Education of Residents in the Operating Room

Education of Residents in the Operating Room Megan Arnold1 and Lauren Alden1 Hubert K. Huang, Ph.D.1,2 1Division of Education, Lehigh Valley Health Network 2Research Scholar Program Mentor Abstract It is of paramount importance that the technical skills of surgical residents is evaluated. There are obstacles in the operating room setting, however, that interfere with teaching, such as limited time because of efficiency and patient safety. Debriefing after the case has been found to increase the educational value of a case. For this study, residents from the obstetrics and gynecology training program were observed performing four types of sentinel cases. The number of questions the resident asked and the number of teaching points the attending surgeon asked intraoperatively were observed and recorded. During a debriefing session following each case, the video footage collected was available for review and playback. Of the 40 cases that were observed throughout the study, sufficient data to analyze the educational value of the case was only collected from 15 of the cases. The overall average learning experience reported from the attending and resident surgeons for all collected cases was 4.5 on a 1 to 5 Likert scale. In conclusion, higher-level residents were found to ask less questions and were given fewer teaching points. SimCapture technology was found to be a useful tool for resident evaluation, and should be implemented into other specialties beyond obstetrics and gynecology. Keywords SimCapture, video capture, obstetrics and gynecology, OPRS, surgery, technical skill, evaluation, assessment Introduction Since the Accreditation Council for Graduate Medical Education (ACGME) created six general competencies to be used to evaluate medical education, the complicated system of assessing the proficiency of residents in the operating room has been based heavily on these competencies in many specialties. Patient care, medical knowledge, and interpersonal skills are among the competencies identified by the ACGME.3 Technical skill, however, is critical in the operating room and must also be evaluated. It is important for surgical residents to be objectively assessed concerning their technical skills during surgery. There are many ways to do so, ranging from direct observation to animal models to virtual simulation of procedures.1 Technical skill can be measured using standard validated scoring tools such as the Operative Performance Rating System (OPRS) and milestone evaluations. Financial pressure to increase productivity can limit the volume of surgeries residents are exposed to during their training period,1 therefore each teaching opportunity in the operating room is highly valuable. Residents must become proficient quickly. Video recording of residents performing surgical procedures is a method that may be utilized to assess technical skills without requiring extra staff members to be present in the operating room to watch the live procedure. The videos could be sent to various blinded faculty members for evaluation, which would increase the objectivity of the assessment.1 SimCapture is a portable, multi-camera system complete with video software that has been purchased by Lehigh Valley Health Network (LVHN). Implementation of this system is intended to enhance the education and feedback surgical residents receive after operative cases.2 The system is capable of connecting to the existing endoscopic towers in the operating rooms to record laparoscopic cases. Specific events that occur during the cases can be referenced during debriefing sessions to show residents areas of strength or weakness in their technical skills. The present study aims to assess whether video-capture technology, specifically the SimCapture system, is an effective evaluative tool for resident surgeons. Performance of the resident is to be evaluated by a proctoring surgeon as well as the resident themselves, using several evaluative tools. The patient as well as the operating surgeons will not be identifiable, as only the video from the endoscopic tower and the hands of the resident surgeon will be videotaped.2 Crowdsourcing is collecting services from a large number of people, generally through an online database.4 This study intends to eventually utilize crowdsourcing to evaluate resident performance of technical skills, in order increase objectivity and efficiency. In a recent study, Crowd Sourced Assessment of Technical Skill (CSATS) was used to rate skills of surgical trainees. Results of the study showed that CSATS is an accurate and fast way to gather technical skills assessments for residents, as inter-rater reliability between surgeons and the crowd was found to be excellent.4 Verbal interactions among resident and attending surgeons can serve to keep the operation flow moving forward, as well as provide teaching opportunities. The operating room is one of the most critical places for the education of residents to occur, despite the limited time that is available for teaching during surgical procedures.5 Educational value can be further increased by the attending and resident surgeons having a short debriefing following the case. Discussing the procedure and revisiting teaching points that were touched on during the operation helps solidify the information and leads to better performance in the future.5 Methods Participants comprised of different surgical residents from the obstetrics and gynecology training program. Attending surgeons in the respective programs were also involved in the study in that they participated in evaluation of the residents and debriefing sessions. All participants are employed by Lehigh Valley Health Network. Participants were selected based on operative schedules during weekdays; only resident surgeons performing five specified sentinel case types were recorded and evaluated. A SimCapture team made up of two summer research scholars oversaw the setup and recording of the selected procedures in the operating room. The SimCapture system, provided by B-Line Medical, was utilized for this project. OPRS and milestone evaluation forms were used by residents and attending physicians to rate the performance of the residents during the surgical procedures. An additional form was created for use by the SimCapture team to keep a record of