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Update on Simulation and Integration into Your Training Program SELECT A SPEAKER BELOW TO SKIP DIRECTLY TO THE PRESENTATION
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Methodist Cardiovascular Fellows' Bootcamp Jean Bismuth, MD, Methodist Hospital, Houston, TX Introduction to Academic Vascular Surgery Murray Shames, MD, University of South Florida Morsani, Tampa, FL FVS at LSU Course Malachi G. Sheahan, III, MD, LSU Health Sciences Center School of Medicine, New Orleans, LA ABSTRACT: Advanced Vascular Surgery Surgical Skills and Simulated Assessment Program for Senior Vascular Surgery Trainees Mark A. Mattos, MD, Michigan Vascular Center, Flint, MI and O. William Brown, MD, William Beaumont Hospital, Royal Oak, MI Toronto Simulation Course Jonathan Cardella, MD, Yale-New Haven Medical Center Program, New Haven, CT ABSTRACT: REHEARSAL Using Patient Specific Simulation to Improve Endovascular Efficiency Matthew Wooster, MD, University of South Florida Morsani, Tampa, FL ABSTRACT: Resident Perspectives on Feedback Before and After the Introduction of a Mobile Assessment Tool April Rodriguez, MD, Niten Singh, MD, and Elina Quiroga, MD, University of Washington, Seattle, WA ABSTRACT: Reported Differences in Vascular Surgery Operative Experience Between Integrated Vascular Residents and the Independent Vascular Surgery Fellows Adam Tanious, MD, Mathew Wooster, MD, Andrew Jung, BA, Peter Nelson, MD, and Murray Shames, MD, University of South Florida Morsani, Tampa, FL ABSTRACT: Use of Mock Oral Exams in Vascular Surgery Training Programs – A Nationwide Survey Matthew R. Smeds, Rose An, Katherine Kimbrough, and Mohammed M. Moursi, University of Arkansas for Medical Sciences, Little Rock, AR Open Vascular Surgery Project Howard Champion, MD, SimQuest, Boston, MA
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The Cardiovascular Fellow’s Bootcamp
Houston Methodist Hospital
1
Jean Bismuth, MD FACSAssociate ProfessorHouston Methodist HospitalHouston, TX
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Cardiovascular Fellows’ Bootcamp
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Cardiovascular Fellows’ Bootcamp 2016DeBakey Institute for Cardiovascular Education & Training (DICET)
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• Course started in 2009• Initially didactic, skills lab introduced in 2011• First year only 50 participants were taken• This quickly grew to 150 the second year• Currently run parallel agendas for Cardiology and
Cardiac Surgery (some didactics overlap)
Cardiovascular Fellows’ Bootcamp
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Overview
• Tracks: Vascular Surgery & Cardiology/Cardiac• Audience: Residents entering a CV fellowship• Duration: 2 ½ day crash course • Agenda: 1 day hands-on training, 1 ½ days
didactics
Cardiovascular Fellows’ Bootcamp
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OverviewCardiovascular Fellows’ Bootcamp
Hands-on training at Methodist Institute for Technology, Innovation & Education (MITIE)
Didactics at boutique hotel - Hotel ZaZa
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Vascular Agenda: Day 1Cardiovascular Fellows’ Bootcamp 2016
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OverviewCardiovascular Fellows’ Bootcamp
Hands-on training and access to faculty
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OverviewCardiovascular Fellows’ Bootcamp
Hands-on training floor plan
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Vascular Agenda: Day 2Cardiovascular Fellows’ Bootcamp 2016
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Follow Up Content on DICET YouTubeCardiovascular Fellows’ Bootcamp 2016
https://www.youtube.com/c/DeBakeyInstituteForCardiovascularEducationTraining
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Course Pitfalls and Strengths
• Cost• Needs assessment - know your target audience• Playing in the sandbox with others is great but….
• Know your faculty, they make the course• Make it as painless as possible for faculty• Start small, don’t be too ambitious• Need other courses to complement (Finishing
School and Pre-Intern)
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Introduction to Academic Vascular
Surgery at USF
Murray L. Shames, MD
Professor of Surgery and RadiologyProgram Director
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History
Initiated in 2012 to coincide with opening of our simulation center.
