Efficacy of Mindfulness-Based Cognitive Training in Surgery

Invited Commentary

Robotic-assisted surgery is increasingly being used in thoracic surgery. Currently, the Integrated Thoracic Surgery Residency Program lacks a standardized curriculum or requirement for training residents in robotic-assisted thoracic surgery. In most circumstances, because of the lack of formal residency training in robotic surgery, hospitals are requiring additional training, mentorship, and formal proctoring of cases before granting credentials to perform robotic-assisted surgery. Therefore, there is necessity for residents in Integrated Thoracic Surgery Residency Program to have early exposure and formal training on the robotic platform. We propose a curriculum that can be incorporated into such programs that would satisfy both training needs and hospital credential requirements. We surveyed all 26 Integrated Thoracic Surgery Residency Program Directors in the United States. We also performed a PubMed literature search using the key word "robotic surgery training curriculum." We reviewed various robotic surgery training curricula and evaluation tools used by urology, obstetrics gynecology, and general surgery training programs. We then designed a proposed curriculum geared toward thoracic Integrated Thoracic Surgery Residency Program adopted from our credentialing experience, literature review, and survey consensus. Of the 26 programs surveyed, we received 17 responses. Most Integrated Thoracic Surgery Residency Program directors believe that it is important to introduce robotic surgery training during residency. Our proposed curriculum is integrated during postgraduate years 2 to 6. In the preclinical stage postgraduate years 2 to 3, residents are required to complete introductory online modules, virtual reality simulator training, and in-house workshops. During clinical stage (postgraduate years 4-6), the resident will serve as a supervised bedside assistant and progress to a console surgeon. Each case will have defined steps that the resident must demonstrate competency. Evaluation will be based on standardized guidelines. Expansion and utilization of robotic assistance in thoracic surgery have increased. Our proposed curriculum aims to enable Integrated Thoracic Surgery Residency Program residents to achieve competency in robotic-assisted thoracic surgery and to facilitate the acquirement of hospital privileges when they enter practice.

Objective To investigate the effectiveness and rationality of objective structured clinical examination (OSCE) used as achievement assessment for Postgraduate Year 1 surgery residents. Then the form and content of training and examination can be improved according to test results. Methods 31 Postgraduate Year 1 surgery residents were involved in the examination. The examination was composed of 5 stations, which were case analysis, wound dressing change, plaster fixation, laparoscopic simulator basic skills and irregular wound debridement suture. Each station was evaluated by centesimal system score and limited in 15 minutes. A questionnaire on their opinion and perception of the examination was given to each resident at the end of examination. A total number of 31 questionnaires were issued and recycled. The difficulty, discrimination and reliability of each station were calculated, and the correlation between each station was analyzed. Results The average OSCE score was (74.66±4.39). The difficulty of total stations was 0.747. The distinction was 0.578 and the reliability was 0.402. The second station was lowest difficulty, and the fifth station was most difficult. Every station's discrimination was larger than 0.400. The reliability of the second and the fourth station was low. There was moderate correlation between the first station and the second station, as well as the first station and the fourth station. But there was no significant correlation between other stations. Residents' questionnaire survey showed that the fourth and the fifth stations were considered as the most difficult, and the second station was the simplest. They thought the fourth was most helpful for clinic. They performed best at the second station and worst at the fifth station. Conclusions OSCE can effectively evaluate the efficacy of the resident training. The residents' practical competency skills can be assessed better by examination simulating complex clinical scenario. Besides, after examination, we need to objectively evaluate the assessment efficiency, and dynamically adjust the training content and examination form according to residents’ subjective opinions. Key words: Objective structured clinical examination (OSCE); The standardized training of residents; Surgery residents; Reliability; Evaluation

Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning

Declining Surgical Resident Operative Autonomy—All Trainees Are Not Created Equal

Objective To evaluate dynamically the outcome of the standardized training of postgraduate year 1 surgery residents at surgical school. To investigate the effectiveness and rationality of the improved objective structured clinical examination (OSCE). Methods According to the results of OSCE in 2015, the design and content of OSCE’s stations were improved in 2016. The difficulty, discrimination and reliability of each station were calculated, and the correlation between each station was analyzed by SPSS 22.0. In addition, the results of OSCE’s in 2016 were compared to that in 2015. Results The average OSCE score was (72.98±4.93). The difficulty of total stations was 0.730. The distinction was 0.683 and the reliability was 0.453. The first, second and sixth station were lowest difficulty, and the fourth and fifth station was moderate difficulty. Each station’s discrimination was more than 0.400. The reliability of the sixth station was low. There were moderate correlation between the first station and the sixth station, the second station and the fourth station, as well as the second station and the sixth station. But there was no significant correlation between other stations. The scores of laparoscopic simulator basic skills in 2016 were significantly lower than that in 2015, but the station’s reliability was higher in 2016. The scores of irregular wound debridement and suture in 2016 were significant higher than that in 2015. Conclusions Through the continuous improvement of OSCE, surgical school evaluates effectively the outcome of the standardized training of postgraduate year 1 surgery residents and improve the training effect step by step. Key words: The standardized training of residents; Surgery school; Objective structured clinical examination (OSCE); Evaluation

