Corner Stich: Bridging knowledge gaps and meeting new demands of vascular surgical training

Christopher Audu and Scot Stanulis

This month in Corner Stitch, we highlight a trainee-centric study presented at the 2023 Midwestern Vascular Surgical Society (MVSS) annual meeting held in Minneapolis, Minnesota (Sept. 7–9). With the rise of Entrustable Professional Activities (EPAs) and the diminishing number of open aortic cases being performed across the country, this study from the group at Southern Illinois University provides an idea of how we may begin bridging these knowledge gaps and meeting the new educational demands coming to surgical training. For this, Christopher Audu, MD, interviews vascular surgery resident Scot Stanulis, MD, who presented his work on “Video-based self-assessment is an effective method of open surgical education for vascular surgery trainees.”

CA: In your study, your group evaluated open surgical skills using cadavers. Can you share the origin story for this idea? What prompted a cadaveric simulation study?

SS: An important topic in vascular surgery education at the moment, with the advent of integrated residencies and as the proportion of endovascular procedures increases, is that our residents may be exposed to fewer open vascular cases in their training. We wanted to start looking at solutions to this problem, and as we already have a great relationship with our surgical simulation lab, we thought this would be a natural start. The surgical literature, particularly in general surgery, shows promise for integrating more simulation into resident education, and we wanted to see if we could step it up a notch by including complete operations from skin-to-skin, and to see if video recordings, along with faculty and self-assessment, could increase the educational value.

CA: Bravo on taking on a really cool project to meet the need for open skills. How did you go about procuring permission from your anatomy department for this simulation? Is this something any residency can do to improve their resident/fellow open skills?

SS: Luckily, we already have a great relationship with our anatomy department, and many surgical subspecialties at our institution use the surgical simulation lab for cadaveric-based education. For standardization purposes, we needed to request cadavers that had not already underwent dissection in the operative field for a carotid endarterectomy (CEA), and we needed to ensure we could set up a live video-feed with overhead cameras. We were able to work with our simulation lab faculty to solve these pretty quickly. If a residency program does not already have access to cadavers, this would be a bigger obstacle to overcome; however, cadaveric education is an important part of robust simulation education, even outside of our project, and we would recommend any program strive to include some form of cadaveric education in their curriculum.

CA: In the paper you presented, you focused on carotid endarterectomies. What were the areas that the juniors improved in the most? Needle handling? Draping? Steps of the procedure?

SS: For our first exploration in video-based simulation, we chose CEAs for a few reasons: it is a procedure that all our residents had some exposure to; it has well-established, replicable steps, which aids in standardization; and it encompasses a broad range of vascular surgical skills.

In our experience with CEA, we found that the junior residents improved the most in the initial parts of the procedure, including draping and positioning, incision, and initial dissection and exposure. Additionally, there were some specific steps; for example, the PGY1 was able to clamp in the correct order the second time around; and the PGY2 improved at identifying each nerve during dissection. Our senior residents nearly aced our evaluation forms from the first attempt, so there was not much room for improvement—meaning we need to challenge them with more stringent evaluation criteria or a more difficult operation.

CA: That makes sense. What was your observed correlation between areas identified by the resident and those identified by the faculty? Can you infer anything about how a resident is able to assess their own growth?

SS: Residents and faculty were generally congruent on objective measures like “clamping order,” but for subjective measures like “overall proficiency” or even “proper nerve exposure,” we found more of a difference. We did see some improvement in resident self-assessment ability across sessions, but at this point it is clear that a junior resident will need faculty feedback to properly assess their operative performance, at least until they further develop their skill of self-assessment.

CA: That is very interesting. Did the improved residents notice greater autonomy in the operating room (OR) for carotid cases?

SS: At our program, our residents do already get a fair bit of autonomy, and it is hard to say how much that improved from this one experience, particularly as our experience was blinded and the faculty did not get to see an individual resident’s improvement to then grant more autonomy. However, residents did say that they felt more confident and prepared going into their next CEA, and we do believe that this preparation can make it so residents get more out of their real cases once they have overcome some of the learning process in simulation.

CA: I see. So, one unintended benefit of this is improving resident/trainee confidence, which then translates into OR proficiency. How do you envision the platform being used for other vascular cases? Did your faculty find this a helpful exercise in their assessment of residents?

SS: I think the real benefit for this type of experience is augmenting surgical education in operations that our residents will see less often. Providing residents with confidence and foundational skills in open abdominal cases will be invaluable as we see a trend of residents reporting fewer of these cases in the endovascular era.

Faculty did report that it was useful to see the general weak points of residents so they could better direct teaching in the OR, but our experience was set up more for resident learning, and we did not assess if faculty improved at teaching or assessment.

CA: Right on. I suppose faculty evaluation of their teaching can be a future project. What open vascular operation are you going to do next?

SS: The next operation we will evaluate will be an open abdominal aortic aneurysm (AAA) repair. We chose this because we want to challenge our senior residents more, and see if this model holds up with a more complex operation. Challenges include keeping a larger operative field in the camera view, creating reasonable standardized evaluation forms, and increased time requirements in the simulation lab. If this model works for both a CEA and an open AAA, I don’t see many reasons that would prevent it from being used for a multitude of other open vascular surgery cases.

CHRISTOPHER AUDU is the Vascular Specialist resident/fellow editor. He is a resident at the University of Michigan in Ann Arbor, Michigan.


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