Publications by authors named "Hannah K James"

11 Publications

  • Page 1 of 1

Freestyle Deliberate Practice Cadaveric Hand Surgery Simulation Training for Orthopedic Residents: Cohort Study.

JMIR Med Educ 2022 Jun 29;8(2):e34791. Epub 2022 Jun 29.

Department of Trauma and Orthopaedics, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.

Background: Cadaveric simulation training may be part of the solution to reduced quantity and quality of operative surgical training in the modern climate. Cadaveric simulation allows the early part of the surgical learning curve to be moved away from patients into the laboratory, and there is a growing body of evidence that it may be an effective adjunct to traditional methods for training surgical residents. It is typically resource constrained as cadaveric material and facilities are expensive. Therefore, there is a need to be sure that any given cadaveric training intervention is maximally impactful. Deliberate practice (DP) theory as applied to cadaveric simulation training might enhance the educational impact.

Objective: The objectives of this study were (1) to assess the impact of a freestyle DP cadaveric hand surgery simulation training intervention on self-reported operative confidence for 3 different procedures and (2) to assess the subjective transfer validity, perceived educational value, and simulation fidelity of the training.

Methods: This study used validated questionnaires to assess the training impact on a cohort of orthopedic residents. The freestyle course structure allowed the residents to prospectively define personalized learning objectives, which were then addressed through DP. The study was conducted at Keele Anatomy and Surgical Training Centre, a medical school with an integrated cadaveric training laboratory in England, United Kingdom. A total of 22 orthopedic surgery residents of postgraduate year (PGY) 5-10 from 3 regional surgical training programs participated in this study.

Results: The most junior (PGY 5-6) residents had the greatest self-reported confidence gains after training for the 3 procedures (distal radius open reduction internal fixation, flexor tendon repair, ulnar shortening osteotomy), and these gains diminished with resident seniority. The confidence gains were proportional to the perceived procedural complexity, with the most complex procedure having the lowest pretraining confidence score across all experience levels, and the greatest confidence increase in posttraining. Midstage (PGY 7-8) residents reported receiving the highest level of educational benefit from the training but perceived the simulation to be less realistic, compared to either the junior or senior residents. The most senior residents (PGY 9-10) reported the greatest satisfaction with the self-directed, freestyle nature of the training. All groups reported that they were extremely likely to transfer their technical skill gains to their workplace, that they would change their current practice based on these skills, and that their patients would benefit as a result of their having undertaken the training.

Conclusions: Freestyle, resident-directed cadaveric simulation provides optimum DP conditions whereby residents can target their individualized learning needs. By receiving intensive, directed feedback from faculty, they can make rapid skill gains in a short amount of time. Subjective transfer validity potential from the training was very high, and objective, quantitative evidence of this is required from future work.
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http://dx.doi.org/10.2196/34791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9280454PMC
June 2022

Assessing technical skill in ankle fracture surgery from the postoperative radiograph : pilot development and validation of a final product analysis core outcome set.

Bone Jt Open 2022 Jun;3(6):502-509

Department of Trauma & Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.

Aims: To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten's criteria for effective assessment.

Methods: An e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases.

Results: Overall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five 'final product analysis' parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p < 0.001) and categorical (p = 0.001) variables. Concurrent validity of all metrics was poor against PBA score. Intrarater reliability was substantial for all parameters (intraclass correlation coefficient (ICC) > 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA.

Conclusion: Assessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten's utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting. Cite this article:  2022;3(6):502-509.
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http://dx.doi.org/10.1302/2633-1462.36.BJO-2021-0212.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233421PMC
June 2022

Monocular loss of vision following an open tibial fracture: a case of endogenous endophthalmitis.

BMJ Case Rep 2021 Apr 21;14(4). Epub 2021 Apr 21.

Trauma & Orthopaedic Surgery, Coventry and Warwickshire Hospital, Coventry, UK

Rare intraocular complication in a healthy immunocompetent patient with an atypical organism following presumed haematogenous spread after a highly contaminated open tibial fracture.
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http://dx.doi.org/10.1136/bcr-2020-241292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061824PMC
April 2021

The dawn of a new competency-based training era.

Bone Jt Open 2021 Mar;2(3):181-190

Department of Trauma and Orthopaedic Surgery, University Hospital of North Durham, Durham, UK.

