The RoboCOS Study : Development of an international core outcome set for the comprehensive evaluation of patient, surgeon, organisational and population level impacts of robotic assisted surgery

ACKNOWLEDGEMENTS We would like to thank sincerely all those who contributed to the interviews, the focus group, the Delphi survey and the consensus meeting, and Paul Manson (Health Services Research Unit, University of Aberdeen) for helping to retrieve full text copies of reports identified by the literature search. We also thank HSRU (Health Services Research Unit) at University of Aberdeen for providing support for this work. Funding: The study was funded from NHS Grampian Endowment Fund and the University of Aberdeen. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2023 Robertson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Peer reviewedPublisher PD

Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey.

Aims: The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation. Methods: The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK. Results: Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes. Conclusion: There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision

Spite and the scale of competition in Pseudomonas aeruginosa

This work was funded by the European Research Council and the Leverhulme Trust (A.B.), the Natural Environment Research Council (R.F.I. and A.B.), and Balliol College and the Royal Society (A.G.).Scale of competition has been shown to be an important factor in shaping the evolution of social interactions. Although many theoretical and experimental studies have examined its effect on altruistic cooperation, relatively little research effort has been focused on spiteful behaviors-actions that harm both the actor and the recipient. In this study, we expand on existing theory by investigating the importance of the global frequency of spiteful alleles, and we determine experimentally how the scale of competition affects selection for spite in the bacterial pathogen Pseudomonas aeruginosa under high and intermediate spatial relatedness. Consistent with our theoretical results, we found in our experiments that spiteful genotypes are more favored under local (rather than global) competition and intermediate (rather than high) spatial relatedness, conditions that have been shown to select against indiscriminate altruism.Publisher PDFPeer reviewe

Improving simulation training in orthopaedics

The way surgical trainees acquire technical skills is changing in modern surgical training programmes: simulation is proposed as a key part of those changes. Arthroscopy is a surgical technique that is increasing in both incidence and technical complexity; where simulation is becoming common, but evidence is limited. Real-world performance improvements can be measured following simulation training in other fields, but equivalent measures of intra-operative performance are inadequate. Thus, although surgical simulation is popular and improves simulated performance, there is little objective evidence that it improves intra-operative performance. The original contribution of this thesis is to objectively demonstrate the transfer of simulation training into improved intra-operative technical skills. To achieve this, a systematic literature review investigated the quantitative metrics currently used to measure arthroscopic performance, identifying wireless motion analysis as a potential method to assess performance intra-operatively. Motion analysis is a recognised objective method to measure surgical activity which correlates with surgical experience, so wireless motion analysis was validated against a wired motion analysis method commonly used in simulation but not feasible for intra-operative use. Wireless motion analysis metrics were further validated with a simulated arthroscopy list: this environment allowed deliberate practice of arthroscopic sub-skills with proximate feedback for independent practice. This simulated arthroscopy list with wireless motion analysis was used in two randomised studies: the penultimate study of this thesis investigated the impact of simulated practice on the arthroscopic learning curve and showed that performance improved rapidly with independent practice but was not modified by feedback, while the final study investigated additional simulation practice during early surgical training, and objectively demonstrated that additional simulation training improved intra-operative performance compared to traditional training alone. This thesis is the first to objectively show that simulation affects intra-operative behaviour. It sets the groundwork for further investigations into efficient, cost-effective simulation and the impact of simulation training on patient outcomes.</p