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Content
§ Vascular surgery skills – Open – Endo
§ Fundamentals of research– Actual oral presentations
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Attendees'
§ Abstract invitation to all Vascular PD’s– Medical students– GS Residents– VS Residents – VS Fellows
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Meeting Requirements
§ All applicants required to submit abstract§ Peer review, 40 applicants selected to
attend§ 18 Abstracts selected for presentation
competition– 6 students– 6 GS residents– 6 VS residents/fellows
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Faculty
§ 10-15 faculty§ 4-5 local§ 10 national
– FVS/FEVS faculty
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Funding
§ 100% Industry funded through educational grants§ Budget approximately $125K§ All travel/ accommodation/meals
coordinated through simulation center§ Industry donation includes: financial
support, technical support, simulators, prosthetic grafts, porcine aortic tissue/cadaver veins etc.
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Agenda
§ 3 Day meeting– Day 1: IAVS didactics + Sim session– Day 2: Sim session + IAVS didactics– Day 3: Abstract competition
• Reception and prizes
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Didactic AgendaThe ideal research environmentHow to get started in research - clinical/translationalHow to get started in research - basic scienceFinding a mentorFinding an ideaFunding your research - time and dollarsResearch during residency
IRB and human subjects issuesClinical research - data collectionBasic science - documentation and the lab notebookBasic statisticsAdvanced statistics
So you want to publish a paperWriting an abstractCreating a posterThe 10 minute talkEffective use of PowerPointWriting a manuscriptPeer review
What does an academic career mean
Academics and the VAConstructing and maintaining a proper CVMulticenter clinical trialsA career as as an educator
My Journey:
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IAVS Simulation Agenda
§ Group 1 (FVS)
§ Explanation of "Clock Face" Face Skills Trainer
§ "Clock Face" skills workshop § Explanation of the "Patch"
Skills Trainer§ Patch skills workshop§ Explanation of "End-to- Side"
Skills Trainer§ End-to-side skills workshop
§ Group 2
§ EVAR/TEVAR - Symbionix§ Symbionix - FEVS skills
assessment § Open aneurysm repair -
Maquet model§ REVAR Simulation –
Compass§ Hansen Robot Demo§ Overview of Hybrid Room
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Vascular Surgery Skills
§ Porcine Aorta– End-end anastamosis
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CAMLS - Virtual Patient Care Center
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FVS – Skills Assessment
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Surgical Skills - FVS
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Basic Skills
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Endo Skills Training
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Open Surgical Models
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Open and Endovascular AAA repair
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Anatomic Models
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Fem-pop bypass
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CAMLS - Hybrid Endosuite
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RAAA Model - Medtronic
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Abstract Competition
§ Immediate feedback§ Judged on content, style, slide quality,
public speaking.§ Judged in 3 groups and overall§ $ Prizes for winners
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Feedback
§ Overall very positive§ Enjoyable and valuable experience§ Would like more time with faculty§ More simulation time§ More statistics§ More info on how to set up for research
time in residency§ Reorganize lectures to allow time to edit
talks for Saturday
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Evaluations
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Evaluations
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Evaluations
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Conclusions
§ Valuable learning experience§ Unique opportunity for
research/presentation simulation§ Open and endo simulation§ Direct interaction with faculty
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Malachi Sheahan, MDClaude C. Craighead Jr., Professor and Chair
Division of Vascular and Endovascular SurgeryLouisiana State University Health Sciences Center
New Orleans, LA
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ûWell attendedûSome evidence for
technique improvement
ûRated highly by attendees
ûPaved the way for enhanced simulation devices
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ûMostly funded by attendeesûRemote locationûTemporary facilityûEndo simulation primitive
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ûNo formal assessment of skill
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ûFormed ad hoc Simulation Committeeû2010 – Rolled into Education Committee
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The Center for Advanced Practiceû 30,000 square feet û 4 simulation ORsûComputer center û Reception/meeting roomsûACS Accredited Education
Institute
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Fundamentals of Vascular Surgery at LSUFeb. 14-16, 2013New Orleans, LA
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• 26 Trainees (21 0+5, 5 Fellows)• Airfare and tuition covered• Objective scoring given back to respective
programs
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û3 daysûEndovascular and open simulation
trainingûSkill testingûNew skill incorporation
• Cardiac cath skills• Neuroradiology• Embryology
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û8 Instructors/Examiners• Predominantly APDVS members
û13 LSU Faculty
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ûAnatomy Lab• Femoral/Popliteal/Tibial• Carotid/Subclavian• Thoracoabdominal exposure• Thoracic aortic repair• Aortoiliac exposure
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ûAM - Skill Testingñ Three models
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?
