DOI: https://doi.org/10.21203/rs.2.15506/v1
Backgroud: It is of vital importance to standardize wound management knowledge and operations in the early stage of resident training. A simulated wound management curriculum for postgraduate Year 1 surgery residents (PGY1s) was designed and its effectiveness evaluated.
Methods: We used a quasi-experimental method. PGY1s in 2014 constituted the control group, while PGY1s in 2015 and 2016 constituted the intervention group. The traditional curriculum given to the control group comprised a one-hour lecture plus demonstrations by the instructor, followed by a three-hour practice session. Conversely, the curriculum given to the intervention group included a four-hour curriculum with four components. At the end of each year, the wound management curriculum was evaluated.
Results: Subjective assessment showed the intervention group’s scores were significantly higher for dissociation of subcutaneous tissue and quality of suturing and knots. Objective assessment showed there was no obvious improvement in residual marking of incision margin, but the accuracy of debridement depth was greatly improved in the intervention group, the rate of spindle resection decreased and the number of key sutures was significantly higher.
Conclusions: The simulated wound management curriculum for PGY1s revealed a generally satisfactory training outcome. It could be implemented in other Chinese universities.
Traditional surgical resident training has long followed the classical Halstedian teaching model of “see one, do one, teach one” 1. However, Great changes have taken place regarding the training of surgical residents in China as simulation-based training2 and competence-based medical education3 have become widely practiced. Additionally, surgical training now places more weight on technical skills training, simulation, and learning by doing. In the protected training environment of skills labs, residents are able to continually improve their surgical skills through “mistake for giving” 4 and deliberate practice 5,6.
In order to implement the standardized training for surgical residents effectively, Peking University First Hospital (PKUFH) set up surgery school in 2014, which is an important innovation in China7. And for the first time, plastic surgeons replace general surgeons to taking charge of the wound management curriculum. We taught the postgraduate Year 1 surgery residents (PGY1s) in the traditional pattern in 2014, which includes one-hour lecture plus demonstration followed by three-hour practice, but the summative assessment didn’t show a satisfactory results. They can’t handle an irregular wound well in a limited time. Considering wound management is an essential skill for PGY1s, because they often act as the first-line doctors dealing with different kinds of wounds either in the emergency situation or in the ward. Therefore, based on our national conditions, we design a wound management curriculum for PGY1s with reference to the US experiences, which basically covers the core skills listed in the US surgical curriculum8. The curriculum was applied since 2015, and this study was carried out to evaluate the effectiveness of this new pattern of wound management curriculum.
The wound management curriculum took place during the fourth month of standardized resident training. It covered surgical skills such as making incisions, tissue protection, tissue dissociation, suturing, and local skin flaps, among others. PGY1s in 2014 constituted the control group, while PGY1s in 2015 and 2016 constituted the intervention group. The same teaching contents were given to both groups but in different patterns. At the end of the first year (seven months after the wound management curriculum), the skills of PGY1s were assessed, and the curriculum was evaluated. All the PGY1s were tested on irregular wound repair (debridement and suture). The assessment criteria were the same for each group of PGY1s, and the test content and scoring criteria were not known to PGY1s beforehand. In the test, an irregular area of 10×3.8cm2 was marked on cadaveric pork belly skin (Fig. 1A), representing tissue necrosis down to/affecting the deep fascia. PGY1s were required to perform a primary suture after debridement within 15 minutes. Key suture numbers and dog ear treatment were showed in Fig. 1.
[Fig.1 here]Irregular wound debridement and suture test (from one of the residents). A. the irregular area marked on cadaveric pork belly skin; B. the appearance of the wound after debridement; C. the key suture numbers (the red box) and dog ear treatment (the blue circle).
The examiners included one plastic surgery attending and two general surgery attending, they would receive a brief training by the instructor before the test. They had to make both a subjective and objective assessment of the PGY1s’ technical skills of wound debridement and closure. A global rating scale (GRS) was used to assess the performance from six dimensions9, namely, “maintaining a sterile field,” “knowledge and handling of instrument,” “quality of excision,” “quality of debridement,” “dissociation of subcutaneous tissue,” and “quality of suturing and knots,” and each dimension was assessed on a 10-point scale, the internal consistency reliability turned out to be acceptable10. The objective assessment included key suture numbers, residual necrotic tissue condition, resection depth, and dog ear treatment. The average score was calculated as the final score. The instructor remained the same person during three years, which was one of the correspond authors.
