ASSET: An effective educational experience for practicing surgeons

ASSET lab instructor Dr. Luchette reviewing anatomy with students.

ASSET lab instructor Dr. Luchette reviewing anatomy with students.

Numerous advances have occurred in trauma care in the past three decades, resulting in reduced rates of patient morbidity and mortality. One such advance—the evolution of radiologic imaging and computed tomography—has resulted in more precise and early diagnosis of numerous injuries. Most patients who are hemodynamically normal now can be managed nonoperatively. Simultaneously, a decrease in the incidence of gunshot wounds and stabbing injuries has occurred due to a reduction in personal violence, while improvements in automotive engineering have reduced traffic fatalities and confined more injuries to the extremities instead of the torso, based on the experiences of the authors of this article.

Work-hour restrictions have further limited residents’ opportunities to care for injured patients and elective surgical cases. Additionally, advances in laparoscopic surgery and endovascular techniques have reduced residents’ participation in more traditional, open surgical procedures. Taken together, these changes have significantly limited residents’ experience with the emergency life- and limb-saving operations necessary to care for injured patients.

Simulation has emerged as an educational modality to augment traditional experiential training in medicine. Several specialties have incorporated these new tools into resident training for learning outside the operating room. The American College of Surgeons (ACS) Program for Accredited Education Institutes is dedicated to educating trainees by using a variety of standardized, innovative teaching methods, including simulation. The American Board of Surgery has embraced the educational value of simulation offered by professional organizations with the requirement that candidates be certified in Advanced Trauma Life Support® and the Fundamentals of Laparoscopic Surgery before applying for the qualifying examination.

Course development

Table 1: ASSET pre- and post-course self-assessments, instructor mean evaluation scores

Table 1: ASSET pre- and post-course self-assessments, instructor mean evaluation scores

The ACS Committee on Trauma (COT) recognized the need to address the reduction in residents’ operative experience when caring for injured patients during surgical training. In 2005, the ACS COT leadership established the Surgical Skills Committee, which was charged with developing a standardized, didactic, skills-based course that was designed to teach proper techniques for exposing organs to treat various injuries. The committee comprised nationally recognized experts in trauma care from the ACS.

The committee’s first task was to define the course content. Each member submitted a description of either a life-threatening or limb-threatening injury to be considered for inclusion in the course. Using a modified Delphi process with a 90 percent consensus, the committee extracted a list of 50 injuries from these submissions, representing six anatomic regions: neck, thorax, abdomen, pelvis, retroperitoneum, and the extremities. Similar to the ACS Advanced Trauma Operative Management (ATOM) course, a modular format was selected for the course design. Each specific exercise in a module would begin with the presentation of a clinical scenario depicting the likely injuries: the Advanced Surgical Skills for Exposure in Trauma (ASSET) course.

Next, the instructor would present a narrated high-fidelity video demonstrating the pertinent anatomy and the technical maneuvers required for proper exposure of the specific injury. The instructor would then evaluate each student’s performance of the procedure. In contrast to the ATOM course—which assesses the student’s technical abilities to repair various injuries that have been simulated using a porcine model—the ASSET course assesses the student’s knowledge of anatomy and surgical skills to efficiently expose the injuries using a fresh, whole-body human cadaver.

The ASSET course is intended for senior surgery residents, fellows, and practicing community surgeons and can be completed in seven hours. Members of the committee created a student manual that includes educational objectives for each module. One chapter describes each of the 50 exposures and features color illustrations of the relevant anatomy, as well as a list of potential pitfalls. Each student receives a DVD that contains the videos illustrating each of the procedures.

A professional educator assisted with the development of various tools used to assess students’ prior experience, pre- and post-course self-efficacy, and perceptions of the course. Each student completes a survey that quantitates their previous operative experience. An additional questionnaire asks students to assess their ability to perform each of the operative exposures in the curriculum before and after completing the course.

Table 2: ASSET course mean evaluation scores

Table 2: ASSET course mean evaluation scores

A pretest was created to evaluate the student’s surgical and anatomic knowledge of the various exposures. After completing the course, students take a posttest. (The specific questions for the tests were created by the authors of each module and validated for content by the entire committee membership.) Finally, participants complete a 10-item questionnaire in which they are asked to rate the components of the course on a scale of 1 (poor) to 5 (excellent). The ACS Division of Education reviewed the course materials and evaluation tools and approved the ASSET course for continuing medical education credit.

