Do Surgical Residents Need Boot Camp

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Do Surgical Residents Need Boot Camp?

• Darra D. Kingsley, MD
• Associate Program Director
• ddkingsley_at_salud.unm.edu
• Department of Surgery
• University of New Mexico School of Medicine
• B.A.T.C.A.V.E.

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UNM Boot Camp 2007 (Kingsley 2007)

• Introduction
• Previous efforts (e.g. see-one, do-one,
  teach-one)
• Benefits to the learner, faculty and program
• Application of competencies
• Medical student to resident transition (to safe
  provider)

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UNM Boot Camp 2007 (Kingsley 2007)

• Introduction
• Medical student to resident transition (to safe
  provider)
• Accelerated skills acquisition
• On-call scenarios
• Observation of assumed medical knowledge and
  patient care activities (formative assessment,
  recognition and correction of misconceptions)

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UNM Boot Camp 2007 (Kingsley 2007)

• Introduction
• Medical student to resident transition (to safe
  provider)
• Initial portfolio creation
• Diversity of teaching methods (learner
  engagement, re-enforcement of objectives)

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UNM Boot Camp 2007 (Kingsley 2007)

• Methods
• Eleven 10-hour days
• 7 interns participated (two international medical
  graduates) during their 1st month of residency
• Tuesdays/Fridays/Saturday spent with primary team
• Objectives based on those created by the ACS
  Committee on Resident Education
• Faculty base
• Assessment activities (diversity of tools)
• Themes (on-call tasks)

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• American College of Surgeons Graduate Medical
  Education Committee. Pre-requisite objectives
  for graduate surgical education A study of the
  Graduate Medical Education Committee American
  College of Surgeons. J Am Coll Surg 186 50.
  1998.
• Ganzel, TM, Curet, MJ, Kaiser, S, et al., eds.
  Successfully navigating the first year of
  surgical residency Essentials for medical
  students and PGY-1 residents. Chicago, IL
  American College of Surgeons. 2005.

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• SUCCESSFULLY NAVIGATING THE FIRST YEAR OF
  SURGICAL RESIDENCY
• Essentials for Medical Students And PGY-1
  Residents
• CONTENTS PAGE
• Foreword..2
• Essentials for Entering PGY1..3
• Medical Knowledge Patient Care..3
• Professionalism...7
• Interpersonal Communication Skills..8
• Practice-Based Learning Improvement...8
  
• Systems-Based Practice...8
• Essentials for Completing PGY-1....10
• Medical Knowledge Patient Care10
• Professionalism.16
• Interpersonal Communication Skills..17
  
• Practice-Based Learning Improvement..17
  
• Systems-Based Practice..18

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Medical Knowledge/Patient CareClinical
Assessment and Preoperative Management

• Effectively and efficiently perform a history and
  physical examination that is appropriate for
  age, sex, and clinical problem
• Identify factors that increase preoperative risk
• Diseases Conditions
• Cardiac Extremes of age
• Psychiatric Pregnancy
• Endocrine Immune suppression
• Pulmonary Substance abuse
• Hepatic Metabolic disorders
• Renal
• Infectious
• Develop appropriate differential diagnoses and
  management plans
• Write daily inpatient notes in an appropriate
  format, noting progress and changes in health
  status

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UNM Boot Camp 2007 (Kingsley 2007)

• Faculty
• Lorena Beeman (RN Educator),
• Dr. Mike Bryan (PGY-5, Administrative Chief),
• Dr. Jennifer Chan (PGY-5),
• Lisa Cody (Surgery Coder),
• Dr. Aric Coffman (Surgery Faculty),
• Della Daniels (OR Nurse Educator),
• Luke Esquibel (BATCAVE),
• Doug Gadomski (BATCAVE),
• Rose Gonzales (St. Vincent's),
• David Hananel (METI),
• Dr. Hasson (OB/GYN),
• Kay Lusk (Surgery Coder),
• Dr. Teresita McCarty (Office of Assessment),