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ûPM- Skill Stations• 1. Carotid and Renal Interventions• 2. Radiation Safety• 3. Coronary Interventions• 4. TEVAR/EVAR• 5. EVAR Measurement• 6. Suturing with the Experts
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ûLecture series• Radiation safety• Neurovascular anatomy• CT imaging• Embryology
ûNAIS model with cryo veinûFeedback session
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ûExternal feedback on trainee performance
ûOpportunity to modify training and correct deficiency
ûHelp fulfill simulation training requirement
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û1. Direct assessment on three modelsû2. Final product assessment on three
modelsû3. EVAR measurementû4. One on one skill assessment –
descriptiveû5. Resident self assessment
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ûSkill feedbackûRadiation safetyûCoronary interventionsûCTA interpretationûComplex open exposuresûOpen aortic repair
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ûPre and post self assessments:• Significant improvement in :ñ Anatomic knowledgeñ Carotid stent proficiencyñ Renal stent proficiencyñ EVAR measurementsñ EVAR placementñ Coronary anatomyñ Neurovascular anatomy
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Amazing!-PGY 3
Best part of the course!-PGY 6
Need more!-PGY 2
More, more, more!-PGY 3
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ûSuturing with the expertsûEVAR measurementûNAIS
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ûCoronary interventions
I don’t want to be a cardiologist.-PGY 1
Why was this necessary?-PGY 4
What the heck?-PGY 1
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…no feedback was given…-PGY 7
…stressful…-PGY 2
Should have been at the end.-PGY 3
…didn’t learn anything.-PGY 2
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Was this activity helpful? (1-7)
û 2013 4.2û 2014 6.1û 2015 3.9û 2016 6.4
3112296
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!
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Mark A. Mattos, MDMichigan Vascular Center-Michigan State University, Flint, Michigan
O.W. Brown, M.D. William Beaumont Hospital-Oakland University , Royal Oak, Michigan
Advanced Vascular Surgery Surgical Skills and Simulation
Assessment Program
Presented at the 2016 APDVS Spring Meeting, April 1-2, 2016Loews Chicago O’Hare Hotel, Guggenheim ½ Room, Rosemont, Illinois
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Disclosures
• Nothing to Disclose
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Competence in Vascular Surgery
• Cognitive Competence– Determined by oral and written examinations
administered by the Vascular Surgery Board
• Technical Competence – Determined soley by subjective assessment from
faculty members of the vascular trainees institution
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Begs the Questions….?
Should there be a Technical Skills Component to the Vascular Surgery
Board Certification Process?
How Do We Get There?
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Educational Goal
Determine feasibility to perform objective evaluation of advanced vascular skills of
senior vascular trainees
High-fidelity Simulation Models
Independent Board-certified Faculty Proctors
Multiple Skills Assessment Instruments
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Are You Ready to Practice Vascular Surgery?