The imminent introduction of the new Trauma & Orthopaedic (T&O) curriculum, and the implementation of the Improving Surgical Training initiative, reflect yet another paradigm shift in the recent history of trauma and orthopaedic training. The move to outcome-based training without time constraints is a radical departure from the traditional time-based structure and represents an exciting new training frontier. This paper summarizes the history of T&O training reform, explains the rationale for change, and reflects on lessons learnt from the past. Cite this article: 2021;2-3:181-190.
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http://dx.doi.org/10.1302/2633-1462.23.BJO-2020-0155.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009901PMC
March 2021

Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey.

Bone Jt Open 2020 May 13;1(5):103-114. Epub 2020 May 13.

Clinical Trials Unit, Warwick Medical School, Coventry, UK.

Aims: The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation.

Methods: The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK.

Results: Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes.

Conclusion: There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision.
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http://dx.doi.org/10.1302/2633-1462.15.BJO-2020-0011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677730PMC
May 2020

Assessment of technical skill in hip fracture surgery using the postoperative radiograph: pilot development and validation of a final product analysis core outcome set.

Bone Jt Open 2020 Sep 24;1(9):594-604. Epub 2020 Sep 24.

Clinical Trials Unit, Warwick Medical School, Coventry, UK.

Aims: To develop a core outcome set of measurements from postoperative radiographs that can be used to assess technical skill in performing dynamic hip screw (DHS) and hemiarthroplasty, and to validate these against Van der Vleuten's criteria for effective assessment.

Methods: A Delphi exercise was undertaken at a regional major trauma centre to identify candidate measurement items. The feasibility of taking these measurements was tested by two of the authors (HKJ, GTRP). Validity and reliability were examined using the radiographs of operations performed by orthopaedic resident participants (n = 28) of a multicentre randomized controlled educational trial (ISRCTN20431944). Trainees were divided into novice and intermediate groups, defined as having performed < ten or ≥ ten cases each for DHS and hemiarthroplasty at baseline. The procedure-based assessment (PBA) global rating score was assumed as the gold standard assessment for the purposes of concurrent validity. Intra- and inter-rater reliability testing were performed on a random subset of 25 cases.

Results: In total, 327 DHS and 248 hemiarthroplasty procedures were performed by 28 postgraduate year (PGY) 3 to 5 orthopaedic trainees during the 2014 to 2015 surgical training year at nine NHS hospitals in the West Midlands, UK. Overall, 109 PBAs were completed for DHS and 80 for hemiarthroplasty. Expert consensus identified four 'final product analysis' (FPA) radiological parameters of technical success for DHS: tip-apex distance (TAD); lag screw position in the femoral head; flushness of the plate against the lateral femoral cortex; and eight-cortex hold of the plate screws. Three parameters were identified for hemiarthroplasty: leg length discrepancy; femoral stem alignment; and femoral offset. Face validity, content validity, and feasibility were excellent. For all measurements, performance was better in the intermediate compared with the novice group, and this was statistically significant for TAD (p < 0.001) and femoral stem alignment (p = 0.023). Concurrent validity was poor when measured against global PBA score. This may be explained by the fact that they are measuring difference facets of competence. Intra-and inter-rater reliability were excellent for TAD, moderate for lag screw position (DHS), and moderate for leg length discrepancy (hemiarthroplasty). Use of a large multicentre dataset suggests good generalizability of the results to other settings. Assessment using FPA was time- and cost-effective compared with PBA.

Conclusion: Final product analysis using post-implantation radiographs to measure technical skill in hip fracture surgery is feasible, valid, reliable, and cost-effective. It can complement traditional workplace-based assessment for measuring performance in the real-world operating room . It may have particular utility in competency-based training frameworks and for assessing skill transfer from the simulated to live operating theatre.Cite this article: 2020;1-9:594-604.
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http://dx.doi.org/10.1302/2633-1462.19.BJO-2020-0101.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7659686PMC
September 2020

Analysis of Tools Used in Assessing Technical Skills and Operative Competence in Trauma and Orthopaedic Surgical Training: A Systematic Review.

JBJS Rev 2020 06;8(6):e1900167

1Clinical Trials Unit, Warwick Medical School, Coventry, United Kingdom 2Department of Trauma & Orthopedic Surgery, University Hospitals Coventry & Warwickshire, Coventry, United Kingdom.

