Minimally invasive approaches to hysterectomy, including Vaginal Hysterectomy (VH) and Laparoscopic Hysterectomy (LH) have less complications and a faster return to work. While VH has been part of gynecologic education for decades, LH is new and many practicing gynaecologists do not have these skills, which negatively impacts quality of care. It also negatively impacts resident’s ability to learn LH.
The CSEP was developed by an ad hoc committee tasked with the creation of a professional development program to assist clinician educators in the acquisition of needed surgical skills for procedures with proven efficacy and safety. The committee included members from all surgical divisions in our department, as well as clinical gynecology faculty from community hospitals. The program uses a preceptor model to facilitate new skill development for practicing gynecologists. The essential elements of the CSEP include clearly defined procedures for participant enrollment, documentation of progress and successful completion of the requirements, a credentialing mechanism, and a system to remunerate preceptors. Ultimately, Site Heads are responsible for establishing this process, but the CSEP committee provided templates for the preceptor program and the credentialing process. An individual surgeon who wishes to pursue further training through the CSEP initiates this process by submitting a written request to their Site Head. The clinician educator provides evidence of prior knowledge of related anatomy and pathophysiology, for example from didactic continuing professional development (CPD) courses, and of adequate clinical volume to permit maintenance of surgical skills through ongoing practice at the completion of the program. With approval, the Site Head provides a list of available preceptor surgeons as the program depends on faculty members with teaching ability and surgical skills matching the procedure to be taught. Preceptors do not need to be primarily located at the learner’s site, but should regularly perform the procedure and be willing to mentor the learner. The learner notifies the preceptor of their desire to schedule patients with them through the CSEP. This provides an opportunity for the preceptor to discuss their expectations and prerequisite skill development. The learner provides surgical patients from their own practice. These patients are informed that the learner is working through the CSEP to enhance their skills. The patient needs to understand that their attending gynecologist will be working with a preceptor surgeon during their case. This is part of the informed consent process and is documented in the medical record. In addition, both surgeons are listed on the OR slate and consent form. The learner provides the preceptor with a full history and physical documenting the patient’s case, including indications for surgery, prior interventions, and comorbidities. They also send a copy of the OR posting form, so the preceptor can ensure that adequate OR time is scheduled. The preceptor may request a formal consult. Cases are either scheduled during OR time dedicated to the Preceptor Program (Hospital A), or during the learner’s OR time allotment (Hospital B). Residents and medical students do not participate and are not present at these cases. The preceptor determines surgical roles during the case, with the intent of advancing the learner’s skills. They provide specific feedback to the learner based on Objective Structured Assessment Technical Skills (OSATS) criteria and suggest a curriculum for improvement of skills when indicated. Because different learners develop independent skills at different paces, competency is not based on volume. Final determination of the learner’s ability to perform procedures independently and safely is the preceptor’s responsibility. A learner does not need to schedule all of their cases with a single preceptor, and any preceptor can approve the learner as competent in the new surgical technique. Surgeons who are approved by a preceptor as able to perform the procedure independently are given provisional privileges for that procedure. Following approval of a surgeon for a new technique, re-credentialing is based on a review of outcomes and complications during a one-year probationary period. Rewarding department members for participation as preceptors is essential to the program’s sustainability and we sought to accomplish this without industry support. Towards that end, the preceptor surgeon receives financial compensation by billing as the primary surgeon for all preceptor cases, while the learner surgeon bills as an assistant. The preceptor surgeon also benefits from additional surgical time, that positively impacts the calculation of future OR allocations. As this does not fully remunerate the time spent teaching in the program, participation in the CSEP as a preceptor is also recognized as academic service to the department that counts toward expected academic contributions.
The CSEP was introduced at two urban academic health care centres. Hospital A serves urban and indigent populations. It has 12 ORs. The UBC Department of Obstetrics & Gynaecology sites Urogynaecology and General Obstetrics & Gynaecology at Hospital A. It is also the tertiary hospital for maternal complications in pregnancy for the region. Hospital B is the largest hospital in British Columbia, with 21 ORs as well as 8 outpatient ORs at a geographically separate location. Approximately 60% of the reported cases for Hospital B occurred in the outpatient ORs. Forty percent of Hospital B’s patients are referred from other parts of the Province. The UBC Department of Obstetrics and Gynaecology has sited Gynaecologic Oncology, Pelvic Pain, and General Gynaecology at Hospital B. There is no maternity service. Both hospitals added 2 staff members during the 5 years reported. While both hospitals had fellowship trained laparoscopic specialists, when the study began LH was already done by two surgeons at Hospital B, but was not performed routinely at Hospital A. Hospital A started with one preceptor but had 5 by the end of the study, while Hospital B started with 2 preceptors and added 1. The additional mentors successfully completed the CSEP before becoming preceptors.
