The concept and trajectory of "operative competence" in surgical training.
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Clinical Competence↗
Biomedical subjects
Ethan D Grober
Publications and source records attributed to Ethan D Grober.
Defining medical error.
Medical errors represent a serious public health problem and pose a threat to patient safety. As health care institutions establish "error" as a clinical and research priority, the answer to perhaps the most fundamental question remains elusive: What is a medical error? To reduce medical error, accurate measurements of its incidence, based on clear and consistent definitions, are essential prerequisites for effective action. Despite a growing body of literature and research on error in medicine, few studies have defined or measured "medical error" directly. Instead, researchers have adopted surrogate measures of error that largely depend on adverse patient outcomes or injury (i.e., are outcome-dependent). A lack of standardized nomenclature and the use of multiple and overlapping definitions of medical error have hindered data synthesis, analysis, collaborative work and evaluation of the impact of changes in health care delivery. The primary objective of this review is to highlight the need for a clear, comprehensive and universally accepted definition of medical error that explicitly includes the key domains of error causation and captures the faulty processes that cause errors, irrespective of outcome.
Humans↗
Microsurgical treatment of persistent or recurrent varicocele.
OBJECTIVE: To examine the effectiveness of subinguinal microsurgical varicocelectomy in the treatment of persistent or recurrent varicocele. DESIGN: Retrospective chart review. SETTING: Urban, tertiary care, academic teaching hospital. PATIENT(S): Fifty-four men who presented for treatment of persistent or recurrent varicocele. INTERVENTION(S): A single surgeon using an artery and lymphatic sparing subinguinal microsurgical technique with delivery of the testis repaired all varicocele. MAIN OUTCOME MEASURE(S): Preoperative to postoperative changes in semen parameters (volume of ejaculate, sperm concentration, percent motility, percent morphologically normal sperm, total motile sperm concentration), serum hormone levels, and testicular volume. Pregnancy rates and surgical complications were documented. RESULT(S): Postoperative mean serum T and mean testicular volume increased significantly from prevaricocelectomy levels. Median sperm concentration, percent motility, and total motile sperm per ejaculate improved significantly following recurrent varicocelectomy. Among patients with follow-up over 24 weeks (65%, 35 out of 54), the overall pregnancy rate was 40% (14 out of 35), including 23% (8 out of 35) of pregnancies achieved through natural intercourse, 9% (3 out of 35) with IVF/intracytoplasmic sperm injection, and 9% (3 out of 35) with IUI. Complications such as hydrocele, hematoma, wound infection, and testicular atrophy were not observed during the follow-up period. CONCLUSION(S): Treatment of persistent or recurrent varicocele using an artery and lymphatic sparing subinguinal microsurgical technique with delivery of the testis improves semen parameters, serum T levels, and testicular volume from preoperative levels without a significant risk of postoperative complications.
Female↗
Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill.
PURPOSE: We evaluated the durability of laboratory based technical skills training in urological microsurgery using bench model simulators. METHODS AND MATERIALS: A total of 50 junior surgery residents (post-graduate years 1 to 3) were recruited to participate in a focused training program in urological microsurgery. Prior to training subjects were randomized to receive hands-on training with bench model simulators (silicone tubing or live rat vas deferens, 40) or didactic training alone (10). Four months following the original training program the technical performance of 18 returning subjects (13 from the bench model and 5 from the didactic training group) was reevaluated using a high fidelity, live animal model (vasovasostomy and rat vas deferens). Outcome measures included blinded, expert assessment of videotaped performance using checklists and global rating scores, and evaluation of anastomotic patency. RESULTS: The retention test checklist (p <0.001), global rating scores (p <0.001) and anastomotic patency rates (p = 0.05) in the live animal model remained significantly higher for subjects who originally received hands-on bench model training compared with those who received didactic training alone. The number of interim practice opportunities with microsurgery correlated significantly with expert global ratings of surgical performance irrespective of the nature of training (r = 0.54, p = 0.02). CONCLUSIONS: Laboratory based technical skills training with bench models can lead to a significant retention of technical skill by novice surgeons. Measured performance improvements appear to be durable with time. However, the opportunity for repeat hands-on practice appears to maximize the retention of technical skill.
Adult↗
The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures.
