The complexity of gynaecologic surgery has increased in recent years, while the duration of residency training has remained fixed with reduced work hours compared with our predecessors. Residents may not be graduating with the advanced surgical skill set required for complex cases, which are now considered standard of care. The ever-changing advancements in the field of gynaecologic surgery warrant the development of training programmes for practicing surgeons to incorporate recent advances and best practices. This can be accomplished through mentorship in training residents as well as the continuing professional development of safe gynaecologic surgeons. This review outlines the process of mentorship to enhance surgical skills, and objective feedback tools for surgeons seeking to improve performance. Mentorship programmes can help surgeons incorporate new technologies in a structured environment, which seeks to decrease the risk of complications for our patients.
Highlights
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Simulation shortens the surgical learning curve maximizing operating room resources.
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Mentorship in the operating room can lead to improved surgical outcomes.
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Standardized assessment tools should be used for objective feedback.
Becoming safe surgeons through training programmes and mentorship
Traditionally, residency programmes have relied on the preceptorship model, which is often referred to as ‘see one, do one, teach one’ . In recent years, this informal learning process has been criticized with regard to patient safety, standardization and best practice . Over the past decade, we have seen significant changes within our residency training programmes that have consequently led to decreased work hours. At present, residents are exposed to smaller volumes of surgical cases with a simultaneous significant increase in surgical complexity . The impact of these challenges on the surgical capabilities of newly graduated specialists has been discussed on an international level. A study of graduates from Canadian residency programmes from 2005 to 2010 reported that only 26% were comfortable performing a total laparoscopic hysterectomy (LH) once in practice . Similarly, Australian obstetrics and gynaecology (OBGYN) trainees have admitted their lack of confidence performing a range of advanced laparoscopic procedures at the completion of their training . While many current residency training programmes use box trainers and virtual reality simulation to teach minimally invasive surgery (MIS) techniques, there is general agreement that these simulated environments complement but do not replace real-time operating room (OR) experience .
Mentorship has the potential to improve a surgeon’s confidence and decrease medical error. Mentoring has been described as a two-way, face-to-face long-term relationship between a ‘supervisor’ and a ‘novice student’ that fosters the mentee’s professional, academic or personal development . Although there are several definitions for the term mentoring , all of them include elements of a senior/junior advice and guidance. In the context of surgical mentorship, the mentor serves the important roles of both teaching and skill transfer to less experienced mentees. Recent studies use the terms ‘surgical mentorship’, ‘surgical coaching’, ‘mentoring’ and ‘mentor traineeship’ interchangeably to describe the relationship of a skilled surgeon guiding a trainee to incorporate new skills in their practice. For the most part, the mentor-mentee relationship is described positively; however, negative outcomes have been reported. These are generally related to lack of time and professional expertise mismatch . Despite the use of mentorship during residency training to graduate competent newly qualified surgeons, the realities of training at present warrant the relationships of mentors be explored well into our surgical careers . To accomplish positive outcomes as a consequence of the mentor–mentee relationship, we must first investigate the underlying principles of teaching surgical skill.
Principles of education and teaching
The challenge of creating an effective mentor–mentee relationship is not a new concept. Bloom’s taxonomy was designed to improve communication between educators on the design of curricula and examinations . The educational process according to Bloom can be categorized into the following steps: (1) remembering, (2) knowledge of specifics, (3) understanding, (4) interpretation, (5) applying, (6) analysing, (7) evaluating and (8) creating. This taxonomy can be applied to surgical teaching. Learning surgical procedures consists of perfecting the skills required in the OR and learning the indications, alternatives, preoperative and post-operative management. These would fit in the first four categories (1–4) of Bloom’s educational process and should be studied before the OR setting through a combination of didactics, video instruction and simulation .
Bloom’s taxonomy serves as the backbone of many teaching philosophies, but other educators have since created psychomotor taxonomies. Simpson proposed the following levels: (1) Perception followed by readiness to act; this involves a guided response, which includes imitation and trial and error. (2) Adequacy of performance is achieved by practice; following which learned responses become habitual and the movements can be performed with some confidence and proficiency. (3) Reaching a complex overt response; whereby the learner incorporates skilful performance of motor acts that involve complex movement patterns. (4) Proficiency, which is indicated by a quick, accurate and highly coordinated performance. (5) Adaptation, where skills are well developed and the individual can modify movement patterns to fit special requirements. Bloom and Simpson’s educational principles, although not designed for the field of surgery, can easily be extrapolated to the teaching and learning of surgical procedures and technique.
