Carol-Anne Moulton - Academia.edu (original) (raw)

Papers by Carol-Anne Moulton

Academic Medicine, 2010

Automaticity is integral to expert performance, but experts must be able to transition from an au... more Automaticity is integral to expert performance, but experts must be able to transition from an automatic mode into a more effortful state when required. In this study, the authors identified and characterized the manifestations of the phenomenon of "slowing down when you should" to stay out of trouble in operative practice. The authors interviewed 28 surgeons (60-minute, semistructured format) from various specialties at four academic medical centers and observed 5 hepatopancreatobiliary surgeons in the operating room (29 cases, 147 hours) during 2007-2009. Using a grounded theory qualitative methodology, they conducted a thematic analysis of transcripts and field notes in an iterative manner. Data collection continued until saturation. They adopted a reflexive approach throughout. Surgeons described and the authors observed four phenomenological manifestations of the transition to a more effortful state. In the most extreme manifestation, "stopping," surgeons actually stopped the procedure, whereas in the most subtle manifestation, "fine-tuning," surgeons were able to continue the procedure and focus on minor events simultaneously. A separate phenomenon of "drifting" represented surgeons' failure to transition out of the automatic mode when appropriate, resulting in surgical errors or near misses. The manifestations of the slowing down phenomenon represent acts of cognitive refocusing during the potentially more-critical moments of operative practice. Further, the authors challenge the conception of automaticity as effortless, arguing that automatic behavior can be attentive (fine-tuning) as well as inattentive (drifting).

Journal of Critical Care, 2015

The goal of this study was to better understand how clinical supervisors integrate teaching inter... more The goal of this study was to better understand how clinical supervisors integrate teaching interactions with medical trainees into 2 types of clinical activities in the critical care setting: multidisciplinary rounds and medical crises. We conducted a qualitative, observational study based on an ethnographic approach. We observed the teaching interactions among clinical supervisors and medical trainees during 12 multidisciplinary rounds and 74 medical crises in 2 academic hospitals. Grounded theory methods (theoretical sampling and saturation, inductive thematic coding, and constant comparison) were used to analyze data. Two models of integration of teaching interactions into clinical activities are described: the in series model, typical of multidisciplinary rounds and characterized by well-structured learning bubbles uninterrupted by patient care, and the in parallel model, common during medical crises and involving multiple, short learning flashes intricately related to and frequently interrupted by patient care. By adopting a model over the other, supervisors appeared to adapt to 2 contexts that differed in terms of priority, supervisor's understanding of events, and social context of interactions. Each model presented complementary opportunities and limitations for learning. Modern views of medical apprenticeship and clinical teaching need to take into account the specific clinical context in which learning occurs. Teaching interactions that differ in structure and content in response to changing clinical circumstances could impact learning in unique ways. Learning outcomes resulting from different models of integration of teaching into clinical activities need to be further explored.

Journal of the American College of Surgeons, 2014

Advances in Medical Education, 2011

Annals of the American Thoracic Society, 2015

ABSTRACT Rationale: In acute care environments, increased levels of trainee autonomy during clini... more ABSTRACT Rationale: In acute care environments, increased levels of trainee autonomy during clinical activities can represent unacceptable risks for patients. However, allowing progressive levels of trainee autonomy is considered essential for clinical learning. How clinical supervisors and trainees working in acute care environments can establish progressive levels of autonomy without compromising patient safety is largely unknown. Objectives: To explore how bedside interactions among clinical supervisors and medical trainees relate to trainee involvement in patient care and clinical oversight of trainees' clinical activities. Methods: We conducted a qualitative study based on constructivist grounded theory methodology. We selected participant observation as our data collection strategy. We observed the overt teaching interactions among critical care residents, fellows and staff physicians rotating in the critical care units of two Canadian university-affiliated hospitals during 74 acute care episodes. We used grounded theory methods for the data analysis and elaboration of a theoretical model of clinical supervision. Measurements and Main Results: A model of interactive clinical supervision is proposed based on three main themes: engaging without enactment, sharing care with support, and caring independently with feedback. Each theme regroups different types of teaching interactions observed among clinical supervisors and trainees. Engaging in monologues and dialogues about patient care and facilitating hands-off provision of care involved progressive levels of trainee involvement without risk for the patients. Facilitating hands-on provision of care and providing support-in-action encouraged higher levels of trainee involvement with limited risks for the patients. Providing feedback-on-action created learning opportunities after high level of trainee involvement in high-risk activities for the patients. Conclusions: Engaging in different types of teaching interactions during acute care episodes can help trainees to exercise progressive levels of autonomy and supervisors to provide adequate oversight of trainees' clinical activities. Our model of interactive clinical supervision can be used for faculty development initiatives. The learning outcomes resulting from different levels of trainee autonomy should be further explored. Primary Source of Funding: The Physicians' Services Incorporated (PSI) Foundation (operating grant).

