How an EVATS rotation can address the challenges of your resident education program
Karen Horvath, MD, FACS and Carlos Pellegrini, MD, FACS
Department of Surgery, University of Washington, Seattle
In the spring of 2003, our program was facing a number of new challenges. We had invested time and resources into developing an open and laparoscopic technical skills curriculum for our residents, but the curriculum was underutilized. Our resident education committee had decided that our residents should all graduate with at least one completed academic project, but the residents who did not go into the lab expressed concern about the availability of time to complete a project during the clinical rotations. The Accreditation Council for Graduate Medical Education (ACGME) Competency Project was requiring increasingly more education in non-operative areas such as ethics, professionalism, and sleep deprivation. Finally the 80-hour workweek required flexibility in the curriculum schedule for resident vacations and emergency leave while maintaining the 80-hour rules. We decided to convert the challenges into an opportunity and make a relatively "radical" change to our residency structure to address these challenges. To that end, we developed a new rotation, which we called "EVATS," with the following goals in mind.
E – Emergency coverage flexibility. Residents rotating on EVATS are available to cover a hole left by another resident who is attending to an emergency (eg, illness, paternity leave).
V – Vacation. All vacation is taken during the EVATS rotation or provided for by an EVATS rotator. This is described in more detail later in this article. When an EVATS resident is on vacation, that resident is not available for emergency coverage during his/her vacation time.
A – Time to do a required academic project and time for formal, independent learning in the ACGME competency areas not covered during other rotations.
TS – A designated period of time for residents to spend on technical skills in a laboratory setting. This time slot can easily be developed with minimal resources and ‘low tech’ simulators, like knot boards and laparoscopic mirror boxes.
How to Develop an EVATS Rotation
1. Decide which resident level(s) you would like to create an EVATS rotation in. You will need a rotation slot. In the table below, you can see that the EVATS service is an actual rotation.
Resident #1
ER
SICU
SurgOnc
EVATS
Trauma
Resident #2
Trauma
ER
SICU
SurgOnc
EVATS
2. Consult with residents and faculty and get the support of your chairman. This measure is important to help make the EVATS rotation meaningful for the program and to help facilitate acceptance of the rotations throughout your institution.
3. Create a curriculum with goals and objectives for the rotation.
4. Develop clear guidelines in advance about when an EVATS resident can be made available for emergency coverage. Emergency coverage is the biggest threat to the educational value of the EVATS rotation. Our motto is, "Protect the EVATS rotator at all costs." We first try to cover any holes left by an absent resident with existing manpower. For example, when a resident leaves town for an interview, we expect the resident will adjust the call schedule accordingly in advance using the "accordion method" of coverage or by paying back their colleagues. We only ask an EVATS resident to cover if patient care, resident education, or the 80-hour workweek rules will suffer without a fill-in. It is rare for us to use an EVATS resident for emergency coverage reasons. In a two-year period, we found that a resident spends an average of 2.7 days doing E coverage per year per EVATS rotation in a program of 80 residents.
5. Develop a vacation plan. One option is to do block vacations from the EVATS rotation. The option, which we utilize, is to have a two-week vacation from EVATS (either in a two-week block or separate weeks as each resident desires) plus one week covering for a vacationing resident who is on another rotation service. Our residents preferred this vacation system because it provides them with a vacation every six months. To do this in a large program, a vacation rotation must be designated each year for a given residency level. In the table below, the SICU rotation is the vacation rotation. During this rotation, the SICU resident will leave for vacation for one week and be replaced full-time by the EVATS rotator.
Resident #1
VA
SICU
*1 wk vacation (hole covered by EVATS Resident #2)
SurgOnc
Peds Surg
EVATS
*2 wks vacation + 1 wk vacation coverage for SICU Resident #2
Resident #2
SurgOnc
EVATS
*2 wks vacation + 1wk vacation coverage for SICU Resident #1
Peds Surg
VA
SICU
*1 wk vacation (hole covered by EVATS Resident #1)
6. Develop a technical skills curriculum for the rotation which takes into consideration the level of training the resident is in (eg, R1, R2, etc). This curriculum must be made part of the overall curriculum for the residency, for example, it must be integrated into the master curriculum. Thus, the tasks to be taught vary, from working with knot boards, to practicing vascular anastomoses on grafts using loupes, to computer-simulated laparoscopic exercises, if available. An effective technical skills curriculum can be easily developed with minimal resources using low-tech simulators such as knot boards and laparoscopic mirror boxes. Our curriculum has many independent learning pieces, but also requires that an EVATS resident work with another EVATS resident. Since the curriculum is tailored to each level of residency, the chief residents may be focusing on intracorporeal suturing in a laparosopic trainer, but will also have a significant educational component with the junior residents. The curriculum components include a check-off sheet for completion as well as a technical skills test administered by a faculty member, fellow, or skills lab technician. Many of the computer simulators provide tests with printable forms for the residency director. We also monitor time spent in the skills lab by having our residents use a punch clock.