Background: Robust assessment of skills acquisition and surgical performance during training is vital to ensuring operative competence among orthopaedic surgeons. A move to competency-based surgical training requires the use of tools that can assess surgical skills objectively and systematically. The aim of this systematic review was to describe the evidence for the utility of assessment tools used in evaluating operative performance in trauma and orthopaedic surgical training.

Methods: We performed a comprehensive literature search of MEDLINE, Embase, and Google Scholar databases to June 2019. From eligible studies we abstracted data on study aim, assessment format (live theater or simulated setting), skills assessed, and tools or metrics used to assess surgical performance. The strengths, limitations, and psychometric properties of the assessment tools are reported on the basis of previously defined utility criteria.

Results: One hundred and five studies published between 1990 and 2019 were included. Forty-two studies involved open orthopaedic surgical procedures, and 63 involved arthroscopy. The majority (85%) were used in the simulated environment. There was wide variation in the type of assessment tools in used, the strengths and weaknesses of which are assessor and setting-dependent.

Conclusions: Current technical skills-assessment tools in trauma and orthopaedic surgery are largely procedure-specific and limited to research use in the simulated environment. An objective technical skills-assessment tool that is suitable for use in the live operative theater requires development and validation, to ensure proper competency-based assessment of surgical performance and readiness for unsupervised clinical practice.

Clinical Relevance: Trainers and trainees can gain further insight into the technical skills assessment tools that they use in practice through the utility evidence provided.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360100PMC
June 2020

Cadaveric simulation versus standard training for postgraduate trauma and orthopaedic surgical trainees: protocol for the CAD:TRAUMA study multicentre randomised controlled educational trial.

BMJ Open 2020 09 25;10(9):e037319. Epub 2020 Sep 25.

Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK.

Introduction: The quantity and quality of surgical training in the UK has been negatively affected by reduced working hours and National Health Service (NHS) financial pressures. Traditionally surgical training has occurred by the master-apprentice model involving a process of graduated responsibility, but a modern alternative is to use simulation for the early stages of training. It is not known if simulation training for junior trainees can safeguard patients and improve clinical outcomes. This paper details the protocol for a multicentre randomised controlled educational trial of a cadaveric simulation training intervention versus standard training for junior postgraduate orthopaedic surgeons-in-training. This is the first study to assess the effect of cadaveric simulation training for open surgery on patient outcome. The feasibility of delivering cadaveric training, use of radiographic and clinical outcome measures to assess impact and the challenges of upscaling provision will be explored.

Methods And Analysis: We will recruit postgraduate orthopaedic surgeons-in-training in the first 3 years (of 8) of the specialist training programme. Participants will be block randomised and allocated to either cadaveric simulation or standard 'on-the-job' training, learning three common orthopaedic procedures, each of which is a substudy within the trial. The procedures are (1) dynamic hip screw, (2) hemiarthroplasty and (3) ankle fracture fixation. These procedures have been selected as they are very common procedures which are routinely performed by junior surgeons-in-training. A pragmatic approach to sample size is taken in lieu of a formal power calculation as this is novel exploratory work with no a priori estimate of effect size to reference. The primary outcome measure is the technical success of the surgery performed on patients by the participating surgeons-in-training during the follow-up period for the three substudy procedures, as measured by the implant position on the postoperative radiograph. The secondary outcome measures are procedure time, postoperative complication rate and patient health state at 4 months postoperation (EQ-5D-substudies 1 and 2 only).

Ethics, Registration And Dissemination: National research ethics approval was granted for this study by the NHS Research Authority South Birmingham Research Ethics Committee (15/WM/0464). Confidentiality Advisory Group approval was granted for accessing radiographic and outcome data without patient consent on 27 February 2017 (16/CAG/0125). The results of this trial will be submitted to a peer-reviewed journal and will inform educational and clinical practice.

Trial Registration Number: ISRCTN20431944.
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http://dx.doi.org/10.1136/bmjopen-2020-037319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520841PMC
September 2020

Disruption to Surgical Training during Covid-19 in the United States, United Kingdom, Canada, and Australasia: A Rapid Review of Impact and Mitigation Efforts.