Advances in Health Sciences Education, 2014

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clini... more Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Background: Psychological reactions of surgeons to their major errors and complications constitut... more Background: Psychological reactions of surgeons to their major errors and complications constitute an understudied area within the field of human factors associated with medical and diagnostic error. Understanding surgeons’ reactions is important in our overarching goal of studying error prevention, professional reaction, and response to error. The purpose of this study is to characterize surgeons’ reactions and responses to error and to explore the impact of these reactions on subsequent judgment and decision-making. Methods: A qualitative study with grounded theory iterative methodology was used to explore surgeons’ reactions to complication and error. The study is currently in Phase I, consisting of one-hour semi-structured interviews of surgeons from different specialties and at varying stages of their careers. These interviews focused on recollections of past reactions. A preliminary framework was created from the emergent themes discussed at the interviews. Psychological frame...

Annals of surgical oncology, Jan 29, 2015

Colorectal cancer liver metastases (CRLMs) are potentially curable with resection, but most patie... more Colorectal cancer liver metastases (CRLMs) are potentially curable with resection, but most patients recur and succumb to their disease. Clinical covariates do not account for all outcomes. Circulating tumor cells (CTCs) are prognostic in the primary and metastatic settings of breast, prostate and colorectal cancer (CRC), and evolving evidence supports their role in CRLMs. Our objective was to determine whether CTCs in peripheral (PV) and hepatic venous (HV) compartments are associated with disease-free survival (DFS) and overall survival (OS) post-CRLM resection. CTCs were measured by CellSearch assay from intraoperative HV and PV samples from 63 patients who underwent CRLM resection from June 2007 to August 2012 at a single center. DFS and OS were primary endpoints. HV CTCs > 3 were associated with shorter DFS and OS, but not PV CTCs, although no significant difference was found between CTC measurements in the two compartments. By univariate analysis, CRC stage and site, CRLM r...

Transactions of the ... Meeting of the American Surgical Association, 2006

Surgical skills laboratories have become an important venue for early skill acquisition. The prin... more Surgical skills laboratories have become an important venue for early skill acquisition. The principles that govern training in this novel educational environment remain largely unknown; the commonest method of training, especially for continuing medical education (CME), is a single multihour event. This study addresses the impact of an alternative method, where learning is distributed over a number of training sessions. The acquisition and transfer of a new skill to a life-like model is assessed. Thirty-eight junior surgical residents, randomly assigned to either massed (1 day) or distributed (weekly) practice regimens, were taught a new skill (microvascular anastomosis). Each group spent the same amount of time in practice. Performance was assessed pretraining, immediately post-training, and 1 month post-training. The ultimate test of anastomotic skill was assessed with a transfer test to a live, anesthetized rat. Previously validated computer-based and expert-based outcome measures were used. In addition, clinically relevant outcomes were assessed. Both groups showed immediate improvement in performance, but the distributed group performed significantly better on the retention test in most outcome measures (time, number of hand movements, and expert global ratings; all P values <0.05). The distributed group also outperformed the massed group on the live rat anastomosis in all expert-based measures (global ratings, checklist score, final product analysis, competency for OR; all P values <0.05). Our current model of training surgical skills using short courses (for both CME and structured residency curricula) may be suboptimal. Residents retain and transfer skills better if taught in a distributed manner. Despite the greater logistical challenge, we need to restructure training schedules to allow for distributed practice.

