HAND/PERIPHERAL NERVE Essential Hand Surgery Procedures for Mastery by Graduating Plastic Surgery Residents: A Survey of Program Directors Shelley S. Noland, Lauren H. Fischer, Gordon K. Lee, Jeffrey B. Friedrich, Vincent R. Hentz,
M.D. M.D. M.D. M.D. M.D.
Stanford, Calif.; and Seattle, Wash.
Background: This study was designed to establish the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach technical skills in hand surgery. Methods: Ten expert hand surgeons were surveyed regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. The top 10 procedures from this survey were then used to survey all 89 Accreditation Council for Graduate Medical Education–approved plastic surgery program directors. Results: There was a 69 percent response rate to the program director survey (n = 61). The top nine hand surgery procedures included open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, closed reduction and percutaneous pinning of metacarpal fracture, excision of dorsal or volar ganglion, zone II flexor tendon repair with multistrand technique, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release. Conclusions: Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method for accomplishing this task. There has been no consensus regarding which hand surgery procedures should be mastered by graduating plastic surgery residents. The authors have identified nine procedures that are overwhelmingly supported by plastic surgery program directors. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery. (Plast. Reconstr. Surg. 132: 977e, 2013.)
N
asca et al. recently introduced the Next Graduate Medical Education Accreditation System.1 Building on the introduction of the six core competencies in 1999,2 the Accreditation Council for Graduate Medical Education is mandating considerable restructuring of graduate medical education. The Next Graduate Medical Education Accreditation System mandate for outcomesbased residency education presents a challenge From the Division of Plastic Surgery, Department of Surgery, and the Robert A. Chase Center for Hand and Upper Limb, Stanford University Hospital; and the Department of Orthopedic Surgery and the Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center. Received for publication March 19, 2013; accepted June 13, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a8066b
for surgical educators. Historically, surgical education has relied on written examinations and subjective evaluations. To meet the new requirements and adhere to the work-hour restrictions, surgical educators need to develop objective methods of teaching technical skills and document their attainment and retention. To accomplish this, the Objective Structured Assessment of Technical Skill has been introduced and implemented into surgical education.3–13 The Objective Structured Assessment of Technical Skill, first described by Martin et al.,14 consists of a benchtop, cadaver, or live animal model designed to simulate a specific technical skill. The technical ability of the resident is assessed using detailed checklists and a global ratings scale.15 Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • December 2013 The purpose of this article is to establish consensus regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. Our group has previously published the consensus regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents.16 This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.
METHODS Hand Surgery Expert Survey Ten senior expert hand surgeons selected by the senior author (V.R.H.) were sent an anonymous online survey.17 These 10 senior experts included department chairmen and program directors and were chosen based on their extensive experience training plastic surgery residents and fellows. They were given 15 common hand surgery procedures and asked to rank those that should be mastered by graduating plastic surgery residents. These 15 procedures were chosen based on both the proposed Plastic Surgery Residency Review Committee “milestones”18 as part of the Next Accreditation System and the senior author’s (V.R.H.) 35 years’ experience training plastic surgery residents. The 10 senior experts were also given the opportunity to suggest other procedures that may have been overlooked. The top 10 choices of the overall 15 were then used for the plastic surgery program director survey. This survey protocol was adapted from Fan et al.19 Plastic Surgery Program Director Survey All 89 Accreditation Council for Graduate Medical Education–approved plastic surgery program directors were sent an anonymous online survey. Using the established top 10 procedures from the hand surgery expert survey, we asked the program directors whether or not they felt each procedure should be mastered by graduating plastic surgery residents. We also asked about the presence of a hand surgery fellowship at their home institution, whether they themselves had completed a hand surgery fellowship, and whether they themselves were comfortable performing each of the procedures. This survey was adapted from Fan et al.19
RESULTS Hand Surgery Expert Survey We received a 90 percent response rate (n = 9) to our hand surgery expert survey. The 15
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Table 1. Ranked Results of the Expert Hand Surgery Survey 1. Open carpal tunnel release 2. Flexor tendon sheath steroid injection 3. Open A1 pulley release 4. Incision and drainage of the flexor tendon sheath for flexor tenosynovitis 5. Excision of dorsal or volar ganglion 6. Closed reduction and percutaneous pinning of metacarpal fracture 7. Open cubital tunnel release 8. Zone II flexor tendon repair with multistrand procedure 9. ORIF distal radius fracture 10. Digital nerve repair with microscope 11. Arthroplasty for basilar joint arthritis 12. Palmar fasciectomy for Dupuytren contracture 13. Percutaneous pinning of scaphoid fracture 14. Digital replantation 15. Syndactyly release ORIF, open reduction and internal fixation.
