Mara B. Antonoff MD Jonathan D’ Cunha MD, PhD

1. Development of PGY-1 Surgery Preparatory Course Curricula: Identification of Key Curricular Components Mara B. Antonoff MD Jonathan D’Cunha MD, PhD

2. Problem New PGY-1 surgical residents are underprepared

3. Background • Specific training during fourth year of medical school is highly variable • Impaired patient care • Inefficient • Poor quality • Unsafe Stevens, Acad Med 2010 Antonoff et al, Surgery 2010

4. Background • Importance of preparing senior medical students is clear • Initiatives to standardize curricula are of national interest

5. Solution: PGY-1 Prep Course • Most existing courses focus on technical skills • Additional areas of potential value: • Cognitive tasks for daily patient care • Professionalism, interpersonal skills

6. Aim To identify key curricular components in the design of a PGY-1 surgery preparatory course

7. Aim • Determine topics • Most valued by students • Most needed by students • Potential for improvement through instruction

8. Methods: Course Design • Elective 4-week course • Variety of teaching modalities: • Interactive didactics • Simulation of postoperative emergencies • Small group discussions • Procedural instruction with skills practice

9. Methods: Course Design • 55 sessions • Instruction in 3 main areas: • 19 Ward Management Tasks (WMT) • 12 Operative and Technical Skills (OTS) • 4 Professionalism Skillsets (PS)

10. Methods: Course Design • Ward Management Tasks (WMT) • Patient tracking • Responding to pages • Preopeval and informed consent • Prescribing medications • Ordering IV fluids and electrolyte replacement • Managing nutrition • Making transfusion decisions • Managing common postop issues • Chart documentation • Patient discharge process & counseling • Handling emergent situations in postop patients • Management of arrhythmias, pacers, VADs • Indications and interpretations of arterial blood gases • Indications and interpretation of imaging • Trauma systems and initial management • Managing postoperative cardiothoracic patients • Managing postoperative transplant patients • Signouts/handoffs • Cross covering other surgical services • Operative and Technical Skills (OTS) • Understanding steps/caveats of operations • Asepsis and skin preparation • Suturing, knot tying, local anesthetic • General critical care management • General management of ventilators • Chest tubes, arterial lines, and central lines • Conducting a Doppler examination • Endoscopy/bronchoscopy • Professionalism Skillsets (PS) • Describing expectations of residents • Emotional shifting/stress management • Effective & empathetic communication • Professionalism in surgery residency

11. Methods: Course Design • Ward Management Tasks (WMT) • Patient tracking • Responding to pages • Preopeval and informed consent • Prescribing medications • Ordering IV fluids and electrolyte replacement • Managing nutrition • Making transfusion decisions • Managing common postop issues • Chart documentation • Patient discharge process & counseling • Handling emergent situations in postop patients • Management of arrhythmias, pacers, VADs • Indications and interpretations of arterial blood gases • Indications and interpretation of imaging • Trauma systems and initial management • Managing postoperative cardiothoracic patients • Managing postoperative transplant patients • Signouts/handoffs • Cross covering other surgical services • Operative and Technical Skills (OTS) • Understanding steps/caveats of operations • Asepsis and skin preparation • Suturing, knot tying, local anesthetic • General critical care management • General management of ventilators • Chest tubes, arterial lines, and central lines • Conducting a Doppler examination • Endoscopy/bronchoscopy • Professionalism Skillsets (PS) • Describing expectations of residents • Emotional shifting/stress management • Effective & empathetic communication • Professionalism in surgery residency

12. Methods: Course Design • Ward Management Tasks (WMT) • Patient tracking • Responding to pages • Preopeval and informed consent • Prescribing medications • Ordering IV fluids and electrolyte replacement • Managing nutrition • Making transfusion decisions • Managing common postop issues • Chart documentation • Patient discharge process & counseling • Handling emergent situations in postop patients • Management of arrhythmias, pacers, VADs • Indications and interpretations of arterial blood gases • Indications and interpretation of imaging • Trauma systems and initial management • Managing postoperative cardiothoracic patients • Managing postoperative transplant patients • Signouts/handoffs • Cross covering other surgical services • Operative and Technical Skills (OTS) • Understanding steps/caveats of operations • Asepsis and skin preparation • Suturing, knot tying, local anesthetic • General critical care management • General management of ventilators • Chest tubes, arterial lines, and central lines • Conducting a Doppler examination • Endoscopy/bronchoscopy • Professionalism Skillsets (PS) • Describing expectations of residents • Emotional shifting/stress management • Effective & empathetic communication • Professionalism in surgery residency