Surgical simulation and education
The early phases of surgical learning should occur in a simulated environment with a lens for optimizing patient safety, rather than an OR where repeated trial and error are not an option. Simulation has been successful in shortening learning curves without compromising patient care or scarce OR resources . Ultimately, the true application of surgical knowledge and refinement of skill does come in an OR setting.
Surgical simulation offers us an opportunity to enhance quality of care by refining skills outside of a patient encounter. Numerous studies have shown improved operating performance with the use of simulators before real-time OR performance . Palter’s 2012 study randomized 25 surgical residents to traditional residency training or a comprehensive simulation curriculum for laparoscopic colorectal surgery. Residents in the intervention group participated in a didactic teaching session and practised psychomotor skills on a virtual reality (VR) simulator with preset proficiency benchmarks and a cadaver laboratory. At the conclusion of the study, all residents performed a laparoscopic hemicolectomy, which was video-recorded and judged by a blinded observer using two previously validated assessment tools. Residents in the simulation-training group demonstrated a statistically significant improvement in OR performance (global score 16.0 (14.5–18.0) vs. 8.0 (6.0–14.5), P = 0.030; number of operative steps performed 16.0 (12.5–17.5) vs. 8.0 (6.0–14.5), P = 0.021; procedure-specific score 71.1 (54.4–81.6) vs. 51.1 (36.7–74.4), P = 0.122) . The mentor can play an important role in encouraging and guiding the trainee to participate in simulation exercises before the OR setting.
Despite the established value of simulators, comprehensive curriculum development is unfortunately lacking . A recent study of OBGYN residency programme directors found that 73% of residency programmes have a simulation curriculum, yet only 59% were satisfied with their approach to teaching laparoscopic gynaecology . The majority of responding programmes (97%) were interested in implementing a standardized gynaecologic laparoscopy curriculum for their residents . Curriculum should reflect practice patterns at diverse institutions and encompass cognitive knowledge, technical skills and non-technical skills . A framework has been proposed by Shore et al. to teach junior gynaecology trainees the basics of gynaecologic laparoscopy with cognitive, technical and team-based training components. This framework also includes expert-driven proficiency benchmarks, which trainees and mentors can use to create local goals for trainees who are seeking proficiency at MIS procedures .
Principles of education and teaching
The challenge of creating an effective mentor–mentee relationship is not a new concept. Bloom’s taxonomy was designed to improve communication between educators on the design of curricula and examinations . The educational process according to Bloom can be categorized into the following steps: (1) remembering, (2) knowledge of specifics, (3) understanding, (4) interpretation, (5) applying, (6) analysing, (7) evaluating and (8) creating. This taxonomy can be applied to surgical teaching. Learning surgical procedures consists of perfecting the skills required in the OR and learning the indications, alternatives, preoperative and post-operative management. These would fit in the first four categories (1–4) of Bloom’s educational process and should be studied before the OR setting through a combination of didactics, video instruction and simulation .
Bloom’s taxonomy serves as the backbone of many teaching philosophies, but other educators have since created psychomotor taxonomies. Simpson proposed the following levels: (1) Perception followed by readiness to act; this involves a guided response, which includes imitation and trial and error. (2) Adequacy of performance is achieved by practice; following which learned responses become habitual and the movements can be performed with some confidence and proficiency. (3) Reaching a complex overt response; whereby the learner incorporates skilful performance of motor acts that involve complex movement patterns. (4) Proficiency, which is indicated by a quick, accurate and highly coordinated performance. (5) Adaptation, where skills are well developed and the individual can modify movement patterns to fit special requirements. Bloom and Simpson’s educational principles, although not designed for the field of surgery, can easily be extrapolated to the teaching and learning of surgical procedures and technique.
Surgical simulation and education
The early phases of surgical learning should occur in a simulated environment with a lens for optimizing patient safety, rather than an OR where repeated trial and error are not an option. Simulation has been successful in shortening learning curves without compromising patient care or scarce OR resources . Ultimately, the true application of surgical knowledge and refinement of skill does come in an OR setting.
Surgical simulation offers us an opportunity to enhance quality of care by refining skills outside of a patient encounter. Numerous studies have shown improved operating performance with the use of simulators before real-time OR performance . Palter’s 2012 study randomized 25 surgical residents to traditional residency training or a comprehensive simulation curriculum for laparoscopic colorectal surgery. Residents in the intervention group participated in a didactic teaching session and practised psychomotor skills on a virtual reality (VR) simulator with preset proficiency benchmarks and a cadaver laboratory. At the conclusion of the study, all residents performed a laparoscopic hemicolectomy, which was video-recorded and judged by a blinded observer using two previously validated assessment tools. Residents in the simulation-training group demonstrated a statistically significant improvement in OR performance (global score 16.0 (14.5–18.0) vs. 8.0 (6.0–14.5), P = 0.030; number of operative steps performed 16.0 (12.5–17.5) vs. 8.0 (6.0–14.5), P = 0.021; procedure-specific score 71.1 (54.4–81.6) vs. 51.1 (36.7–74.4), P = 0.122) . The mentor can play an important role in encouraging and guiding the trainee to participate in simulation exercises before the OR setting.