suggested procedures were ranked by importance for mastery by graduating plastic surgery residents (Table 1). Four additional “write-in” procedures were suggested by the senior experts (nail-bed repair, upper extremity fasciotomy, split-thickness skin graft, and de Quervain release), but none was suggested more than once and thus they were not incorporated into the program director survey. Plastic Surgery Program Director Survey We received a 69 percent response rate (n = 61 of 89) to our plastic surgery program director survey. The top 10 ranked procedures are shown in Figure 1. The top nine of the 10 procedures received overwhelming support (>90 percent of program directors felt that they should be mastered by graduating plastic surgery residents), whereas open reduction and internal fixation of distal radius fracture was not supported as unanimously (only 40 percent felt that this procedure should be mastered by graduating plastic surgery residents). When filtered for program directors that had completed a hand surgery fellowship [n = 21 (34 percent)] or for program directors with a hand surgery fellowship at their institution [n = 23 (38 percent)], there were only minimal differences in overall ranking (Figs. 2 and 3). The one exception was that 57 percent of program directors with a hand fellowship at their home institution felt that open reduction and internal fixation of distal radius fracture should be mastered by graduating plastic surgery residents compared with 30 percent of program directors with no hand fellowship at their home institution. All program directors that had completed a hand surgery fellowship were comfortable
Volume 132, Number 6 • Hand Surgery Procedures
Fig. 1. Ranked results of the plastic surgery program director survey showing the percentage of program directors who felt the individual procedure should be mastered by graduating plastic surgery residents. OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
performing the top nine procedures (Fig. 4). Sixty-seven percent of those who had completed a hand surgery fellowship were comfortable performing an open reduction and internal fixation of distal radius fracture. Of the program directors that had not completed a hand surgery fellowship, there was variability in comfort level, with greater than 70 percent comfortable performing the top nine procedures (Fig. 4).
DISCUSSION As program directors familiarize themselves with the details of the Next Graduate Medical Education Accreditation System, surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method of accomplishing this task as demonstrated by VanHeest et al.13 However, there has been no consensus on which hand surgery procedures should be mastered by graduating plastic surgery residents. The goal of this article was to identify hand surgery procedures that are overwhelmingly supported by plastic surgery program directors as essential and therefore are to be mastered by plastic surgery residents during their period of residency. We identified nine procedures that can be
used as a starting point and a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery. The Plastic Surgery Residency Review Committee is currently in the process of finalizing “milestones” for plastic surgery residents to master.18 Of the 14 patient care milestones currently being tested (under which technical ability is classified), two pertain to hand surgery. The first is nontrauma hand surgery, which includes seven of the nine procedures on our list (i.e., open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, excision of dorsal or volar ganglion, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release). The second is upper extremity trauma, which includes two of the nine procedures on our list (i.e., closed reduction and percutaneous pinning of metacarpal fracture and zone II flexor tendon repair with multistrand technique). Using these nine procedures to develop Objective Structured Assessment of Technical Skill would facilitate the assessment of these two milestones. The top nine procedure rankings differed only slightly when filtered for program directors with hand surgery fellowship training, suggesting
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Plastic and Reconstructive Surgery • December 2013
Fig. 2. Ranked results of the program director survey with the percentage of program directors who felt the individual procedure should be mastered by graduating plastic surgery residents, broken down by program directors with and without hand surgery fellowship training. OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
a broad consensus with minimal bias introduced by the program director’s personal background and experience. Similarly, the rankings differed only slightly when filtered for program directors with a hand fellowship at their home institution, with one exception: open reduction and internal fixation of distal radius fracture. Fifty-seven percent of program directors with a hand fellowship at their home institution felt that open reduction and internal fixation should be mastered by graduating plastic surgery residents, compared with 30 percent of program directors with no hand fellowship at their home institution. Perhaps the residency programs with a hand surgery fellowship provide plastic surgery residents with increased access to hand surgery procedures, including distal radius fracture management. The program director may have noticed that his or her residents were performing this procedure routinely as part of their hand surgery rotation. As expected, all program directors who had completed a hand surgery fellowship were comfortable performing the top nine procedures, and 67 percent of this group were comfortable performing an open reduction and internal fixation
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of distal radius fracture. Of the program directors that had not completed a hand surgery fellowship, there was variability in comfort level, but greater than 70 percent were comfortable performing the top nine procedures, suggesting that plastic surgeons are learning (and retaining) the most common hand surgery procedures, even if the majority of their practice is not hand surgery. Hand surgery is one of many components of a comprehensive plastic surgery residency. Most of the program directors with no hand surgery fellowship training were comfortable with the top nine procedures. Although the majority of plastic surgery residents will not pursue a hand surgery fellowship,20 these top nine procedures are an important component of a comprehensive plastic surgery education. Fan et al. addressed this topic with regard to craniofacial surgery and identified five procedures (i.e., bone graft for nasal reconstruction, perialar rim bone graft, lateral canthopexy, osseous genioplasty, and bone graft harvest for orbital floor defects) that should be mastered by graduating plastic surgery residents.19 Similarly, the top procedures for other subspecialties of plastic surgery (e.g., breast reconstruction,