7. Develop guidelines for your residents to complete an academic project. Not all our residents do lab time, so many residents do their academic project during their clinical and EVATS time. We have left the requirements of what constitutes an academic project to be very broad, including presentation at a national meeting, publication of a peer-reviewed manuscript, writing a book chapter, presentation at a state American College of Surgeons chapter meeting, or a presentation at our local monthly Seattle Surgical Society meetings.
8. Create a repository for ACGME competency and other training modules (eg, "How to Teach Medical Students"). We do an independent study format using a library of videos, books, DVDs, CDs (listed in the References and Resources section at the end of this article). We monitor usage by asking the residents to borrow these resources from the education office and record a very brief write-up about what they learned and how it will change what they do into their EVATS portfolio. The EVATS portfolio is reviewed by the program director and the faculty mentor at the biannual review.
9. The EVATS rotation should be entered as a formal rotation into your evaluation system so that you can improve the rotation over time (and provide data for phase three of the ACGME competency project which requires a quality improvement program).
Pros of an EVATS Rotation
We committed to create an EVATS rotation for all levels of residents in our program and all residents in the at-large program, including all designated and non-designated preliminary residents. However, implementation does not require an all-or-nothing approach. Since EVATS works independently within each year of training, the rotation can be given to one class and not another, for example, the R3 class may be the only class with an EVATS rotation. This might provide a program the opportunity to do a one-year trial of an EVATS rotation without committing significant time and resources to revising the entire program structure. Another advantage of an EVATS rotation is the ability to provide education in other non-conventional areas. The ACGME 80-hour guidelines require flexibility to accommodate emergencies and vacations, which EVATS provides. Our EVATS rotation provides this flexibility, but it also has a significant positive impact on our ability to maintain the 80-hour workweek rules. The Residency Review Committee (RRC) for Surgery will also require some formal technical skills training for all residencies beginning in 2008, which would be provided for during EVATS. Also, we feel that EVATS improves patient care continuity. Because residents no longer take vacations from various clinical rotations throughout the year, their continuity on each service is better. Once they arrive on a service, they stay for the duration, with the exception of one week off for the designated vacation rotation.
Cons of an EVATS Rotation
An EVATS rotation might not work for all programs, especially some smaller programs. However, a small program would not need to commit an entire rotation period to EVATS, but possibly just one part of a rotation period. The process of creating an EVATS rotation requires either one of the following: Create a new rotation slot at a given R-level by eliminating a rotation, or condensing two rotations into one, or successfully getting an increase in resident complement from the RRC and committing this extra slot to an EVATS rotation. Both of these approaches could be deterrents. A significant concern is that the residents may develop an ‘extended vacation’ mentality for the EVATS rotation, though this has not been a problem in our program. Our residents have been extremely self-motivated to use their EVATS time effectively for independent learning projects directed at their interests. However, it is possible that without each resident creating an EVATS portfolio--with careful oversight--the development of a lackadaisical mentality might become a problem. Another disadvantage is the loss of vacation flexibility, since residents must take two weeks of vacation during EVATS and one week during the designated vacation rotation. But since we let our residents choose their rotation sequence and their vacation weeks within those calendar constraints, we have not found this loss of flexibility to be an issue. In fact, residents prefer the option of being able to have two weeks off at once.
Recommendations
If you decide to implement an EVATS rotation in your program, it is important to educate your faculty, residents, and residency coordinator in advance. It is advisable to clearly define, up front, what the goals and objectives of the rotation are and to be steadfast in maintaining them. The EVATS rotation has become an important educational period for our residents. However, if not careful, EVATS can quickly become a dumping ground for requests from the faculty and staff: "We can have the EVATS resident do it," or "The trauma service is especially heavy in the summer; maybe we could have the EVATS resident help out." Early on, our residents had their own ideas of EVATS as a melting pot of increased options such as requests for educational elective time including, "Doing some additional CT rotations to prepare me for my fellowship," or "Spending a week or two in Africa doing an international health elective." These requests have all disappeared as the EVATS culture has become more established. Thus, the educational value of the rotation can quickly be undermined if not protected from encroachment on what it is supposed to provide.
Summary
The EVATS rotation has become an important part of our training program, more as an educational enhancement than a stopgap for the 80-hour workweek and ACGME competency requirements, though it provides both. The idea was vetted through and supported by the RRC for Surgery prior to implementation. It was presented at the 2005 ACGME meeting as a way to effectively enhance education while maintaining work-hour requirements. Resident and faculty satisfaction with EVATS is extremely high in our program.
References and Resources
- Horvath KD, Mann GN, Pellegrini CA. EVATS: A Proactive Solution to Improve Surgical Education and Maintain Flexibility in the New Training Era. In press, Current Surgery.
- American College of Surgeons Practice Management CD-Rom: http://www.facs.org/education/practicemanagement.html
- American College of Surgeons Division of Education: http://www.facs.org/education/index.html
- Association for Surgical Education. Educational Clearinghouse: http://www.surgicaleducation.com/educlear/index.htm
- LifeCurriculum website: http://www.lifecurriculum.info/programtour.htm
- Laparoscopy 101. Ethicon Endosurgery Training Institute: http://www.residenteducation.com/
Online April 10, 2006