ABSTRACTBackground: An increased demand for accountability and transparency in medicine have initiated a shift toward a more objective and standardized approach for postgraduate medical training.Objective: To develop and evaluate an objective method to assess clinical competence of postgraduate year 1 surgery residents.Design: Thirty-one postgraduate year 1 surgery residents, who had been trained in the Surgical School of Peking University First Hospital for one year, participated in an objective structured clinical examination as a final assessment of their clinical competence. A test station of irregular wound repair (debridement and suture) was specially designed to test the residents’ surgical integrative competence in a complex-trauma treatment procedure. A modified global rating scale, in combination with wound area measurement, was applied to evaluate residents’ surgical performance. The validity of the subjective global rating scale was evaluated by the objective measurement results from the software.Results: The global rating scale score had no obvious correlation with the area of the removed tissue and the residual wound area after the suture. There was significant difference in the debridement time and the residual wound area between 0–3 and >3 total stitches. There were significant differences in the area of the removed tissue between 0 and 1–2 grey stitches and 0 and 3–4 grey stitches, and in the residual wound area after suture between 0 and 3–4 grey stitches and 1–2 and 3–4 grey stitches.Conclusions: An irregular wound repair procedure could be an effective method to assess the integrative competence of surgery residents. The training for surgical thinking in the early stage of junior residents needs to be strengthened. The entire measurement process was more complex and time-consuming than expected. The possibility of measurement by simply counting the numbers of the key spots might be explored in the future.Abbreviations: ACS/APDS American College of Surgeons/Association of Program Directors in Surgery; GRS Global rating scale; LSD-T Least significant difference-test; OSATS Objective structured assessment of technical skills; OSCE Objective structured clinical examination; PBT Proficiency based training; PGY1 Postgraduate Year 1

Lessons Learned in Maximizing Open Surgical Experience for Vascular Integrated Residents During the Nonvascular Months of Training

An Interdisciplinary Approach to Surgical Skills Training Decreases Programmatic Costs

779 CLINICAL COORDINATION AND INTENSE PROACTIVE MONITORING TO IMPROVE UTILIZATION OF RESOURCES AND REDUCE EXPENDITURES IN HIGH-RISK IBD PATIENTS (CAPTURE IBD): A RANDOMIZED, CONTROLLED QUALITY IMPROVEMENT TRIAL

Patients with schizophrenia exhibit impairments in working memory that often appear in attenuated form in persons at high risk for the illness. The authors hypothesized that deviations in task-related brain activation and deactivation would occur in persons with an at-risk mental state performing a working memory task that entailed the maintenance and manipulation of letters. Participants at ultra high risk for developing psychosis (N=60), identified using the Comprehensive Assessment of At-Risk Mental States, and healthy comparison subjects (N=38) 14 to 29 years of age underwent functional MRI while performing a verbal working memory task. Group differences in brain activation were identified using analysis of covariance. The two groups did not show significant differences in speed or accuracy of performance, even after accounting for differences in education. Irrespective of task condition, at-risk participants exhibited significantly less activation than healthy comparison subjects in the left anterior insula. During letter manipulation, at-risk persons exhibited greater task-related deactivation within the default-mode network than comparison subjects. Region-of-interest analysis in the at-risk group revealed significantly greater right dorsolateral prefrontal cortex activation during manipulation of letters. Despite comparable behavioral performance, at-risk participants performing a verbal working memory task exhibited altered brain activation compared with healthy subjects. These findings demonstrate an altered pattern of brain activation in at-risk persons that contains elements of reduced function as well as compensation.

The human dorsolateral prefrontal cortex (DLPFC; approximately corresponding to Brodmann areas 9 and 46) has demonstrable roles in diverse executive functions such as working memory, cognitive flexibility, planning, inhibition, and abstract reasoning. However, it remains unclear whether this is the result of one functionally homogeneous region or whether there are functional subdivisions within the DLPFC. Here, we divided the DLPFC into seven areas along rostral-caudal and dorsal-ventral axes anatomically and explored their respective patterns of structural and functional connectivity. In vivo probabilistic tractography (11 females and 13 males) and resting-state functional magnetic resonance imaging (fMRI; 57 females and 21 males) were employed to map out the patterns of connectivity from each DLPFC subregion. Structural connectivity demonstrated graded intraregional connectivity within the DLPFC. The patterns of structural connectivity between the DLPFC subregions and other cortical areas revealed that the dorsal-rostral subregions connections were restricted to other frontal and limbic areas, whereas the ventral-caudal region was widely connected to frontal, parietal, and limbic cortex. Functional connectivity analyses demonstrated that subregions of DLPFC were strongly interconnected to each other. The dorsal subregions were associated with the default mode network (DMN), while middle dorsal-rostral subregions were linked with the multiple demand network (MDN). The ventral-caudal subregion showed increased functional coupling with both DMN and MDN. Our results suggest that the connectivity of the DLPFC may be subdivided along a dorsorostral-ventrocaudal axis with differing (albeit graded) patterns of connectivity reflecting the integrative executive function of the DLPFC.SIGNIFICANCE STATEMENT Research has shown that the dorsolateral prefrontal cortex (DLPFC) plays a role in various executive functions. By dividing the DLPFC into seven areas along rostral-caudal and dorsal-ventral axes anatomically, we explored their patterns of structural and functional connectivity. The patterns of connectivity within DLPFC subregions demonstrated graded intraregional connectivity. There were distinctive patterns of connectivity with other cortical areas in dorsal-rostral and ventral-caudal DLPFC subregions. Divisions across DLPFC subregions seem to align with their structural and functional connectivity. Our results suggest that DLPFC may be subdivided by the diagonal axis of the dorsal-ventral axis and rostral-caudal axis, supporting the framework of a functional organization along the anterior-posterior axis in the lateral PFC.

