The Future of Surgical Training: Needs Assessment of National Stakeholders

1. The Future of Surgical
Training:
Needs Assessment of
National Stakeholders
ACS-AEI Curriculum Committee
Sara Kim, Brian Dunkin, John Paige, Jane Eggerstadt,
Cate Nicholas, Melina Vassiliou, Donn Spight, Jose
Pliego, Rob Rush, James Lau, Daniel Scott

2. Introduction
Future
Surgical
Training

3. 1 2 3
Gap
Between
Ideal and
Actual
Practices
Educational
Solutions
for
Targeting
Gaps
Vision for
Advancing
Future
Surgical
Training
Introduction: Study Purpose

4. Introduction: Questions
How can surgeons improve patient care?
What do you think are the most important issues in
the care of a patient having surgery?
What steps can be taken to address some of these
problems?
How do surgeons learn best?
Among the issues mentioned, which ones might
be most impacted by educational programs?
Who should pay for these programs?
1
2
3
4
5
6

5. Method: Study Design
Study Planned:
August 2011
6 Pilot Interviews:
September 2011
9 IRB Approvals
incl. 1 Master IRB
21 Interviews Conducted,
Transcribed, Analyzed
Interview Coding Scheme
Developed, Tested, Revised

6. Method: Study Subjects
Trainees
9%
Patient
5%
Clinicians
(Surgery,
Anesthesia,
Nursing)
29%
PhD Surgical
Educators
14%
Board,
Credentialing,
Risk
Management
29%
Dean,
Assistant
Dean, Med
Director
14%

7. Geographic Distribution
(Quebec)
Interviewer
Interviewee

8. Method: Qualitative Analyses

9. Method: Qualitative Analyses
Examine
Meanings,
Relations,
Patterns
Member
Check In,
Saturation
of Themes
Define Key
Findings

10. Communi-
cation
Take Time to Explain What to
Anticipate, Engage Patients in
Shared Decision Making (Pre-
Op)
Provide Timely, Clear and
Thorough Post-Op Instructions
(Post-Op Care)
Patients & Family
Results:
How Can Surgeons Improve Patient Care

11. Communi-
cation
Results:
How Can Surgeons Improve Patient Care
Implement Time Out, Hand Off
Communications, Set Expectation (Pre-
Op)
Practice Teamwork vs. Captaincy, Elicit
Questions form Surgical Team
Members (Intraoperative)
Patient Care Team
Write Timely and Appropriate Notes,
Read Notes of Other
Caregivers/Consultants (Post-Op)

12. Results:
How Can Surgeons Improve Patient Care
Focus on
Surgeon’s
Ability
Develop Core Fund of Knowledge,
Core Set of Medical Management,
Technical Skills (Knowledge &
Skills)
Maintain Excellent Technical Skills, In
Shape with Uncommon, Complex,
New Procedures
(Skill Maintenance)
Possess Surgical Maturity, Knowing
Own Limitations, Asking for Help
(Surgical Judgment)

13. Results:
How Can Surgeons Improve Patient Care
Use Evidence to Guide Medical
Management; Evaluate Surgeon’s
Performance against National Benchmarks
(Outcomes-Driven Patient Safety)
Implement Rigorous Selection and
“Weeding Out” Process
(Selection and Monitoring of Trainees)
Other Themes

14. Communi-
cation
Personally Communicate with
Patient about Outcomes,
Recovery Time, Post-Op Care
(Patients & Family)
Set Team Expectations,
Communicate Openly with Team
Members
(Team)
Develop System-Wide
Perspectives Among and
Between Hospital Services
(System)
Results: What are Most Important Issues in the
Care of a Patient Having Surgery?

15. Knowledge,
Skills,
Judgment
Results: What are Most Important Issues in the
Care of a Patient Having Surgery?
Have Thorough Knowledge,
Diagnostic Skills, Willing to
Partner with Other Specialties
(Knowledge, Skills)
Select the Right Patient for the
Right Surgery
(Surgical Judgment)
Know Own Strengths and
Limitations
(Self-Assessment)
Ethics
&
Professional-
ism

16. Trainees
Practicing
Surgeons
System
Early Training in
Communication/Cli
nical Skills
Use Skills Centers
to Teach Surgical &
Patient Interaction
Skills
Incentivized/Mandat
ory CME in
Communication
Skills
Training, Re-
Certification 
Privileging
Team Responsibility
Standardized
Process
Outcomes-Based
Quality Monitoring
Results: What Steps Can Be Taken to Address
Some of These Problems?
Training in Self-
Assessment

17. Results: How Do Surgeons Learn Best?
Optimal
Teaching
Methods
Peer
Surgeons
as
Teachers
Relevant
Learning
Materials
Deliberate
Practice
Active
Learning
Simulation
Mentors
Narratives
Surgical
Champions

18. High
Impact
Areas
Technical
Skills
Commu-
nication
Skills
Teamwork/
Team
Commu-
nication
Pre- & Post
Op Patient
Education
Results: Which Issues Might be Most Impacted by
Educational Programs?