January 7-9, 2016Marcia & Eugene Applebaum Surgical Learning Institute
William Beaumont Hosptial, Royal Oak, Michigan
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Program Content
• 2. 5 Day Course
• Open Vascular Skills Performance Sessions
• Endovascular Skills Performance Sessions
• Didactic Lectures
– Vascular Society-specific, Practice-based
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Program Content
• Index vascular surgical procedures
• Industry-based skills and simulation models
• Procedure-specific Assessment Instruments
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Trainee Participants
• PGY-7 Vascular Fellows (16)
• PGY-5 Vascular Residents (3)
• Midwest Region (14)
• Invited Regions (5)
– Southeast
– Southwest
– East
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Faculty Proctors
• 25 Vascular Surgery Faculty
– Local, Regional, National
– Board Certified, Education-Interested
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Program Environment
• 25 skills performance stations
• 12 assessment sessions
• Vascular trainees perform 12 simulated procedures
- rotate station to station
• 60 minutes per assessment session
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10 Industry Simulation Partners
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5 Simulated Open Vascular Procedures
• Open Repair AAA
• Carotid Endarterectomy with patch
• Femoral-Popliteal Artery Bypass
• Hemodialysis Access Placement
• Mismatched End-to-Side Anastomosis
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Simulated Open Vascular Procedures
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7 Simulated Endovascular Procedures
• EVAR
• TEVAR
• Carotid Artery Angioplasty and Stenting
• Renal Artery Angioplasty and Stenting
• Iliac Artery Angioplasty and Stenting
• Superficial Femoral-Popliteal Artery Angioplasty and
Stenting
• Percutaneous Closure
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Simulated Endovascular Procedures
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Simulated Endovascular Procedures
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Assessment Methodology
• Single vascular faculty proctor (1:1)
• Faculty are “passive” 1st assistants
• 4 operative assessment instruments
• Immediate feedback to trainee
• Comprehensive summative
feedback to program directors
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Measurements of Performance
1. Global Rating Scale Score
2. Global Rating Scale Summary
3. Critical Task Completion Performance
4. Critical Task Time Measurements
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Standards of Proficiency*
1. Global Rating Scale Score:
1. >80% of maximum possible score
2. Global Rating Summary Score
1. Level 4 or Level 5 Performance
3. Critical Task Completion Performance:
1. 100% completion of all critical skill tasks
4. Critical Task Time Measurements
1. 100% completion of all measurable procedural skill tasks under procedure-
specific time limit
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Proficiency Rating*
• Performance = Proficient vs. or Not Proficient
• 4 Individual Proficiency Assessment Ratings
• 1 Collective Proficiency Assessment Rating
*Faculty-derived performance standards - Not validated
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Brief Results
• 202 Procedural Assessments Performed
• Proficiency ratings were variable– 83% Global Rating Scale– 75% Global Rating Summary– 49% Critical Task and Time Performance– 47% Collective Proficiency
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Brief Results
• Assessment reporting errors or omissions– 18%
• Endovascular simulator malfunctions– 4%
• Open simulator malfunctions– Unable to determine
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Video Assessment - Metric Validation
• 6 Assessment Stations • 72 Procedures videotaped
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Lessons Learned
• Inconsistency in Faculty Assessments
• Differences in faculty opinions regarding milestone metrics for simulated vascular procedures
• Determining optimal time limits for performance, assessment and feedback of simulated procedures
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Lessons Learned
• Small but defined failure rates of simulators
• Logistical Issues regarding performing assessments simultaneously on 2 floors
• Logistical Issues regarding trainees and faculty changing assessment stations at same time
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Plans for 2017 Program
• Add 6 Senior Vascular Trainees (25)
• Add 10 Vascular Faculty Proctors (35)
• Add 5 New Industry Sponsors (15)
• Add 3 New Simulation Stations (25)
• Add 3 New Skills Assessments (15)
• Add Assessment Training Session for faculty
• Formalizing Assessment Instruments
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Conclusion
• Feasible to perform objective assessment of senior vascular surgery trainees using various evaluation instruments
• Simulation models exhibited good durability and consistency, and appear useful for assessment for assessement of advanced vascular surgical skills
• Data from this initial feasibility program can be used to determine reproducible objective assessment metrics
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Conclusion
These assessment metrics, once validated serve as foundation for a
technical competence examination in vascular surgery
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Canadian Endovascular Skills Course
Jonathan A. Cardella, MD, FRCSAssistant Professor
Section of Vascular SurgeryYale University
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Canadian Endo Skills Course(CESS)
• 27 Residents and Fellows representing all programs in Canada
• Location: Toronto• Duration: 2 Days• Cost to Trainee: $0 (Industry)• Actual Cost: $30k + Faculty
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Course Format
• Lectures: VERY SHORT and over a Meal
– Case Planning – Devices and Techniques – Radiation Safety – Industry Relationships
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Practical Sessions
• Simulators– 2 Mentice simulators and 1 Simbionix– Proctored Iliacs and SFA
• Pig models– U/S Guided Access
• Micropuncture technique• Closure Devices
– Interventions• Up and Over, Angioplasty, Renal Stenting, Carotids,
Viabahns, Onyx Glue, Coils
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Things Done Well
• Cost neutral for programs and residents• Porcine endo cases are fun!• Every major company represented• Use all devices• Heavy on doing, Light on sitting
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Adjustments to make
• Bigger pig is a better pig!– 50 kg or greater
• Probably less wet lab and more porcine• Fewer trainees and more instructors• Timing of Course• Should have studied as intervention
• Use of animals for open!