Cancer Metastasis – Biology and Treatment, 2011

ABSTRACT Few malignancies have their prognosis changed by resection of their metastatic deposits.... more ABSTRACT Few malignancies have their prognosis changed by resection of their metastatic deposits. Why this should be possible with colorectal cancer is being investigated by researchers worldwide. This observation, however, has seen surgical therapy of colorectal liver metastases witness revolutionary changes over the past years. Historically, liver resection was seen as a formidable operation fraught with complications. Perioperative safety has improved and specialist centers performing liver resection for colorectal liver metastases are reporting operative mortality rates of less than 1%. A challenge for the future is to make more patients eligible for curative intent surgery by downstaging the tumours with chemotherapy to make them resectable. Specialist centers are expanding the operations applied to this disease with vein resection, interposition vascular grafting, in-vivo liver isolation even ex vivo resections with re-implantation of the liver. Surgery is becoming safer for the patient and chemotherapy is slowing the progress of metastatic colorectal cancer to allow surgery to add more effectively to increase patient survival. Five year survival rates continue to improve. Chemotherapy does have effects on the liver which at times limit the possibilities for resection; however, newer therapies, combinations of therapies, timing and shorter courses of therapy see similar tumour responses without the deleterious effects. The amount of liver remaining after resection also limits which tumours are technically resectable. The volume of residual liver required has been further defined. Portal vein embolization can preoperatively selectively hypertrophy the future liver which the patient will be dependant upon. Better imaging and volumetric analysis has seen an extension of the criteria of what is thought resectable. Tumour margins of the resected specimen have been shown to be important only if less than 1mm, therefore expanding the indications for resection. The evolving field of chemotherapeutics will continue to push the limits of tumour response. These improvements will see dynamic changes in the roles of the members of the multidisciplinary cancer care team. KeywordsColorectal carcinoma-Liver metastasis-Surgical resection-Chemotherapy

Annals of Surgery, 2015

To explore surgeons&a... more To explore surgeons' perceptions of and potential concerns about coaching. There is growing recognition that the traditional model of continuing professional development is suboptimal. This has led to increasing interest in alternative strategies that take place within the actual practice environment such as coaching. However, if coaching is to be a successful strategy for continuing professional development, it will need to be accepted by surgeons. This was a qualitative interview-based study using a constructivist grounded theory approach. Participants included 14 surgeons from University of Toronto-affiliated hospitals. Participants expressed 3 main concerns about coaching: questioning the value of technical improvement ("As you get older if you don't have the stimulation from surgery to get better or to do things that are different and you are so good at so much, why bother [with coaching]?" P009), worry about appearing incompetent ("I think it would be perceived as either a sign of weakness or a sign of inability" P532), and concern about losing autonomy ("To me that would be real coaching where it's self-identified, I'm motivated, I find the person and then they coach me" P086). Coaching faces unique challenges in the context of a powerful surgical culture that values the portrayal of competency and instills the value of surgical autonomy. This study suggests that hanging on to these tightly held values of competency and autonomy is actually limiting the ways, and extent to which, surgeons can improve their practice.

Surgical Clinics of North America, 2012

is an active 56-year-old professor of engineering recently diagnosed with colorectal cancer. Eage... more is an active 56-year-old professor of engineering recently diagnosed with colorectal cancer. Eager to find the best surgeon around, Tom asked advice from a friend, a nurse on your surgical ward, who recommended he see you. He came to your office with his wife of 30 years and was relieved that you recommended surgery the week after. He said he would delay a preorganized family holiday he was taking with his wife and 3 children to get this surgery behind him. As he left the office, you thought how difficult this diagnosis must be for him briefly imagining how you might feel if you received the same news. You are not that different in age after all, and the thought of dying at such a young age was a little too difficult to imagine. It was a fairly straightforward operation with no signs that the cancer had spread elsewhere. The tumor was a little lower in the rectum than you expected, but you decided that a covering stoma was not necessary, so you performed the anastomosis and closed. Tom's wife and 3 teenaged children were waiting in the operating room as you walked in to tell them the good news.