the number of questions asked by the resident and teaching points given by the attending surgeon during each case. Four case types were evaluated for this study, including cesarean sections, operative hysteroscopy, laparoscopic bilateral tubal ligation, and robotic hysterectomy. A SimCapture team set up the system and cameras in the operating room immediately before or after the patient was brought into the operating room. Parts of the surgery that were performed by the resident surgeon were annotated using the SimCapture software for easy playback. During the procedure, a member of the SimCapture team counted the number of questions the resident surgeon asked and the number of teaching points that were offered by the attending surgeon throughout the procedure. After each case, both the resident surgeon and attending surgeon completed two evaluation forms, the OPRS (specific to the particular procedure) and milestone evaluations. A member of the SimCapture team then mediated a brief, five- to ten-minute discussion between resident and attending regarding the resident’s performance. This conversation allowed a comparison of the resident and attending surgeons’ perceptions of how the case went. Lastly, a short survey was sent electronically to both the resident and attending surgeon about their perception of the educational value of the procedure. Results After the collection of the needed data, the SimCapture team collected 40 cases that had usable material to be sent out to third party experts. Most of the results were coming from cesarean sections because they are simply the most common procedures that the SimCapture team was recording (almost always 3 a day are performed). We did run into some problems in the first couple weeks because of issues with the actual technology, and trial and error occurrences. Problems also occurred when cases were cancelled, pushed back, or the resident was simply not going to be performing any of the surgery. Some of the cases that were recorded could not be used due to HIPPA violations. Therefore, the SimCapture team has less data than was expected, but still enough for outside party members to create a fair assessment. Almost always, the attending surgeon, resident, and staff were receptive to the project overall. The SimCapture team was able to find that residents who are at a higher level generally ask less questions and are also given less teaching points, with the exception of some outliers due to the variety in attending surgeons and residents. Most residents who are their second year asked a lot of questions during the procedure as opposed to a fourth year resident. The debriefing sessions varied in length and quality; some were quick and precise and others were lengthy with a lot of description. Some debriefing sessions did not occur at all because of time or schedule conflicts The results from the outside party members is still to be collected although they have been sent out. The SimCapture team will then compare the results from a third party to the results of the attending evaluation of the same case. Discussion SimCapture technology provides an overall beneficial educational value of the residents’ crucial learning period. With the ability to watch the video at their leisure, and have a formal debriefing session with an attending, residents can become efficiently more competent. After analyzing data, we were able to find that both residents and attending physicians find the overall educational value to be very high, averaging a 4.2 on a 1 to 5 scale. The level of a resident was found to impact the number of teaching points as well as the amount of questions asked in the operating room. Many upper level residents asked fewer questions and received fewer teaching points whereas lower level resident tended to do the opposite. In these cases, the overall educational value was still ranked high, even if there were fewer questions asked and fewer teaching points. It was also found that there was no difference in the overall OPRS evaluation and the overall educational value, meaning that the OPRS is an evaluation tool of quality in which attending surgeons can formally recognize how well a resident is performing. Also, the OPRS provides a means for the resident and attending to sit down and have an open discussion about his or her performance, therefore increasing the education value. Because of this, SimCapture technology is crucial to a resident in training. They themselves can go back and watch the footage during a debriefing session and can assess their strengths and weakness. It would be beneficial to continue using SimCapture technology throughout not only the OB/GYN department but all other departments so that residents can more effectively and efficiently learn during a crucial time in their careers. Acknowledgements We would like to thank everyone who assisted us in our research and clinical observation. Thank you to Joe Patruno, President Elect of Medical Staff at Lehigh Valley Health Network, for his guidance and supervision. We could not have made the progress we did without his enthusiasm and help getting into the operating room. Thank you also to Martin A. Martino, gynecologic oncologist, and Timothy M. Pellini, obstetrics and gynecology, for their patience and assistance in getting this project off the ground. Thank you to our mentor and the Summer Research Scholars program director, Hubert Huang, for providing this opportunity for all of our personal and professional growth. References Moorthy Krishna, Munz Yaron, Sarker Sudip K,Darzi Ara. Objective assessment of technical skills in surgery BMJ 2003; 327 :1032 Patruno JE, Pellini T, Huang H, Cesanek P, Martino M. The use of video-capture technology to optimize the education, evaluate technical performance in residents. Greenberg JA, Irani JL, Greenberg CC, et al. The ACGME competencies in the operating room. Surgery.2007 Aug;142(2):180–4. Holst Daniel, Kowalewski Timothy M., White Lee W., Brand Timothy C., Harper Jonathan D., Sorenson Mathew D., Kirsch Sarah, and Lendvay Thomas S.. Journal of Endourology. May 2015, 29(5): 604-609. doi:10.1089/end.2014.0616. Roberts Nicole, Brenner Michael, Williams Reed, Kim Michael, Dunnington Gary. Capturing the teachable moment: A grounded theory study of verbal teaching interactions in the operating room. Surgery. 2012 May; 151(5):643-50