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL Using Patient Specific
Simulation to Improve Endovascular
Efficiency
Mathew Wooster, Adam Doyle, Sean Hislop, Roan Glocker, Paul Armstrong, David Gillespie, Michael Singh, Karl Illig
APDVS Spring MeetingChicago, ILApril 2016
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:CONFLICTS OF INTEREST
• None
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Background
• “Surgical skills simulation”
0
50
100
150
200
250
300
350
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Background
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Objective
• To determine if the use of procedural rehearsal by the endovascular surgeon using patient specific simulation prior to performance of the actual procedure improves procedural efficiency and outcomes.
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Methods
• All patients scheduled for carotid artery stenting who had an adequate CTA were considered for enrollment
• Randomized 1:1 by random number generation• Control: routine stenting procedure without rehearsal• REHEARSAL: Patient CTA loaded into Simbionix
endovascular simulator and the surgeon simulated the case within 24 hours of the scheduled procedure
• Contrast usage, fluoroscopy time, and timing of procedural steps were recorded by a blinded observer
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Data Sheet
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Results
Control REHEARSAL
N 9 6
Contrast volume (mL) 76.9 (38-120) 59.2 (29-108)
Fluoroscopy time (min) 19.4 (9.8-38) 11.4 (5.4-19.8)
Operative time (min) 42.5 (30.9-69) 31.9 (14.2-54)
Time to carotid cannulation (min) 23.3 (13.4-30.5) 17 (7.2-30.1)
Carotid sheath duration (min) 19.2 (11.8-26.5) 14.9 (6.1-23.9)
**All P values > 0.05
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Discussion
• Results are limited by small N value– Suspect type II error
• The simulator is currently unavailable, hindering further evaluation
• Blind observers subjectively identified REHEARSAL cases to have better procedural flow
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Division of Vascular and Cardiothoracic Surgery
REHEARSAL:Conclusion
• No statistically significant differences identified
• REHEARSAL group trended towards reduced contrast volume and radiation time
• REHEARSAL group trended towards reduction in time for ALL operative steps
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April L Rodriguez MD, Niten Singh MD, Elina Quiroga MD
Division of Vascular SurgeryUniversity of Washington
APDVS - 2016 Annual MeetingApril 01, 2016
Chicago, IL
Resident Perspectives on Feedback Before and After the Introduction of a
Mobile Assessment Tool
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Feedback • Discordance between
residents and attendings
– Quantity
– Quality
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Where was the disconnect?
We live in a ratings economy
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Mobile assessment tool
• Frequent reminders
• Easy access
• Case specific
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Survey
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Quantitative outcomes
Number of evaluations per month increased
1 17
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Qualitative outcomes
• Face to face
• Targeted
• Timing
• Comments not numbers
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Feedback as an expectation
• Dispel fear
• Create trust
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Comments not numbers
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Conclusions• A mobile assessment tool can objectively improve
the number of evaluations and most importantly the residents perception of the quality of feedback provided.
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Specific feedback• A tool developed with residents in mind that also
meets compliance, not a compliance tool that might be useful to residents.