Despite the established value of simulators, comprehensive curriculum development is unfortunately lacking . A recent study of OBGYN residency programme directors found that 73% of residency programmes have a simulation curriculum, yet only 59% were satisfied with their approach to teaching laparoscopic gynaecology . The majority of responding programmes (97%) were interested in implementing a standardized gynaecologic laparoscopy curriculum for their residents . Curriculum should reflect practice patterns at diverse institutions and encompass cognitive knowledge, technical skills and non-technical skills . A framework has been proposed by Shore et al. to teach junior gynaecology trainees the basics of gynaecologic laparoscopy with cognitive, technical and team-based training components. This framework also includes expert-driven proficiency benchmarks, which trainees and mentors can use to create local goals for trainees who are seeking proficiency at MIS procedures .
The role of mentors in the operating room
The mechanism of learning in the OR has been described as experiential learning. In this theory, experience serves as the basis for development where skills are learned through preceptorship and practice. Experiential learning provides the foundation for the majority of surgical teaching during residency . Kirschner et al. have criticized this practice stating that minimal guidance during instruction limits best practice . Although experiential learning offers trainees with opportunities to engage in practical experiences, their learning may be limited by a lack of analytic reflection on these experiences. Surgical residents have reported that faculty infrequently spent time preoperatively to identify the learning needs of the trainee or provide specific debriefing at the end of the case . This lack of feedback can limit a surgeon’s skill acquisition. Surgical skills should evolve to a continuous process of self-evaluation, but lack of analytic reflection on surgical experiences may be limited by inaccurate self-assessment . Methods to improve self-assessment, including debriefing, have been suggested, but their implementation is challenging . Mentors have the potential to provide objective assessment and feedback as well as encourage the mentee’s development of self-assessment skills.
A structured encounter template has been suggested to enhance hands-on OR mentorship. Leung et al. published the positive impact of structured teaching in the OR. Using this structured template, the trainee completed the preoperative briefing and set the learning objectives for the case, coded according to Bloom’s Taxonomy . The intraoperative teaching focused on meeting the needs of the trainee-identified learning objectives for that specific case. Debriefing was conducted after the completion of the surgical procedure in order to provide the opportunity to reflect on the performance and discuss skills or techniques. Using a standard template, the trainee and mentor were able to participate in the preoperative assurance that the clinical history, pathology and anticipated challenges were addressed, while encouraging feedback from faculty intraoperatively and during the postoperative evaluation to complete the mentorship process. The stated learning objectives included cognitive, psychomotor and affective parameters. Overall, the trainees confirmed the positive impact of using a structured template in goal setting, focused teaching and feedback. While this structure has not been evaluated in terms of reducing complications, allowing the trainee the opportunity to set objectives and receive feedback empowers them and enhances their educational experience .
Observation of videotaped cases, along with interviews of surgeons involved in teaching, confirm that surgical mentors use a variety of verbal and physical teaching parameters to guide trainees . Successful teaching behaviours in the OR have not been well defined, yet surveys have identified that trainees prefer to learn from attending physicians with surgical expertise who are calm and courteous and who encourage resident participation . As surgical mentors, we likely adopt teaching methods from our own experience of how we were taught in the OR. The approach we take with our mentees is therefore emulated by each successive generation of surgeons and deserves careful attention. To evaluate the effectiveness of those teaching parameters in terms of improving skills and decreasing the risk of complications, more research is warranted.
Surgical coaching and reducing the risks of surgical complications
In an insightful article, Gawande compares the role of surgical mentors to that of coaches for performance athletes and singers. He logically describes the process of using a mentor to coach surgical practice in order to reach personal best . We can extrapolate that mentorship through a coaching relationship leads to enhanced surgical skills, in turn increasing surgical quality and decreasing complications. Following skill acquisition and enhancement in a simulated environment, surgical skill in the OR necessitates evaluation and further constructive feedback.
Available tools for surgical coaching
To reduce complications, two methods of performing OR assessments have been explored: (1) global assessment of surgical skills and (2) a generic error-rating tool.
