Faculty Surgical Preceptor Program Enhances Quality of Care and Resident Surgical Experience

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ObjectivesFaculty Surgical Preceptor Program Enhances Quality of Care and Resident Surgical Experience.

Context

• Minimally invasive hysterectomy have less complications and a faster return to work. – Vaginal (VH) + Laparoscopic (LH)

• Many practicing gynaecologists do not have skills to do LH – Negatively impacts quality of care. – Negatively impacts resident’s ability to learn LH.1,2

1. Fung Kee Fung MP, Temple LM, Ash KM. JSOGC 1996; 18:859-67.2. Cundiff GW. Obstet Gynecol 1997;90:854–9.

Continuing Surgical Education Program• Professional Development program directed

at acquisition of new surgical skills• Preceptor Model• Key Elements– Established process for enrollment– Structured assessment of competence– Credentialing mechanism– Remuneration model for preceptors

Methods

• Hypothesis: The CSEP will enhance resident education by building a base of surgeons skilled in laparoscopic hysterectomy (LH)

• Design: retrospective analysis of quality assurance program, CSEP– REB waived ethics approval

Methods: Analysis • Longitudinal analysis of surgeons’ volume of hysterectomies

stratified by surgical approach– Minimally invasive hysterectomy (MIH) = vaginal hysterectomy (VH) +

laparoscopic hysterectomy (LH)– Stratify surgeons based on completing 50% or more by MIH.

• Comparison of 2 hospital sites with different implementation (dedicated OR slates at one)– Uptake of LH and its impact on VH– Number of surgeons meet the 50% MIH criterion

• Analysis the volume of hysterectomy teaching cases stratified by surgical approach

Results: Comparison of Two Sites Hospital A Hospital B

Attending Gynaecologists 18 15

Established Laparoscopic specialists 1 2

Annual surgical volume of Hysterectomy (mean) 329 363

Annual TVH prior to initiation of CSEP 47 54

Annual LH prior to initiation of CSEP 8 48

OR slates dedicated to CSEP(per month) 2 0

CSEP Preceptors 5 3

Residents on service (mean) 5 5

Results: Cumulative HysterectomiesStratified by Surgical Approach

Includes both hospitals (A+B) per period.

Results: Hysterectomies Stratified by Site and Approach

Results: Percentage of Staff Performing >50% of

Hysterectomies by MIS (TVH + TLH)

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

Hospital A 13% 41% 50% 56% 56%

Hospital B 25% 33% 33% 20% 40%

Hospital A dedicated 2 OR slates/month to CSEP

Results: Proportions of Resident Teaching Cases by approach

Continuing Professional Development• CPD is inadequate for the development of

new surgical skills – Short courses are most common offering1

• Do not allow the acquisition of new motor skills

– Preceptorships valued for hands-on training, immediate feedback, and exchange of tacit knowledge1,2,3

• Scheduling and sponsorship are barriers

1. Wallace T, Birch DW. Am J Surg. 2007 May;193(5):593-5.2. Lord JL, et al. Surg Endosc. 2006 Jun;20(6):929-33. Epub 2006 May 11.3. Cottam D, et al. Surg Endosc. 2007 Dec;21(12):2237-9. Epub 2007 Apr 10.

Continuing Professional Development• The majority of CPD is sponsored or funded by

the surgical industry to showcase products 1 – Creates ethical issues around bias and conflict of

interest– Disconnected from the credentialing

responsibilities of hospitals. • The CPD event may be accredited, but there is no

mechanism to objectively evaluate surgeon competence with the new skill. 2

1. Gagliardi AR, et al. J Contin Educ Health Prof. 2009 Fall;29(4):269-75.2. Maillet B, et al. Presse Med. 2011 Apr;40(4 Pt 1):357-65. Epub 2011 Mar 3.

Continuing Surgical Education ProgramClinical Advantages

• Effective in facilitating competence in LH – Applicable to any new surgical procedure that has

proven safety and efficacy.

• Scalable. – Applied CSEP to mid-urethral slings, and prolapse

procedures as well as LH. – Used it at community and rural hospitals.

Continuing Surgical Education ProgramEducational Advantages

• Facilitates the development of a faculty base of clinician educators with the necessary skills to implement a new residency surgical curriculum.

• Successfully moved the skill of LH into the realm of the generalist

Continuing Surgical Education ProgramImplementation is Important

• More effective when implemented with dedicated OR slates. – Encourage participation by eliminating any impact

on the learner’s practice. – Helps to build up a cadre of preceptors that

sustain the momentum of the program.

Continuing Surgical Education ProgramA Better Model for CPD in Surgery

• Advantages– Sustainable– Insulated from industry influence– Capable of providing objective assessment of

competency

• Should lead to better patient care and enhancement of educational mission

References• Wallace T, Birch DW. A needs-assessment study for continuing professional development in

advanced minimally invasive surgery. Am J Surg. 2007 May;193(5):593-5; discussion 596.• Lord JL, Cottam DR, Dallal RM, Mattar SG, Watson AR, Glasscock JM, Ramananthan R, Eid GM,

Schauer PR. The impact of laparoscopic bariatric workshops on the practice patterns of surgeons. Surg Endosc. 2006 Jun;20(6):929-33. Epub 2006 May 11.

• Cottam D, Holover S, Mattar SG, Sharma SK, Medlin W, Ramananthan R, Schauer P. The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery. Surg Endosc. 2007 Dec;21(12):2237-9. Epub 2007 Apr 10.

• Gagliardi AR, Wright FC, Victor JC, Brouwers MC, Silver IL. Self-directed learning needs, patterns, and outcomes among general surgeons. J Contin Educ Health Prof. 2009 Fall;29(4):269-75.

• Maillet B, Maisonneuve H. [Long-life learning for medical specialists doctors in Europe: CME, DPC and qualification]. Presse Med. 2011 Apr;40(4 Pt 1):357-65. Epub 2011 Mar 3.