Publications

Introduction and hypothesis

Surgeon kinematics play a significant role in the prevention of patient injury. We hypothesized that elbow extension and ulnar wrist deviation are associated with bladder injury during simulated midurethral sling (MUS) procedures.

Methods

We used motion capture technology to measure surgeons’ flexion/extension, abduction/adduction, and internal/external rotation angular time series for shoulder, elbow, and wrist joints. Starting and ending angles, minimum and maximum angles, and range of motion (ROM) were extracted from each time series. We created anatomical multibody models and applied linear mixed modeling to compare kinematics between trials with versus without bladder penetration and attending versus resident surgeons. A total of 32 trials would provide 90% power to detect a difference.

Results

Out of 85 passes, 62 were posterior to the suprapubic bone and 20 penetrated the bladder. Trials with versus without bladder penetration were associated with more initial wrist dorsiflexion (−27.32 vs −9.03°, p = 0.01), less final elbow flexion (39.49 vs 60.81, p = 0.03), and greater ROM in both the wrist (27.48 vs 14.01, p = 0.02), and elbow (20.45 vs 12.87, p = 0.04). Wrist deviation and arm pronation were not associated with bladder penetration. Compared with attendings, residents had more ROM in elbow flexion (14.61 vs 8.35°, p < 0.01), but less ROM in wrist dorsiflexion (13.31 vs 20.33, p = 0.02) and arm pronation (4.75 vs 38.46, p < 0.01).

Conclusions

Bladder penetration during MUS is associated with wrist dorsiflexion and elbow flexion but not internal wrist deviation and arm supination. Attending surgeons exerted control with the wrist and forearm, surgical trainees with the elbow. Our findings have direct implications for MUS teaching.

Keywords: Biomedical engineering; Kinematics; Midurethral sling; Motion capture; Patient safety; Surgical education; Surgical simulation.

Objective: 

In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction.

Design: 

We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR.

Setting: 

Midwestern academic university teaching hospital.

Participants: 

Six attending and 6 resident surgeons.

Results: 

Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech.

Conclusions: 

Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.

Keywords: communication; linguistics; semantics; surgery; surgical education.

Highlights

• This is the first study applying linguistic inquiry and word count to intraoperative spoken language.

• Attending surgeons spoke more words and used more language of clout.

• Residents used more informal speech with an emotional tone and assent.

• There were no meaningful differences in language use according to gender.

Objective

Previous work has analyzed residency letters of recommendation for agentic and communal language, but this has not been applied to spoken language. Our objective was to analyze intraoperative spoken language by attending and resident surgeons for the use of agentic and communal language.

Design

We completed a linguistic inquiry and word count (LIWC) analysis on 16 operating room transcripts (total time 615 minutes) between attendings and resident surgeons for categories associated with agentic and communal speech. Wilcoxon signed rank and Mann-Whitney U tests were used to compare attending versus resident and male versus female speech patterns for word count; “I,” clout, and power (agentic categories); and “we,” authentic, social (communal categories).

Setting

Midwestern academic university teaching hospital.

Participants

Sixteen male (9 attendings, 7 residents) and 16 female (7 attendings, 9 residents) surgeons, from 6 surgical specialties, most commonly from General Surgery.

Results

Attending surgeons used more words per minute than residents (40.01 vs 16.92, p < 0.01), were less likely to use “I” (3.18 vs 5.53, p < 0.01), and spoke more language of “clout” (75.82 vs 55.47, p < 0.01). There were no significant differences between attendings and residents in use of analytic speech (23.72 vs 24.67, p = 0.32), “causation” (1.20 vs 1.08, p = 0.72), or “cognitive processing” (10.20 vs 10.54, p = 0.74). Residents used more speech with “emotional tone” (92.91 vs 79.92, p = 0.03), “positive emotion” (4.98 vs 3.86, p = 0.04), more “assent” language (4.89 vs 3.09, p < 0.01), and more “informal” language (9.27 vs 6.77, p < 0.01). There were no gender differences, except for male residents speaking with greater certainty than female residents, although by less than 1% of the total word count.