Course assessment

The first ASSET course was offered in 2008 at the Uniformed Services University School of Medicine in Bethesda, MD. The faculty for this course and the subsequent courses were members of the COT Surgical Skills Committee. To further assess and refine the course format and content, five beta courses were presented from 2008 to 2010 at various educational centers. The sites included Northwestern Center for Advanced Surgical Education (n=2) in Chicago, IL; Stritch School of Medicine (Loyal University) (n=1) in Chicago; University of Nevada School of Medicine (n=1) in Las Vegas; and the University of Maryland School of Medicine (n=1) in Baltimore. Debriefing sessions at the end of each course provided valuable feedback on the course content, length of the course, and instructional materials. Each of the course evaluation tools also was revised based on statistical analysis of data from the beta sites. A total of 79 trainees (comprising PGY-4, PGY-5, and fellows), 36 from the U.S. and two international fellows, participated in the first five courses.

Figure 1: U.S. and Canadian ASSET training sites

Figure 1: U.S. and Canadian ASSET training sites

Data from the pre-course operative questionnaire confirm that senior surgical residents have a limited operative experience in trauma care during their training. The median number of trauma patients evaluated by participants was 250 and ranged from 20 to 2,000. Most (55 percent) of the trainees reported performing ≤1 procedures for 16 of the 29 procedures classified as trauma operations on the pre-course operative questionnaire. Trainee ratings of self-efficacy to perform surgical exposures in the six body regions increased from 2.84 before the course to 3.89 (1, low; 5, high) upon completion of the course. Ratings for each specific body region are summarized in Table 1. Instructors’ post-course evaluation of each participant’s ability to perform the various surgical exposures ranged from 3.93 to 4.12 (1, poor; 5, excellent) overall. The average rating for the post-course evaluation by the residents was 4.73 (range, 4.32 to 4.91), with a score of 5 signifying, “I would recommend this course to colleagues” (see Table 2).

Since 2010, the ACS COT Surgical Skills Committee has developed an instructor manual, a course director manual, and specific criteria needed to become a designated course site for the ASSET course. In 2010, ASSET became an official course of the ACS COT and is offered to senior surgical residents and fellows, as well as to practicing surgeons for continuing medical education credit. The Surgical Skills Committee oversees the ASSET and ATOM courses.

As of June, 83 ASSET courses have been completed across the U.S., encompassing more than 650 residents, fellows, and practicing surgeons who have completed the course. The course has also been promulgated to Canada, and plans are under way to introduce the ASSET course in other countries as well. More than 150 instructors have been trained, so ASSET is poised for continued growth. Figure 1 is a map of the U.S. and Canada representing states and provinces where ASSET training sites have been established.

If you are interested in registering for an ASSET course or offering an ASSET course at your institution, contact the ACS Trauma Department at asset@facs.org or by calling 312-202-5160.


Faculty and trainees from Las Vegas course in 2010.

Faculty and trainees from Las Vegas course in 2010.

Acknowledgements

The authors would like to acknowledge the significant contributions of many individuals to the ASSET course materials, ASSET Manual, and successful introduction of the ASSET Course.

Faculty and trainees at inaugural course at Uniformed Services University in 2008.

Faculty and trainees at inaugural course at Uniformed Services University in 2008.

John L. D. Atkinson, MD, FACSRochester, MNWalter L. Biffl, MD, FACSDenver, CO

Mark W. Bowyer, MD, FACS, DMCC

Bethesda, MD

Patricia Byers, MD, FACS

Miami, FL

Will Chapleau, EMT-P, RN, TNS

ATLS Program Manager

Chicago, IL

Joseph B. Cofer, MD, FACS

Chattanooga, TN

Raul Coimbra, MD, PhD, FACS

San Diego, CA

Francisco D. S. Collet de Silva, MD, FACS, PhD (med)