• Well timed, targeted, face-to-face
• My two cents
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Division of Vascular and Cardiothoracic Surgery
Reported Differences in Vascular Surgery Operative
Experience Between Integrated Vascular
Residents and Independent Vascular Surgery Fellows
Adam Tanious, MD; Mathew Wooster, MD; Andrew Jung, BA; Peter Nelson, MD;
Paul Armstrong, DO; Murray Shames, MD
APDVS4/1/2016
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Division of Vascular and Cardiothoracic Surgery
Conflicts of Interest
• None
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Division of Vascular and Cardiothoracic Surgery
• 2015 – Integrated Vascular Surgery Residents (IVSR) vs. Vascular Fellows (VF) graduate survey– 9 IVSR and 16 VF (same institutions)
– Groups reported similar• Training Case Volume, Training Satisfaction,
First Job Attainment, Starting Salary– IVSR higher disposition towards academic jobs
– VF had more interview offers
IVSR Program Assessment
Colvard B, Shames M, Schanzer A, Rectenwald J, Chaer R, Lee JT. A Comparison of Training Experience, Training Satisfaction, and Job Search Experiences Between Integrated Vascular Surgery Residency and Traditional Vascular Surgery Fellowship Graduates. Annals of Vascular Surgery. June 2015:1-18. doi:10.1016/j.avsg.2015.04.078.
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Division of Vascular and Cardiothoracic Surgery
• 2015 – First case-log comparison of IVSR to their VF counterparts– Case Log analysis of 11 IVSR and 121 VF
• Similar Open Vascular Training
• IVSR > VF in Overall Vascular and Endovascular Volume
• VF > IVSR in Overall Surgical Volume
IVSR Program Assessment
Batista P, Abai B, Salvatore D, DiMuzio P. The first assessment of operative logs for traditional vascular fellowship track versus integrated vascular training programs. J Vasc Surg. July 2015:1-7. doi:10.1016/j.jvs.2015.05.039.
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Division of Vascular and Cardiothoracic Surgery
Objectives
1. What is the overall operative experience offered by both the integrated vascular and vascular surgery fellowship programs?
2. How does the training experience differ with respect major case categories (as defined by the ACGME) between both groups?
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Division of Vascular and Cardiothoracic Surgery
Methods
• ACGME National Resident Reports compiled for both graduating IVSR and VF– Focused on Vascular Surgery Cases
– Between 2012 – 2014
• 30 IVSR
• 243 VF
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Division of Vascular and Cardiothoracic Surgery
• Case Categories– IVSR
• Surgeon Chief, Surgeon Junior, and Secondary Procedures
– VF• Surgeon Fellow and Secondary Procedures• All vascular cases done in general surgery
residency (using averages of General Surgery Resident ACGME case log data)
Methods
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Division of Vascular and Cardiothoracic Surgery
Results
Category IntegratedVascular Vascular Fellows P
Total Major Vascular 694.7 616.3 .0106
Total Peripheral Obstructive 343.6 293.4 .0032
Total Extra-Anatomic 21.4 14.4 .0001
Total Thrombolysis/Thrombectomy 24.6 14.1 .0001
Total Vascular Trauma 30.0 22.5 .0172
Total Venous 120.8 75.0 .0001
Total Amputations 54.8 44.8 .0008
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Division of Vascular and Cardiothoracic Surgery
Results
Category IntegratedVascular Vascular Fellows P
Total Vascular Procedures 1446.0 1533.6 .2648
Total Open Aortic 58.0 57.4 .9020
Total Endovascular Aortic 121.1 115.8 .4131
Total Aneurysm 114.0 114.6 .9217
Total Cerebrovascular 78.8 85.0 .1132
Total Abdominal Obstructive 34.0 32.3 .6162
Total Upper Extremity 21.7 22.4 .7241
Total Endovascular Diagnostic 437.3 395.2 .1557
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Division of Vascular and Cardiothoracic Surgery
Conclusions
• IVSR and traditional VF graduate with comparable overall vascular surgery operative experience.