OBJECTIVE: To evaluate the impact of bench model fidelity on the acquisition of technical skill using clinically relevant outcome measures. METHODS: Fifty junior surgery residents participated in a 1-day microsurgical training course. Participants were randomized to 1 of 3 groups: 1) high-fidelity model training (live rat vas deferens; n = 21); 2) low-fidelity model training (silicone tubing; n = 19); or 3) didactic training alone (n = 10). Following training, all participants were assessed on the high- and low-fidelity bench models. Immediate outcome measures included procedure times, blinded, expert assessment of videotaped performance using checklists and global rating scales, anastomotic patency, suture placement precision, and final product ratings. Delayed outcome measures (obtained from the live rat vas deferens 30 days following training) included anastomotic patency, presence of a sperm granuloma, and the presence of sperm on microscopy. RESULTS: Following training, checklist (P < 0.001) and global rating scores (P < 0.001) on the bench model simulators were higher among subjects who received hands-on training, irrespective of model fidelity. Immediate anastomotic patency rates of the rat vas deferens were higher with increasing model fidelity training (P = 0.048). Delayed anastomotic patency rates were higher among subjects who received bench model training, irrespective of model fidelity (P = 0.02). Rates of sperm presence on microscopy were higher among subjects who received high-fidelity model training compared with subjects who received didactic training (P = 0.039) but did not differ among subjects in the high- and low-fidelity groups. CONCLUSIONS: Surgical skills training on low-fidelity bench models appears to be as effective as high-fidelity model training for the acquisition of technical skill among novice surgeons.
Adult↗
Correlation of the primary Gleason pattern on prostate needle biopsy with clinico-pathological factors in Gleason 7 tumors.
OBJECTIVES: To correlate the primary Gleason pattern among patients with biopsy-derived Gleason 7 tumors with the radical prostatectomy specimen Gleason grading and other clinical and pathologic outcomes. METHODS AND MATERIALS: Among 474 patients who underwent radical prostatectomy for clinically localized prostate cancer between 1997-2001, 205 (43%) had Gleason 7/10 tumors on pre-operative needle biopsy. Among theses patients, 148 (72.2%) were assigned a primary Gleason 3 pattern (3+4 = 7) and 57 (27.8%) were assigned a primary Gleason 4 pattern (4+3 = 7). The two groups were compared with respect to age, serum PSA levels, Gleason grade in the radical prostatectomy specimen, pathological stage and surgical margin status. RESULTS: Among patients with 3+4 tumors on needle biopsy, 64% remained primary Gleason grade 3 while 35% were up-graded to a primary pattern 4 following analysis of the radical prostatectomy specimen. Patients with 4+3 tumors on needle biopsy remained primary Gleason grade 4 in 51% of patients, while 49% of patients had their tumors down-graded to a primary 3 pattern (p = 0.09). There were no differences between patients with needle biopsy 3+4 and 4+3 patterns with respect to total Gleason score in the radical prostatectomy specimen (p = 0.42), pTNM stage (p = 0.36), extra-prostatic extension (p = 0.88), surgical margin involvement (p = 0.16), and seminal vesicle invasion (p = 0.19). In contrast, the primary Gleason pattern in the radical prostatectomy specimen correlated significantly with pTNM stage (p = 0.02) and seminal vesicle invasion (p= 0.003), but not with extra-prostatic extension (p = 0.32) and surgical margin involvement (p = 0.17). CONCLUSIONS: Among patients with Gleason 7 adenocarcinoma of the prostate, the biopsy-derived primary Gleason pattern does not appear to correlate with important clinical and pathologic outcomes. The utility of distinguishing a primary Gleason pattern on needle biopsy among patients with Gleason 7 tumors remains unclear given the limited and conflicting literature addressing this issue.
Adenocarcinoma↗
Validation of novel and objective measures of microsurgical skill: Hand-motion analysis and stereoscopic visual acuity.
Our purposes were: 1) to establish the predictive validity of stereoscopic visual acuity and microsurgical performance, and 2) to establish the construct and concurrent validity of hand-motion analysis as an objective and sensitive measure of microsurgical performance. Using a surgical microscope, 50 surgical residents completed a standardized microsurgical suturing task at baseline and following microsurgical training. Microsurgical performance was evaluated by blinded, expert microsurgeons using global rating scales. Measures of stereoscopic visual acuity and hand-motion analysis were correlated with expert global rating scores. Global rating scores correlated significantly with number of hand movements (r = -0.47, P = 0.001) and hand-travel distance (r = -0.37, P = 0.008). Economy of hand-motion improved significantly following microsurgical training (number of hand movements, P = 0.046; hand-travel distance, P = 0.04). Measures of stereoscopic visual acuity did not correlate significantly with global rating scores. Hand-motion analysis appears to be an objective and sensitive instrument for assessing microsurgical performance, with evidence of both concurrent and construct validity. The predictive validity of stereoscopic visual acuity and microsurgical performance remains unclear.
Adult↗
Visual-spatial ability correlates with efficiency of hand motion and successful surgical performance.