In 2014, the curriculum was arranged as a one-hour lecture plus demonstration followed by three-hour practice session for PGY1s. Feedback was given in the end. The teaching materials were rabbits under general anesthesia.
In 2015 and 2016, the curriculum was conducted as a four-component pilot study with a four-hour curriculum: pretest, didactic teaching, basic surgical skills, and reparation and reconstruction. The teaching materials were cadaveric pork belly skin. The four components were as follows:
Before beginning any teaching, PGY1s were given a pretest to assess their surgical skills so that the curriculum content could be adjusted to their educational needs. The necrotic area was marked on cadaveric pork belly skin (see the black area in Fig. 2A). PGY1s were required to perform a complete excision of the lesion and primary closure of the wound. The recommended procedure is shown in Fig. 1. PGY1s were expected to leave flap a and b open (Fig 2B) and suture the two key points—point c to point a and point b to point d (Figure 2C)—to close the wound. The instructor was required to observe PGY1s’ operation procedure, focusing on wound debridement and closure.
[Fig.2 here]Baseline surgical skills assessment. A. the schematic of the necrotic area on cadaveric pork belly skin; B. the recommended closure; C. two key points; D. the schematic of spindle resection; E. the schematic of another inappropriate closure.
Based on the pretest results, the instructor covered topics related to wound debridement and closure, including incision selection, respect for tissue, debridement scope and level, dissociation and suturing of subcutaneous tissue, suture methods and techniques, and the like. Then, PGY1s were asked to restart or proceed with the wound debridement and closure according to their individual performances in the pretest.
In this part of the curriculum, PGY1s were expected to complete the closure of round, square, and triangular wounds. Using a modified version of Peyton’s Four-Step Approach11, the instructor offered basic surgical skills training (excision, suturing, knot-tying, etc.) in the form of small group teachingwith a focus on deconstruction and comprehension12. Deliberate practice13 was required of the students to reinforce correct operational habits. The instructor inspected PGY1s’ wound closure process and prepared for Component 4.
Instructor and PGY1s worked together to reflect on their acquired knowledge and progress in wound closure, with instructor providing feedback and explaining basic local flap principles and concepts. In addition, PGY1s learned about aesthetic issues such as dog ear in their surgical maneuvers, respect for tissue, and wound reparation and reconstruction. In terms of surgical practice, PGY1s completed round, square, and triangular wound closures if it had not been finished in component 3. Some PGY1s who exhibited a higher skill level were given individualized surgical tasks involving more complex wounds.
The training in 2015 and 2016 followed the same four-component approach, but we dynamically adjusted the content and proportion of each component according to the pretest results and the summative assessment from the previous year (see Fig. 3).
[Fig.3 here]All results were expressed as mean and standard deviation in the form of mean±SD. The data were statistically analyzed using the t-test, least significant difference test, and Kolmogorov-Smirnov statistic, and linear correlation, using SPSS 22.0 software (IBM Corporation, USA). A p-value of less than 0.05 was regarded as statistically significant.
The number of participants in 2014, 2015 and 2019 are 31, 39, and 37, respectively (Table 1). There was no significant difference in the age of PGY1s trained in the years 2014, 2015, and 2016 (p = 0.295, F = 1.235).
All PGY1s in 2015 and 2016 were supposed to take the pretest, but a few PGY1s missed it for being late due to the surgeries or other clinical things. The results indicated that the wound closure performance of PGY1s trained in 2015 (2015 PGY1s hereinafter) were better than that of PGY1s trained in 2016 (2016 PGY1s hereinafter), and spindle resection was significantly less observed in 2015 PGY1s than in 2016 PGY1s (Table 2).
The results indicate an GRS scores of PGY1s presented anincreasing trend in scores over the three years. The scores of 2015 and 2016 PGY1s were significantly higher than those of 2014 PGY1s for the dimensions of “dissociation of subcutaneous tissue” and “quality of suturing and knots.” None of the 2014 PGY1s performed dissociation of subcutaneous tissue, so they scored zero on this dimension. Based on the assessment results in 2015, we reinforced training for “quality of debridement” and “dissociation of subcutaneous tissue” for 2016 PGY1s, leading to the significant improvement of GRS scores. (See Table 3 and Fig. 4)
[Fig.4 here]Subjective assessment results of postgraduate Year 1 surgery residents over the three years.