China, Europe, and the Pandemic Recession: Beijing’s Investments and Transatlantic Security

Given the depth and breadth of the pandemic-induced recession in Europe, private companies in need of capital and governments looking to shed state-owned enterprises may be tempted to sell shares, assets, or outright ownership to investors with liquidity to spare. Of greatest concern is the role that China might play in Europe, building Beijing’s soft power, weakening allied geopolitical solidarity, and potentially reprising the role it played in the 2010s, when its investments in Europe expanded dramatically. More specifically, there is concern over China’s investments in infrastructure and sensitive technologies relevant to American and allied military operations and capabilities. Whether Europe is prepared and able to parry Beijing’s economic statecraft is somewhat unclear, given varied attitudes toward China and the patchwork of investment screening mechanisms across the continent. Regardless, the outcomes will have significant implications for US security and for the Defense Department specifically. In support of US European Command (EUCOM) and the Department of Homeland Security (DHS), the U.S. Army War College’s Strategic Studies Institute (SSI) assembled an interdisciplinary team to examine these issues and offer actionable policy recommendations for military leaders and decisionmakers on both sides of the Atlantic. Study sponsors (nonfunding): United States European Command, United States Department of Homeland Securityhttps://press.armywarcollege.edu/monographs/1945/thumbnail.jp

Rare Copy Number Variants in \u3cem\u3eNRXN1\u3c/em\u3e and \u3cem\u3eCNTN6\u3c/em\u3e Increase Risk for Tourette Syndrome

Tourette syndrome (TS) is a model neuropsychiatric disorder thought to arise from abnormal development and/or maintenance of cortico-striato-thalamo-cortical circuits. TS is highly heritable, but its underlying genetic causes are still elusive, and no genome-wide significant loci have been discovered to date. We analyzed a European ancestry sample of 2,434 TS cases and 4,093 ancestry-matched controls for rare (\u3c 1% frequency) copy-number variants (CNVs) using SNP microarray data. We observed an enrichment of global CNV burden that was prominent for large (\u3e 1 Mb), singleton events (OR = 2.28, 95% CI [1.39–3.79], p = 1.2 × 10−3) and known, pathogenic CNVs (OR = 3.03 [1.85–5.07], p = 1.5 × 10−5). We also identified two individual, genome-wide significant loci, each conferring a substantial increase in TS risk (NRXN1 deletions, OR = 20.3, 95% CI [2.6–156.2]; CNTN6 duplications, OR = 10.1, 95% CI [2.3–45.4]). Approximately 1% of TS cases carry one of these CNVs, indicating that rare structural variation contributes significantly to the genetic architecture of TS

Wind-Induced Vibration Energy Harvesting Using Piezoelectric Transducers Coupled with Dynamic Magnification

Flexible cylindrical structures subjected to wind loading experience vibrations from periodic shedding of vortices in their wake. Vibrations become excessive when the natural frequencies of the cylinder coincide with the vortex shedding frequency. In this study, cylinder vibrations are transmitted to a beam inside the structure via dynamic magnifier system. This system amplifies the strain experienced by piezoelectric patches bonded to the beam to maximize the conversion from vibrational energy into electrical energy. Realworld applicability is tested using a wind tunnel to create vortex shedding and comparing the results to finite element modeling that shows the structural vibrational modes. A crucial part of this study is conditioning and storing the harvested energy, focusing on theoretical modeling, design parameter optimization, and experimental validation. The developed system is helpful in designing wind-induced energy harvesters to meet the necessity for novel energy resources