Cognitive deficits are an integral part of schizophrenia. This is a single-centre, single-blind randomised sham-controlled study to evaluate the effect of bilateral transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex on cognitive deficits in schizophrenia, specifically targeting improvements in cognitive insight and working memory deficits. Thirty patients with schizophrenia were randomly allocated to receive 10 sessions of bilateral tDCS (anodal F3 and cathodal F4) into active and sham tDCS groups. A series of assessment tests were completed among patients having Schizophrenia, at baseline and after the 10 sessions, for instance, Beck Cognitive Insight Scale (BCIS), N-Back (0' Back) task and Trail Making Test (TMT), Scale for Assessment of Positive Symptoms (SAPS), Scale for Assessment of Negative Symptoms (SANS) and Clinical Global Impression (CGI) scale. Out of a total of 30, twenty-seven participants (n = 13, Active and n = 14, Sham group) completed the study. However, an intention-to-treat analysis using Mixed model ANOVA was done on all the subjects. The study showed significant interaction effect (Time × Treatment) indicating that the active tDCS treatment had large effect on psychotic symptoms' reduction (SAPS: F(1,28) = 12.55, p = .001, partial η2 = 0.31; SANS: F(1,28) = 10.43, p = .003, partial η2 = 0.27) and significantly improved cognitive performance (N-Back Accuracy percentage: F(1,28) = 27.66, p < .001, partial η2 = 0.45; N-Back Reaction Time (in seconds): F(1,28) = 57.41, p < .001, partial η2 = 0.67). Furthermore, for cognitive insight, there was improvement in cognitive confidence (BCIS-C: F(1,28) = 5.43, p = .03, partial η2 = 0.16) and composite index (BCIS R-C: F(1,28) = 1.97, p = .17; partial η2 = 0.06) in Active vs. Sham group. TMT scores reduced more in the Active (-18.8s) as compared to the Sham group, suggesting better cognitive functioning, especially in the areas of attention, speed and mental flexibility (F(1,28) = 6.15, p = .02, partial η2 = 0.18). The study suggests that the adjunctive bifrontal tDCS over DLPFC helps improve cognitive insight and working memory deficits among patients having schizophrenia.

Background/Objectives: Attention-Deficit Hyperactivity Disorder (ADHD) is an immensely heterogeneous developmental disorder, uniquely impacting each individual. Physical movement is a promising adjunct behavioral treatment that can promote executive functioning in children with ADHD. The current study used neuroimaging and behavioral techniques to investigate the impact of movement during executive functioning on dorsolateral prefrontal cortical (DLPFC) activity and inhibitory control in children with ADHD, with particular focus on key individual difference factors in ADHD, such as subtype, severity, and gender. Methods: Twenty-eight children with ADHD completed a Stroop task while remaining stationary (stationary condition) and while desk cycling (movement condition). Simultaneous functional near-infrared spectroscopy (fNIRS) recorded oxygenated and deoxygenated changes in hemoglobin within the left DLPFC. Participants were categorized into ADHD subtype (hyperactive/impulsive, inattention, combined), ADHD severity (low, moderate, high), and gender (male, female). Results: Those with the hyperactive and combined ADHD subtypes, those with high ADHD severity, and males with ADHD showed greater DLPFC activation when engaging in movement during executive functioning compared to remaining stationary. In contrast, those with the inattentive ADHD subtype, those with low-to-moderate ADHD severity, and females with ADHD showed greater DLPFC activation when remaining stationary during executive functioning compared to engaging in movement. Inhibitory control improved in the stationary condition for females who were predominantly inattentive. Conclusions: This work underscores the importance of considering individual difference factors in ADHD when designing physical activity interventions, as treatment efficacy may vary.

Does a Difference Exists in Comprehensive Basic Science Examination Scores of 4-Year versus 6-Year Oral-Maxillofacial Surgery Residents?