The Surgical Autonomy Program: A Pilot Study of Social Learning Theory Applied to Competency-Based Neurosurgical Education

Neurosurgical education is a continually developing field with an aim of training competent and compassionate surgeons who can care for the needs of their patients. The Mayo Clinic utilizes a unique mentorship model for neurosurgical training. In this paper, the authors detail the historical roots as well as the logistical and experiential characteristics of this teaching model. This model was first established in the late 1890s by the Mayo brothers and then adopted by the Mayo Clinic Department of Neurological Surgery at its inception in 1919. It has since been implemented enterprise-wide at the Minnesota, Florida, and Arizona residency programs. The mentorship model is focused on honing resident skills through individualized attention and guidance from an attending physician. Each resident is closely mentored by a consultant during a 2- or 3-month rotation, which allows for exposure to more complex cases early in their training. In this model, residents take ownership of their patients’ care, following them longitudinally during their hospital course with guided oversight from their mentors. During the chief year, residents have their own clinic, operating room (OR) schedule, and OR team and service nurse. In this model, chief residents conduct themselves more in the manner of an attending physician than a trainee but continue to have oversight from staff to provide a “safety net.” The longitudinal care of patients provided by the residents under the mentorship model is not only beneficial for the trainee and the hospital, but also has a positive impact on patient satisfaction and safety. The Mayo Clinic Mentorship Model is one of many educational models that has demonstrated itself to be an excellent approach for resident education.

Section: Discussionmentioning

confidence: 99%

A mentorship model for neurosurgical training: the Mayo Clinic experience

Singh

Peña

Suárez‐Meade

et al. 2022

“…Prior work has demonstrated that residents progress in autonomy at different rates on a core index procedure. 20 Once a sufficient number of surgical cases across multiple institutions are logged, future studies reporting the identification of fast versus slow learners using SAP are warranted. Further research will also include evaluating the number of cases required to reach competency compared with the standard case minimums dictated by residency review committees.…”

Section: Discussionmentioning

confidence: 99%

“…This model uses a modified version of the Zwisch scale, called the TAGS framework, in combination with Vygotsky's social learning theory, which subdivides a large learning task into discrete, smaller zones of proximal development (ZPDs). 20 In order to deploy SAP, our group developed a smartphone application (app) to track residents' progress and allow for formative, rapid feedback. Our SAP smartphone app was designed to be user-friendly and provide real-time formative feedback for residents.…”

mentioning

confidence: 99%

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Construct validity of the Surgical Autonomy Program for the training of neurosurgical residents

Kirsch

Suarez

McDaniel

et al. 2022

Self Cite

OBJECTIVE There is no standard way in which physicians teach or evaluate surgical residents intraoperatively, and residents are proving to not be fully competent at core surgical procedures upon graduating. The Surgical Autonomy Program (SAP) is a novel educational model that combines a modified version of the Zwisch scale with Vygotsky’s social learning theory. The objective of this study was to establish preliminary validity evidence that SAP is a reliable measure of autonomy and a useful tool for tracking competency over time. METHODS The SAP breaks each surgical case into 4 parts, or zones of proximal development (ZPDs). Residents are evaluated on a 4-tier autonomy scale (TAGS scale) for each ZPD in every surgical case. Attendings were provided with a teaching session about SAP and identified appropriate ZPDs for surgical cases under their area of expertise. All neurosurgery residents at Duke University Hospital from July 2017 to July 2021 participated in this study. Chi-square tests and ordinal logistic regression were used for the analyses. RESULTS Between 2017 and 2021, there were 4885 cases logged by 27 residents. There were 30 attendings who evaluated residents using SAP. Faculty completed evaluations on 91% of cases. The ZPD of focus directly correlated with year of residency (postgraduate year) (χ2 = 1221.1, df = 15, p < 0.001). The autonomy level increased with year of residency (χ2 = 3553.5, df = 15, p < 0.001). An ordinal regression analysis showed that for every year increase in postgraduate year, the odds of operating at a higher level of independence was 2.16 times greater (95% CI 2.11–2.21, p < 0.001). The odds of residents performing with greater autonomy was lowest for the most complex portion of the case (ZPD3) (OR 0.18, 95% CI 0.17–0.20, p < 0.001). Residents have less autonomy with increased case complexity (χ2 = 160.28, df = 6, p < 0.001). Compared with average cases, residents were more likely to operate with greater autonomy on easy cases (OR 1.44, 95% CI 1.29–1.61, p < 0.001) and less likely to do so on difficult cases (OR 0.72, 95% CI 0.67–0.77, p < 0.001). CONCLUSIONS This study demonstrates preliminary evidence supporting the construct validity of the SAP. This tool successfully tracks resident autonomy and progress over time. The authors’ smartphone application was widely used among surgical faculty and residents, supporting integration into the perioperative workflow. Wide implementation of SAP across multiple surgical centers will aid in the movement toward a competency-based residency education system.

“…Correspondingly, a tendency for women neurosurgery residents to underestimate their abilities has been noted in the context of self-evaluation of operative skills. In the Surgical Autonomy Program launched at Duke University, 4 which allows neurosurgery residents and their supervising faculty to independently grade progress on a spectrum from novice observer to independent operator during different "zones" of a given operation, women tended to more frequently grade themselves lower than faculty, compared to men, for the most critical zone of the procedure; i.e., representing the key portion of the operation (Haglund MM et al, unpublished data, 2022).…”

Section: Does Is Matter?mentioning

confidence: 99%

Editorial. “Sometimes wrong, never in doubt” or “fake it till you make it”?

Amin‐Hanjani

Haglund

2022

T he classically quoted refrain of the surgeon, "sometimes wrong, never in doubt," is called into question in the study by Zaed and co-authors, who examine the prevalence of the imposter syndrome (IS) in a cohort of young Italian neurosurgeons and neurosurgical trainees. 1 As the authors note, the imposter phenomenon is characterized by doubt in personal ability and a sense that accomplishments are fraudulent and ill-deserved. Through a survey of neurosurgeons/trainees ≤ 40 years old, the authors examine scores on the Clance Imposter Phenomenon Scale and define scores > 40 (on a range of 6 to 100) to be indicative of IS. They find a substantial percentage of the 103 respondents (who represent approximately 25% of those surveyed) to meet the stated threshold, with 82% scoring in the defined range of reporting moderate to intense signs of the syndrome. It would appear, therefore, that many of the cohort feel that they have to "fake it till you make it" despite the implicit accomplishment of undertaking neurosurgery as a profession. This paper raises a number of issues worth examining in further detail.