Cognitive and Physical Demands of Activities of Daily Living In Older Adults: Validation of Expert Panel Ratings: The SAGES Functional Measures Working Group

Background: Difficulties with performance of functional activities may result from cognitive and/or physical impairments. To date, there has not been a clear delineation of the physical and cognitive demands of activities of daily living. Objectives: To quantify the relative physical and cognitive demands required to complete typical functional activities in older adults. Design: Expert panel survey. Setting: Web-based platform. Participants: Eleven experts from eight academic medical centers and 300 community dwelling elderly adults age 70 and older scheduled for elective non-cardiac surgery from two academic medical centers. Methods: Sum scores of expert ratings were calculated and then validated against objective data collected from a prospective longitudinal study. Main Outcome Measurements Correlation between expert ratings and objective neuropsychological tests (memory, language, complex attention) and physical measures (gait speed and grip strength) for performance-based tasks. Results: Managing money, self-administering medications, using the telephone, and preparing meals were rated as requiring significantly more cognitive demand, while walking and transferring, moderately strenuous activities, and climbing stairs were assessed as more physically demanding. Largely cognitive activities correlated with objective neuropsychological performance (r=0.13–0.23, p<.05) and largely physical activities correlated with physical performance (r=0.15–0.46, p<.05). Conclusions: Quantifying the degree of cognitive and/or physical demand for completing a specific task adds an additional dimension to standard measures of functional assessment. This additional information may significantly influence decisions about rehabilitation, post-acute care needs, treatment plans, and caregiver education

Evaluation of individual and ensemble probabilistic forecasts of COVID-19 mortality in the United States

Short-term probabilistic forecasts of the trajectory of the COVID-19 pandemic in the United States have served as a visible and important communication channel between the scientific modeling community and both the general public and decision-makers. Forecasting models provide specific, quantitative, and evaluable predictions that inform short-term decisions such as healthcare staffing needs, school closures, and allocation of medical supplies. Starting in April 2020, the US COVID-19 Forecast Hub (https://covid19forecasthub.org/) collected, disseminated, and synthesized tens of millions of specific predictions from more than 90 different academic, industry, and independent research groups. A multimodel ensemble forecast that combined predictions from dozens of groups every week provided the most consistently accurate probabilistic forecasts of incident deaths due to COVID-19 at the state and national level from April 2020 through October 2021. The performance of 27 individual models that submitted complete forecasts of COVID-19 deaths consistently throughout this year showed high variability in forecast skill across time, geospatial units, and forecast horizons. Two-thirds of the models evaluated showed better accuracy than a naïve baseline model. Forecast accuracy degraded as models made predictions further into the future, with probabilistic error at a 20-wk horizon three to five times larger than when predicting at a 1-wk horizon. This project underscores the role that collaboration and active coordination between governmental public-health agencies, academic modeling teams, and industry partners can play in developing modern modeling capabilities to support local, state, and federal response to outbreaks

The United States COVID-19 Forecast Hub dataset

Academic researchers, government agencies, industry groups, and individuals have produced forecasts at an unprecedented scale during the COVID-19 pandemic. To leverage these forecasts, the United States Centers for Disease Control and Prevention (CDC) partnered with an academic research lab at the University of Massachusetts Amherst to create the US COVID-19 Forecast Hub. Launched in April 2020, the Forecast Hub is a dataset with point and probabilistic forecasts of incident cases, incident hospitalizations, incident deaths, and cumulative deaths due to COVID-19 at county, state, and national, levels in the United States. Included forecasts represent a variety of modeling approaches, data sources, and assumptions regarding the spread of COVID-19. The goal of this dataset is to establish a standardized and comparable set of short-term forecasts from modeling teams. These data can be used to develop ensemble models, communicate forecasts to the public, create visualizations, compare models, and inform policies regarding COVID-19 mitigation. These open-source data are available via download from GitHub, through an online API, and through R packages