• Joseph Morales (Respiratory Therapy),
• Marie Parks (Office of Assessment),
• Peggy Plumb (CNOR),
• Carla Prando (UNM Legal Counsel),
• Deana Richter (Teacher and Educational
  Development),
• Dr. Anne Simpson (I Med/Ethics),
• Dr. Jose Sterling (PGY-5),
• Dr. William Syme (Surgery Faculty),
• Dr. Caesar Ursic (Surgery Faculty),
• Dr. Anthony Vigil (Surgery Faculty),
• Dr. Libby Watch (Surgery Faculty)

Special acknowledgement to Dr. Maria Terry and
David Hananel for project Development.
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UNM Boot Camp 2007 (Kingsley 2007)

• Curriculum acknowledgments
• The Virtual Patient A Self-directed Study Guide
  in Surgery Ed. Rebekah Naylor, MD (University of
  Texas Southwestern Medical Center at Dallas)
  2006.
• Scott DJ, Goova MT, Tesfay ST. A cost-effective
  proficiency-based knot-tying and suturing
  curriculum for residency programs. J Surg Res
  141(1)7-15. 2007.
• McCarty, T, et al. Improved patient notes from
  medical students during web-based teaching using
  faculty-calibrated peer review and
  self-assessment. Acad Med 80(10 Suppl)S67-70.
  2005.

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UNM Boot Camp 2007 (Kingsley 2007)
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Teaching Methods (Kingsley 2007)

• Small group discussion (SG)
• The Virtual Patient case-based (VP)
• Human patient simulator (HPS)
• Surgical skills lab (SSL)
• Laparoscopic simulators, central line models,
  ventilator mechanics, chest tube model, OR
  introduction, UT Southwestern Knot Tying
  curriculum
• Systems-based learning (SBL)
• Lecture (L)

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UNM Boot Camp 2007 (Kingsley 2007)
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UNM Boot Camp 2007 (Kingsley 2007)
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Medical Knowledge Patient Care
(Completing)Identify the physical findings of
abnormal intravascular volumeMedical Knowledge
Patient Care (Entering)Discuss the primary
survey of the trauma patient, including the
ABCsControl bleeding from external
woundsInterpret standard (12-lead) telemetry
electrocardiogram and identify common
abnormalitiesObtain Advanced Cardiovascular Life
support certification, including Assessing the
adequacy of the airway Obtaining oropharyngeal
control of the airway and providing bag/mask
ventilation (simulated) Performing orotracheal
intubation (simulated)Medical Knowledge
Patient Care (Completing)Perform minor surgical
procedures under supervision e.g., Skin suture
using simple, subcutaneous, and mattress sutures
as well as staplesRemove sutures and staples
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Medical Knowledge Patient Care
(Entering)Practice universal precautions
routinely Assess the presence of peripheral
blood flow using handheld Doppler
instrumentsScrub, gown, and glove
properlyMaintain appropriate sterile technique
in the Clinic Emergency department Intensive
care unit Operating room Patients roomUse
proper techniques for skin preparation and
draping of the incision siteUnderstand
potential complications of the above procedures
as they relate to patient safety
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Systems-based Practice
(Entering)Describe the principles of patient
safety and patient safety practices, such as
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) patient safety standards
e.g., Improving the accuracy of patient
identification Improving the effectiveness of
communication among caregiversImproving the
safety of using high-alert medicationsEliminating
wrong-site, wrong patient, wrong-procedure
surgeryUsing a time-out in operative procedures
Interpersonal and Communication Skills
(Entering)Convey key information accurately to
the transition team assuming care
Practice-Based Learning and Improvement
(Entering)Use electronically available medical
information in patient care
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Medical Knowledge Patient Care
(Entering)Discuss the primary survey of the
trauma patient, including the ABCsControl
bleeding from external woundsInterpret standard
(12-lead) telemetry electrocardiogram and
identify common abnormalitiesObtain Advanced
Cardiovascular Life support certification,
includingAssessing the adequacy of the
airwayObtaining oropharyngeal control of the
airway and providing bag/mask ventilation
(simulated)Performing orotracheal intubation
(simulated)Calculate and interpret Acid/base
balance Anion gap Arterial blood gasesDescribe
the findings and appropriate treatment of
Airway compromise Pericardial
Tamponade Tension pneumothorax
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Medical Knowledge Patient Care
(Entering)Write concise clinic encounter notes
in an appropriate format -Write daily inpatient
notes in an appropriate format, noting progress
and changes in health status-Maintain medical
records in a legible, legally appropriate
professional manner Interpersonal and
Communication Skills (Entering)Convey key
information accurately to the transition team
assuming care Practice-Based Learning and
Improvement (Entering)Use electronically
available medical information in patient
Administer a local anesthetic Describe the
estimation of total body surface area burn in
thermal injuryDescribe initial fluid
resuscitation in thermal injuryProfessionalism
(Entering)Maintain an inquisitive mind and
lifelong learning habitsDemonstrate an awareness
of ones own limitationsDemonstrate
self-directed learning skills
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Practice-Based Learning and
Improvement (Entering)Use electronically
available medical information in patient
careMedical Knowledge Patient Care
(Entering)Interpret standard (12-lead) telemetry
electrocardiogram and identify common
abnormalitiesObtain Advanced Cardiovascular Life
support certification, includingAssessing the
adequacy of the airwayObtaining oropharyngeal
control of the airway and providing bag/mask
ventilation (simulated)Performing orotracheal
intubation (simulated)Describe the estimation of
total body surface area burn in thermal
injuryDescribe initial fluid resuscitation in
thermal injuryProfessionalism
(Entering)Describe the principles of informed
consentDescribe the basic principles of medical
ethicsBeneficencePatient autonomy
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UNM Boot Camp 2007 -- Objectives
(abbreviated)Interpersonal and Communication
Skills (Entering)Convey key information
accurately to the transition team assuming care
Practice-Based Learning and Improvement
(Entering)Use electronically available medical
information in patient careMedical Knowledge
Patient Care (Entering)Calculate routine
maintenance fluid requirements appropriate for
age and clinical problem, and write orders for
themWrite orders for appropriate monitoring and
calculate intake and outputDiscuss prevention of
deep vein thrombosis (DVT) and pulmonary
embolismDiscuss basic pharmacology of common
drugs Analgesics Antibiotics Gastric
acid-reducing SedativesUse electronically
available medical information in patient care
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UNM Boot Camp 2007 (Kingsley 2007)