• IVSR reported, on average, a significantly higher number of major vascular procedures during their tenure as trainees as well as a significantly increased number of cases in 6 of the other ACGME categories.
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Division of Vascular and Cardiothoracic Surgery
Thank You
Questions?
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Division of Vascular and Cardiothoracic Surgery
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1Matthew R. Smeds, MD, FACS
Use of Mock Oral Exams in Vascular Surgery Training Programs: A Nationwide Survey
1Division of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
1Rose An, MD, 2Katherine Kimbrough, MD, 1Mohammed M. Moursi, MD
2Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Disclosures
ØNone.
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Background
ØVascular Surgery Certifying Examination (VCE): important and final step for board certificationØRequires:
• Vascular knowledge-base• Communication/interpersonal skills:
-Clarity/certainty of answers-Mastery of anxiety-Body language
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BackgroundØUse of mock oral examinations (MOE)
ubiquitous in general surgery programs-Resident preparation for CE-Program evaluation of resident-Program evaluation of curriculum
ØLiterature supports:-Improved pass rates-Predictive value for passing-Improved resident comfort level with CE
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Background
ØUse of MOE by vascular surgery training programs not extensively studied-Newly approved for residency training-Familiar with fellows
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BackgroundØMOE programs at regional vascular
professional society meetings:-Positive preparatory experience by examinees and examiners-No advantage in VCE pass rates by participants
ØExaminers identified common deficits among examinees -Management of complications-Ability to describe open procedures
Goldman MP et al. Journal of Surgical Education 2015;72(6):1085-1089.
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Objective
ØDetermine current use and design of MOE in U.S. vascular surgery training programs
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Methods
ØAnonymous electronic survey (www.surveymonkey.com) sent to program directors of all U.S. vascular surgery training programs (n = 108)-Importance of MOE-Details of current use-Barriers to implementation-Preparedness of current trainees to sit for the VCE
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Results
ØSurveys completed by 59/108 (55%)
Type of Program
ResidencyFellowshipBoth
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Results
Ø30/59 (51%) programs provide mock oral experiences
0%10%20%30%40%50%60%70%80%90%
100%
Provide MockOralsDon't ProvideMock Orals
*No correlation with sizeof program, geographicallocation, or years of program
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ResultsØ48/59 (81%) thought MOE was
moderately/very important for fellows preparation for VCE Ø51/59 (86%) thought MOE was
moderately/very important for residents preparation for VCE
0%20%40%60%80%
100%
Residents Fellows
All Programs
Give Mock Orals
Don't Give MockOrals
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ResultsØLevel of training of those who receive
MOE:ØFellowship only programs:
-13/14 (93%) give MOE to both Junior and Senior fellows
ØPrograms with vascular residencies:-5/16 (31%) give MOE to all years of training-1/16 (6%) give MOE to PGY2 and above-7/16 (44%) give MOE to PGY3 and above-3/16 (19%) give MOE to PGY 4 and above
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Results
0%20%40%60%80%
100%
Frequency ofExam
1x/year2x/year>2x/year
0%
20%
40%
60%
80%
Location of MOE
FacultyOfficeTestingCenterOther
0%20%40%60%80%
100%
Number of Rooms
1 rooms2 rooms3 rooms>3 rooms0%
20%40%60%80%
100%
Number ofScenarios
<44>4
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ResultsMOE Characteristics % Yes
Images Used? 83%
Questions Modified Based on PGY Level? 27%
Recorded? 7%
Other Trainees in the Room? 17%
How is Feedback Given % Yes
Numeric Score 3%
Pass/Fail Based on PGY Level 13%
Review of Correct/Incorrect Answers 23%
Pass/Fail Compared to “Real VCE” 30%
Group Debriefing 47%
One on One with PD 60%
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Results
Ø18/30 (60%) use results in their CCC evaluationsØ29/30 (97%) give feedback on
communication styles
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ResultsBarriers to Implementation / Continuing MOE % Yes
Lack of Examiner’s Time 56%
Lack of Available Faculty 47%
Lack of Available Questions 24%
Lack of Trainee Time 24%
Lack of Testing Location 7%
Lack of Trainee Interest 3%
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Results
Ø62% of programs not providing MOE expect their residents to get MOE experiences elsewhere-95% from regional/national conferences-5% from another institution