ANZ journal of surgery, 2004

Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocyt... more Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocytoma. Our aim was to establish whether laparoscopic adrenalectomy for phaeochromocytoma was a safe and feasible technique at our institution. Patients requiring adrenalectomy were entered into a prospective database that included patient details, operative data, hormone excretion, tumour size, hospital stay and complications. All operations were performed under the supervision of a single surgeon. Analysis was performed for those patients with a diagnosis of phaeochromocytoma. Of 60 patients having laparoscopic adrenal surgery, 18 had phaeochromocytoma as the indication. Seventeen (89%) of 19 tumours in these 18 patients were successfully removed laparoscopically. Median operative time was 180 min (range 130-300 min) and this was significantly longer compared with other adrenal pathology. The median tumour size was 6 cm which was significantly larger than other adrenal tumours. Seven (38%...

Journal of Surgical Education, 2014

The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliar... more The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. Division of General Surgery, University of Toronto. HPB surgeons affiliated with the University of Toronto. A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

Journal of Surgical Education, 2014

The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliar... more The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. Division of General Surgery, University of Toronto. HPB surgeons affiliated with the University of Toronto. A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

JAMA, 2014

Patients with colorectal cancer with liver metastases undergo hepatic resection with curative int... more Patients with colorectal cancer with liver metastases undergo hepatic resection with curative intent. Positron emission tomography combined with computed tomography (PET-CT) could help avoid noncurative surgery by identifying patients with occult metastases. To determine the effect of preoperative PET-CT vs no PET-CT (control) on the surgical management of patients with resectable metastases and to investigate the effect of PET-CT on survival and the association between the standardized uptake value (ratio of tissue radioactivity to injected radioactivity adjusted by weight) and survival. A randomized trial of patients older than 18 years with colorectal cancer treated by surgery, with resectable metastases based on CT scans of the chest, abdomen, and pelvis within the previous 30 days, and with a clear colonoscopy within the previous 18 months was conducted between 2005 and 2013, involving 21 surgeons at 9 hospitals in Ontario, Canada, with PET-CT scanners at 5 academic institutions. Patients were randomized using a 2 to 1 ratio to PET-CT or control. The primary outcome was a change in surgical management defined as canceled hepatic surgery, more extensive hepatic surgery, or additional organ surgery based on the PET-CT. Survival was a secondary outcome. Of the 263 patients who underwent PET-CT, 21 had a change in surgical management (8.0%; 95% CI, 5.0%-11.9%). Specifically, 7 patients (2.7%) did not undergo laparotomy, 4 (1.5%) had more extensive hepatic surgery, 9 (3.4%) had additional organ surgery (8 of whom had hepatic resection), and the abdominal cavity was opened in 1 patient but hepatic surgery was not performed and the cavity was closed. Liver resection was performed in 91% of patients in the PET-CT group and 92% of the control group. After a median follow-up of 36 months, the estimated mortality rate was 11.13 (95% CI, 8.95-13.68) events/1000 person-months for the PET-CT group and 12.71 (95% CI, 9.40-16.80) events/1000 person-months for the control group. Survival did not differ between the 2 groups (hazard ratio, 0.86 [95% CI, 0.60-1.21]; P = .38). The standardized uptake value was associated with survival (hazard ratio, 1.11 [90% CI, 1.07-1.15] per unit increase; P < .001). The C statistic for the model including the standardized uptake value was 0.62 (95% CI, 0.56-0.68) and without it was 0.50 (95% CI, 0.44-0.56). The difference in C statistics is 0.12 (95% CI, 0.04-0.21). The low C statistic suggests that the standard uptake value is not a strong predictor of overall survival. Among patients with potentially resectable hepatic metastases of colorectal adenocarcinoma, the use of PET-CT compared with CT alone did not result in frequent change in surgical management. These findings raise questions about the value of PET-CT scans in this setting. clinicaltrials.gov Identifier: NCT00265356.

