Dunnington advocates skills labs, immediate post-surgical feedback to improve resident autonomy and operative performance
By Josh Shepherd, UK Department of Surgery
Link to Surgical Symposium Powerpoint presentations and reception picture page.
A great teacher in the operating room knows when to offer cues to residents and when it is best “to stand and do nothing,” said Dr. Gary Dunnington, who delivered the keynote presentation at the 2016 Schwartz Memorial Lecture and Surgical Symposium in early November 2016.
Gary Dunnington is the Jay L. Grosfeld Professor of Surgery at Indiana University and one of the nation’s leading researchers in the field of surgical training. He was invited by Dr. Andrew Bernard and Dr. David Sloan of the Division of General Surgery to deliver the annual lecture in memory of Dr. Richard Schwartz.
Before launching into his presentation, Measuring and Improving Performance in Surgical Training, Dr. Dunnington took a few moments to reflect on his memories of Dr. Schwartz. He described his friend and former UK surgical faculty member as “ahead of his time.”
“We shared many things ... a passion for education and a passion for leadership development,” Dunnington said. Their relationship is one he will always cherish.
On the subject of improving operative performance measurement and evaluation, Dunnington began by summarizing roughly two decade’s worth of ideas and initiatives that influenced the development of a proficiency-based operative performance system. He then elaborated on several key points.
A link to Dr. Dunnington’s full presentation is included with this article along with a list of time signatures touching on specific points in his lecture. There is also a link to his slide presentation.
One way to improve resident operative performance is mandatory time in surgical skills labs mastering the basics for residents in program years one and two. The idea, of course, is not new but in recent years, skills practice in a lab has largely been seen as a voluntary activity – something to be done in a resident’s spare time.
“In the 90s, I became convinced that the future of surgical training would involve greater reliance on labs for residents to drill on basic skills,” said Dunnington. Surprisingly, the idea had difficulty gaining traction among more established surgical faculty, most of whom felt that the proper place for residents was in the OR. To validate his basic stand, Dunnington offered the analogy of a student at the Julliard School of Music dreaming of playing Carnegie Hall. To attain that dream, a budding musician’s first home is a dingy little practice room where they spend hours and years honing their skills. They earn the right to play Carnegie.
Likewise, residents and medical students must earn their place in the performance arena through mandatory practice in the lab, Dunnington said. Importantly, skills lab sessions, which would be taught by trained non-MD coaches, would include faculty feedback and opportunities to drill on individual problem areas.
The advantages of using skills labs for year one and two residents are that they avoid exposing patients to “the sharpest slope of the surgical skills learning curve,” Dunnington argued. Furthermore, labs enhance the quality of OR teaching by relieving the attending from the tedious task of teaching basics. Faculty can introduce advanced techniques earlier in training, he said.
Skills labs, however, are but one practical aspect of formal surgical training.
One of the major points in Dr. Dunnington’s lecture was an elaboration on the importance of a formal process of graduated autonomy and confidence building in surgical residency programs. In so doing, Dunnington cited the contribution of UK Department of Surgery chair, Dr. Jay Zwischenberger, whose four-tiered “Zwisch Scale” was adapted into the SIMPL app, a web-based operative performance evaluation system developed from a collaboration among Northwestern University, Indiana University, and Massachusetts General Hospital.
“As residents mature into chiefs, attendings have to learn how to fade,” Dunnington elaborated. There must be an organized system in place that develops and encourages resident autonomy over a five year program. The process is a progression from providing detailed cues in a procedure early in resident training, then gradually withdrawing those cues to the point when the attending merely observes and provides post-op feedback.
Few would argue against that idea, but attendings often underestimate the amount of guidance they given to their chiefs while in the OR. Dunnington offered himself as an example of this tendency.
In the early stages of researching a resident evaluation system, Dunnington arranged for an OR session to be recorded. Reviewing the video afterward, he watched himself provide a cued narrative of the entire procedure to a medical student in the OR while the chief was at work.
“I wound up guiding the entire procedure without realizing what I was doing,” Dunnington commented. It was a growth experience for him as an instructor. Flipping an old adage around, when it comes to chief residents, Dunnington advised his fellow attendings to “don’t do something, just stand there.”
That is, he said, until the procedure is concluded. At that point, studies have shown that immediate feedback from instructors and multiple objective “raters” is critical for residents to improve their skills.
One of the consistent critiques of surgical education programs are delays in addressing identified problems with an individual resident’s performance. “There is too much reliance on remediation to correct problems.” Furthermore, he said that there was also a need for more surgical educators to be involved in the evaluation process.
Dr. Dunnington also highlighted some practical teaching strategies that could be easily implemented in the OR. One idea Dunnington suggested was a strategy suggested by a Ph.D. on his research team called the BID Method. The acronym stands for Briefing, Inter-Operative Teaching, and De-Briefing.
Briefing: At the scrub sink, either the resident or attending discuss what skills needs developing. “An attending can ask the resident ‘what do they want to improve on in this case?’”
Interoperative Teaching: During the case, the attending engages in the usual teaching until they reach the area of particular focus. At that point, said Dunnington, the procedure should really slow down to include a conversation about technique.
De-Briefing: At the end of case, provided the issues to be discussed are constructive, the attending can give the resident and the operative team feedback on the procedure. It is particularly important to have this discussion as soon after the procedure as possible, Dunnington stressed.
“A master surgeon is capable of multi-tasking in the OR. They are experienced enough to divide their attention between performing the procedure and discussing it. In general, a resident’s attention, even a chief’s, is occupied 100 percent by the procedure,” he commented. Remarks made at the table do not teach as well as advice that comes afterward.
Dunnington also suggested a practical strategy to “avoid the takeover” of the case by the attending.
He concluded his talk with a general outline of a vision for a proficiency based operative performance system, aspects of which are currently under evaluation in a major American Board of Surgery project involving multiple institutions including the University of Kentucky.
“The numbers we’re getting in this study are just staggering,” Dunnington said. Researchers on his team are excited over the potential results and information to be gleaned from this study.
Though unable to elaborate on the details or conclusions in some of the research in advance of publication, Dunnington did say that there are concerns about the individual performance ratings of those achieving “Practice Ready” ratings. Though there have been some noted improvements in autonomy and performance scores individually, they are not where they should be.
Through the final minutes of the lecture, Dunnington discussed ideas which are very much in the conceptual stage. One idea was developing surgical proficiency via modules of specific procedures that residents must master before moving on to more advanced surgeries.
There are practical barriers to work through, “but I really think that this is the future direction of surgery,” said Dunnington.