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Results
Ø97% of respondents believe trainees are adequately prepared for VCEØComparing residents to fellows
preparedness:-64% thought fellows = residents-30% thought fellows > residents-2% thought fellows < residents
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Conclusions
ØMOE are regarded as highly valuable tool in preparation for the VCE… but only half of programs currently provide institutional MOE programs
ØMost common barriers to implementation include faculty availability and time
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Conclusions
ØA third of PD believe fellows are more prepared than residents for VCE
ØFurther investigation into more rigorous and standardized preparation of residents for the VCE may be warranted
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Virtual/Augmented Reality
Physics-Based Simulator to Teach Hands-On Vascular
Surgical SkillsNIH SBIR grant #2 R44 HL118939
HR Champion, MD, FRCS, FACSProfessor of Surgery
Uniformed Services University of the Health SciencesFounder, Executive Chairman, SimQuest
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The Problemó Challenges in vascular surgery training ó Open/endovascular: multiple specialtiesó General/vascular/trauma surgeons ó Military and civilian
The Solutionó Biofidelic technology-assisted trainingó Objective Performance Metricsó Real time assessmentó Adaptive learningó Personal and metadata
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Funded by US Government SimQuest has produced a prototype system that allows trainees to hold real surgical tools while looking at their hands as simulated surgical scenes are presented on a stereoscopic display surface. The tools are held in an advanced, low-cost seven degree-of-freedom (7DOF) haptic device specifically designed for surgical training.
The system has enabled the team to solve the human factors issues for an effective trainer, and is the foundation of an open-incision surgery simulation platform.
Prototype System
Biofidelic force feedback
Haptic device for surgery, 7DOF + range of motion
Interchangeable real surgical instruments
Real visual experience
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ó Physics-based biofidelic simulations of real-life operative experiencesó One platform, multiple simulation-based training procedures with different
instrumentsó Progressive technical and cognitive challenges (scenarios), variety and flexibilityó Objective metrics formulated by training expertsó Unencumbered practiceó Real-time performance feedbackó Adaptive learning – documented proficiencyó Databasing and training metadata potentialó Cost savingsó Patient safety activationó Open-source development platform for interested partners
Discriminant Attributes
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ó Benchmarking: novice/intermediate/skilled on fresh perfused cadavers
ó Development of physics simulation for suturing
ó Development of automatic metricsó Refinement of haptic interfacesó Implementation of an initial specific learning
scenariosó User/learner feedback to refine the simulator,
and evaluation to assess how well it meets the training needs
ó Outline didactic and decisionmaking knowledge acquisition
Phase II In Process
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Phase II In-Progress Screenshot
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Phase II Metrics to discriminate
novice from expert1. Distance of hands from knot when knot tying2. Movement of vessels when knot tying3. Slowness § Placing sutures§ Total time
4. Smoothness – Multiple steps to pull needle through5. Placement§ Distance from edges§ Distance between
6. Pull-through completeness7. Inversion of surface line8. Vessel narrowing9. Repeat placement of suture10. Attending surgeon takeover11. Amount of leakage
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Exemplar Real Time Metric Dashboard
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Preoperativesteps
Sutureplacement
metrics
Thread tension Knot tying Leak test Overall
FAILReturn to didactics & pretest
REMEDIALSimpler scenariosOpen-ended questionsTrigger mentor
ACCEPTABLESimpler scenarios
EXCELMore difficult scenarios
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Validation Methodologies by Anthony Gallagher, PhD, DSc
“The vascular simulator currently being developed and
validated by SimQuest is the best and most promising open virtual
reality simulator that I have seen.”
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Involvement of Vascular and Trauma Surgery Community
ó Benchmarking exerciseó Hands-on testing of prototypesó Iterative designó Metrics evaluationó Case scenarios – presentationó Learning sciencesó Adaptive learning testingó Summative metricsó Validation studies