Conclusions

In the operating room, attending surgeons were more likely to use agentic language compared to resident surgeons based on LIWC analysis. These differences did not depend on gender and likely relate to surgeon experience and confidence, learning versus teaching, and power dynamics.

Key words

communication, surgery, surgical education, gender, language

Importance: 

Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications.

Objective: 

The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP).

Study design: 

We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8.

Results: 

Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years.

Conclusion: 

Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

Introduction: 

Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events.

Methods:

 In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.

Results: 

The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC¹ was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete.

Conclusions: 

Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

Keywords: Anesthesia; Communication; Interprofessional teamwork; OR nursing staff; Surgery; Surgical error.

Background

Instructions form a vital part of OR communication, yet ambiguous language is common. This study compares attending and resident understanding of ambiguous intraoperative instructions using concepts from formal semantics.

Methods

We filmed attending and resident surgeons during intraoperative critical moments, the portion most crucial for safe, effective surgery. We transcribed all communication and with a semanticist, analyzed transcripts for instructions that could be interpreted ambiguously, while simultaneously viewing case video for context. We distinguished explicit instruction from implicit instruction as delivered only by implicature. Afterward, we interviewed the surgeons independently about their interpretation of each implicit instruction. We compared their answers, noted misunderstanding, and conducted thematic analysis to explore what makes instruction semantically clear versus misunderstood.

Results

The team recorded 169 min of critical moments from 6 cases, involving 6 attending and 8 resident surgeons, and interviewed 12 surgeons. We identified 334 instructions, 79.9% from the attendings and 20.1% from residents: 113 (33.8%) were explicit and 267 (66.2%) implicit. 7% of potential ambiguities provoked misunderstanding, including one not recovered. Attending and resident understanding of implicit instruction was context-dependent, involving high degrees of tacit knowledge. Some instructions allowed the resident to practice decision-making. Many implicit instructions involved highly varied ways to instruct someone to begin a motion, prepare to stop, or stop. Many were constructed with polite formulas.

Conclusion

The majority of instruction to residents is implicitly stated or contains lexical ambiguities, yet is well-understood. Future research should examine the impact of misunderstood instruction on resident educational and patient safety.

Keywords Communication· Surgery· Surgical education· Linguistics· Semantics

Purpose

Our objective was to understand the cognitive strategies used by surgeons to mentally visualize navigation of a surgical instrument through blind space.

Methods

We conducted semi-structured interviews with 15 expert and novice surgeons following simulated retropubic trocar passage on 3D-printed models of pelvises segmented from preop MRIs. Midurethral sling surgery involves blind passage of a trocar among the urethra, bladder, iliac vessels, and bowel while relying primarily on haptic feedback from the suprapubic bone (SPB) for guidance. Our conceptual foundation was based on Lahav’s study on blind people's mental mapping of spaces using haptic cues. Participants detailed how they mentally pictured the trocar’s location relative to vital anatomy. We coded all responses and used constant comparative analysis to generate themes, confirmed with member checking.

Results

Expert and novice participants utilized multiple cognitive strategies combined with haptic feedback to accomplish safe trocar passage. Some used a step-by-step route strategy, visualizing sequential 2D axial images of anatomy adjacent to the SPB. Others used a map strategy, forming global 3D pictures. Although these mental pictures vanished when they were “lost,” a safe zone could be reestablished by touching the SPB. Experts were more likely to relate their body position to the trocar path and rely on minor variations in resistance. Novices were more inclined toward backtracking of the trocar.

Conclusions

Our findings may be extended to any blind surgical procedure. Teaching visualization strategies and incorporating tactile feedback can be used intraoperatively to help learners navigate their instrument safely around vital organs.

Keywords: Cognitive strategies; Midurethral sling; Patient safety; Qualitative methodology; Surgical education; Surgical simulation.

INTRODUCTION AND HYPOTHESIS:

Retropubic midurethral sling surgery involves the blind passage of trocars near vital organs. We quantified the proximity of surgeons mental representation of trocar position relative to actual position using a pelvis simulation platform. We hypothesized that novice surgeons, compared with experts, would estimate the trocar s location to be further from the actual location.

