Publications

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.

OBJECTIVE:

Psychological resilience has been studied in several demanding professions, including the military and competitive sports, yet specific strategies for managing stress are not commonly addressed during surgical training. The objective of this study was to investigate how surgeons view performance under pressure during high-risk surgical steps.

DESIGN:

Using constructivist grounded theory, we conducted 12 individual semi-structured interviews with a theoretical sample teaching surgeons, representing 10 different specialties and a range of experience. We drew on Luthar s concept of resilience as positive adaptation, an active and flexible process in which critical choices are made in stressful situations. We asked about both protective and vulnerability factors contributing to resilience in high-risk surgery. We coded transcripts, transforming each category of codes into a visual schematic highlighting our findings related to performance under pressure and resilience, which we transformed into a conceptual model.

SETTING:

Truman Medical Center, Kansas City, MO, tertiary hospital. PARTICIPANTS: Twelve teaching surgeons from 10 different surgical specialties.

RESULTS:

Mental 3D visualization is necessary for proper preoperative planning, enacting contingency plans in the face of intra-operative challenges, and managing emotions during high-risk surgery. Each of these factors informs staying calm under pressure and is necessary for building long-term surgical resilience. Negotiating challenges in high-risk surgery is contingent upon adapting to risk developed over time through surgical experience, mental 3D visualization, intentionality, and self-reflection.

CONCLUSIONS:

Mental 3D visualization informs processes for staying calm under pressure and is essential for building long-term surgical resilience. We recommend that residency curricula offer progressive education on mental 3D visualization and foster intraoperative environments that promote adapting to risk.

Keywords: Resilience; intraoperative period; qualitative research; stress; three-dimensional maps

BACKGROUND:

Patient safety in the Operating Room (OR) depends on unobstructed team communication. Yet the typical OR is loud, containing numerous sounds from surgical machinery overlayed with human-caused sounds. Our objective was to compare machine vs human-caused sounds for their loudness and distraction, and potential impact on team communication.

METHODS:

After surveying OR staff about sounds that interfere with job performance and team communication, we recorded 19 machine and 48 human-caused sounds measuring their acoustical intensity. We compared peak measures of machine vs human-caused sound loudness, using Student s t-test. We observed the effect of these sounds on OR staff in 59 live surgeries, rating level of interference with team function. We visually depicted competing sounds through a spectral analysis.

RESULTS:

The survey response rate was 62.8%. 93% of respondents indicated that OR noise, especially human-caused sounds such as irrelevant conversations, interfere with team communication, hearing, and focus. OR peak decibel levels ranged from 56.8 dB (surgical packaging) to 105.0 dB (kicked metal stepstool). Human-caused sounds were comparable to machine-caused sounds in terms of mean peak dB levels (77.0 versus 73.8 dB, p = 0.32), yet were rated as more interfering with surgical team function. The spectral analysis illustrated both machine and human-caused sound sources obscuring the surgeon s instructions.

CONCLUSIONS:

Avoidable human-caused sounds are a major source of disruption in the OR and interfere with communication and job performance. We recommend surgical team training to minimize these distractions.

Introduction:

In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics.

Methods:

We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International
Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression.

Results:

Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49).

Conclusions: 

Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting
with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study. 

Keywords: acute pyelonephritis; overactive bladder; urinary tract infection.

Background:

Vital injuries during midurethral sling surgery are avoided by maintaining constant trocar contact with bone, and yet this is challenging for a teaching surgeon to monitor during this blind procedure. We modified a retropubic trocar with a load cell to distinguish on-bone and off-bone movement 1and tested it on a midurethral sling surgery 3-dimensional surgery simulator.

Methods:

Two experts and 3 novice surgeons performed retropubic trocar passage on the physical pelvic floor model using the modified trocar. Biofidelity was assessed comparing expert performance on a Thiel-embalmed cadaver and the physical model. The test-retest was assessed comparing performance on the physical pelvic model 2 weeks apart. The force variables were analyzed with paired and independent tests. We performed post hoc analyses comparing the experts to novices on the physical model.

