Publications

OBJECTIVES:

The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS).

METHODS:

We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis.

RESULTS:

Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders.

CONCLUSIONS: The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.

BACKGROUND:

Surgical residents desire independent operating experience but recognize that attendings have a responsibility to keep cases as short as possible.

METHODS:

We analyzed video and interviews of attending surgeons related to more than 400 moments in which the resident was the primary operator. We examined these moments for themes related to timing and pace.

RESULTS:

Our surgeons encouraged the residents to speed up when patient safety could be jeopardized by the case moving too slowly. In contrast, they encouraged the residents to slow down when performing a crucial step or granting independence. Attending surgeons encouraged speed through economical language, by substituting physical actions for words, and through the use of Intelligent Cooperation. Conversely, they encouraged slowing down via just-in-time mini-lectures and by questioning the trainee.

CONCLUSIONS:

We present recommendations for safe teaching in the operating room while simultaneously maintaining overall surgical flow. Teaching residents to operate quickly can save time and is likely based on an automaticity in teaching. Slowing a resident down is vital for trainee skill development and patient safety.

Keywords: Pace; Patient safety; Qualitative research; Surgery; Surgical teaching; Videotape.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.

CONTEXT:

Observational research is increasingly being used in health professions education (HPE) research, yet it is often criticised for being prone to observer effects (also known as the Hawthorne Effect), defined as a research participant s altered behaviour in response to being observed. This article explores this concern.

METHODS:

First, this article briefly reviews the initial Hawthorne studies and the original formulation of the Hawthorne Effect, before turning to contemporary studies of the Hawthorne Effect in HPE and beyond. Second, using data from two observational studies (in the operating theatre and in the intensive care unit), this article investigates the Hawthorne Effect in HPE.

RESULTS:

Evidence of a Hawthorne Effect is scant, and amounts to little more than a good story. This is surprising given the foundational nature of the Hawthorne Studies in the social sciences and the prevalence of our concern with observer effects in HPE research. Moreover, the multiple and inconsistent uses of the Hawthorne Effect have left researchers without a coherent and helpful understanding of research participants responses to observation. The authors HPE research illustrates the complexity of observer effects in HPE, suggests that significant alteration of behaviour is unlikely in many research contexts, and shows how sustained contact with participants over time improves the quality of data collection.

CONCLUSION:

This article thus concludes with three recommendations: that researchers, editors and reviewers in the HPE community use the phrase participant reactivity when considering the participant, observer and research question triad; that researchers invest in interpersonal relationships at their study site to mitigate the effects of altered behaviour; and that researchers use theory to make sense of participants altered behaviour and use it as a window into the social world. The term participant reactivity better reflects current scientific understandings of the research process and highlights the cognitive work required of participants to alter their behaviour when observed. Perhaps the most important lesson to be learned from the original Hawthorne experiments is the power of a good story (Levitt & List, 2011).