METHODS:

Novice and expert surgeons performed bilateral retropubic trocar passes of a Gynecare TVT trocar (#810041B-#810,051) on the simulation platform. We measured the trocar tip's position using a motion capture system, and recorded vocalizations when they perceived contacting the bone and crossing three landmark-oriented planes. We calculated differences (∆(Bone), ∆(Turn), ∆(Top), ∆(Pop)) between vocalization times and when the trocar crossed the corresponding plane. We performed Mann-Whitney and Chi-squared tests to investigate differences between novices and experts and Levene's test to assess equality of variances for subject-level variation.

RESULTS:

A total of 34 trials, including 22 expert and 12 novice trials, were performed by six participants. ∆(Bone) was significantly smaller among novice surgeons (1.27 vs 2.81 s, p=0.013). There were no significant differences in the remaining three deltas or in vocalizing early versus late. Levene's test revealed no significant differences in within-subject variability for any of the four deltas. Novices passed the trocar anterior to the pubic bone on three passes.

CONCLUSIONS:

Novices were similar to expert surgeons in their estimation of the trocar s location and may have relied more heavily on anticipatory mechanisms to compensate for lack of experience. Teaching surgeons should make sure the novice surgeon trocar pass starts posterior to the bone.

Keywords: Biomedical engineering; Midurethral sling; Patient safety; Surgical education; Surgical simulation.

Background

According to tacit knowledge theory, checklists and textbooks cannot convey important aspects of non-routine Mask Ventilation (MV) learned experientially. Our objective was to elicit tacit knowledge underlying experienced MV performance to support novice anesthesia providers’ MV execution by identifying targets for clinical coaching.

Methods

We employed the Critical Decision Method to elicit experienced anesthesia providers’ tacit knowledge during non-routine MV. Using semi-structured interviews guided by a general anesthesia (GA) induction checklist and conducted using equipment used in GA induction, we probed participants’ experiences. A cognitive map was produced depicting critical MV decisions and associated environmental cues. We validated the map via member check and comparison against GA checklists, textbooks and novice MV knowledge.

Results

Experience is necessary to skillfully interpret environmental cues signaling changing conditions in non-routine MV. Our cognitive map featured 34 critical decisions and 23 environmental (visual, tactile, auditory, and olfactory) cues. Validation identified 45 (16 preoperative, 29 intraoperative) items not found in the GA induction checklist, 15 not presented in textbooks, and 16 not identified by novices.

Identifying tacit knowledge may provide a novel way to guide novice anesthesia learners’ experiential learning. Highlighting the environmental cues could guide hands on learning, accelerating time to competency.

Keywords: Anesthesia education, cognitive task analysis, Critical Decision Method (CDM),induction of general anesthesia, mask ventilation

BACKGROUND:

The objective of this study was to identify intraoperative instructional strategies that embody the ways that learning occurs in the social contexts of surgery.

METHODS:

We performed a qualitative review of examples of intraoperative teaching from transcripts of ten videotaped surgeries, coupled with interviews with surgical attendings and residents. We coded the examples according to the key tenets of sociocultural learning theories and used these codes to develop instructional strategies aimed at improving resident surgical autonomy.

RESULTS:

The sociocultural learning theories prompted six intraoperative teaching strategies (Assess Learner Needs, Inquire, Coach, Permit, Entrust, and Debrief) to address residents learning needs in specific surgical tasks. The six strategies involve identifying procedure-specific learning needs; discussing interventions based on strategies successful with other learners; providing in-the-moment, interactive coaching; allowing the resident to struggle; increasing the resident s graduated responsibility; debriefing about successes and struggles.

CONCLUSIONS:

We argue that these six strategies should improve the quality of intraoperative teaching, and therefore, enhance progression to autonomous practice.

Keywords: Graduate medical education; Sociocultural learning theory; Struggling resident; Surgical curriculum; Surgical education.