Keywords
plastic surgery - training - patient safety - free flap
Introduction
Plastic surgery is an ever-evolving branch and so is surgical training. With the day-to-day
advancement in surgical nuances, more emphasis is being given to patient safety. There
are various avenues for surgical training namely training on animals, cadavers, ex
vivo tissues, mannequins, computer simulators, and virtual simulators,[1] but none of these can measure up to real-time clinical training. Studies have shown
that a successful outcome depends 75% on decision making and 25% on surgical skills.[2] Only bedside clinics and real-time learning in operation suites can train a surgeon
in decision making. However, in most plastic surgical training systems, where trainees
learn skills in the operating theaters, training is provided at the expense of longer
operating times and greater potential for misadventure because of the relative inexperience
of the trainee.[3] We devised a three-phase approach of preoperative preparatory talk (PPT) to prevent
these mishaps ([Table 1]). The PPT is two-way communication between the senior surgeon and the surgical trainee.
Table 1
Phases of preoperative preparatory talk
|
|
Learning domains addressed
|
|
Phase 1
|
In outpatient at the time of admission
|
Cognitive and affective
|
|
Phase 2
|
On preoperative day
|
cognitive
|
|
Phase 3
|
On the day of surgery
|
Cognitive and psychomotor
|
Methodology
Between July 1, 2019 to December 31, 2021, the free flap surgeries performed in our
tertiary care center were divided into study group and control group depending upon
whether our teaching model was followed or not. Mean operative time of surgeries in
the two groups was calculated and compared. We also analyzed the time taken in various
steps of the free flap surgery and compared these times between the two groups of
surgeries. These steps included planning and harvesting of the flap, preparation of
recipient site including vessel dissection, division of partial inset of flap before
anastomosis, and anastomosis and flap inset completion. The performance of residents
in each surgery was marked on Objective Structured Assessment of Technical Skill (OSATS)
global rating scale and their mean OSATS score for the two sets of surgeries was compared
and statistically analyzed using unpaired t-test. OSATS score involves scoring the resident's performance on seven parameters
on a scale ranging from 1 to 5.[4]
Our teaching method PPT involves three phases of discussions between surgical preceptor
and resident surgeon. PPT phase 1 takes place when the patient presents to the OPD.
Here, the senior surgeon instructs the resident surgeon to get the required investigations
done, to arrange the reports of previously done radiological investigations, and,
if required, to take opinions from other specialties.
Phase 2 of the PPT takes place the next day during ward rounds where the senior surgeon
informs the trainee on various aspects of surgical planning. The trainee is informed
about the part preparation of the patient, arrangement of sutures, instruments and
implants required for the surgery, and salient points to be communicated to the patient
as part of the operative consent. After discussing the operative steps in detail,
the resident is encouraged to discuss the radiological films with colleagues from
radiology to develop an understanding of the radiological anatomy and to relay it
to the senior surgeon. The senior surgeon also suggests important resources to be
read by the resident before coming to the surgery.
Phase 3 of PPT takes place on the day of surgery inside the operative suite. Here,
the resident has to show his preparation for the surgery by presenting the plan in
the form of Microsoft Powerpoint slide ([Fig. 1]) or a whiteboard/flipchart diagram similar to the whiteboard talks mentioned by
Demirseren et al.[5] Senior surgeon assesses the preparation of the resident when the resident is presenting
his plan ([Fig. 2]).
Fig. 1 Digital preoperative preparatory talk slide.
Fig. 2 Trainee presenting the slide to the senior surgeon in the operation suite.
Patients were allotted into two groups depending upon the availability of senior surgeon
and resident surgeon for the three phases of PPT and whether the resident surgeon
has prepared the presentation properly. For the study group, the senior surgeon was
available for both the days prior to the surgery and all three phases of PPT took
place. Cases for which any phase of PPT could not be done due to unavailability of
the senior surgeon or trainee surgeon were placed in control group. It is to be noted
that the resident prepared for the surgeries in the control group on their own without
involvement of the surgical preceptor.
Results
Out of the 63 free flap surgeries that we performed during the course of our study,
37 cases were put in the control group and 26 cases were put in study group. Mean
operative time of entire surgery and for various stages of free flap surgeries in
two groups was compared and statistically analyzed using unpaired t-test. In study group, mean operative time for entire surgery was 376 minutes, while
it was 443 minutes in control group (p-value < 0.05). Effect size for the unpaired t-test is −2.05.Mean time taken for flap planning and harvest was 149 minutes in study
group and 193 minutes in control group (p-value < 0.05). Mean time taken for recipient vessel dissection and recipient site
preparation was 77 minutes in study group and 93 minutes in control group (p-value <0.05). Mean time taken for division and partial inset of flap was 49 minutes
in study group and 53 minutes in control group (p-value < 0.05). Mean time taken in anastomosis and flap inset completion was 101 minutes
in study group and 104 minutes in control group (p-value = 0.53).
Mean OSATS scores of residents were 33.08/35 for study group and 28.08/35 for control
group, and statistically analyzed using unpaired t-test and the difference was found to be significant (p-value < 0.05)([Table 2]).