Objective performance benchmarks
One of our main challenges with surgical coaching rests with the lack of objective proficiency benchmarks. In order to assess progress in technical skills development, objective markers to understand performance are required. Video recordings offer a valuable opportunity for structured assessment and subsequent tailored coaching interventions. Global rating scales have been used to measure the effect of educational interventions and benchmark technical competency . Examples of these rating scales include the Objective Structured Assessment for Technical Skills (OSATS) and the Global Operative Assessment of Laparoscopic Skills (GOALS) The most frequently used objective measure of assessment is the OSATS which lists seven items which are each ranked on a five-point Likert-like Scale with the middle and the extreme point anchored by explicit terms . The OSATS was initially developed by Martin et al. to measure surgical performance at laparotomy. It provides trainees with a global assessment of operative performance by evaluating metrics such as their respect for tissue, and surgical efficiency . The OSATS tool was modified and validated by Grantcharov et al. to evaluate surgical skill at laparoscopic cholecystectomy. These measurement tools are validated to correlate with the level of surgical proficiency, but they lack the details required for task and skill-specific feedback.
Use of a generic error rating tool
The practice of medicine is shifting to focus on patient safety through error prevention . Technical errors at the time of surgery have been associated with an increased risk of adverse outcomes. Retrospective reviews of complications do not allow us to take protective measures to avoid future adverse events through recognition of ‘near misses’ to prevent harm . Bonrath and Husslein have studied a generic error-rating tool (GERT) to objectively assess the procedural details that may result in complications. In contrast to global skill rating frameworks, analysis with GERT assesses every technical ‘error’ that occurs during a laparoscopic procedure ensuring an in-depth analysis of the surgeon’s specific procedural steps. The authors are careful to point out that, in this context, ‘errors’ are counted without discrimination in terms of the suspected severity or assumed consequence. The majority of these ‘errors’ therefore do not lead to any negative consequences for the patient. The extrapolation for improvement in patient safety relies on the fact that a small percentage of these errors in technical procedural skills may consequently lead to a complication; therefore, a reduction in the total number of errors could lead to a reduction of risk to the patient. Their findings indicate a significant difference in total error count between expert and novice surgeons suggesting the validity of GERT as a surrogate marker of surgical performance in the absence of other metrics. In addition, GERT may be used for formative feedback in surgical education as a valuable tool for self-improvement and mentorship .
Surgical coaching for residents
Bonrath et al. recently published their randomized controlled trial documenting the effectiveness of comprehensive surgical coaching on OR performance. They compared traditional residency training with a structured programme of surgical coaching, which included objective assessment, structured debriefing, feedback, behaviour modelling and guided self-reflection. In the coaching sessions, participants received formative feedback and developed generalizable training goals together with the coach who was an experienced advance laparoscopic surgeon. Debriefing was conducted using video playback of edited clips, encouraging self-reflection of observed performance. Practical solutions to address areas of improvement and enhance future performance were developed, communicated and implemented by the participant during subsequent cases in the OR. As coaching represents a personalized approach, distinct learning goals and objectives were identified for each participant. Primary outcome measures were technical performance in the OR as measured by validated rating scales and surgical safety parameters. The residents who were randomized to the comprehensive coaching group scored significantly higher on the validated rating scales and made fewer technical errors compared with their peers . After 2 months of coaching, the participants in the coaching group were able to conduct self-assessments of their performance more accurately compared with those in the traditional residency-training group. In addition, residents in the coaching group required less direction and feedback as they developed the capacity for self-directed learning. Greenberg et al. point out that the coaching study of Bonrath et al. developed new skill sets in residents that will serve them throughout their careers – openness for ongoing performance improvement and the capacity for self-improvement.
Coaching of surgeons in practice
Learning new skills and adapting skills is an ongoing challenge for surgeons in practice as part of their continuing professional development. Although coaching can be an effective strategy, there may be obstacles to the introduction of hands-on coaching within the OR setting. Mutabdzic et al. studied surgeons’ perceptions and concerns regarding hands-on coaching. Participants included 14 practicing surgeons from different surgical specialties and varied years of experience. Most participants were ambivalent about the role of coaching as a strategy for professional development. They expressed concerns relating to image and authority with worries that having a coach could signal incompetence. There were also concerns regarding the potential loss of control over self-regulation of their individual learning agendas. Surgeons wanted to choose a coach who they respected and trusted. These findings raise issues regarding the need for coaches to be sensitive to the basic principle that individual physicians retain the control of their learning process. Adopting widespread coaching would warrant a culture change in our departments.
In order to optimize the mentorship of both trainees and surgeons in practice, it is valuable to incorporate perioperative structured teaching methods and debriefing video analysis using objective markers of performance . The refinement of self-assessment capabilities using these tools is important for successful ongoing professional development of individual surgeons and teams.
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