Video-Based Coaching: An Efficient Learning and Teaching Modality for Pediatric Surgery and Pediatric Urology Training Program.

Coppola V ，Autorino G ，Cerulo M ，Conte FD ，Ricci E ，Borgogni R ，Cardone R ，Escolino M ，Esposito C ... -  《-》

E-learning teaches attendings "how to" objectively assess pediatric urology trainees' surgery skills for orchiopexy.

Established methods to train pediatric urology surgery by residency training programs require updating in response to administrative changes such as new, reduced trainee duty hours. Therefore, new objective methods must be developed to teach trainees. We approached this need by creating e-learning to teach attendings objective assessment of trainee skills using the Zwisch scale, an established assessment tool. The aim of this study was to identify whether or not e-learning is an appropriate platform for effective teaching of this assessment tool, by assessing inter-rater correlation of assessments made by the attendings after participation in the e-learning. Pediatric orchiopexy was used as the index case. An e-learning tool was created to teach attending surgeons objective assessment of trainees' surgical skills. First, e-learning content was created which showed the assessment method videotape of resident surgery done in the operating room. Next, attendings were enrolled to e-learn this method. Finally, the ability of enrollees to assess resident surgery skill performance was tested. Namely, test video was made showing a trainee performing inguinal orchiopexy. All enrollees viewed the same online videos. Assessments of surgical skills (Zwisch scale) were entered into an online survey. Data were analyzed by intercorrelation coefficient kappa analysis (strong correlation was ICC ≥ 0.7). A total of 11 attendings were enrolled. All accessed the online learning and then made assessments of surgical skills trainees showed on videotapes. The e-learning comprised three modules: 1. "Core concepts," in which users learned the assessment tool methods; 2. "Learn to assess," in which users learned how to assess by watching video clips, explaining the assessment method; and 3. "Test," in which users tested their skill at making assessments by watching video clips and then actively inputting their ratings of surgical and global skills as viewed in the video clips (Figure). A total of 89 surgical skill ratings were performed with 56 (65%) exact matches between raters and 89 (100%) matched within one rank. Interclass correlation coefficient (ANOVA) showed statistically significant correlation. (r = 0.725, 95% CI 0.571-0.837, F = 3.976, p ≤ 0.00001). Kappa analysis of inter-rater reliability showed strong consensus between attendings for average measures with ICC = 0.71, 95% CI 0.46-0.95 (p = 0.03). We launched e-learning to teach pediatric urology attendings "how to" assess trainee surgical skills objectively (Zwisch scale). After e-learning, there was strong inter-rater correlation in assessments made. We plan to extend such e-learning to pediatric urology surgical training programs.

Fernandez N ，Maizels M ，Farhat W ，Smith E ，Liu D ，Chua M ，Bhanji Y ... -  《-》

Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre.

Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.

Schroeder RP ，Chrzan RJ ，Klijn AJ ，Kuijper CF ，Dik P ，de Jong TP ... -  《-》

Milestone assessment of minimally invasive surgery in Pediatric Urology fellowship programs.

Minimally invasive surgery has become an important aspect of Pediatric Urology fellowship training. In 2014, the Accreditation Council for Graduate Medical Education published the Pediatric Urology Milestone Project as a metric of fellow proficiency in multiple facets of training, including laparoscopic/robotic procedures. The present study assessed trends in minimally invasive surgery training and utilization of the Milestones among recent Pediatric Urology fellows. Using an electronic survey instrument, Pediatric Urology fellowship program directors and fellows who completed their clinical year in 2015 were surveyed. Participants were queried regarding familiarity with the Milestone Project, utilization of the Milestones, robotic/laparoscopic case volume and training experience, and perceived competency with robotic/laparoscopic surgery at the start and end of the fellowship clinical year according to Milestone criteria. Responses were accepted between August and November 2015. Surveys were distributed via e-mail to 35 fellows and 30 program directors. Sixteen fellows (46%) and 14 (47%) program directors responded. All fellows reported some robotic experience prior to fellowship, and 69% performed >50 robotic/laparoscopic surgeries during residency. Fellow robotic/laparoscopic case volume varied: three had 1-10 cases (19%), four had 11-20 cases (25%), and nine had >20 cases (56%). Supplementary or robotic training modalities included simulation (9), animal models (6), surgical videos (7), and courses (2). Comparison of beginning and end of fellowship robotic/laparoscopic Milestone assessment (Summary Fig.) revealed scores of <3 in (10) 62% of fellow self-assessments and 10 (75%) of program director assessments. End of training Milestone scores >4 were seen in 12 (75%) of fellow self-assessment and eight (57%) of program director assessments. An improvement in robotic/laparoscopic Milestone scores by both fellow self-assessment and program director assessment was observed during the course of training; however, 43% of program directors rated their fellow below the graduation target of a Milestone score of 4. The best ways to teach minimally invasive surgery in fellowship training must be critically considered.