Taking both hospitals together, the total number of hysterectomies was stable over the 5-year period (mean 470, range 443-524, SD 32.36) However, there was a 2.6-fold increase in LH from 63 to 160, with a concurrent 30% decrease in AH.
The decrease in AH(in blue) was similar at both hospitals, although the changes in VH and LH differed. At Hospital A, VH(light green) rose in years 3 and 4 and then stabilized at the same level as the initial year, while at Hospital B, VH(dark green) declined from a high of 54 cases per year in the initial year to a low of 22 cases per year. Both hospitals had sustained increases in LH (in orange), although this also differed between the two sites.
Hospital A saw a steady increase in the number of staff doing LH, as reflected by the number of surgeons who performed 50% or greater MIH case numbers. (blue) By the third year of the program more than half of staff at Hospital A met the 50% MIH criterion and this was sustained over the 5-year study period. In contrast, Hospital B started with twice as many staff meeting the 50% MIH criterion, but had inconsistent growth. In fact, the increase in total volume of LH at hospital B was primarily in the practices of the 2 surgeons who were performing LH at the beginning of the study, and a third of the surgeons meeting the 50% MIH criterion did not participate in the CSEP and did not perform LH. The noted differences between Hospitals A and B may reflect differences in how the CSEP was implemented at the two sites. Hospital A had two OR slates per month dedicated to the CSEP. Preceptors and learners could book cases on these days without negatively impacting their own OR slates. Moreover, as surgeons became newly credentialed in LH, they became preceptors for other faculty members, which increased the number of available mentors. Hospital B did not have dedicated OR slates, and consequently, had a significantly lower uptake. The phenomenon of new mentors did not occur at Hospital B either.
One of the primary ends of the CSEP was to build a base of generalist laparoscopic surgeons to meet the needs of the resident surgical curriculum. Before the CSEP began, resident teaching cases included no LH. The dedication of OR slates without residents to the CSEP, delayed an increase in available LH teaching cases, but with time the number of cases rose. (in red) The rate of MIH was 32% before the CSEP was introduced, and after the initial year increased to 46% where it remained since. The proportion of LH in the MIH has steadily increased each year. During this time the total number of VH has also increased from 68 to 107 per year, reflecting an increase in the volume of cases for all approaches to hysterectomy.
F1 Geoffrey Cundiff - Faculty Surgical Preceptor Program Enhances Quality of Care and Resident Surgical Experience
Faculty Surgical Preceptor Program Enhances Quality of Care and Resident Surgical Experience .
ObjectivesFaculty Surgical Preceptor Program Enhances Quality of Care and Resident Surgical Experience.
Context• Minimally invasive hysterectomy have less complications and a faster return to work. – Vaginal (VH) + Laparoscopic (LH)• Many practicing gynaecologists do not have skills to do LH – Negatively impacts quality of care. – Negatively impacts resident’s ability to learn LH.1,2 1. Fung Kee Fung MP, Temple LM, Ash KM. JSOGC 1996; 18:859-67. 2. Cundiff GW. Obstet Gynecol 1997;90:854–9.
Continuing Surgical Education Program• Professional Development program directed at acquisition of new surgical skills• Preceptor Model• Key Elements – Established process for enrollment – Structured assessment of competence – Credentialing mechanism – Remuneration model for preceptors
Methods• Hypothesis: The CSEP will enhance resident education by building a base of surgeons skilled in laparoscopic hysterectomy (LH)• Design: retrospective analysis of quality assurance program, CSEP – REB waived ethics approval
Methods: Analysis• Longitudinal analysis of surgeons’ volume of hysterectomies stratified by surgical approach – Minimally invasive hysterectomy (MIH) = vaginal hysterectomy (VH) + laparoscopic hysterectomy (LH) – Stratify surgeons based on completing 50% or more by MIH.• Comparison of 2 hospital sites with different implementation (dedicated OR slates at one) – Uptake of LH and its impact on VH – Number of surgeons meet the 50% MIH criterion• Analysis the volume of hysterectomy teaching cases stratified by surgical approach
Results: Comparison of Two Sites Hospital A Hospital BAttending Gynaecologists 18 15Established Laparoscopic specialists 1 2Annual surgical volume of Hysterectomy (mean) 329 363Annual TVH prior to initiation of CSEP 47 54Annual LH prior to initiation of CSEP 8 48OR slates dedicated to CSEP(per month) 2 0CSEP Preceptors 5 3Residents on service (mean) 5 5
Results: Cumulative Hysterectomies Stratified by Surgical Approach Includes both hospitals (A+B) per period.