Compared with 2014, PGY1s in 2015 and 2016 showed no obvious improvement in residual marking of incision margin (Table 4), but their accuracy of debridement depth was greatly improved, and the rate of spindle resection decreased. However, with the decrease of incision tension, PGY1s would close the wound as soon as possible and not choose subcutaneous suture. Starting in 2016, PGY1s were taught to take care to avoid creating dog ears during wound treatment. Table 5 showed that the number of key sutures was also found to be significantly higher in 2015 and 2016 PGY1s than in 2014 PGY1s.
PGY1s’ response when faced with actual, real-life wound management could be better assessed by simulating emergencies, adding complex examination questions, including time pressure, and using a more sophisticated environment. Feedback after training, as well as the cultivation of surgical conception14, might contribute to PGY1s’ skill acquisition and retention. The results of summative assessment seven months after the training showed that the proposed curriculum can help students retain technical skills, which suggested an appropriate curriculum design may accelerate the transformation of technical skills in the lab into core competency15.
Generally, when medical students graduate, their competence and confidence in common medical procedures is lacking16. Moreover, the traditional approach presents a barrier to effective learning17. Wounds usually occur in emergency situations, which are unpredictable and often relatively complicated. Wound management in these cases usually falls into two categories: debridement and closure. Debridement includes respect for tissue, excision/dissection, clearance range, and dissociation, all of which are reflected in the subjective assessment dimensions 3 (quality of excision) and 4 (quality of debridement) and the objective assessment criteria of margin of incision without residual markers, debridement depth to deep fascia, and spindle resection. Meanwhile, closure includes low tension closure, stitching skills and techniques, and aesthetics, which involve the subjective assessment dimensions 5 (dissociation of subcutaneous tissue) and 6 (quality of suturing and knots) and the objective assessment criteria of key suture numbers, subcutaneous suture, and dog ear treatment. For 2015 and 2016 PGY1s, both subjective and objective assessment of their surgical skills were significantly improved as compared with 2014 PGY1s, indicating that the change of curriculum design and content can effectively improve PGY1s’ technical skills.
Although the resident admission criteria of our hospital basically stays the same every year, residents18, fellows19, and senior attending physicians20 have extreme variability in skills. This phenomenon was also revealed in the pretest results, which showed that 2016 PGY1s’ basic understanding of wound management was relatively inadequate as compared to 2015 PGY1s. In light of this information, we had to dynamically adjust the teaching content of the curriculum. In 2015, more time was allotted for the training of repair and reconstruction skills, whereas in 2016, we completed the predetermined teaching content, leaving more time for the explanation of basic concepts. At the same time, based on the summative assessment results in 2015, we reinforced the training of technical skills in efficient debridement and incision tension reduction for 2016 PGY1s. The overall ability of 2016 PGY1s was significantly improved compared with 2015 PGY1s. They even had time to attempt dog ear treatment. As a result of this dynamic, tailored design, the curriculum improves as an ongoing cycle.
Some medical educators believe that the traditional training approach is unsuitable for effective learning. However, with the wide application of simulation training in China, there is also a growing trend of overdependence on new equipment and high simulation, ignoring the advantages of the traditional approach, which utilizes cheap, convenient, and reusable teaching materials. In 2014, we chose living rabbits as the teaching material for the sake of high simulation, but the multi-function of the material interfered with the fulfillment of the real teaching purpose. Therefore, we returned to the traditional, single-purpose material—cadaveric pork belly skin—in 2015 and 2016, focusing on the development of PGY1s’ surgical technical skills and operational thinking progress. Through the adjustment of teaching content and methods, and in line with the needs of PGY1s, instructors could effectively control the training pace and guide the active learning of PGY1s. Furthermore, the replacement of teaching materials can effectively reduce the cost of training and the difficulty of preparation, thus promoting the applicability of the curriculums in other training settings.
Despite the confidentiality of the test questions, the same test questions were used for three consecutive years, which could reduce test efficacy. In addition, mastery learning would be more suitable for the assessment of the curriculum, but ReMERM was not referred to at the beginning of the curriculum design.
PKUFH designed a simulated wound management curriculum for PGY1s, which revealed a generally satisfactory training outcome. It filled a gap in current research in China and could be implemented in other Chinese universities. Some desirable curriculum design practices could be learned from this training process: teaching materials must be carefully chosen; teaching content and methods have to be adjusted in line with trainees’ pretest results; and trainees have to be provided with opportunities for individualized feedback/debriefing and deliberate practice. All these practices will be of great help for the development of PGY1s’ technical skills.