Volume 132, Number 6 • Hand Surgery Procedures
Fig. 3. Ranked results of the program director survey with the percentage of program directors who felt the individual procedure should be mastered by graduating plastic surgery residents, broken down by program directors with and without a hand surgery fellowship at their home institution. OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
cancer reconstruction, aesthetic surgery) should be established as a guideline for developing comprehensive Objective Structured Assessment of Technical Skill for mastery by graduating plastic surgery residents. Ideally, all plastic surgery residents would objectively demonstrate competence for each procedure before graduation. Our group recently published the essential hand surgery procedures for mastery by graduating orthopedic surgery residents.16 Nine procedures that are overwhelmingly supported by orthopedic surgery program directors were identified (i.e., open carpal tunnel release, open A1 pulley release, open reduction and internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of the flexor tendon sheath for flexor tenosynovitis). The two procedures deemed essential in the plastic surgery survey but not in the orthopedic surgery survey were zone II flexor tendon repair with multistrand technique and digital nerve repair with microscope. Only 40 percent of orthopedic surgery program directors felt that zone II flexor
tendon repair with multistrand technique was essential for mastery by graduating orthopedic surgery residents. Perhaps the program directors felt that the complex nature of this procedure warrants hand surgery fellowship training. Thirtytwo percent of orthopedic surgery program directors felt that digital nerve repair with microscope was essential for mastery by graduating orthopedic surgery residents. We posit that training in microsurgical skills is more commonly associated with plastic surgery training than with orthopedic surgery training; that may explain this difference. Likewise, open reduction and internal fixation of distal radius fracture was deemed essential to mastery by graduating orthopedic surgery residents (three-way tie for top technique) but not for graduating plastic surgery residents. We posit that training in fracture management is more commonly associated with orthopedic surgery training than with plastic surgery training, which may explain this difference. Inherent differences exist between orthopedic and plastic surgery training programs. The one area of considerable overlap is prerequisite hand surgery training. Ideally, the orthopedic and plastic surgery residency review committees would
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Fig. 4. Plastic surgery program director comfort level with each procedure. All PD, comfort level of all program directors with each procedure; PD-Hand, percentage of program directors with hand surgery fellowship training who were comfortable performing each individual procedure; PD-No Hand, percentage of program directors with no hand surgery fellowship training who were comfortable performing each individual procedure; OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
work together to develop a consensus regarding which procedures both disciplines should master before graduation. This could potentially facilitate interchangeable hand surgery call at hospitals such that either an orthopedic surgeon or a plastic surgeon could appropriately manage hand surgery consultations fluidly. In our anecdotal experience at a Level I tertiary referral center, the willingness of the referring orthopedic or plastic surgeon to manage certain hand surgery issues is dependent on many factors, one of which is their background training (orthopedic surgery versus plastic surgery). For example, orthopedic surgeons in the community are comfortable managing uncomplicated hand surgery fractures, whereas plastic surgeons in the community sometimes are not. Similarly, plastic surgeons in the community are comfortable managing flexor tendon injuries, whereas orthopedic surgeons in the community sometimes are not. Combining the plastic surgery and orthopedic surgery results from the current study and our previous study16 establish 10 essential procedures for training in hand surgery and could be used as a starting guideline for coordination between plastic
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surgery and orthopedic surgery residency review committees to develop a combined prerequisite training curriculum for hand surgery. These 10 procedures could also be used as a guideline for Accreditation Council for Graduate Medical Education–accredited hand surgery fellowships, which will have similar outcomes-based educational requirements after implementation of the Next Graduate Medical Education Accreditation System. The essential procedures for hand surgery fellowship, however, should probably be more comprehensive and lengthy, and contribution from hand surgery fellowship directors should be sought.21,22 VanHeest et al.13 published comprehensive detailed checklists for open carpal tunnel release, open reduction and internal fixation of distal radius fracture, and open A1 pulley release. The next step is to develop detailed checklists for the remaining procedures identified in this study. These checklists should be combined with a global ratings scale (also published by VanHeest et al.13) to objectively demonstrate competence with each procedure. It is unrealistic to expect every program to have resources to supply cadaver specimens for