Academic Medicine, 2010

Automaticity is integral to expert performance, but experts must be able to transition from an au... more Automaticity is integral to expert performance, but experts must be able to transition from an automatic mode into a more effortful state when required. In this study, the authors identified and characterized the manifestations of the phenomenon of "slowing down when you should" to stay out of trouble in operative practice. The authors interviewed 28 surgeons (60-minute, semistructured format) from various specialties at four academic medical centers and observed 5 hepatopancreatobiliary surgeons in the operating room (29 cases, 147 hours) during 2007-2009. Using a grounded theory qualitative methodology, they conducted a thematic analysis of transcripts and field notes in an iterative manner. Data collection continued until saturation. They adopted a reflexive approach throughout. Surgeons described and the authors observed four phenomenological manifestations of the transition to a more effortful state. In the most extreme manifestation, "stopping," surgeons actually stopped the procedure, whereas in the most subtle manifestation, "fine-tuning," surgeons were able to continue the procedure and focus on minor events simultaneously. A separate phenomenon of "drifting" represented surgeons' failure to transition out of the automatic mode when appropriate, resulting in surgical errors or near misses. The manifestations of the slowing down phenomenon represent acts of cognitive refocusing during the potentially more-critical moments of operative practice. Further, the authors challenge the conception of automaticity as effortless, arguing that automatic behavior can be attentive (fine-tuning) as well as inattentive (drifting).

Journal of Critical Care, 2015

The goal of this study was to better understand how clinical supervisors integrate teaching inter... more The goal of this study was to better understand how clinical supervisors integrate teaching interactions with medical trainees into 2 types of clinical activities in the critical care setting: multidisciplinary rounds and medical crises. We conducted a qualitative, observational study based on an ethnographic approach. We observed the teaching interactions among clinical supervisors and medical trainees during 12 multidisciplinary rounds and 74 medical crises in 2 academic hospitals. Grounded theory methods (theoretical sampling and saturation, inductive thematic coding, and constant comparison) were used to analyze data. Two models of integration of teaching interactions into clinical activities are described: the in series model, typical of multidisciplinary rounds and characterized by well-structured learning bubbles uninterrupted by patient care, and the in parallel model, common during medical crises and involving multiple, short learning flashes intricately related to and frequently interrupted by patient care. By adopting a model over the other, supervisors appeared to adapt to 2 contexts that differed in terms of priority, supervisor's understanding of events, and social context of interactions. Each model presented complementary opportunities and limitations for learning. Modern views of medical apprenticeship and clinical teaching need to take into account the specific clinical context in which learning occurs. Teaching interactions that differ in structure and content in response to changing clinical circumstances could impact learning in unique ways. Learning outcomes resulting from different models of integration of teaching into clinical activities need to be further explored.

Journal of the American College of Surgeons, 2014

Advances in Medical Education, 2011

Annals of the American Thoracic Society, 2015

ABSTRACT Rationale: In acute care environments, increased levels of trainee autonomy during clini... more ABSTRACT Rationale: In acute care environments, increased levels of trainee autonomy during clinical activities can represent unacceptable risks for patients. However, allowing progressive levels of trainee autonomy is considered essential for clinical learning. How clinical supervisors and trainees working in acute care environments can establish progressive levels of autonomy without compromising patient safety is largely unknown. Objectives: To explore how bedside interactions among clinical supervisors and medical trainees relate to trainee involvement in patient care and clinical oversight of trainees' clinical activities. Methods: We conducted a qualitative study based on constructivist grounded theory methodology. We selected participant observation as our data collection strategy. We observed the overt teaching interactions among critical care residents, fellows and staff physicians rotating in the critical care units of two Canadian university-affiliated hospitals during 74 acute care episodes. We used grounded theory methods for the data analysis and elaboration of a theoretical model of clinical supervision. Measurements and Main Results: A model of interactive clinical supervision is proposed based on three main themes: engaging without enactment, sharing care with support, and caring independently with feedback. Each theme regroups different types of teaching interactions observed among clinical supervisors and trainees. Engaging in monologues and dialogues about patient care and facilitating hands-off provision of care involved progressive levels of trainee involvement without risk for the patients. Facilitating hands-on provision of care and providing support-in-action encouraged higher levels of trainee involvement with limited risks for the patients. Providing feedback-on-action created learning opportunities after high level of trainee involvement in high-risk activities for the patients. Conclusions: Engaging in different types of teaching interactions during acute care episodes can help trainees to exercise progressive levels of autonomy and supervisors to provide adequate oversight of trainees' clinical activities. Our model of interactive clinical supervision can be used for faculty development initiatives. The learning outcomes resulting from different levels of trainee autonomy should be further explored. Primary Source of Funding: The Physicians' Services Incorporated (PSI) Foundation (operating grant).