The study was approved by Peking University First Hospital Ethics Committee. The consent was unnecessary in this study and the ethics committee approved this point.
Not applicable.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
The authors report no conflicts of interest.
This work was supported by Project of Medical Education Research from Medical Education Branch of Chinese Medical Association & Medical Education Professional Committee of China Association of Higher Education (2018B-N05035); National Natural Science Foundation of China for Young Scholars (71804005). The both funding supported the financial and administrative affairs regarding study design, data collection, and statistical analyses.
XQ and QL designed the curriculum, XQ and RH collected the data, did statistical analysis and wrote the manuscript, XQ and HB W formulated the research idea and critically edited the draft of the paper. BW supervised the whole work and revised the manuscript. All authors approved the final manuscript.
The authors wish to thank Haichao Li, Ying Wang and Yan Li for their supports; Qian Lu and Huaqin Cheng for their advices.
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Table 1. Demographic information of postgraduate Year 1 surgery residents trained 2014–2016
|
Year |
Total Number (n) |
Male (n) |
Female (n) |
Average Age (y) |
p |
|
2014 |
31 |
30 |
1 |
24.94±1.67 |
0.295 |
|
2015 |
39 |
36 |
3 |
24.95±1.16 |
|
|
2016 |
37 |
35 |
2 |
25.46±1.94 |
Table 2. Pretest results of postgraduate Year 1 surgery residents trained in 2015 and 2016
|
Year |
Total number of residents (n) |
C [%(n)] |
D [%(n)] |
E [%(n)] |
Wound closure [%(n)] |
|
2015 |
34 |
47.0(16) |
11.8(4) |
41.2(14) |
11.8(4) |
|
2016 |
30 |
10.0(3) |
43.3(13) |
46.7(14) |
0(0) |
Note: C: local flap transfer; D: spindle resection; E: necrosis resection, aimless and convenient suture
Table 3. Comparison of the results of subjective assessment
|
Dimension |
Mean |
|
p |
||||
|
2014 n=31 |
2015 n=39 |
2016 n=37 |
|
2014 vs. 2015 |
2014 vs. 2016 |
2015 vs. 2016 |
|
|
1. Maintaining a sterile field |
7.53±0.72 |
7.68±1.20 |
7.79±0.32 |
|
0.524 |
0.048* |
0.565 |
|
2. Knowledge and handling of instrument |
7.63±0.90 |
8.03±0.51 |
7.85±0.51 |
|
0.022* |
0.224 |
0.113 |
|
3. Quality of excision |
7.59±0.79 |
7.61±0.82 |
7.87±0.51 |
|
0.936 |
0.091 |
0.093 |
|
4. Quality of debridement |
7.12±1.33 |
7.47±0.95 |
7.89±0.56 |
|
0.222 |
0.005** |
0.025* |
|
5. Dissociation of subcutaneous tissue |
0.00 |
5.82±2.67 |
7.52±0.77 |
|
<0.001** |
<0.001** |
<0.001** |
|
6. Quality of suturing and knots |
7.03±1.19 |
7.54±0.72 |
7.71±0.83 |
|
0.043* |
0.010* |
0.334 |
|
Global rating scale |
36.91±3.29 |
44.15±4.52 |
46.64±2.36 |
|
<0.001** |
<0.001** |
0.004** |
Note: *: p<0.05; **: p<0.01
Table 4. Objective assessment results of postgraduate Year 1 surgery residents in the three years
|
Year |
Residual marking of incision margin n (%) |
Depth to deep fascia n (%) |
Spindle resection n (%) |
Dog ear treatment n (%) |
Subcutaneous suture n (%) |
|
2014 (n=31) |
7 (22.6) |
7 (22.6) |
8 (25.8) |
0 (0.0) |
14 (45.2) |
|
2015 (n=39) |
12 (30.8) |
30 (76.9) |
1 (2.6) |
0 (0.0) |
6 (15.4) |
|
2016 (n=37) |
11 (29.7) |
27 (73.0) |
3 (8.1) |
5 (13.5) |
7 (18.9) |
Table 5. Comparison of key suture numbers
|
|
Median number (min, max) |
|
p |
||||
|
2014 n=31 |
2015 n=39 |
2016 n=37 |
|
2014 vs. 2015 |
2014 vs. 2016 |
2015 vs. 2016 |
|
|
Key suture numbers |
1(0,4) |
3(0,4) |
3(0,4) |
|
0.002** |
0.005** |
0.774 |
Note: *: p<0.05; **: p<0.01