Analysis of shared heritability in common disorders of the brain

ience, this issue p. eaap8757 Structured Abstract INTRODUCTION Brain disorders may exhibit shared symptoms and substantial epidemiological comorbidity, inciting debate about their etiologic overlap. However, detailed study of phenotypes with different ages of onset, severity, and presentation poses a considerable challenge. Recently developed heritability methods allow us to accurately measure correlation of genome-wide common variant risk between two phenotypes from pools of different individuals and assess how connected they, or at least their genetic risks, are on the genomic level. We used genome-wide association data for 265,218 patients and 784,643 control participants, as well as 17 phenotypes from a total of 1,191,588 individuals, to quantify the degree of overlap for genetic risk factors of 25 common brain disorders. RATIONALE Over the past century, the classification of brain disorders has evolved to reflect the medical and scientific communities' assessments of the presumed root causes of clinical phenomena such as behavioral change, loss of motor function, or alterations of consciousness. Directly observable phenomena (such as the presence of emboli, protein tangles, or unusual electrical activity patterns) generally define and separate neurological disorders from psychiatric disorders. Understanding the genetic underpinnings and categorical distinctions for brain disorders and related phenotypes may inform the search for their biological mechanisms. RESULTS Common variant risk for psychiatric disorders was shown to correlate significantly, especially among attention deficit hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder (MDD), and schizophrenia. By contrast, neurological disorders appear more distinct from one another and from the psychiatric disorders, except for migraine, which was significantly correlated to ADHD, MDD, and Tourette syndrome. We demonstrate that, in the general population, the personality trait neuroticism is significantly correlated with almost every psychiatric disorder and migraine. We also identify significant genetic sharing between disorders and early life cognitive measures (e.g., years of education and college attainment) in the general population, demonstrating positive correlation with several psychiatric disorders (e.g., anorexia nervosa and bipolar disorder) and negative correlation with several neurological phenotypes (e.g., Alzheimer's disease and ischemic stroke), even though the latter are considered to result from specific processes that occur later in life. Extensive simulations were also performed to inform how statistical power, diagnostic misclassification, and phenotypic heterogeneity influence genetic correlations. CONCLUSION The high degree of genetic correlation among many of the psychiatric disorders adds further evidence that their current clinical boundaries do not reflect distinct underlying pathogenic processes, at least on the genetic level. This suggests a deeply interconnected nature for psychiatric disorders, in contrast to neurological disorders, and underscores the need to refine psychiatric diagnostics. Genetically informed analyses may provide important "scaffolding" to support such restructuring of psychiatric nosology, which likely requires incorporating many levels of information. By contrast, we find limited evidence for widespread common genetic risk sharing among neurological disorders or across neurological and psychiatric disorders. We show that both psychiatric and neurological disorders have robust correlations with cognitive and personality measures. Further study is needed to evaluate whether overlapping genetic contributions to psychiatric pathology may influence treatment choices. Ultimately, such developments may pave the way toward reduced heterogeneity and improved diagnosis and treatment of psychiatric disorders

The Science Performance of JWST as Characterized in Commissioning

This paper characterizes the actual science performance of the James Webb Space Telescope (JWST), as determined from the six month commissioning period. We summarize the performance of the spacecraft, telescope, science instruments, and ground system, with an emphasis on differences from pre-launch expectations. Commissioning has made clear that JWST is fully capable of achieving the discoveries for which it was built. Moreover, almost across the board, the science performance of JWST is better than expected; in most cases, JWST will go deeper faster than expected. The telescope and instrument suite have demonstrated the sensitivity, stability, image quality, and spectral range that are necessary to transform our understanding of the cosmos through observations spanning from near-earth asteroids to the most distant galaxies.Comment: 5th version as accepted to PASP; 31 pages, 18 figures; https://iopscience.iop.org/article/10.1088/1538-3873/acb29

Genomic Relationships, Novel Loci, and Pleiotropic Mechanisms across Eight Psychiatric Disorders

Genetic influences on psychiatric disorders transcend diagnostic boundaries, suggesting substantial pleiotropy of contributing loci. However, the nature and mechanisms of these pleiotropic effects remain unclear. We performed analyses of 232,964 cases and 494,162 controls from genome-wide studies of anorexia nervosa, attention-deficit/hyper-activity disorder, autism spectrum disorder, bipolar disorder, major depression, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome. Genetic correlation analyses revealed a meaningful structure within the eight disorders, identifying three groups of inter-related disorders. Meta-analysis across these eight disorders detected 109 loci associated with at least two psychiatric disorders, including 23 loci with pleiotropic effects on four or more disorders and 11 loci with antagonistic effects on multiple disorders. The pleiotropic loci are located within genes that show heightened expression in the brain throughout the lifespan, beginning prenatally in the second trimester, and play prominent roles in neurodevelopmental processes. These findings have important implications for psychiatric nosology, drug development, and risk prediction.Peer reviewe