Results:

The root-mean-squared force was similar between the cadaver and model (24.3 vs 21.1 pounds, P ¼ .62), suggesting biofidelity. Root-mean-squared force was also similar between the test and retest (14.0 vs 19.1 pounds, P ¼. 30). The expert surgeons exhibited a larger maximum force amplitude (51.2 vs 22.7 pounds, P ¼ .03), shorter time to maximum force (2.7 vs 9.5 seconds, P ¼ .03) and larger maximum rate of force development (171.5 vs 54.0 pounds/second, P ¼ .01).

Conclusion:

This study suggested high test-retest reliability and adequate biofidelity of the modified trocar used on our midurethral sling surgery 3-dimensional surgery simulator. This innovative trocar can be used both in simulation and in the operating room to help the novice surgeons stay on the bone and to help the attending surgeon monitor safe surgery.

Background:

African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical  cancers are caused by human papillomavirus (HPVs)  infections. The National Institutes of Health (NIH) co- developed HPV self-test kits to increase access to screening, which may be critical for underserved populations.

Purpose/Research Design:

This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church- affiliated African American women. Study 
Sample/Data Collection: Participants (N = 35) aged 25–53 participated in focus groups and completed a survey.

Results:

Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children’s healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy.

Conclusions:

Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.
 

Keywords: African American women; HPV self-testing; cervical cancer disparities; community-engaged research; theory of planned behavior.

OBJECTIVE:

This study aimed to determine the impact of a rural vs urban hospital location on the risk of undergoing a second surgery for stress urinary incontinence.

STUDY DESIGN:

Using the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between January 1, 2010 and November 30, 2018. Stress incontinence surgeries included synthetic midurethral slings, fascial slings, retropubic urethral suspension, and other surgeries for stress urinary incontinence, such as the laparoscopic sling or the Pereyra procedure. Patients were divided into 2 cohorts, namely those who had a single operation and those who had a reoperation, defined as any second stress incontinence surgery or revision after initial incontinence surgery. Logistic regression analysis was performed to determine whether urban vs rural hospital location impacted reoperation rates. We adjusted for significant sociodemographic variables identified in the univariate analysis with a P value <.1.

RESULTS:

Of the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. Of these, 346 (51.7%) patients underwent were a second stress incontinence procedure, 307 (45.9%) underwent revisions of the index case, and 16 (2.4%) underwent both. Women in the single surgery cohort were older (median age, 54 vs 53 years; P=.029). In the total sample, 85.5% identified as White and 4.5% identified as Black. Of the study cohort, 7720 (30.8%) had obesity and 2660 (10.6%) had diabetes. There was a higher rate of reoperation among patients with obesity (3.0% vs 2.5%; P=.017). Among patients who underwent a concomitant prolapse surgery with their index surgery, there were fewer reoperations (2.2% vs 2.8%; P=.012). In the univariate analysis, we did not detect a difference between women who lived in rural vs urban areas (3.0% vs 2.6%; P=.16). After adjusting for confounders, we still did not see a significant association between rural hospital location and the risk for repeat surgery (odds ratio, 1.00; 95% confidence interval, 0.76−1.31). In this multivariable regression, obesity increased the risk for having a reoperation (odds ratio, 1.20; 95% confidence interval, 1.02−1.41), whereas patients who had concomitant prolapse procedures with their index surgery had a reduced risk for having a reoperation (odds ratio, 0.80; 95% confidence interval, 0.66−0.98).

CONCLUSION:

We did not detect an association between hospital location (rural vs urban) and the risk for reoperation among women under- going stress incontinence surgery. With low reoperation  rates, patients can be reassured that they are receiving excellent care in either setting.

Keywords: hospital status; incontinence; reoperation; repeat operation; rural; stress incontinence; urban; urogynecology