key: cord-0805804-3ke93c0g
authors: Wlodarczyk, Jordan R.; Alicuben, Evan T.; Hawley, Lauren; Sullivan, Maura; Ault, Glenn T.; Inaba, Kenji
title: Development and emergency implementation of an online surgical education curriculum for a General Surgery program during a global pandemic: The University of Southern California experience
date: 2020-09-03
journal: Am J Surg
DOI: 10.1016/j.amjsurg.2020.08.045
sha: 7262d80461b282854a760b30a732c53ca1c52776
doc_id: 805804
cord_uid: 3ke93c0g

BACKGROUND: Physical distancing required by coronavirus disease 2019 (COVID-19) has limited traditional in-person resident education. We present our novel online curriculum for incorporation into traditional surgical educational programs. METHODS: The online curriculum utilized weekly sub-specialty themed faculty and resident created lectures, ABSITE practice questions, and weekly sub-specialty synchronized readings. Attendance, resident and faculty surveys, and completed ABSITE practice questions evaluated for curriculum success. Curriculum was adapted as COVID-19 clinical restructuring ended. RESULTS: 77% and 80% of clinical residents attended faculty lectures and resident led topic discussions as compared to 66% and 48% attending traditional in-person grand rounds and SCORE curriculum (both p > 0.05). 71.9% of residents and 16.6% of faculty reported improved resident participation while none reported decreased levels of participation (p < 0.001). 87.1% of residents and 66.7% of faculty preferred the online curriculum (p = 0.374). Completed ABSITE practice questions per resident increased from 21 to 31 questions/week (p = 0.541). CONCLUSION: Our online educational curriculum demonstrates success and can serve as a model for online restructuring of resident education.

In response to the coronavirus disease 2019 (COVID-19) pandemic, surgical programs worldwide have restructured their clinical and educational activities to prepare for the anticipated surge of patients and have physically distanced their residents, thus decreasing the potential for cross-contamination. 1,2 To maintain continuity of education at our institution, we developed and implemented a multimodal curriculum over the course of 3 days in compliance with the Accreditation Council for Graduate Medical Education (ACGME) mandate on March 13 th 2020 ( Figure 1 ). This mandate emphasized the need for continuing educational activities while decreasing inter-trainee contact 3, 4 The goal of our educational curriculum was to facilitate knowledge retention through the incorporation of a multimodal educational platform. Home readings coupled with online lectures were designed to facilitate knowledge acquisition while an online question bank and online question review sessions designed in a flipped classroom setting facilitated active knowledge recall and integration. This substituted for the traditional in-person didactic model. Here we describe the rapid restructuring of our educational curriculum, provide a roadmap for recreation at other institutions and discuss the incorporation of this curriculum into training programs post-pandemic.

Thirty-five General Surgery residents from an ACGME Accredited program participated in the online curriculum which began March 23 rd , 2020. We utilized our institutional Health Insurance Portability and Accountability Act (HIPAA) compliant version of Zoom as the foundation our interactive e-curriculum (Zoom Video Communications, Inc., San Jose, J o u r n a l P r e -p r o o f 3 California). We chose this because online e-learning has the capacity to satisfy three major pillars of knowledge acquisition: interaction with content, interaction with instructors, and interaction among peers 5 .

We felt it was critical to provide organized structure for daily activities. Our daily educational activities incorporated a surgical sub-specialty weekly theme which focused discussion at specific specialties ( Figure 2 ). Each day, a topic was selected, and two text chapters were assigned in preparation for the daily online activity (Figure 3 ). Faculty lectures were scheduled during previously protected educational time facilitating the greatest number of resident attendance while the resident led lectures were scheduled for after work hours to facilitate resident attendance. Each day, residents participated in 1-2 online activities to allow for interaction. All sessions were developed for the curriculum with novel content. The content was created to stimulate both passive and active learning in a flipped classroom setting with educational activities every day. Educational activities were structured to stimulate not only superior knowledge acquisition, but also active recall and utilization of knowledge acquired.

Specific educational modules were created to practice test taking strategies, conquer test anxiety, and practice critical thinking. These educational activities included:

Faculty preference guided selection of lecture topics with readings of textbook chapters and relevant clinical guidelines selected as preparation for the residents (Figure 4 ). These topics, chosen by faculty, were scheduled three times per week. We found little difficulty filling the spots because of faculty interest in their chosen topic. Two faculty lectures were directed at core surgical content and the third lecture was directed at an increasingly complex topic. Our online J o u r n a l P r e -p r o o f 4 platform allowed for faculty members to interact electronically by asking and fielding questions directly from the residents.

Two resident-led sessions were scheduled for the remaining days of the week. These sessions fostered resident educational independence through presentation development and delivery, and improvement of cognitive thought processes. Each surgical topic was split into components with an accompanying list of questions to be addressed by a single resident (Table   1) .

Weekly journal club sessions discussing two publications were included as residentgenerated content. First, a landmark study within the weekly sub-specialty theme was included to understand the foundation for management decisions considered standard of care. The second study consisted of a contemporary publication examining an unsettled issue in the literature. The discussion focused on study design critiques and considerations for integration into current surgical practices. Each assigned article was presented by one senior resident (PGY4-5) and one junior resident (PGY1-3) and guidelines were provided with specific questions to be addressed (Table 2) .