19. Results: Who Should Pay For These Programs?
Trainees
Practicing
Surgeons
Training Programs/Schools
Whoever Mandates Training
Surgeons
Industry
Federal Government,
Specialty Boards

20. Results: Who Should Pay For These Programs?
Trainees
Practicing
Surgeons
Training Programs/Schools
Whoever Mandates Training
Surgeons
Industry
Federal Government,
Specialty Boards
“…it depends on the needs
of the community, needs of
the hospitals, the needs of
individual surgeons…”

21. Discussion
Key Interview Findings Validate
Recommendations Made in the Literature
1
Surgeons’ consistent communication with and
education of patients and families from pre-op to
post-op
Surgeons’ essential role as “guardian of the
surgical patient”. Care of patient 
“comprehensive management skills” (Bass et al.,
2009)

22. 2
Surgeons initiating team communication
and developing system-wide perspectives of
patient care
Surgeon must “listen, understand, discuss and
interact positively” with team (Bass et al. 2009);
Evolving multi-disciplinary, inter-professional
collaborations (Debas et al 2005)
Discussion
Key Interview Findings Validate
Recommendations Made in the Literature

23. 3
Surgeons’ need to re-tool, remediate and
demonstrate competencies in core knowledge,
skills and surgical judgment
Need to self-regulate the profession, engage in
life-long learning (Bass et al. 2009); Continuous
professional development in surgical skill
acquisition and maintenance (Debas et al. 2004)
Discussion
Key Interview Findings Validate
Recommendations Made in the Literature

24. Discussion
Key Interview Findings Validate
Recommendations Made in the Literature
4
Use multi-modal educational approaches (e.g.
simulation) to make training efficient, relevant, and
timely
Principles of adult education  Experiential
educational experiences (Debas et al. 2005);
Programs need to teach more effectively and
deliberately (Lewis, Klingensmith, 2012)

25. Discussion
Key Interview Findings Validate
Recommendations Made in the Literature
5
Indispensible and integral role of simulation
training for procedural, patient interaction, and
decision making skills
Augment experiences with uncommon problems,
errors (Pellegrini, 2012); Link simulation with
patient outcomes, long-term follow up (Scott et al.,
2011); Simulation for certification (Stefanidis et al
2011)

26. Discussion
Key Interview Findings Validate
Recommendations Made in the Literature
6
Ability to recognize own limitations and areas
needing help is a professionalism issue
Need for honest professional assessment (Bass et
al., 2009); Continuous self-assessment with
practice analysis and outcomes tracking
(Pellegrini, 2012)

27. Notable Challenges
Duty Hour Restrictions Resulting in:
 Insufficient procedural training, inconsistent exposure
to uncommon, complex cases
 Longitudinal patient care experiences compromised
Simulation Training Can Be Expensive
Faculty Still Using Traditional Teaching
Methods

28. Notable Challenges
Surgeons’ Time Constraints Limit
Patient Interaction and Education
Lack of Structured Methods to Certify
Residents as Independent Surgeons
Lack of Formal Channels to Report
Incompetent Surgeons
Lack of Standard Processes for
Introducing New Technologies

29. Next Steps
1. Delphi Method for
Ranking Training Targets
2. Prioritize Committee
Work Around Top
Targets

30. THANK YOU!
 ACS-AEI Leadership
 Amy Johnson, ACS-AEI
 ACS-AEI Curriculum Committee

31. References
 Bass BL, Polk HC, Jones RS, Townsend CM, Whittemore AD,
Pellegrini CA, Busuttil RW, Lillemoe KD, Trunkey DD, Mulholland
MW, Grosfeld JL. Surgical privileging and credentialing: a report
of a discussion and study group of the American Surgical
Association. J Am Coll Surg. 2009 Sep;209(3):396-404
 Debas HT, Bass BL, Brennan MF, Flynn TC, Folse JR, Freischlag JA,
Friedmann P, Greenfield LJ, Jones RS, Lewis FR Jr, Malangoni MA,
Pellegrini CA, Rose EA, Sachdeva AK, Sheldon GF, Turner PL,
Warshaw AL, Welling RE, Zinner MJ; American Surgical Association
Blue Ribbon Committee. American Surgical Association Blue
Ribbon Committee Report on Surgical Education: 2004. Ann Surg.
2005 Jan;241(1):1-8.
 Lewis FR, Klingensmith ME. Issues in general surgery residency
training--2012. Ann Surg. 2012 Oct;256(4):553-9.

32. References
 Pellegrini CA. Surgical education in the United States 2010:
developing intellectual, technical and human values. Updates
Surg. 2012 Mar;64(1):1-3.
 Scott DJ, Pugh CM, Ritter EM, Jacobs LM, Pellegrini CA, Sachdeva
AK. New directions in simulation-based surgical education and
training: validation and transfer of surgical skills, use of
nonsurgeons as faculty, use of simulation to screen and select
surgery residents, and long-term follow-up of learners. Surgery.
2011 Jun;149(6):735-44.
 Stefanidis D, Arora S, Parrack DM, Hamad GG, Capella J,
Grantcharov T, Urbach DR, Scott DJ, Jones DB; Association for
Surgical Education Simulation Committee. Research priorities in
surgical simulation for the 21st century. Am J Surg. 2012
Jan;203(1):49-53.