Advances in Health Sciences Education, 2014

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clini... more Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Background: Psychological reactions of surgeons to their major errors and complications constitut... more Background: Psychological reactions of surgeons to their major errors and complications constitute an understudied area within the field of human factors associated with medical and diagnostic error. Understanding surgeons’ reactions is important in our overarching goal of studying error prevention, professional reaction, and response to error. The purpose of this study is to characterize surgeons’ reactions and responses to error and to explore the impact of these reactions on subsequent judgment and decision-making. Methods: A qualitative study with grounded theory iterative methodology was used to explore surgeons’ reactions to complication and error. The study is currently in Phase I, consisting of one-hour semi-structured interviews of surgeons from different specialties and at varying stages of their careers. These interviews focused on recollections of past reactions. A preliminary framework was created from the emergent themes discussed at the interviews. Psychological frame...

Annals of surgical oncology, Jan 29, 2015

Colorectal cancer liver metastases (CRLMs) are potentially curable with resection, but most patie... more Colorectal cancer liver metastases (CRLMs) are potentially curable with resection, but most patients recur and succumb to their disease. Clinical covariates do not account for all outcomes. Circulating tumor cells (CTCs) are prognostic in the primary and metastatic settings of breast, prostate and colorectal cancer (CRC), and evolving evidence supports their role in CRLMs. Our objective was to determine whether CTCs in peripheral (PV) and hepatic venous (HV) compartments are associated with disease-free survival (DFS) and overall survival (OS) post-CRLM resection. CTCs were measured by CellSearch assay from intraoperative HV and PV samples from 63 patients who underwent CRLM resection from June 2007 to August 2012 at a single center. DFS and OS were primary endpoints. HV CTCs > 3 were associated with shorter DFS and OS, but not PV CTCs, although no significant difference was found between CTC measurements in the two compartments. By univariate analysis, CRC stage and site, CRLM r...

Transactions of the ... Meeting of the American Surgical Association, 2006

Surgical skills laboratories have become an important venue for early skill acquisition. The prin... more Surgical skills laboratories have become an important venue for early skill acquisition. The principles that govern training in this novel educational environment remain largely unknown; the commonest method of training, especially for continuing medical education (CME), is a single multihour event. This study addresses the impact of an alternative method, where learning is distributed over a number of training sessions. The acquisition and transfer of a new skill to a life-like model is assessed. Thirty-eight junior surgical residents, randomly assigned to either massed (1 day) or distributed (weekly) practice regimens, were taught a new skill (microvascular anastomosis). Each group spent the same amount of time in practice. Performance was assessed pretraining, immediately post-training, and 1 month post-training. The ultimate test of anastomotic skill was assessed with a transfer test to a live, anesthetized rat. Previously validated computer-based and expert-based outcome measures were used. In addition, clinically relevant outcomes were assessed. Both groups showed immediate improvement in performance, but the distributed group performed significantly better on the retention test in most outcome measures (time, number of hand movements, and expert global ratings; all P values <0.05). The distributed group also outperformed the massed group on the live rat anastomosis in all expert-based measures (global ratings, checklist score, final product analysis, competency for OR; all P values <0.05). Our current model of training surgical skills using short courses (for both CME and structured residency curricula) may be suboptimal. Residents retain and transfer skills better if taught in a distributed manner. Despite the greater logistical challenge, we need to restructure training schedules to allow for distributed practice.