Improving simulation training in orthopaedics

The way surgical trainees acquire technical skills is changing in modern surgical training programmes: simulation is proposed as a key part of those changes. Arthroscopy is a surgical technique that is increasing in both incidence and technical complexity; where simulation is becoming common, but evidence is limited. Real-world performance improvements can be measured following simulation training in other fields, but equivalent measures of intra-operative performance are inadequate. Thus, although surgical simulation is popular and improves simulated performance, there is little objective evidence that it improves intra-operative performance. The original contribution of this thesis is to objectively demonstrate the transfer of simulation training into improved intra-operative technical skills. To achieve this, a systematic literature review investigated the quantitative metrics currently used to measure arthroscopic performance, identifying wireless motion analysis as a potential method to assess performance intra-operatively. Motion analysis is a recognised objective method to measure surgical activity which correlates with surgical experience, so wireless motion analysis was validated against a wired motion analysis method commonly used in simulation but not feasible for intra-operative use. Wireless motion analysis metrics were further validated with a simulated arthroscopy list: this environment allowed deliberate practice of arthroscopic sub-skills with proximate feedback for independent practice. This simulated arthroscopy list with wireless motion analysis was used in two randomised studies: the penultimate study of this thesis investigated the impact of simulated practice on the arthroscopic learning curve and showed that performance improved rapidly with independent practice but was not modified by feedback, while the final study investigated additional simulation practice during early surgical training, and objectively demonstrated that additional simulation training improved intra-operative performance compared to traditional training alone. This thesis is the first to objectively show that simulation affects intra-operative behaviour. It sets the groundwork for further investigations into efficient, cost-effective simulation and the impact of simulation training on patient outcomes.</p

Key performance and training parameters in primary total hip arthroplasty – an expert consensus using the Delphi technique

Aims: Primary total hip arthroplasty (THA) is a commonly performed and successful operation which orthopaedic trainees must demonstrate competence in prior to completion of surgical training. An assessment of agreement between surgical trainers regarding the critical steps of a primary THA has never been undertaken. The aim of this study was to define and rank the key steps of a primary THA regards ease of teaching and their importance in achieving the best patient outcome. Materials and methods: The Delphi technique with 3 iterative rounds was used to establish expert group consensus. The benchmark for consensus was set at an 80% agreement in any category for each step of a THR. The intra-class correlation coefficient (ICC) was used to report on the inter- and intra-rater reliabilities between and within participants responses respectively in rounds 2 and 3. Results: 50 consultant orthopaedic hip surgeons completed round 2, and 28 completed round 3. Overall, 27 steps (54 parameters) were identified, with 16 parameters achieving consensus agreement for their impact on patient outcome, and 17 for ease of teaching. The inter-rater ICC for patient outcome parameters was 0.89 and 0.92 in rounds 2 and 3 respectively while for teaching parameters it was 0.82 and 0.73. 50% of surgeons agreed that acetabular reaming, assessing and accurately restoring leg length, and acetabular cup anteversion were the 3 most difficult steps to teach trainees, while 90% agreed these 3 steps were substantially important to patient outcome. Another 5 steps achieved consensus for their substantial impact on patient outcome but failed to achieve consensus for ease of teaching. Conclusions: The results of this expert consensus have produced a rank-order list of the key steps in primary THA, which may be used for orthopaedic curriculum development and guiding focused improvements for surgical training in primary THR including simulation

Spite and the scale of competition in Pseudomonas aeruginosa

Scale of competition has been shown to be an important factor in shaping the evolution of social interactions. Although many theoretical and experimental studies have examined its effect on altruistic cooperation, relatively little research effort has been focused on spiteful behaviors-actions that harm both the actor and the recipient. In this study, we expand on existing theory by investigating the importance of the global frequency of spiteful alleles, and we determine experimentally how the scale of competition affects selection for spite in the bacterial pathogen Pseudomonas aeruginosa under high and intermediate spatial relatedness. Consistent with our theoretical results, we found in our experiments that spiteful genotypes are more favored under local (rather than global) competition and intermediate (rather than high) spatial relatedness, conditions that have been shown to select against indiscriminate altruism.</p

What is known about the attributes of a successful surgical trainer? A systematic review