Based on the previous week's sub-specialty theme senior residents led moderated review sessions of ABSITE exam type questions. Participants were encouraged to read through and answer the test questions vocalizing their critical thinking process. This exercise in articulation of critical thinking is directly applicable to oral board scenarios. Test taking strategies were discussed in the context of answer elimination, question stem analysis and logical guessing with J o u r n a l P r e -p r o o f 5 higher-level reasoning questions stemming from the original clinical scenario available for more senior residents.

All sessions were recorded and accompanying presentation materials were uploaded to our institution's cloud-based HIPAA file sharing educational repository. The educational repository was organized by the week's sub-specialty theme providing an opportunity for those unable to attend the live online session to watch the content later providing the ability for residents on clinical duties to learn on their own schedule. 

When evaluated, faculty lectures were attended by 77% (n=27) of clinical residents as compared to pre-COVID in-person grand rounds which averaged an attendance of 66% (n=23) (p=0.289). Resident driven topic discussions, journal clubs, and question sessions were attended by 80% (n=28), 54% (n=19), and 62% (n=13) of clinical residents, respectively. This compared favorably to the average attendance of 48% (n=10) for the pre-COVID in-person SCORE educational sessions. Attendance at resident driven topic discussions was statistically higher than in-person SCORE educational sessions (p=0.012) while journal clubs, and question sessions were not (p=0.628 and p=0.352, respectively). Our faculty lecture recorded lectures have also been re-watched on average an additional 24 times which contributes more to their viewership. 

The resident survey was completed by 94% (n=32) of clinical residents. The majority of the residents reported an increase in the weekly time devoted to their education, from <2 hours/week (37.5% of respondents, n=12) before the implementation of the online educational platform to 6-8 hours/week (40.0% of respondents, n=13) after its implementation. 56.2% of clinical residents (n=15) reported completing around 40-60% of their assigned readings per week while only 12.5% (n=4) reported failure to complete any assigned readings. When asked why they chose to participate 90.6% (n=29) cited their desire to support their colleagues while presenting and 96.1% (n=30) cited its important educational benefit. 71.9% (n=23) stated their level of participation in the sessions was improved from pre-COVID in-person didactic sessions.

Of the 23 clinical residents who reported more participation 52.2% (n=12) cited increased comfort with the informal educational environment and greater comfort asking questions through the online platform's chat features as opposed to the in-person sessions.

When asked as to the weaknesses of the online educational platform, 66.7% (n=14) stated that too much content was assigned per week. 85.7% (n=12) of these respondents indicated that the readings were over assigned. When asked to state the weaknesses of the pre-COVID inperson didactic educational curriculum 75.0% (n=24) responded that they were too busy with clinical duties to attend the in-person sessions and 56.3% (n=18) stated that the in-person Impressively, resident attendance for these resident driven presentations mirrored faculty lead sessions (80% vs. 77%, respectively). This was hypothesized to be due to an accountability felt to their fellow resident presenter with over 90% of reporting a strong desire to support their presenting colleagues. This not only increased participation but also had the benefit of fostering a sense of solidarity in a time of physical isolation. 6 Interaction with peers is increasingly becoming a recognized protective factor in resident burnout. 7 Arguments against incorporating an online educational platform stem from its inability to foster traditional interpersonal interactions. Body language expressed by the audience can be an important tool for the presenter to assess audience engagement and adapt the pace and audience interaction of the lecture in real time. An interesting observation that was made between our resident and faculty surveys was the discordance between self-reported resident participation and presenting faculty's perception of resident participation. While 71.9% of residents reported that their level of participation was increased only 16.6% of presenting faculty reported the same increase in resident participation. While it is important to note that none of the residents or faculty surveyed reported less participation, the discordance in opinion can be explained by two factors; a lack resident comfort asking questions and presenting viewpoints on the online 12 platform, and the inability of the presenting faculty to assess audience engagement over the online platform. As our residents and faculty's experience with Zoom increases, their ability to utilize this technology to facilitate interaction will only grow. The presenter's ability to assess audience engagement can be improved increased experience checking the chat feature of Zoom for questions posed by residents, utilizing the poll feature to gauge audience comprehension of a specific topic, and utilizing the multiscreen audience view to observe engagement. Tools for audience member to better express their comprehension and participate in the topic discussion include the annotate feature and the raise hand feature of Zoom. 8 Initially, approximately 20 hours of structured education time per week was provided to our residents including assigned self-study readings and practice questions. With the return to a normal schedule and the resulting increase in operative volume, our online educational platform must adapt to remain a viable adjunct to our traditional educational model. Based on feedback provided by our surveys the online educational platform was modified to accommodate the change in resident and faculty workload. Our education model was scaled back from 5 days of online lectures, readings, and assigned questions to three days with one day incorporating faculty lecture, morbidity and mortality conference and grand rounds. The remaining days were composed of resident driven education sessions. These will alternate between resident driven journal clubs, topic discussions, and question review sessions. All sessions will be augmented with assigned TrueLearn questions and suggested readings. To date we have completed four weeks of our modified curriculum with initial success.

13 While it is difficult to see the silver lining of changes forced upon our healthcare system, our online surgical education curriculum serves as an example of how a crisis can bring about meaningful change. The documentation of our online surgical education curriculum can easily be broken down into its individual components for incorporation by other institutions looking to expand their educational program. Ultimately the success of our online educational curriculum will be measured by continued resident participation after the return to the pre-COVID-19 clinical duties 9 . Continued review and adaptation of our educational curriculum and assessment of its success will be an area of future research at our institution. What are the frequencies associated with these complications? o What diagnostic workup is required for each diagnosis? o What are the principles of management including need to return to the operating room? This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors and the listed authors have no conflicts of interest.

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