Cancer Metastasis – Biology and Treatment, 2011

ABSTRACT Few malignancies have their prognosis changed by resection of their metastatic deposits.... more ABSTRACT Few malignancies have their prognosis changed by resection of their metastatic deposits. Why this should be possible with colorectal cancer is being investigated by researchers worldwide. This observation, however, has seen surgical therapy of colorectal liver metastases witness revolutionary changes over the past years. Historically, liver resection was seen as a formidable operation fraught with complications. Perioperative safety has improved and specialist centers performing liver resection for colorectal liver metastases are reporting operative mortality rates of less than 1%. A challenge for the future is to make more patients eligible for curative intent surgery by downstaging the tumours with chemotherapy to make them resectable. Specialist centers are expanding the operations applied to this disease with vein resection, interposition vascular grafting, in-vivo liver isolation even ex vivo resections with re-implantation of the liver. Surgery is becoming safer for the patient and chemotherapy is slowing the progress of metastatic colorectal cancer to allow surgery to add more effectively to increase patient survival. Five year survival rates continue to improve. Chemotherapy does have effects on the liver which at times limit the possibilities for resection; however, newer therapies, combinations of therapies, timing and shorter courses of therapy see similar tumour responses without the deleterious effects. The amount of liver remaining after resection also limits which tumours are technically resectable. The volume of residual liver required has been further defined. Portal vein embolization can preoperatively selectively hypertrophy the future liver which the patient will be dependant upon. Better imaging and volumetric analysis has seen an extension of the criteria of what is thought resectable. Tumour margins of the resected specimen have been shown to be important only if less than 1mm, therefore expanding the indications for resection. The evolving field of chemotherapeutics will continue to push the limits of tumour response. These improvements will see dynamic changes in the roles of the members of the multidisciplinary cancer care team. KeywordsColorectal carcinoma-Liver metastasis-Surgical resection-Chemotherapy

Annals of Surgery, 2015

To explore surgeons&a... more To explore surgeons' perceptions of and potential concerns about coaching. There is growing recognition that the traditional model of continuing professional development is suboptimal. This has led to increasing interest in alternative strategies that take place within the actual practice environment such as coaching. However, if coaching is to be a successful strategy for continuing professional development, it will need to be accepted by surgeons. This was a qualitative interview-based study using a constructivist grounded theory approach. Participants included 14 surgeons from University of Toronto-affiliated hospitals. Participants expressed 3 main concerns about coaching: questioning the value of technical improvement ("As you get older if you don't have the stimulation from surgery to get better or to do things that are different and you are so good at so much, why bother [with coaching]?" P009), worry about appearing incompetent ("I think it would be perceived as either a sign of weakness or a sign of inability" P532), and concern about losing autonomy ("To me that would be real coaching where it's self-identified, I'm motivated, I find the person and then they coach me" P086). Coaching faces unique challenges in the context of a powerful surgical culture that values the portrayal of competency and instills the value of surgical autonomy. This study suggests that hanging on to these tightly held values of competency and autonomy is actually limiting the ways, and extent to which, surgeons can improve their practice.

Surgical Clinics of North America, 2012

is an active 56-year-old professor of engineering recently diagnosed with colorectal cancer. Eage... more is an active 56-year-old professor of engineering recently diagnosed with colorectal cancer. Eager to find the best surgeon around, Tom asked advice from a friend, a nurse on your surgical ward, who recommended he see you. He came to your office with his wife of 30 years and was relieved that you recommended surgery the week after. He said he would delay a preorganized family holiday he was taking with his wife and 3 children to get this surgery behind him. As he left the office, you thought how difficult this diagnosis must be for him briefly imagining how you might feel if you received the same news. You are not that different in age after all, and the thought of dying at such a young age was a little too difficult to imagine. It was a fairly straightforward operation with no signs that the cancer had spread elsewhere. The tumor was a little lower in the rectum than you expected, but you decided that a covering stoma was not necessary, so you performed the anastomosis and closed. Tom's wife and 3 teenaged children were waiting in the operating room as you walked in to tell them the good news.

