Plastic Surgery Foundation

To present a study that investigated sacrococcygeal skeletal structure as a possible nonmodifiable intrinsic risk factor for pressure injury and identify possible issues caused by its morphology. This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. After participating in this educational activity, the participant will:1. Recognize the background information the authors considered when planning and conducting their study of sacrococcygeal skeletal structure as a possible pressure injury risk factor.2. Identify the characteristics of the two groups of study participants.3. Choose the results of the study clinicians may consider when implementing evidence-based practice.

To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance. Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective-more task rather than procedure-oriented-and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety. Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items. A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals. This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

INTRODUCTION: Plastic surgery education has traditionally been built on the apprenticeship model, where experts teach skills to novices using real patients. While this is a well-established process, there are limitations and areas for improvement to maximize the educational benefit of residents and to optimize patient safety. We have previously reported results of our online training program, showing that residents who had access to our novel website significantly improved both their cognitive and technical skills. The second part of our study provides an objective means for expert evaluators to reliably rate trainees’ technical skills under the microscope. METHODS: “Microsurgery Essentials” (http://smartmicrosurgery.com) is our novel on-line curriculum providing basic information and training on microsurgery. The website has step-by-step instructions, as well as multiple intra-operative videos narrated by senior faculty. Residents were randomly divided into two groups: one group reviewed this online resource and the other did not. Pre- and post-tests consisted of videotaped microsurgical sessions in which the trainee performed “microsurgery” on 3 different models: latex glove, penrose drain, and the dorsal vessel of a chicken foot. The videotapes were reviewed and graded by expert senior level surgeons using our novel global rating scale. The SMaRT scale consists of nine categories graded on a 5-point Likert scale. Results were analyzed with ANOVA and student’s T-test, with p<0.05 indicating statistical significance. RESULTS: Seventeen residents participated in the study, ranging from PGY-1 to PGY-6. The SMaRT scale adequately differentiated the performance of more experienced senior residents (PGY-4 to PGY-6, total average score = 3.43) from less experienced junior residents (PGY-1 to PGY-3, total average score = 2.10, p<0.0001). This differentiation confers validity. There were no significant differences in scoring among all three evaluators (p>0.05). This consistency indicates strong inter-rater reliability. Additionally, junior residents who had access to our website showed a significant increase in their graded technical performance by 0.7 points when compared to residents who did not have access to the website who showed an improvement of only 0.03 points (p=0.01). CONCLUSION: Our SMaRT scale is valid and reliable in assessing the microsurgical skills of residents and other trainees. As self-directed online education becomes more and more the norm, our efficient and easy-to-use global rating scale ensures that residents are achieving appropriate technical milestones.