Volume 132, Number 6 • Hand Surgery Procedures Objective Structured Assessment of Technical Skill sessions; thus, the Objective Structured Assessment of Technical Skill ideally will be incorporated into other venues, including the operating room and perhaps the surgical skills simulation laboratory. One approach involves the attending surgeon having a smartphone application containing the Objective Structured Assessment of Technical Skill detailed checklists and global ratings scales. The surgeon could then document the results of an Objective Structured Assessment of Technical Skill virtually at the conclusion of an appropriate case. According to Nasca et al.,1 programs with high-quality outcomes will be freed of constraining data collection processes and allowed to innovate with their educational processes. Under the Next Accreditation System, innovation, such as a comprehensive Objective Structured Assessment of Technical Skill program, will be strongly encouraged. The weaknesses of this study include the limited response rate of plastic surgery program directors (69 percent), the subjective selection of expert hand surgeons by the senior author (V.R.H.), and the initial selection of 15 hand surgery procedures distributed to the senior expert hand surgeons. Although the 69 percent response rate is not 100 percent, we believe it is reasonable for this type of study. Regarding the selection of expert hand surgeons by the senior author, we are confident that hand surgery colleagues would not disagree with the selected group, as they all have extensive experience training plastic surgery residents. Regarding the bias of the original 15 procedures, it is evident that this list of 15 is not inclusive of all possible hand surgery procedures that a plastic surgeon could encounter. It does correlate well with the plastic surgery milestones that have been suggested for the Next Graduate Medical Education Accreditation System and also reflects the senior author’s 35 years’ experience training plastic surgery residents and fellows. However, certain procedures, such as revision amputation and phalanx fracture fixation, may have been overlooked by both the authors and the senior expert hand surgeons. This survey technique and method have been previously documented by Fan et al.19 The strengths include the consensus regarding the essential nine procedures that should be mastered by graduating plastic surgery residents. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery. The findings of
this study can also be combined with our previous study16 and could be used as a starting point for coordination between plastic and orthopedic surgery residency review committees to develop a combined prerequisite training curriculum for hand surgery. These 10 procedures could also be used as a guideline for Accreditation Council for Graduate Medical Education–accredited hand surgery fellowships. Future areas for research include developing Objective Structured Assessment of Technical Skill checklists for all nine procedures suggested here, creating a combined hand surgery prerequisite curriculum for orthopedic and plastic surgery programs, and comparing our findings to actual procedural statistics from third-party payers. Shelley S. Noland, M.D. 4245 Roosevelt Way NE Seattle, Wash. 98105 [email protected]
REFERENCES 1. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system: Rationale and benefits. N Engl J Med. 2012;366:1051–1056. 2. Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29:648–654. 3. Reznick RK, MacRae H. Teaching surgical skills: Changes in the wind. N Engl J Med. 2006;355:2664–2669. 4. Bodle JF, Kaufmann SJ, Bisson D, Nathanson B, Binney DM. Value and face validity of objective structured assessment of technical skills (OSATS) for work based assessment of surgical skills in obstetrics and gynaecology. Med Teach. 2008;30:212–216. 5. Chipman JG, Schmitz CC. Using objective structured assessment of technical skills to evaluate a basic skills simulation curriculum for first-year surgical residents. J Am Coll Surg. 2009;209:364–370.e2. 6. Goff BA, Lentz GM, Lee D, Houmard B, Mandel LS. Development of an objective structured assessment of technical skills for obstetric and gynecology residents. Obstet Gynecol. 2000;96:146–150. 7. MacRae H, Regehr G, Leadbetter W, Reznick RK. A comprehensive examination for senior surgical residents. Am J Surg. 2000;179:190–193. 8. Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84:273–278. 9. Nielsen PE, Foglia LM, Mandel LS, Chow GE. Objective structured assessment of technical skills for episiotomy repair. Am J Obstet Gynecol. 2003;189:1257–1260. 10. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative “bench station” examination. Am J Surg. 1997;173:226–230. 11. Siddiqui NY, Stepp KJ, Lasch SJ, Mangel JM, Wu JM. Objective structured assessment of technical skills for repair of fourth-degree perineal lacerations. Am J Obstet Gynecol. 2008;199:676.e1–676.e6. 12. Sultana CJ. The objective structured assessment of technical skills and the ACGME competencies. Obstet Gynecol Clin North Am. 2006;33:259–265, viii.
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Plastic and Reconstructive Surgery • December 2013 13. VanHeest A, Kuzel B, Agel J, Putnam M, Kalliainen L, Fletcher J. Objective structured assessment of technical skill in upper extremity surgery. J Hand Surg Am. 2012;37: 332–337, 337.e1–337.e4. 14. Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84:273–278. 15. Faulkner H, Regehr G, Martin J, Reznick R. Validation of an objective structured assessment of technical skill for surgical residents. Acad Med. 1996;71:1363–1365. 16. Noland SS, Fischer LH, Lee GK, Hentz VR. Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: A survey of program directors. J Hand Surg Am. 2013;38:760–765. 17. Willis G. Beyond cognitive testing: Affiliated pretesting methods. In: Cognitive Interviewing: A Tool for Improving Questionnaire Design. Thousand Oaks, Calif: Sage; 2005: 230–254.
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18. Accreditation Council for Graduate Medical Education. The Plastic Surgery Milestone Project. Available at: www.acgmenas.org/assets/pdf/Milestones/PlasticSurgeryMilestones. pdf. Accessed May 5, 2013. 19. Fan K, Kawamoto HK, McCarthy JG, et al. Top five craniofacial techniques for training in plastic surgery residency. Plast Reconstr Surg. 2012;129:477e–487e. 20. Chung KC, Lau FH, Kotsis SV, Kim HM. Factors influencing residents’ decisions to pursue a career in hand surgery: A national survey. J Hand Surg Am. 2004;29:738–747. 21. Sears ED, Larson BP, Chung KC. Program director opinions of core competencies in hand surgery training: Analysis of differences between plastic and orthopedic surgery accredited programs. Plast Reconstr Surg. 2013;131:582–590. 22. Davis Sears E, Larson BP, Chung KC. A national survey of program director opinions of core competencies and structure of hand surgery fellowship training. J Hand Surg Am. 2012;37:1971–1977.e7.
M.D. M.D. M.D. M.D. M.D.
Stanford, Calif.; and Seattle, Wash.
