Background The surgical learning curve persists for years after training, yet existing CME efforts targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intra-operative performance. Study Design Four complex operations performed by surgeons of varying experience – a chief resident accompanied by the operating senior surgeon, a surgeon with <10 years in practice, another with 20–30 years, and a surgeon with >30 years of experience – were video-recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio-recorded, transcribed, and thematically coded. Results The sessions focused on operative technique, both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the resident’s technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure-to-progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. Conclusions Video-based coaching is an educational modality that targets intra-operative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.
Background The importance of leadership is recognized in surgery, but the specific impact of leadership style on team behavior is not well understood. In other industries, leadership is a well-characterized construct. One dominant theory proposes that transactional (task-focused) leaders achieve minimum standards, whereas transformational (team-oriented) leaders inspire performance beyond expectations. Study Design We video-recorded 5 surgeons performing complex operations. Each surgeon was scored on the Multifactor Leadership Questionnaire, a validated method for scoring transformational and transactional leadership style, by an organizational psychologist and a surgeon-researcher. Independent coders assessed surgeons' leadership behaviors according to the Surgical Leadership Inventory and team behaviors (information-sharing, cooperative, and voice behaviors). All coders were blinded. Leadership style (MLQ) was correlated with surgeon behavior (SLI) and team behavior using Poisson regression, controlling for time and the total number of behaviors, respectively. Results All surgeons scored similarly on transactional leadership (2.38-2.69), but varied more widely on transformational leadership (1.98-3.60). Each 1-point increase in transformational score corresponded to 3× more information-sharing behaviors (p<0.0001) and 5.4× more voice behaviors (p=0.0005) amongst the team. With each 1-point increase in transformational score, leaders displayed 10× more supportive behaviors (p<0.0001) and 12.5× less frequently displayed poor behaviors (p<0.0001). Excerpts of representative dialogue are included for illustration. Conclusions We provide a framework for evaluating surgeons' leadership and its impact on team performance in the OR. As in other fields, our data suggest that transformational leadership is associated with improved team behavior. Surgeon leadership development therefore has the potential to improve the efficiency and safety of operative care.
Background Communication failure is a common contributor to adverse events. We sought to characterize communication failures during complex operations. Methods We video recorded and transcribed six complex operations, representing 22 h of patient care. For each communication event, we determined the participants and the content discussed. Failures were classified into four types: audience (key individuals missing), purpose (issue nonresolution), content (insufficient/inaccurate information), and/or occasion (futile timing). We added a systems category to reflect communication occurring at the organizational level. The impact of each identified failure was described. Results We observed communication failures in every case (mean 29, median 28, range 13–48), at a rate of one every 8 min. Cross-disciplinary exchanges resulted in failure nearly twice as often as intradisciplinary ones. Discussions about or mandated by hospital policy (20%), personnel (18%), or other patient care (17%) were most error prone. Audience and purpose each accounted for >40% of failures. A substantial proportion (26%) reflected flawed systems for communication, particularly those for disseminating policy (29% of system failures), coordinating personnel (27%), and conveying the procedure planned (27%) or the equipment needed (24%). In 81% of failures, inefficiency (extraneous discussion and/or work) resulted. Resource waste (19%) and work-arounds (13%) also were frequently seen. Conclusions During complex operations, communication failures occur frequently and lead to inefficiency. Prevention may be achieved by improving synchronous, cross-disciplinary communication. The rate of failure during discussions about/mandated by policy highlights the need for carefully designed standardized interventions. System-level support for asynchronous perioperative communication may streamline operating room coordination and preparation efforts.
BACKGROUND With advances in oncologic treatment, cosmesis after mastectomy has assumed a pivotal role in patient and provider decision making. Multiple studies have confirmed the safety of both chemotherapy before breast surgery and immediate reconstruction. Little has been written about the effect of neoadjuvant chemotherapy on decisions about reconstruction. METHODS The authors identified 665 patients with stage I through III breast cancer who received chemotherapy and underwent mastectomy at Dana-Farber/Brigham & Women’s Cancer Center from 1997 to 2007. By using multivariate logistic regression, reconstruction rates were compared between patients who received neoadjuvant chemotherapy (n = 180) and patients who underwent mastectomy before chemotherapy (n = 485). The rate of postoperative complications after mastectomy was determined for patients who received neoadjuvant chemotherapy compared with those who did not. RESULTS Reconstruction was performed immediately in 44% of patients who did not receive neoadjuvant chemotherapy but in only 23% of those who did. Twenty-one percent of neoadjuvant chemotherapy recipients and 14% of adjuvant-only chemotherapy recipients underwent delayed reconstruction. After controlling for age, receipt of radiotherapy, and disease stage, neoadjuvant recipients were less likely to undergo immediate reconstruction (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.37, 0.87) but were no more likely to undergo delayed reconstruction (OR, 1.29; 95% CI, 0.75, 2.20). Surgical complications occurred in 30% of neoadjuvant chemotherapy recipients and in 31% of adjuvant chemotherapy recipients. CONCLUSIONS The current results suggest that patients who receive neoadjuvant chemotherapy are less likely to undergo immediate reconstruction and are no more likely to undergo delayed reconstruction than patients who undergo surgery before they receive chemotherapy.
According to ICC criteria, reliability of PE teachers' measurements was "excellent." However, the criteria for mean absolute differences were not consistently met. Results highlight the importance of staff training and data cleaning.
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