J Surg Educ 2021 Jan-Feb;78(1):308-314. Epub 2020 Jun 25.

Department of Trauma & Orthopedic Surgery, University Hospital Coventry & Warwickshire, Coventry, United Kingdom.

Objective: To synthesise the current evidence of pandemic-related impact on surgical training internationally and describe strategies that have been put in place to mitigate disruption.

Design: Rapid scoping review of publically available published web-literature.

Setting: Five large English speaking countries; United States (US), United Kingdom (UK), Canada, Australia and New Zealand (NZ).

Results: Recruitment and selection to residency programmes in the US, Australia and NZ has been largely unaffected. Canada has implemented video-conferencing in lieu of face-to-face interviews. The UK has relied upon trainee self-assessment for selection. Widespread postponement and cancellation of surgical board examinations was seen across the studied countries. Resident assessment-in-training and certification procedures have been heavily modified. Most didactics have moved online, with some courses and conferences cancelled where this has not been possible. None of the studied countries had a central mandate on resident operating privileges during Covid-19.

Conclusions: The collective response by international surgical training bodies to the dual challenges of safeguarding residents whilst minimising disruption to training has been agile and resident centred. The pandemic has exposed weaknesses in existing training systems and has highlighted opportunity for future improvement.
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http://dx.doi.org/10.1016/j.jsurg.2020.06.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315967PMC
January 2021

How Does Cadaveric Simulation Influence Learning in Orthopedic Residents?

J Surg Educ 2020 May - Jun;77(3):671-682. Epub 2020 Mar 5.

Clinical Trials Unit, Warwick Medical School, Coventry, United Kingdom.

Objective: The objectives of this study were to understand how cadaveric simulation impacts learning in orthopedic residents, why it is a useful training tool, and how skills learnt in the simulated environment translate into the workplace.

Design: This is a qualitative research study using in-depth, semistructured interviews with orthopedic residents who underwent an intensive cadaveric simulation training course.

Setting: The study was conducted at the University Hospital Coventry & Warwickshire, a tertiary care center with integrated cadaveric training laboratory in England, United Kingdom.

Participants: Orthopedic surgery residents in the intervention group of a randomized controlled trial comparing intensive cadaveric simulation training with standard "on the job" training were invited to participate. Eleven of 14 eligible residents were interviewed (PGY 3-6, 8 male and 3 female).

Results: Learning from cadaveric simulation can be broadly categorized into intrinsic, surgeon-driven factors, and extrinsic environmental factors. Intrinsic factors include participant ability to "buy-in" to the simulation exercise, willingness to push one's own learning boundaries in a "safe space" and take out on resident experience and self-reported confidence, with the greatest learning gains seen at around the PGY4 stage in individuals who reported low preintervention operative confidence. Extrinsic factors included; the opportunity to perform operations in their entirety without external pressures or attending "take-over," leading to subjective improvement in participant operative fluency and confidence. The intensive supervision of subspecialist attending surgeons giving real-time performance feedback, tips and tricks, and the opportunity to practice unusual approaches was highly valued by participants, as was paired learning with alternating roles as primary surgeon/assistant and multidisciplinary involvement of scrub-staff and radiographers. Cadaveric simulation added educational value beyond that obtained in low-fidelity simulation training by "stirring into practice" and "becoming through doing." In providing ultrarealistic representation of the space, ritualism, and costuming of the operating theater, cadaveric simulation training also enabled the development of a range of nontechnical skills and sociocultural "nontechnical" lessons of surgery.

Conclusions: Cadaveric simulation enhances learning in both technical and nontechnical skills in junior orthopedic residents within a single training package. Direct transfer of skills learnt in the simulation training to the real-world operating theater, with consequent patient benefit, was reported. Cadaveric simulation in the UK training system of orthopedics may be of greatest utility at around the PGY 4 stage, at which point operative fluency, independence, and confidence can be rapidly improved in the cadaveric laboratory, to enable the attainment of competence in index trauma operations.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.006DOI Listing
June 2021

Use of cadavers to train surgeons: what are the ethical issues? - body donor perspective.

J Med Ethics 2020 07 26;46(7):476. Epub 2020 Feb 26.

Clinical Trials Unit, University of Warwick, Coventry, UK

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http://dx.doi.org/10.1136/medethics-2019-105998DOI Listing
July 2020
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