• Results
• Pre- and post-testing
• Pre- and post-survey
• Faculty and resident participation
• Statistical analysis (comparison of means)

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UNM Boot Camp 2007 (Kingsley 2007)

• ASSESSMENT TOOLS
• Initial Intern Survey
• Pretest on Gastrointestinal Bleeding
• Self-Proficiency Rating on Gastrointestinal
  Bleeding
• Pretest on Knot Tying and Suturing-Initial Exit
• Self-Proficiency Rating on Knot Tying and
  Suturing-Initial Exit
• Self-Proficiency Rating on Operating Room-Initial
  Exit
• July 2nd Feedback Sheet
• July 2nd Reflective Writing
• Progress Notes
• How People LearnImplications for Interns Work
  Book
• July 11th Feedback Sheet
• Calibrated Peer Review calculations
• Pre-test and Post-test on Inguinal Hernia Anatomy
• History and Physicals

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UNM Boot Camp 2007 (Kingsley 2007)

• HOMEWORK during time with primary team
• Call Task Check-in check-out
• Call Task Writing inpatient and outpatient
  SOAP notes
• Call Task Writing History and Physicals
• Call Task Writing History and Physicals and
  Informed Consent
• Call Task History and Physicals Admission
  Orders
• Call Task Informed Consent Teaching
  Activities
• Call Task Feedback and Assessment

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UNM Boot Camp 2007 (Kingsley 2007)

• Observations and Discussion
• Learner differences
• Varied skill and knowledge base (deficient
  overall)
• Poor insight
• Curriculum fluidity
• Need for repetition to acquire basic
  skills/concepts
• Need for instruction in clinical skills sets
  presumed to be basic knowledge

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UNM Boot Camp 2007 (Kingsley 2007)

• Discussion
• Benefits to the learner, faculty and program
• Future direction
• Dedicated month as medical student (ACS
  Accredited Centers)

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UNM Boot Camp 2007 (Kingsley 2007)

• Discussion
• Other
• Objectives that required re-enforcement of
  concept Baseline knowledge
• Focus objective-based learning during routine
  service-based activities
• System-based learning