Background: This study was designed to establish the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach technical skills in hand surgery. Methods: Ten expert hand surgeons were surveyed regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. The top 10 procedures from this survey were then used to survey all 89 Accreditation Council for Graduate Medical Education–approved plastic surgery program directors. Results: There was a 69 percent response rate to the program director survey (n = 61). The top nine hand surgery procedures included open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, closed reduction and percutaneous pinning of metacarpal fracture, excision of dorsal or volar ganglion, zone II flexor tendon repair with multistrand technique, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release. Conclusions: Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method for accomplishing this task. There has been no consensus regarding which hand surgery procedures should be mastered by graduating plastic surgery residents. The authors have identified nine procedures that are overwhelmingly supported by plastic surgery program directors. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery. (Plast. Reconstr. Surg. 132: 977e, 2013.)
N
asca et al. recently introduced the Next Graduate Medical Education Accreditation System.1 Building on the introduction of the six core competencies in 1999,2 the Accreditation Council for Graduate Medical Education is mandating considerable restructuring of graduate medical education. The Next Graduate Medical Education Accreditation System mandate for outcomesbased residency education presents a challenge From the Division of Plastic Surgery, Department of Surgery, and the Robert A. Chase Center for Hand and Upper Limb, Stanford University Hospital; and the Department of Orthopedic Surgery and the Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center. Received for publication March 19, 2013; accepted June 13, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a8066b
for surgical educators. Historically, surgical education has relied on written examinations and subjective evaluations. To meet the new requirements and adhere to the work-hour restrictions, surgical educators need to develop objective methods of teaching technical skills and document their attainment and retention. To accomplish this, the Objective Structured Assessment of Technical Skill has been introduced and implemented into surgical education.3–13 The Objective Structured Assessment of Technical Skill, first described by Martin et al.,14 consists of a benchtop, cadaver, or live animal model designed to simulate a specific technical skill. The technical ability of the resident is assessed using detailed checklists and a global ratings scale.15 Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • December 2013 The purpose of this article is to establish consensus regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. Our group has previously published the consensus regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents.16 This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.
METHODS Hand Surgery Expert Survey Ten senior expert hand surgeons selected by the senior author (V.R.H.) were sent an anonymous online survey.17 These 10 senior experts included department chairmen and program directors and were chosen based on their extensive experience training plastic surgery residents and fellows. They were given 15 common hand surgery procedures and asked to rank those that should be mastered by graduating plastic surgery residents. These 15 procedures were chosen based on both the proposed Plastic Surgery Residency Review Committee “milestones”18 as part of the Next Accreditation System and the senior author’s (V.R.H.) 35 years’ experience training plastic surgery residents. The 10 senior experts were also given the opportunity to suggest other procedures that may have been overlooked. The top 10 choices of the overall 15 were then used for the plastic surgery program director survey. This survey protocol was adapted from Fan et al.19 Plastic Surgery Program Director Survey All 89 Accreditation Council for Graduate Medical Education–approved plastic surgery program directors were sent an anonymous online survey. Using the established top 10 procedures from the hand surgery expert survey, we asked the program directors whether or not they felt each procedure should be mastered by graduating plastic surgery residents. We also asked about the presence of a hand surgery fellowship at their home institution, whether they themselves had completed a hand surgery fellowship, and whether they themselves were comfortable performing each of the procedures. This survey was adapted from Fan et al.19
RESULTS Hand Surgery Expert Survey We received a 90 percent response rate (n = 9) to our hand surgery expert survey. The 15
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Table 1. Ranked Results of the Expert Hand Surgery Survey 1. Open carpal tunnel release 2. Flexor tendon sheath steroid injection 3. Open A1 pulley release 4. Incision and drainage of the flexor tendon sheath for flexor tenosynovitis 5. Excision of dorsal or volar ganglion 6. Closed reduction and percutaneous pinning of metacarpal fracture 7. Open cubital tunnel release 8. Zone II flexor tendon repair with multistrand procedure 9. ORIF distal radius fracture 10. Digital nerve repair with microscope 11. Arthroplasty for basilar joint arthritis 12. Palmar fasciectomy for Dupuytren contracture 13. Percutaneous pinning of scaphoid fracture 14. Digital replantation 15. Syndactyly release ORIF, open reduction and internal fixation.