Discussion
A proper surgical training requires improvement in all three domains of learning,
namely cognitive, psychomotor, and affective.[6] While most residents join the residency program with a focus on psychomotor domain
of training, it is necessary for the training director to ensure that residents are
finally equipped in all three domains before passing out from the program. Multiple
studies have focused on improving outcomes in each of the domains separately. However,
an ideal surgical teaching and training program should consider a global improvement
in all the domains for the trainee. In addition, consideration is to be placed toward
the comfort, ethicality, and outcomes for the patient. Permitting a surgical trainee
to assist a senior surgeon without acquiring adequate surgical competency of the procedure
is a drain on resources as it can increase the operation theater time by as much as
40%.[7] Studies have shown that each minute of operative theater time costs US$ 9.57, and
that is excluding the cost of increased anesthesia.[8] Also, it fails to inculcate the habit of discipline that is an important trait of
a surgeon. Studies have shown that surgical knowledge can be best acquired by dealing
with an actual patient, and surgical skill by operating on a patient and affective
skills are best developed by communicating with the patient. Data are scarce on the
best way to improve efficiency of a surgical trainee in a real environment. By introducing
this stepwise training system of PPT, we hope to help the residents approach surgical
patient care in a focused manner. The first phase helps to orient the resident toward
preoperative workup of a surgical patient. This phase can start on the day of admission
or even when the patient first comes for an OPD consultation. Here, the resident develops
the affective skills of communicating with the patient counselling about the treatment
options and outcomes of surgery. The resident also builds up on the knowledge of the
disease condition itself, investigations relevant to reach a diagnosis, and the pathology
itself. The second phase of PPT happens post-admission and prior to the actual day
of operation. Here, the resident is instructed to examine the patient, plan treatment,
and present in form of a case presentation. The senior surgeon then assesses the understanding
of the resident, discusses the relevant investigation findings and operative plan,
thereby building up the cognitive domain of the resident. Phase 3 of the PPT starts
on the day of surgery when the resident is advised to come prepared with the information
of the patient, surgery to be done, and steps of surgery to be performed. The resident
presents his plan to the senior surgeon and additional inputs may be given by the
latter. This phase aims to evaluate the psychomotor domain of surgical learning. It
becomes easier for the resident to follow the chief surgeon when they come prepared
with the steps of surgery and relevant anatomy beforehand thus facilitating the conduct
of actual procedure when needed.
After following PPT, all the stages of a free flap surgery took significantly shorter
time to finish except microvascular anastomosis ([Fig. 3]).
Fig. 3 Chart comparing mean operative times between various stages of free flaps with and
without applying preoperative preparatory talk (PPT).
This can be attributed to the fact that a surgeon's comfort and coordination with
their first assistance determines the ease and pace at which a microvascular anastomosis
is performed. This step was not influenced by the PPT training method as much as the
other steps of the surgery.
We found that all the senior residents showed a significant improvement in their knowledge
of instruments, use of assistants, flow of operation and forward planning, and knowledge
of specific procedure after following PPT. There was no significant improvement with
respect to instrument handling, time and motion, and respect for tissue. This shows
that three rounds of PPT will improve the resident's knowledge of the steps of the
specific procedure and the instruments involved in that surgery that will in turn
improve the flow of operation and use of assistants, while the other parameters pertaining
to basic surgical skill like respect for tissue, time, and motion and instrument handling
will only improve with time and increased hands-on experience.
The three phase PPT is an elegant method to improve surgical training irrespective
of the subspeciality as it decreases operative time by better orientation of the assisting
trainee surgeon toward various nuances of the particular surgery.
Conclusion
The authors have tried to devise a training method that stimulates all three domains
of learning as proposed in Blooms's taxonomy. We found that diligent following of
this method leads to better orientation of the resident toward the operative procedure
and thereby results in better time management. It also ensures better patient safety
as the resident is well-versed with preoperative workup required for the patients.
The presence of these three checkpoints before the trainee scrubs ensures that all
the safety parameters are ensured. We recommend the three rounds of PPT to be incorporated
in all plastic surgery training programs and may be adopted in other surgical branches
as well.
Table 2
Comparison of durations of steps of free flap surgery and performance of residents
with and without following PPT
|
Parameter
|
Time taken (in minutes)/ OSATS score (out of 35) in study group
|
Time taken (in minutes)/OSATS score (out of 35) in control group
|
p-Value in unpaired t-test
|
|
Flap planning and harvest
|
149
|
193
|
<0.05
|
|
Recipient vessel dissection and recipient site preparation
|
77
|
93
|
<0.05
|
|
Division and partial flap inset
|
49
|
53
|
<0.05
|
|
Microvascular anastomosis and inset completion
|
101
|
104
|
0.53
|
|
Total operative time
|
376
|
443
|
<0.05
|
|
OSATS score (out of 35)
|
33.08
|
28.08
|
<0.05
|
Abbreviations: OSATS, Objective Structured Assessment of Technical Skill; PPT, preoperative
preparatory talk.
