic curriculum Regurgitation from textbooks Lack of audience interaction Session taught by residents lacked depth and scope Inadequate simulation exposure Inadequate preparation time (learner & presenter)

25. Residents’ comments post implementation All lectures more structured and beneficial –Presenters and learners better prepared Presentations much more interactive and engaging The best lectures were those that invite audience participation The intern boot camp is an extremely valuable component of the core curriculum –Taught us from Day 1 important concepts Audience response system engaging and great prep for ABSITE Avoid resident presentations all together I enjoyed the practical portions that have been included in the curriculum –Pig lab, lap trainer –Great chance to practice new skills in an environment not quite so high stress as the OR

26. Conclusions The systematic collaborative approach (faculty and residents) to curriculum development with interactive, objective competency-based presentations, robust simulation, use of online teaching tools, engaged teaching faculty resulted in: –  Resident satisfaction with the curriculum and their self-reported clinical and academic abilities –  Increase in the number of residents scoring in the top quartile in the ABSITE –  Effectively addresses the ACGME competencies

27. Thank you!