suggested procedures were ranked by importance for mastery by graduating plastic surgery residents (Table 1). Four additional “write-in” procedures were suggested by the senior experts (nail-bed repair, upper extremity fasciotomy, split-thickness skin graft, and de Quervain release), but none was suggested more than once and thus they were not incorporated into the program director survey. Plastic Surgery Program Director Survey We received a 69 percent response rate (n = 61 of 89) to our plastic surgery program director survey. The top 10 ranked procedures are shown in Figure 1. The top nine of the 10 procedures received overwhelming support (>90 percent of program directors felt that they should be mastered by graduating plastic surgery residents), whereas open reduction and internal fixation of distal radius fracture was not supported as unanimously (only 40 percent felt that this procedure should be mastered by graduating plastic surgery residents). When filtered for program directors that had completed a hand surgery fellowship [n = 21 (34 percent)] or for program directors with a hand surgery fellowship at their institution [n = 23 (38 percent)], there were only minimal differences in overall ranking (Figs. 2 and 3). The one exception was that 57 percent of program directors with a hand fellowship at their home institution felt that open reduction and internal fixation of distal radius fracture should be mastered by graduating plastic surgery residents compared with 30 percent of program directors with no hand fellowship at their home institution. All program directors that had completed a hand surgery fellowship were comfortable
Volume 132, Number 6 • Hand Surgery Procedures
Fig. 1. Ranked results of the plastic surgery program director survey showing the percentage of program directors who felt the individual procedure should be mastered by graduating plastic surgery residents. OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
performing the top nine procedures (Fig. 4). Sixty-seven percent of those who had completed a hand surgery fellowship were comfortable performing an open reduction and internal fixation of distal radius fracture. Of the program directors that had not completed a hand surgery fellowship, there was variability in comfort level, with greater than 70 percent comfortable performing the top nine procedures (Fig. 4).
DISCUSSION As program directors familiarize themselves with the details of the Next Graduate Medical Education Accreditation System, surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method of accomplishing this task as demonstrated by VanHeest et al.13 However, there has been no consensus on which hand surgery procedures should be mastered by graduating plastic surgery residents. The goal of this article was to identify hand surgery procedures that are overwhelmingly supported by plastic surgery program directors as essential and therefore are to be mastered by plastic surgery residents during their period of residency. We identified nine procedures that can be
used as a starting point and a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery. The Plastic Surgery Residency Review Committee is currently in the process of finalizing “milestones” for plastic surgery residents to master.18 Of the 14 patient care milestones currently being tested (under which technical ability is classified), two pertain to hand surgery. The first is nontrauma hand surgery, which includes seven of the nine procedures on our list (i.e., open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, excision of dorsal or volar ganglion, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release). The second is upper extremity trauma, which includes two of the nine procedures on our list (i.e., closed reduction and percutaneous pinning of metacarpal fracture and zone II flexor tendon repair with multistrand technique). Using these nine procedures to develop Objective Structured Assessment of Technical Skill would facilitate the assessment of these two milestones. The top nine procedure rankings differed only slightly when filtered for program directors with hand surgery fellowship training, suggesting
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Fig. 2. Ranked results of the program director survey with the percentage of program directors who felt the individual procedure should be mastered by graduating plastic surgery residents, broken down by program directors with and without hand surgery fellowship training. OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
a broad consensus with minimal bias introduced by the program director’s personal background and experience. Similarly, the rankings differed only slightly when filtered for program directors with a hand fellowship at their home institution, with one exception: open reduction and internal fixation of distal radius fracture. Fifty-seven percent of program directors with a hand fellowship at their home institution felt that open reduction and internal fixation should be mastered by graduating plastic surgery residents, compared with 30 percent of program directors with no hand fellowship at their home institution. Perhaps the residency programs with a hand surgery fellowship provide plastic surgery residents with increased access to hand surgery procedures, including distal radius fracture management. The program director may have noticed that his or her residents were performing this procedure routinely as part of their hand surgery rotation. As expected, all program directors who had completed a hand surgery fellowship were comfortable performing the top nine procedures, and 67 percent of this group were comfortable performing an open reduction and internal fixation
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of distal radius fracture. Of the program directors that had not completed a hand surgery fellowship, there was variability in comfort level, but greater than 70 percent were comfortable performing the top nine procedures, suggesting that plastic surgeons are learning (and retaining) the most common hand surgery procedures, even if the majority of their practice is not hand surgery. Hand surgery is one of many components of a comprehensive plastic surgery residency. Most of the program directors with no hand surgery fellowship training were comfortable with the top nine procedures. Although the majority of plastic surgery residents will not pursue a hand surgery fellowship,20 these top nine procedures are an important component of a comprehensive plastic surgery education. Fan et al. addressed this topic with regard to craniofacial surgery and identified five procedures (i.e., bone graft for nasal reconstruction, perialar rim bone graft, lateral canthopexy, osseous genioplasty, and bone graft harvest for orbital floor defects) that should be mastered by graduating plastic surgery residents.19 Similarly, the top procedures for other subspecialties of plastic surgery (e.g., breast reconstruction,