13. Methods: Course Design • Ward Management Tasks (WMT) • Patient tracking • Responding to pages • Preopeval and informed consent • Prescribing medications • Ordering IV fluids and electrolyte replacement • Managing nutrition • Making transfusion decisions • Managing common postop issues • Chart documentation • Patient discharge process & counseling • Handling emergent situations in postop patients • Management of arrhythmias, pacers, VADs • Indications and interpretations of arterial blood gases • Indications and interpretation of imaging • Trauma systems and initial management • Managing postoperative cardiothoracic patients • Managing postoperative transplant patients • Signouts/handoffs • Cross covering other surgical services • Operative and Technical Skills (OTS) • Understanding steps/caveats of operations • Asepsis and skin preparation • Suturing, knot tying, local anesthetic • General critical care management • General management of ventilators • Chest tubes, arterial lines, and central lines • Conducting a Doppler examination • Endoscopy/bronchoscopy • Professionalism Skillsets (PS) • Describing expectations of residents • Emotional shifting/stress management • Effective & empathetic communication • Professionalism in surgery residency

14. Methods: Data Collection • IRB approval • Multiple assessment tools • Surveys • Knowledge tests • Performance exams

15. Methods: Survey • 46 items • For each topic • Perceived importance • Pre/post confidence • Extent to which course contributed to confidence levels

16. Methods: Survey • 5-point Likert scales • Pre/post comparison • Student’s t-tests • P < 0.05 significant

17. Topic Importance Which topics are most valued by the students?

18. Methods: Importance • Indicate the level of importance placed on acquiring each skill • Likert scale • 1 = “not at all important” • 5 = “very important”

19. Results: Topic Importance *P<0.05 vsWMT N=22

20. Task-Specific Confidence In which areas do the students lack confidence, and can it be improved with instruction?

21. Results: Confidence • Rank confidence level for each skill • 2 time points • Likert scale • 1 = “extremely nervous” • 5 = “quite confident”

22. Results: Confidence *P<0.05 vsPrecourse N=22

23. Results: Confidence * * N=22 *P < 0.05 vsPrecourse

24. Results: Confidence • Greatest impact seen in WMT • Lowest precourse confidence • Greatest gains in confidence

25. Results: Confidence • Greatest gains seen in WMT *P < 0.005

26. Results: Confidence • Quantify extent of course contribution to graduation confidence levels • Likert scale • 1 = “not helpful” • 5 = “completely responsible”

27. Results: Confidence

28. Results: Confidence • Students more frequently attributed confidence in WMT to course participation • Individual topics with highest scores: • Responding to pages (4.85 +/- 0.07) • Handling emergent situations in postoperative patients (4.36 +/- 0.15)

29. Measured Knowledge and Skills In which topics are the students’ measured weaknesses, and are they modifiable with instruction?

30. Knowledge/Skill Assessments • Written knowledge test • OSATS • Pre/post administration • T-test comparisons • P < 0.05 significant

31. Methods: Knowledge Test • Measured WMT • Baseline knowledge • Impact of course on improvement • 9 representative domains • 50-point, multiple-choice • Everyday patient care • Emergent situations on surgical ward

32. Methods: OSATS • Measured OTS • Assess baseline skill level • Track improvement • Realistic scenario testing multiple procedural skills • Scoring via itemized checklists & global scores

33. Results: Test Performance * * N=22 *P < 0.05 vsPrecourse

34. Results: Knowledge/Skills *P<0.05

35. Summary • Reviewed data from surveys and exams administered during PGY-1 surgery prep course • Compared relative value of topics in 3 categories • WMT • OTS • PS

36. Summary • WMT identified as most important topics • Precourse confidence lowest in WMT, with most dramatic postcourse gain • Poor precourse performance in WMT with clear potential for improvement • Managing emergent situations in postop patients has surfaced as topic of utmost importance

37. Conclusion There is a substantial need for instruction in ward management tasks, and these topics merit emphasis in the development of national, standardized curricula