Skills coaches as part of the Skills coaches as part of the educational team: educational team:

A randomized controlled trialA randomized controlled trial

Michael J. Kim1, Margaret L. Boehler2, Janet K. Ketchum2, Reuben Bueno, Jr. 2, Reed G. Williams2, Gary L. Dunnington2

Departments of Surgery1University of Rochester

2Southern Illinois University

Riding a wave of simulation

Literature on surgical skills Literature on surgical skills training/assessmenttraining/assessment

2008 RRC requirement2008 RRC requirementFLSFLSACS/APDS CurriculumACS/APDS CurriculumWho’s teaching?Who’s teaching?

What’s currently available?Survey of GS Program Directors (n=162)Survey of GS Program Directors (n=162)

72% have supervision72% have supervision 79% staff are attending physicians 79% staff are attending physicians

Korndorffer, Stefanidis, and Scott – 2006Korndorffer, Stefanidis, and Scott – 2006

Survey of established skills labs (n=34)Survey of established skills labs (n=34) Instructors:Instructors:

• 100% Physicians100% Physicians• 42% Residents42% Residents• 35% Lab Staff35% Lab Staff

65% Difficult to find instructors65% Difficult to find instructorsKapadia, DaRosa, MacRae and Dunnington - 2007Kapadia, DaRosa, MacRae and Dunnington - 2007

Barriers to implementationCostCostCurriculum developmentCurriculum development

Finding Instructors!Finding Instructors! Clinical demands on facultyClinical demands on faculty M.D. needed to teach?M.D. needed to teach?

Non-physicians & physicians-in-training

SP as InstructorsSP as Instructors Trained by physicianTrained by physician Exam techniques and teaching skillsExam techniques and teaching skills

SP vs. MD trained students SP vs. MD trained students ≥ ≥ Physician trainedPhysician trained Lasting differencesLasting differences Less intimidationLess intimidation Frees faculty for other teachingFrees faculty for other teaching

Behrens et al - 1979, Gerber et al - Behrens et al - 1979, Gerber et al - 19851985

Current studyCompare teachers: Compare teachers:

Skills coach vs. faculty surgeonSkills coach vs. faculty surgeon

Teaching basic surgical skill Teaching basic surgical skill Subcuticular SuturingSubcuticular Suturing No complex technical or cognitive tasksNo complex technical or cognitive tasks

One method of suturingOne method of suturing

MethodsSelected excellent teaching surgeonSelected excellent teaching surgeon

Clinical expertiseClinical expertise Superb teacherSuperb teacher

Selected excellent skills coachSelected excellent skills coach Years of O.R. experienceYears of O.R. experience Experience with learners in O.R.Experience with learners in O.R. Laboratory directorLaboratory director

Trained the coachTrained the coach Technique, theory, teaching methodsTechnique, theory, teaching methods

Methods

Subjects:Subjects: MS3 and MS4MS3 and MS4 Surgical clerkship/Resident ReadinessSurgical clerkship/Resident Readiness

Consent and randomized Consent and randomized Skills Coach vs. SurgeonSkills Coach vs. Surgeon

Survey of baseline experienceSurvey of baseline experienceTraining on foam modelTraining on foam modelObservers during instructionObservers during instruction

Third Year Students

MS3

Surgeon

Skills Coach

Teaching (1 Hour)

Teaching (1 Hour)

Practice (1 Hour)

Practice (1 Hour)

Testing Retention(6 Weeks)

Fourth Year Students

MS4Pre-

testing

Surgeon

Skills Coach

Training (1 Hour)

Training (1 Hour)

Practice (1 Hour)

Practice (1 Hour)

Testing

MethodsVideo suturing performanceVideo suturing performance

Same modelSame model Gowns/glovesGowns/gloves

Blinded video reviewBlinded video review4 Faculty Surgeons4 Faculty Surgeons

Rating items: Process and ProductSquare knots at both ends

150% or less of the

time

2 375% of the time

4 5100% of the time

Places appropriate depth sutures

150% or less of the

time

2 375% of the time

4 5100% of the time

Uses appropriate tension

150% or less of the

time

2 375% of the time

4 5100% of the time

Avoids penetration of the epidermis

150% or less of the

time

2 375% of the time

4 5100% of the time

Enters each suture directly across from the previous exit

150% or less of the

time

2 375% of the time

4 5100% of the time

Avoids leaving large gaping areas of skin

150% or less of the

time

2 375% of the time

4 5100% of the time

Visual Anchors:““Enters each suture directly across from the previous exit”Enters each suture directly across from the previous exit”

Baseline Experience Survey

0

20

40

60

80

100

Coach Surgeon

3rd Year Students

N = 14 N = 14

0

20

40

60

80

100

Coach Surgeon

4th Year Students

MinModMax

N = 10

N = 10

Mean Performance by Training Group

ResultsSample size needed? Sample size needed?

Mean difference = 1.0 pointMean difference = 1.0 point

Power = 0.99 Power = 0.99 → → N = 25N = 25 Post-test group adequatePost-test group adequate Ability to detect difference 99x/100Ability to detect difference 99x/100

– α = 0.05α = 0.05– Mean Sample Variance = 0.77Mean Sample Variance = 0.77

150% or less of the

time

2 375% of the time

4 5100% of the time

ResultsQualitative ObservationsQualitative Observations

Surgeon:Surgeon:• Started with lecture: tissue layers, suture types, etc. → Started with lecture: tissue layers, suture types, etc. →

DemonstrationDemonstration• Competing factors:Competing factors:

– Pager, Clinic, etc.Pager, Clinic, etc.

• Brought residents Brought residents

Skills Coach:Skills Coach:• Started with demonstration Started with demonstration • Incorporated discussion during practiceIncorporated discussion during practice• No competing tasksNo competing tasks

LimitationsNot a novice coachNot a novice coach

– Teaching and OR skillsTeaching and OR skills

– Understood studentsUnderstood students

– Already established reputationAlready established reputation

Single skill trainedSingle skill trained– One way of doing thingsOne way of doing things

No Transfer No Transfer – Only tested Only tested in vitroin vitro

Need more study of retentionNeed more study of retention– Limited sample sizeLimited sample size

ConclusionsA trained surgical skills coach is capable of A trained surgical skills coach is capable of

teaching a basic surgical skill.teaching a basic surgical skill.

Skills coaches can concentrate on teaching Skills coaches can concentrate on teaching with fewer conflicts.with fewer conflicts.

Skills coaches may have increased role on Skills coaches may have increased role on educational team.educational team.

Thank youThank youSIUSIUJennifer Bartlett Jennifer Bartlett

Dr. Andreas Meier Dr. Andreas Meier

Heather Rogers Heather Rogers

Dr. Hilary Sanfey Dr. Hilary Sanfey

Cathy Schwind Cathy Schwind

Dr. Leslie Smith Dr. Leslie Smith

Dr. Jared WallDr. Jared Wall

U of RochesterDr. Jacob MoalemDr. Jacob Moalem

Dr. Mary Santos Dr. Mary Santos

Dr. Michael SinghDr. Michael Singh

Questions/DiscussionQuestions/Discussion