Smith PH 3rd ，Carpenter M ，Herbst KW ，Kim C ... -  《-》

A Novel Expert Coaching Model in Urology, Aimed at Accelerating the Learning Curve in Robotic Prostatectomy.

The surgical residency model assumes that upon completion, a surgeon is ready to practice and grow independently. However, many surgeons fail to improve after reaching proficiency, which in certain instances has correlated with worse clinical outcomes. Coaching addresses this problem and furthers surgeons' education post-residency. Currently, surgical coaching programs focus on medical students and residents, and have been shown to improve residents' and medical students' technical and non-technical abilities. Coaching programs also increase the accuracy of residents, fellows, and attendings in self-assessing their surgical ability. Despite the potential benefits, coaching remains underutilized and poorly studied. We developed an expert-led, face-to-face, video-based surgical coaching program at a tertiary medical center among specialized attending surgeons. Our goal was to evaluate the feasibility of such a program, measure surgeons' attitudes towards internal peer coaching, determine whether surgeons found the sessions valuable and educational, and to subjectively self-assess changes in operative technique. Surgeons who perform robot-assisted laparoscopic prostatectomies were chosen and grouped by number of cases completed: junior (<100 cases), intermediate (100-500 cases), and senior (>500 cases). Surgeons were scheduled for 3 1-hour coaching sessions 1-2 months apart (February-October 2019), meeting individually with the coach (PS), an expert Urologic Oncologist with thousands of cases of experience performing radical prostatectomy. He received training on coaching methodology prior to beginning the coaching program. Before each session, surgeons selected 1 of their recent intraoperative videos to review. During sessions, the coach led discussion on topics chosen by the surgeon (i.e. neurovascular bundle dissection, apical dissection, bladder neck); together, they developed goals to achieve before the next session. Subsequent sessions included presentation and discussion of a case occurring subsequent to the prior session. Sessions were coded by discussion topics and analyzed based on level of experience. Surgeons completed a survey evaluating the experience. All 6 surgeons completed 3 sessions. Five surgeons completed the survey; most respondents evaluated themselves as having improved in desired areas and feeling more confident performing the discussed steps of the operation. Discussed surgical principles varied by experience group; when subjectively quantifying the difficulty of surgical steps, the more difficult steps were discussed by the higher experience groups compared to the junior surgeons. The senior surgeons also focused more on oncologic potency, continence outcomes, and more theory-driven questions while the junior surgeons tended to focus more on anatomic and technique-based questions such as tissue handling and the use of cautery and clips. Overall, the surgeons thought this program provoked critical discussion and subsequently modified their technique, and "agreed" or "strongly agreed" that they would seek further sessions. Surgical coaching at a large medical center is not only feasible but was rated positively by surgeons across all levels of experience. Coaching led to subjective self-improvement and increased self-confidence among most surgeons. Surgeons also felt that this program offered a safe space to acquire new skills and think critically after finishing residency/fellowship. Themes discussed and takeaways from the sessions varied based on surgeon experience level. While further research is needed to more objectively quantify the impact coaching has on surgeon metrics and patient outcomes, the results of this study supports the initial "proof-of-concept" of peer-based surgical coaching and its potential benefits in accelerating the learning curve for surgeons' post-residency.

Fainberg J ，Vanden Berg RNW ，Chesnut G ，Coleman JA ，Donahue T ，Ehdaie B ，Goh AC ，Laudone VP ，Lee T ，Pyon J ，Scardino PT ，Smith RC ... -  《-》