Volume 132, Number 6 • Hand Surgery Procedures
Fig. 3. Ranked results of the program director survey with the percentage of program directors who felt the individual procedure should be mastered by graduating plastic surgery residents, broken down by program directors with and without a hand surgery fellowship at their home institution. OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
cancer reconstruction, aesthetic surgery) should be established as a guideline for developing comprehensive Objective Structured Assessment of Technical Skill for mastery by graduating plastic surgery residents. Ideally, all plastic surgery residents would objectively demonstrate competence for each procedure before graduation. Our group recently published the essential hand surgery procedures for mastery by graduating orthopedic surgery residents.16 Nine procedures that are overwhelmingly supported by orthopedic surgery program directors were identified (i.e., open carpal tunnel release, open A1 pulley release, open reduction and internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of the flexor tendon sheath for flexor tenosynovitis). The two procedures deemed essential in the plastic surgery survey but not in the orthopedic surgery survey were zone II flexor tendon repair with multistrand technique and digital nerve repair with microscope. Only 40 percent of orthopedic surgery program directors felt that zone II flexor
tendon repair with multistrand technique was essential for mastery by graduating orthopedic surgery residents. Perhaps the program directors felt that the complex nature of this procedure warrants hand surgery fellowship training. Thirtytwo percent of orthopedic surgery program directors felt that digital nerve repair with microscope was essential for mastery by graduating orthopedic surgery residents. We posit that training in microsurgical skills is more commonly associated with plastic surgery training than with orthopedic surgery training; that may explain this difference. Likewise, open reduction and internal fixation of distal radius fracture was deemed essential to mastery by graduating orthopedic surgery residents (three-way tie for top technique) but not for graduating plastic surgery residents. We posit that training in fracture management is more commonly associated with orthopedic surgery training than with plastic surgery training, which may explain this difference. Inherent differences exist between orthopedic and plastic surgery training programs. The one area of considerable overlap is prerequisite hand surgery training. Ideally, the orthopedic and plastic surgery residency review committees would
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Fig. 4. Plastic surgery program director comfort level with each procedure. All PD, comfort level of all program directors with each procedure; PD-Hand, percentage of program directors with hand surgery fellowship training who were comfortable performing each individual procedure; PD-No Hand, percentage of program directors with no hand surgery fellowship training who were comfortable performing each individual procedure; OCTR, open carpal tunnel release; A1Pulley, open A1 pulley release; Nerve, digital nerve repair with microscope; CRPPMC, closed reduction and percutaneous pinning of metacarpal fracture; Ganglion, excision of dorsal or volar ganglion; ZIIFlexor, zone II flexor tendon repair with multistrand technique; Tenosynovitis, incision and drainage of the flexor tendon sheath for flexor tenosynovitis; Steroid, flexor tendon sheath steroid injection; Cubital, open cubital tunnel release; ORIFDR, open reduction and internal fixation of distal radius fracture.
work together to develop a consensus regarding which procedures both disciplines should master before graduation. This could potentially facilitate interchangeable hand surgery call at hospitals such that either an orthopedic surgeon or a plastic surgeon could appropriately manage hand surgery consultations fluidly. In our anecdotal experience at a Level I tertiary referral center, the willingness of the referring orthopedic or plastic surgeon to manage certain hand surgery issues is dependent on many factors, one of which is their background training (orthopedic surgery versus plastic surgery). For example, orthopedic surgeons in the community are comfortable managing uncomplicated hand surgery fractures, whereas plastic surgeons in the community sometimes are not. Similarly, plastic surgeons in the community are comfortable managing flexor tendon injuries, whereas orthopedic surgeons in the community sometimes are not. Combining the plastic surgery and orthopedic surgery results from the current study and our previous study16 establish 10 essential procedures for training in hand surgery and could be used as a starting guideline for coordination between plastic
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surgery and orthopedic surgery residency review committees to develop a combined prerequisite training curriculum for hand surgery. These 10 procedures could also be used as a guideline for Accreditation Council for Graduate Medical Education–accredited hand surgery fellowships, which will have similar outcomes-based educational requirements after implementation of the Next Graduate Medical Education Accreditation System. The essential procedures for hand surgery fellowship, however, should probably be more comprehensive and lengthy, and contribution from hand surgery fellowship directors should be sought.21,22 VanHeest et al.13 published comprehensive detailed checklists for open carpal tunnel release, open reduction and internal fixation of distal radius fracture, and open A1 pulley release. The next step is to develop detailed checklists for the remaining procedures identified in this study. These checklists should be combined with a global ratings scale (also published by VanHeest et al.13) to objectively demonstrate competence with each procedure. It is unrealistic to expect every program to have resources to supply cadaver specimens for