BACKGROUND: This study examines the influence of visual-spatial ability and manual dexterity on surgical performance across 3 levels of expertise. METHODS: Dental students, surgical residents, and staff surgeons completed standardized tests of manual dexterity and visual-spatial ability and were assessed objectively while performing the rigid fixation of an anterior mandible on bench model simulations. Outcome variables included expert assessment of technical performance and efficiency of hand motion during the procedure (recorded using electromagnetic sensors). RESULTS: Visual-spatial scores correlated significantly with surgical performance scores within the group of dental students (r=.40 to.73), but this was not the case for residents or staff surgeons. For all groups, manual dexterity did not correlate with hand motion parameters. There were no differences between groups in visual-spatial ability or manual dexterity, but highly significant differences were seen in surgical performance scores (P<.001), in that surgeons outperformed residents, who in turn outperformed students. CONCLUSIONS: Among novices, visual-spatial ability is associated with skilled performance on a spatially complex surgical procedure. However, advanced trainees and experts do not score any higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time. Thus, the use of these tests for the selection of residents is not currently recommended; they may be of more use in identifying those novice trainees (ie, those with lower test scores) who might benefit most from brief supplementary instruction on specific technical tasks.
Clinical Competence↗
The Canadian Urology Fair: a model for minimizing the financial and academic costs of the residency selection process.
INTRODUCTION: In 1994, the Canadian urology residency training programs designed the "Canadian Urology Fair"--a single-site (Toronto, Ont.), 1-day fair to conduct the personal interview portion of the residency selection process. The objective of the current study was to evaluate the success of the Urology Fair in achieving its original goals of decreasing the financial burden and minimizing time away from medical training for applicants and faculty. METHODS: Both candidates and Canadian urology training programs were surveyed regarding the financial and academic costs (days absent) of attending the 2001 Urology Fair. Data from the 2001 Canadian Resident Matching Service (CaRMS) was used to compare the financial and academic costs of attending personal interviews incurred by candidates declaring urology as their first-choice discipline to candidates interviewing with other surgical specialties throughout Canada. RESULTS: Financial costs incurred by candidates to attend the Urology Fair (mean Can dollar 367) were significantly lower than candidates' estimated costs of attending on-site interviews at the individual programs (mean Can dollar 2065). The financial costs of attending personal interviews by CaRMS applicants declaring urology as their first-choice discipline (mean Can dollar 2002) were significantly lower than the costs incurred by applicants interviewing with other surgical disciplines (mean Can dollar 2744). Financial costs to urology programs attending the fair (mean Can dollar 1931) were not significantly greater than the programs' estimated costs of conducting on-site interviews at their respective program locations (mean Can dollar 1825). Days absent from medical school to attend interviews were significantly lower among CaRMS applicants declaring urology as their first-choice discipline (3 d) compared with applicants who interviewed with other surgical specialties (9.1 d). CONCLUSION: The Canadian Urology Fair represents an innovative and efficient method for residency programs to conduct the personal interview portion of the residency selection process and should serve as a model for making the interview process less expensive and time-consuming for both candidates and faculty.
Absenteeism↗
Preservation of testicular arteries during subinguinal microsurgical varicocelectomy: clinical considerations.
Microsurgical varicocelectomy with intentional preservation of the testicular artery(ies) is regarded as the gold standard approach to varicocele repair. We sought to determine whether the number of testicular arteries preserved at the time of micro-surgical varicocelectomy predicts improvement in postoperative semen parameters. We analyzed the records of 334 infertile men who underwent varicocelectomy performed by a single surgeon using a subinguinal microsurgical technique between July 1996 and January 2003. We examined the association between the number of testicular arteries preserved at the time of varicocelectomy and serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), varicocele grade, testicular volume, and postoperative improvement in semen parameters. Unilateral, left-sided varicocelectomy was performed in 194 men, while bilateral varicocelectomy was performed in 140 men. Mean (+/-SE) sperm concentration (20.1 +/- 1.5 x 10(6)/mL to 26.7 +/- 1.9 x 10(6)/mL, P =.001), percent motility (24.7 +/- 1.0% to 30.9 +/- 1.2%, P =.001), and percent normal morphology (35.8 +/- 1.4% to 37.7 +/- 1.5%, P =.046) improved significantly following varicocelectomy. The mean number of preserved testicular arteries was 1.5 on the left (range, 1-4) and 1.5 on the right (range, 1-4). The number of testicular arteries preserved at the time of varicocelectomy did not correlate significantly with preoperative assessment of serum FSH, LH, varicocele grade, and testicular volume or with postoperative improvement in semen parameters. Our data indicate that preoperative parameters are not predictive of the number of testicular arteries identified at the time of microsurgery. These data also suggest that the number of arteries identified and preserved with meticulous spermatic cord dissection does not correlate with improvement in semen parameters.
Follicle Stimulating Hormone↗