Sao Paulo, Brazil

Edward E. Cornwell, MD, FACS

Washington, DC

Paul R. G. Cunningham, MB, BS, FACS
Greenville, NC

Joseph Cuschieri, MD, FACS

Seattle, WA

Brad M. Cushing, MD, FACS

Portland, ME

Demetrios Demetriades, MD, FACS

Los Angeles, CA

Ronald I. Gross, MD, FACS

Springfield, MA

Enrique A. Guzman Cottallat, MD, FACSGuayaquil, EcuadorJeffrey S. Hammond, MD, FACSSomerville, NJ

David Harrington, MD, FACS

Providence, RI

Danielle S. Haskin

CME and Course Development Specialist

Chicago, IL

Sharon M. Henry, MD, FACS

Baltimore, MD

Rao R. Ivatury, MD, FACS

Richmond, VA

Lenworth M. Jacobs, Jr., MD, FACS

Hartford, CT

Gregory J. Jurkovich, MD, FACS

Denver, CO

M. Margaret Knudson, MD, FACS

San Francisco, CA

John B. Kortbeek, MD, FACS

Calgary, Alberta

Deborah Kuhls, MD, FACS

Las Vegas, NV

Sarvesh Logsetty, MD, FRCSC, FACS

Winnipeg, Manitoba

 

Fred A. Luchette, MD, FACSMaywood, ILStephen Luk, MD, FACSDallas, TX

Douglas Lundy, MD, FACS

Marietta, GA

Robert C. Mackersie, MD, FACS

San Francisco, CA

Mark A. Malangoni, MD, FACS

Philadelphia, PA

Joseph P. Minei, MD, FACS, FCCM

Dallas, TX

Frederick A. Moore, MD, FACS

Gainesville, FL

Allen F. Morey, MD, FACS

Dallas, TX

Kimberly Nagy, MD, FACS

Chicago, IL

Neil Parry, MD, FACS

London, ON

Renato Poggetti, MD, FACS

Sao Paulo, Brazil

Chrystal Price

Data Analyst, NTDB/TQIP

Chicago, IL

Peter Rhee, MD, MPH, FACS, FCCM, DMCC

Tucson, AZ

J. David Richardson, MD, FACS

Louisville, KY

Michael F. Rotondo, MD, FACSGreenville, NCAjit Sachdeva, MD, FACS, FRCSCDirector, Division of Education

Chicago, IL

Carol R. Schermer, MD, FACS

Maywood, IL

John T. Schulz III, MD, PhD, FACS

Bridgeport, CT

Ronald Simon, MD, FACS

New York, NY

Michael J. Sise, MD, FACS

San Diego, CA

David A. Spain, MD, FACS

Stanford, CA

Glen H. Tinkoff, MD, FACS

Newark, DE

Alex B. Valadka, MD, FACS

Austin, TX

Mary H. vanWijngaarden-Stephens, MD, FACS

Edmonton, AB

Matthew J. Wall, Jr., MD, FACS

Houston, TX

Carol Williams

Administrative Director,

Trauma Programs

Chicago, IL

David H. Wisner, MD, FACS

Sacramento, CA

 


References

  1. Fakhry SM, Watts DD, Michetti C, Hunt JP; EAST Multi-Institutional Blunt Hollow Viscous Injury Research Group. The resident experience on trauma: Declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study. J Trauma. 2003(1);54:1-8.
  2. Bittner JG, Hawkins ML, Medeiros RS, Beatty JS, Atteberry LR, Ferdinand CH, Mellinger JD. Non-operative management of solid organ injury diminishes surgical resident operative experience: Is it time for simulation training? J Surg Res. 2010;163(2):179-185. [Epub June 13, 2010.]
  3. Bulinski P, Bachulis B, Naylor DF Jr, Kam D, Carey M, Dean RE. The changing face of trauma management and its impact on surgical resident training. J Trauma. 2003;54(1):161-163.
  4. Lucas CE, Ledgerwood AM. The academic challenge of teaching psychomotor skills for hemostasis of solid organ injury. J Trauma. 2009;66(3):636-640.

The authors would like to acknowledge the significant contributions of many individuals to the ASSET course materials, ASSET Manual, and successful introduction of the ASSET Course.

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