Using SCORE for Distance Learning for Surgical Residents in the COVID-19 Era

Traditionally, surgical education has been heavily didactic-based, requiring group learning, lecture attendance, and the Socratic method. The knowledge gained through patient care, intraoperative experience, and clinical interactions are difficult to replicate. Coronavirus disease 2019 (COVID-19) has created an unprecedented change in surgical training. Federal and local mandates for social distancing, along with widespread disruptions in duty-hours, have forced training programs to cancel or modify their typical in-person conferences. Strategies for optimizing virtual learning have been proposed in the literature in response to COVID-19 and in prior pandemics such as the SARS 2003 outbreak. These strategies illustrate the importance of adaptability and resourcefulness of medical education to meet the needs of learners.^1-3

Fortunately, an infrastructure for distance learning is already in place with the curriculum provided by the Surgical Council on Resident Education (SCORE), in addition to resources we will outline. SCORE was developed by a collaboration of member surgical societies including the American Board of Surgery, American College of Surgeons, Accreditation Council for Graduate Medical Education, American Surgical Association, Association of Program Directors in Surgery, Association for Surgical Education, and Society of American Gastrointestinal and Endoscopic Surgeons, and is used by over 95 percent of general surgery residency programs in the U.S. While it is not the only on-line learning resource, it is the most widely used and broadly vetted by its member organizations. As such, it is worthy of a focused review pertinent to distance learning in the present context. Institutions utilize the SCORE portal in a variety of ways based on their particular resources and needs.⁴ Although it is difficult to replace hands-on operative experience, the capabilities of the SCORE curriculum are very suitable for distance learning encountered by the COVID-19 pandemic. SCORE has content that accommodates a wide variety of different learning styles. However, its utilization for distance learning has yet to be applied with such a broad scope. We will describe various methods for training programs to optimize distance learning.

The Surgical Council on Resident Education is a standalone comprehensive curriculum for general surgery residents at all levels of training, costing programs a $500 annual fee and $175 per resident subscription. It includes the following forms of learning.

When group learning is not possible due to social distancing and/or altered duty schedules, we recommend daily structured learning. This Week in SCORE, also known as “TWIS,” provides a weekly curriculum covering the entirety of general surgery core subjects over a two-year cycle. There are suggested weekly core and advanced readings as well as a weekly TWIS quiz (10 questions). The TWIS quiz consists of highly peer-reviewed unique questions not present in the question bank available on SCORE. We suggest that individual learning take no more than 30 minutes to complete and may be divided into two 15 minute sessions to optimize attention and retention. If this is not feasible due to increased clinical care duties or 24 hours shifts, we recommend 15 minutes a day of dedicated learning. A recent study demonstrated that spending just 15 minutes per day on SCORE and doing questions in TrueLearn results in superior ABSITE performance.⁵ We infer that the SCORE question bank or alternative question bank could be used, as well. We have provided a suggested weekly individual curriculum in Table 1. There are a number of free complementary learning resources including the YouTube channel “SurgEdVidz” authored by Dr. Doug Cassidy, a member of the SCORE Resident Advisory Group that publishes a 1-minute summary of the weekly topic in a pictorial format.⁶

Table 1. A generic template for daily structured learning that follows SCORE’s TWIS curriculum as well as a suggested schedule for time-limited situations for individual learning during pandemic care.

Suggested group learning strategies will vary by the structure at each individual institution. We suggest utilization of the “Conference Prep” section present in each SCORE module to augment this group learning. We suggest guidance be provided by a faculty member in order to ensure the discussion is guided appropriately. These open-ended questions are also easily translatable into a video conference format which is the current method of group learning for many institutions during this time. In addition, the newly released “SCORE School” is a 60-minute video-based lecture occurring weekly to correspond with the TWIS schedule. This can be done at an individual’s pace when time allows and resident participation can be tracked by the institution. The variation of usage amongst individuals and programs is likely to vary based on region and program type. However, as previously described, variation of time using the SCORE curriculum within different residencies does not differ significantly.⁷ The variety of resources available through the SCORE curriculum is what makes SCORE an ideal resource in the COVID era. The curriculum allows residents and programs to continue to modify learning despite significant, rapid changes in current didactic practices.

The SCORE curriculum is well-suited for distance learning in an individual and group setting. Utilization of the curriculum is a readily available and effective way to ensure that didactic and self-guided education continues through this pandemic and in future situations requiring social distancing.

1. Almarzooq Z, Lopes M, Kochar A, Virtual Learning during the COVID-19 Pandemic: A Disruptive Technology in Graduate Medical Education, Journal of the American College of Cardiology (2020), doi: https://doi.org/10.1016/j.jacc.2020.04.015.
2. McKechnie T, et al., Virtual Surgical Training During COVID-19: Operating Room Simulation Platforms Accessible from Home. Ann Surg, 2020. Accepted for publication.
3. Coe, T et al., Practical techniques to adapt surgical resident education to the COVID-19 era. Ann Surg, 2020. Accepted for publication.
4. Joshi, A.R.T., et al., Best Practice for Implementation of the SCORE Portal in General Surgery Residency Training Programs. J Surg Educ, 2018. 75(6): p. e11-e16.
5. Hancock KJ, et al., General Surgery Resident Use of Electronic Resources: 15 minutes a day. JACS, 2020. 230(4): p 442-448.
6. Cassidy DJ, Mullen JT, Gee DW, Joshi ART, Klingensmith ME, Petrusa E, Phitayakorn R: #SurgEdVidz: Using Social Media to Create a Supplemental Video-Based Surgery Didactic Curriculum J Surg Res. Accepted for publication. https://www.youtube.com/channel/UClS6MwgCXnaTM_vwuIcYihQ/featured
7. Onufer EJ, Trolard A, Hickey M, et al. SCORE - Leveling the Playing Field for Surgical Training Programs. J Surg Educ. 2019;76(6):e146‐e151. doi:10.1016/j.jsurg.2019.07.009

Shanley Besett Deal, MD, Virginia Mason Medical Center, Seattle, WA

Paul K. McGaha II MD, MSc, University of Oklahoma Health Sciences Center, Oklahoma City, OK

Amit R.T. Joshi, MD, FACS, Department of Surgery, Einstein Healthcare Network, Philadelphia, PA

Mary E. Klingensmith, MD, FACS, Department of Surgery, Washington University, St. Louis, MO