Volume 132, Number 6 • Hand Surgery Procedures Objective Structured Assessment of Technical Skill sessions; thus, the Objective Structured Assessment of Technical Skill ideally will be incorporated into other venues, including the operating room and perhaps the surgical skills simulation laboratory. One approach involves the attending surgeon having a smartphone application containing the Objective Structured Assessment of Technical Skill detailed checklists and global ratings scales. The surgeon could then document the results of an Objective Structured Assessment of Technical Skill virtually at the conclusion of an appropriate case. According to Nasca et al.,1 programs with high-quality outcomes will be freed of constraining data collection processes and allowed to innovate with their educational processes. Under the Next Accreditation System, innovation, such as a comprehensive Objective Structured Assessment of Technical Skill program, will be strongly encouraged. The weaknesses of this study include the limited response rate of plastic surgery program directors (69 percent), the subjective selection of expert hand surgeons by the senior author (V.R.H.), and the initial selection of 15 hand surgery procedures distributed to the senior expert hand surgeons. Although the 69 percent response rate is not 100 percent, we believe it is reasonable for this type of study. Regarding the selection of expert hand surgeons by the senior author, we are confident that hand surgery colleagues would not disagree with the selected group, as they all have extensive experience training plastic surgery residents. Regarding the bias of the original 15 procedures, it is evident that this list of 15 is not inclusive of all possible hand surgery procedures that a plastic surgeon could encounter. It does correlate well with the plastic surgery milestones that have been suggested for the Next Graduate Medical Education Accreditation System and also reflects the senior author’s 35 years’ experience training plastic surgery residents and fellows. However, certain procedures, such as revision amputation and phalanx fracture fixation, may have been overlooked by both the authors and the senior expert hand surgeons. This survey technique and method have been previously documented by Fan et al.19 The strengths include the consensus regarding the essential nine procedures that should be mastered by graduating plastic surgery residents. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery. The findings of
this study can also be combined with our previous study16 and could be used as a starting point for coordination between plastic and orthopedic surgery residency review committees to develop a combined prerequisite training curriculum for hand surgery. These 10 procedures could also be used as a guideline for Accreditation Council for Graduate Medical Education–accredited hand surgery fellowships. Future areas for research include developing Objective Structured Assessment of Technical Skill checklists for all nine procedures suggested here, creating a combined hand surgery prerequisite curriculum for orthopedic and plastic surgery programs, and comparing our findings to actual procedural statistics from third-party payers. Shelley S. Noland, M.D. 4245 Roosevelt Way NE Seattle, Wash. 98105 [email protected]
REFERENCES 1. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system: Rationale and benefits. N Engl J Med. 2012;366:1051–1056. 2. Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29:648–654. 3. Reznick RK, MacRae H. Teaching surgical skills: Changes in the wind. N Engl J Med. 2006;355:2664–2669. 4. Bodle JF, Kaufmann SJ, Bisson D, Nathanson B, Binney DM. Value and face validity of objective structured assessment of technical skills (OSATS) for work based assessment of surgical skills in obstetrics and gynaecology. Med Teach. 2008;30:212–216. 5. Chipman JG, Schmitz CC. Using objective structured assessment of technical skills to evaluate a basic skills simulation curriculum for first-year surgical residents. J Am Coll Surg. 2009;209:364–370.e2. 6. Goff BA, Lentz GM, Lee D, Houmard B, Mandel LS. Development of an objective structured assessment of technical skills for obstetric and gynecology residents. Obstet Gynecol. 2000;96:146–150. 7. MacRae H, Regehr G, Leadbetter W, Reznick RK. A comprehensive examination for senior surgical residents. Am J Surg. 2000;179:190–193. 8. Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84:273–278. 9. Nielsen PE, Foglia LM, Mandel LS, Chow GE. Objective structured assessment of technical skills for episiotomy repair. Am J Obstet Gynecol. 2003;189:1257–1260. 10. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative “bench station” examination. Am J Surg. 1997;173:226–230. 11. Siddiqui NY, Stepp KJ, Lasch SJ, Mangel JM, Wu JM. Objective structured assessment of technical skills for repair of fourth-degree perineal lacerations. Am J Obstet Gynecol. 2008;199:676.e1–676.e6. 12. Sultana CJ. The objective structured assessment of technical skills and the ACGME competencies. Obstet Gynecol Clin North Am. 2006;33:259–265, viii.
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Plastic and Reconstructive Surgery • December 2013 13. VanHeest A, Kuzel B, Agel J, Putnam M, Kalliainen L, Fletcher J. Objective structured assessment of technical skill in upper extremity surgery. J Hand Surg Am. 2012;37: 332–337, 337.e1–337.e4. 14. Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84:273–278. 15. Faulkner H, Regehr G, Martin J, Reznick R. Validation of an objective structured assessment of technical skill for surgical residents. Acad Med. 1996;71:1363–1365. 16. Noland SS, Fischer LH, Lee GK, Hentz VR. Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: A survey of program directors. J Hand Surg Am. 2013;38:760–765. 17. Willis G. Beyond cognitive testing: Affiliated pretesting methods. In: Cognitive Interviewing: A Tool for Improving Questionnaire Design. Thousand Oaks, Calif: Sage; 2005: 230–254.
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18. Accreditation Council for Graduate Medical Education. The Plastic Surgery Milestone Project. Available at: www.acgmenas.org/assets/pdf/Milestones/PlasticSurgeryMilestones. pdf. Accessed May 5, 2013. 19. Fan K, Kawamoto HK, McCarthy JG, et al. Top five craniofacial techniques for training in plastic surgery residency. Plast Reconstr Surg. 2012;129:477e–487e. 20. Chung KC, Lau FH, Kotsis SV, Kim HM. Factors influencing residents’ decisions to pursue a career in hand surgery: A national survey. J Hand Surg Am. 2004;29:738–747. 21. Sears ED, Larson BP, Chung KC. Program director opinions of core competencies in hand surgery training: Analysis of differences between plastic and orthopedic surgery accredited programs. Plast Reconstr Surg. 2013;131:582–590. 22. Davis Sears E, Larson BP, Chung KC. A national survey of program director opinions of core competencies and structure of hand surgery fellowship training. J Hand Surg Am. 2012;37:1971–1977.e7.