Background Surgical training has been subject to significant upheaval in recent years with an increasingly rigorous assessment regimen for trainees. The assessment of surgical trainers is less well evolved by comparison. Recent proposals from the Royal College of Surgeons of England recommend “professionalising the trainers.” However, they do not suggest any accepted or validated methods of trainer assessment, nor do they indicate how these might be implemented and monitored in a real-world training program to determine their effect on trainee outcomes. Aim To determine what is known about the attributes of successful surgical trainers. Methods We conducted a systematic review of the scientific literature using the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines of the Medline database using specific search criteria. The qualitative analysis involved grouping trainer attributes together into “themes” within 4 “super-themes.” Each theme needed to be mentioned by a minimum of 5 studies. Results After review of the full study texts a total of 14 studies met the inclusion criteria. Thirteen studies involved the views of trainees, whereas only 1 study solely assessed the views of trainers. There was a wide variety of study designs and types of participants. The attribute themes are listed in brackets after each super-theme: “character” (approachability, patience, enthusiasm, encouraging/supportiveness), “procedural” (willingness to let trainee operate, balance between supervision and independence), “teamwork and communication” (sets educational aims and objectives, ability to use appropriate feedback, communication skills, and time availability to train) and “clinical” (capable, good relationships with patients, and the health care team). Conclusions This detailed review describes several perceived important themes for the positive attributes of surgical trainers. The identification of these key attributes is only of value if their presence is confirmed by effective and feasible evaluation, and if the possession of such attributes in trainers is proven to have a positive effect on training. In times of reduced training opportunities, exploring the topics raised by this review through future education research is warranted

Development of a surgical trainer assessment questionnaire.

Background The assessment of surgical trainees has become well-established in practice; however, this is not yet the case for surgical trainers. The aim of this study was to develop a trainer assessment questionnaire (OxTrAQ) based on the 12 key trainer attributes identified by a previous systematic review, to then explore this questionnaire’s potential domains and test its reliability. Methods The OxTrAQ was piloted at two surgical training centres in two surgical subspecialities. At each centre, every trainee assessed every trainer while under their clinical supervision. Results Internal consistency (Cronbach’s alpha) was calculated for this 12-item questionnaire as 0.958. Factor analysis revealed two domains which accounted for 77.997% of the variance; these were the general domain (nine items) and the independence domain (three items). Inter-observer reliability was shown by the intraclass correlation coefficients (ICCs) (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.951, 0.945 and 0.955 for centre 1 and 0.857, 0.819 and 0.883 for centre 2, respectively. Intra-observer reliability was shown by the ICCs (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.925, 0.913 and 0.940, respectively. Construct validity was demonstrated by a high correlation (Spearman rho = 0.886, P = 0.019) between trainer scores and the scores predicted by the trainers themselves. Conclusions The OxTrAQ is a simple trainer assessment questionnaire which has demonstrated both high inter- and intra-observer reliability.</p

What is known about the attributes of a successful surgical trainer? A systematic review

Background Surgical training has been subject to significant upheaval in recent years with an increasingly rigorous assessment regimen for trainees. The assessment of surgical trainers is less well evolved by comparison. Recent proposals from the Royal College of Surgeons of England recommend “professionalising the trainers.” However, they do not suggest any accepted or validated methods of trainer assessment, nor do they indicate how these might be implemented and monitored in a real-world training program to determine their effect on trainee outcomes. Aim To determine what is known about the attributes of successful surgical trainers. Methods We conducted a systematic review of the scientific literature using the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines of the Medline database using specific search criteria. The qualitative analysis involved grouping trainer attributes together into “themes” within 4 “super-themes.” Each theme needed to be mentioned by a minimum of 5 studies. Results After review of the full study texts a total of 14 studies met the inclusion criteria. Thirteen studies involved the views of trainees, whereas only 1 study solely assessed the views of trainers. There was a wide variety of study designs and types of participants. The attribute themes are listed in brackets after each super-theme: “character” (approachability, patience, enthusiasm, encouraging/supportiveness), “procedural” (willingness to let trainee operate, balance between supervision and independence), “teamwork and communication” (sets educational aims and objectives, ability to use appropriate feedback, communication skills, and time availability to train) and “clinical” (capable, good relationships with patients, and the health care team). Conclusions This detailed review describes several perceived important themes for the positive attributes of surgical trainers. The identification of these key attributes is only of value if their presence is confirmed by effective and feasible evaluation, and if the possession of such attributes in trainers is proven to have a positive effect on training. In times of reduced training opportunities, exploring the topics raised by this review through future education research is warranted