Publications

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

Importance

Facial personal protective equipment (FPPE) filters small particles in the operating room (OR) but also affects speech production, diminishing the effective  transfer of information among OR team members.

Objective

The aim of the study is to assess the attenuating effects of different combinations of layered FPPE on speech intensity,  including potential differences in the effect of talkers with varying backgrounds and speaking volumes.

Study Design

We recruited 30 speakers from health and nonhealth occupations with English as either their first or second language. All participants spoke unmasked, at varying voice levels into a portable Zoom H4n device 12 inches from the microphone. These no-mask recordings were played from a Styrofoam head, fitted with 7 combinations of FPPE commonly worn in the COVID-19 era, with the attenuated signals assessed for digital average signal levels. We submitted these attenuation values to an omnibus mixed analysis of variance and performed a spectral analysis on signal attenuation stratified by typical speech frequency bands.

Results

Signal attenuation was strongly determined by FPPE combination, regardless of talker sex, first language, and occupation (P < 0.01, η² = 0.881). The effects of vocal output were also significant (P < 0.01, η² = 0.881). Soft talkers experienced particularly high attenuation at frequency bands higher than 2,000 Hz. The signal of the softest talkers, when asked to speak loudly, was similar to the loud talkers’ signal.

Conclusions

Layered FPPE in the OR protects the surgical team from small particle exposure but may increase communication failures. Our data can help OR staff choose FPPE and alter their vocal volume accordingly.
 

OBJECTIVE:

Teaching and training surgeons work hard in the OR to understand each other, yet miscommunication is an important cause of preventable adverse events in surgery. Our objective was to perform a formal semantic analysis of language in authentic teaching surgical cases, identify the prevalence and typology of ambiguous or potentially ambiguous language, and describe their potential for miscommunication.

DESIGN:

In this secondary analysis of qualitative data, we collaborated with a semanticist, categorizing linguistic phenomena often associated with miscommunication. We defined an ambiguous phenomenon as a string of language that could be reasonably interpreted in more than one way. We analyzed transcripts of 319 minutes of surgery, coding for 14 linguistic categories. Cohen's kappa was calculated. We determined the prevalence and rate of each linguistic category and chose illustrative examples.

PARTICIPANTS AND SETTING:

Six surgical attendings, four fellows, and six residents, ranging from PGY1 to PGY4, at the University of Pittsburgh Medical Center, a tertiary medical center in Pittsburgh, Pennsylvania.

RESULTS:

We found 3912 examples of potentially ambiguous language, 12.3 per minute. Percentage agreement between two expert raters was 76.3%. The most common phenomena were deixis (3.1 per minute), directional (2.6), anaphora (1.3), implicit instruction (1.3), and degree modifiers (0.7). Restatements/reframing occurred 1.4 times per minute. We identified 131 near misses associated with potentially ambiguous language. Cohen's kappa was 0.70 among expert semanticists.

CONCLUSIONS:

Potentially ambiguous language is common and has the potential to jeopardize safe teaching surgery. We postulate that the high amount of potentially ambiguous language use in the operating room places a burden on the training surgeon to comprehend surgical instruction.

Keywords: Communication; Medical education; Patient safety; Semantics; Surgery

OBJECTIVE:

The aim of the study was to determine the rate of subsequent uterine/cervical cancer after hysteropexy compared with hysterectomy with apical prolapse repair.

METHODS:

The study used a retrospective cohort of women with uterovaginal prolapse using the Cerner Health Facts database between 2010 and 2018. We identified sacrospinous or uterosacral ligament suspensions or sacral colpopexy/hysteropexy and excluded those with previous hysterectomy. We used the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for endometrial cancer/hyperplasia and cervical cancer and then reviewed each case, excluding those whose cancer existed at time of prolapse repair. Given that 0 cancer cases were identified, we used Wilson, Jeffreys, Agresti-Coull, Clopper-Pearson, and Rule of 3 to define 95% confidence intervals to estimate the highest possible rate of cancer in each cohort.

RESULTS:

A total of 8,927 patients underwent apical prolapse surgery. Of 4,510 with uterovaginal prolapse, 755 (16.7%) underwent hysteropexy. Seventy one with hysterectomy and 5 with hysteropexy had codes for subsequent gynecologic cancer but were excluded on further review. This left 0 gynecologic cancer cases with the largest 95% confidence interval of 0%-0.61% for hysteropexy versus 0%-0.13% for hysterectomy (P > 0.05). The hysteropexy cohort was older (62.6 years vs 57.3 years, P < 0.0001), more likely to have public insurance (51.0% vs 37.9%, P < 0.0001), and less likely to smoke (4.5% vs 7.6%, P = 0.0026). Median follow-up was longer after hysteropexy (1,480 days vs 1,164 days, P < 0.0009).

CONCLUSIONS:

We can say with 95% certainty that uterine or cervical cancer will develop after hysteropexy in fewer than 0.61% of women, which was not different if hysterectomy was performed. This should be included in preoperative counseling for hysteropexy. Studying longer follow-up after hysteropexy may capture more cases of subsequent cancer development.