ANZ journal of surgery, 2004

Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocyt... more Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocytoma. Our aim was to establish whether laparoscopic adrenalectomy for phaeochromocytoma was a safe and feasible technique at our institution. Patients requiring adrenalectomy were entered into a prospective database that included patient details, operative data, hormone excretion, tumour size, hospital stay and complications. All operations were performed under the supervision of a single surgeon. Analysis was performed for those patients with a diagnosis of phaeochromocytoma. Of 60 patients having laparoscopic adrenal surgery, 18 had phaeochromocytoma as the indication. Seventeen (89%) of 19 tumours in these 18 patients were successfully removed laparoscopically. Median operative time was 180 min (range 130-300 min) and this was significantly longer compared with other adrenal pathology. The median tumour size was 6 cm which was significantly larger than other adrenal tumours. Seven (38%...

Journal of Surgical Education, 2014

The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliar... more The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. Division of General Surgery, University of Toronto. HPB surgeons affiliated with the University of Toronto. A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

Journal of Surgical Education, 2014

The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliar... more The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. Division of General Surgery, University of Toronto. HPB surgeons affiliated with the University of Toronto. A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

JAMA, 2014

Patients with colorectal cancer with liver metastases undergo hepatic resection with curative int... more Patients with colorectal cancer with liver metastases undergo hepatic resection with curative intent. Positron emission tomography combined with computed tomography (PET-CT) could help avoid noncurative surgery by identifying patients with occult metastases. To determine the effect of preoperative PET-CT vs no PET-CT (control) on the surgical management of patients with resectable metastases and to investigate the effect of PET-CT on survival and the association between the standardized uptake value (ratio of tissue radioactivity to injected radioactivity adjusted by weight) and survival. A randomized trial of patients older than 18 years with colorectal cancer treated by surgery, with resectable metastases based on CT scans of the chest, abdomen, and pelvis within the previous 30 days, and with a clear colonoscopy within the previous 18 months was conducted between 2005 and 2013, involving 21 surgeons at 9 hospitals in Ontario, Canada, with PET-CT scanners at 5 academic institutions. Patients were randomized using a 2 to 1 ratio to PET-CT or control. The primary outcome was a change in surgical management defined as canceled hepatic surgery, more extensive hepatic surgery, or additional organ surgery based on the PET-CT. Survival was a secondary outcome. Of the 263 patients who underwent PET-CT, 21 had a change in surgical management (8.0%; 95% CI, 5.0%-11.9%). Specifically, 7 patients (2.7%) did not undergo laparotomy, 4 (1.5%) had more extensive hepatic surgery, 9 (3.4%) had additional organ surgery (8 of whom had hepatic resection), and the abdominal cavity was opened in 1 patient but hepatic surgery was not performed and the cavity was closed. Liver resection was performed in 91% of patients in the PET-CT group and 92% of the control group. After a median follow-up of 36 months, the estimated mortality rate was 11.13 (95% CI, 8.95-13.68) events/1000 person-months for the PET-CT group and 12.71 (95% CI, 9.40-16.80) events/1000 person-months for the control group. Survival did not differ between the 2 groups (hazard ratio, 0.86 [95% CI, 0.60-1.21]; P = .38). The standardized uptake value was associated with survival (hazard ratio, 1.11 [90% CI, 1.07-1.15] per unit increase; P < .001). The C statistic for the model including the standardized uptake value was 0.62 (95% CI, 0.56-0.68) and without it was 0.50 (95% CI, 0.44-0.56). The difference in C statistics is 0.12 (95% CI, 0.04-0.21). The low C statistic suggests that the standard uptake value is not a strong predictor of overall survival. Among patients with potentially resectable hepatic metastases of colorectal adenocarcinoma, the use of PET-CT compared with CT alone did not result in frequent change in surgical management. These findings raise questions about the value of PET-CT scans in this setting. clinicaltrials.gov Identifier: NCT00265356.