Results: HysterectomiesStratified by Site and Approach
Results: Percentage of Staff Performing >50% ofHysterectomies by MIS (TVH + TLH) 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012Hospital A 13% 41% 50% 56% 56%Hospital B 25% 33% 33% 20% 40% Hospital A dedicated 2 OR slates/month to CSEP
Results: Proportions of Resident Teaching Cases by approach
Continuing Professional Development• CPD is inadequate for the development of new surgical skills – Short courses are most common offering1 • Do not allow the acquisition of new motor skills – Preceptorships valued for hands-on training, immediate feedback, and exchange of tacit knowledge1,2,3 • Scheduling and sponsorship are barriers 1. Wallace T, Birch DW. Am J Surg. 2007 May;193(5):593-5. 2. Lord JL, et al. Surg Endosc. 2006 Jun;20(6):929-33. Epub 2006 May 11. 3. Cottam D, et al. Surg Endosc. 2007 Dec;21(12):2237-9. Epub 2007 Apr 10.
Continuing Professional Development• The majority of CPD is sponsored or funded by the surgical industry to showcase products 1 – Creates ethical issues around bias and conflict of interest – Disconnected from the credentialing responsibilities of hospitals. • The CPD event may be accredited, but there is no mechanism to objectively evaluate surgeon competence with the new skill. 2 1. Gagliardi AR, et al. J Contin Educ Health Prof. 2009 Fall;29(4):269-75. 2. Maillet B, et al. Presse Med. 2011 Apr;40(4 Pt 1):357-65. Epub 2011 Mar 3.
Continuing Surgical Education Program Clinical Advantages• Effective in facilitating competence in LH – Applicable to any new surgical procedure that has proven safety and efficacy.• Scalable. – Applied CSEP to mid-urethral slings, and prolapse procedures as well as LH. – Used it at community and rural hospitals.
Continuing Surgical Education Program Educational Advantages• Facilitates the development of a faculty base of clinician educators with the necessary skills to implement a new residency surgical curriculum.• Successfully moved the skill of LH into the realm of the generalist
Continuing Surgical Education Program Implementation is Important• More effective when implemented with dedicated OR slates. – Encourage participation by eliminating any impact on the learner’s practice. – Helps to build up a cadre of preceptors that sustain the momentum of the program.
Continuing Surgical Education Program A Better Model for CPD in Surgery• Advantages – Sustainable – Insulated from industry influence – Capable of providing objective assessment of competency• Should lead to better patient care and enhancement of educational mission
References• Wallace T, Birch DW. A needs-assessment study for continuing professional development in advanced minimally invasive surgery. Am J Surg. 2007 May;193(5):593-5; discussion 596.• Lord JL, Cottam DR, Dallal RM, Mattar SG, Watson AR, Glasscock JM, Ramananthan R, Eid GM, Schauer PR. The impact of laparoscopic bariatric workshops on the practice patterns of surgeons. Surg Endosc. 2006 Jun;20(6):929-33. Epub 2006 May 11.• Cottam D, Holover S, Mattar SG, Sharma SK, Medlin W, Ramananthan R, Schauer P. The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery. Surg Endosc. 2007 Dec;21(12):2237-9. Epub 2007 Apr 10.• Gagliardi AR, Wright FC, Victor JC, Brouwers MC, Silver IL. Self-directed learning needs, patterns, and outcomes among general surgeons. J Contin Educ Health Prof. 2009 Fall;29(4):269-75.• Maillet B, Maisonneuve H. [Long-life learning for medical specialists doctors in Europe: CME, DPC and qualification]. Presse Med. 2011 Apr;40(4 Pt 1):357-65. Epub 2011 Mar 3.
A particular slide catching your eye?
Clipping is a handy way to collect important slides you want to go back to later.