Research

Learn more about the Center for Surgical Education and Research's work and impact.

Vascular Surgery trainees in the simulation center
C-STAR team
Surgical team in the operating room

Center for Surgical Training & Research Overview

There is little evidence with which to inform approaches to training and assessing surgeons. The Center for Surgical Training and Research (C-STAR) is changing that by investigating the science behind assessment, teaching, and educational policy. We address these critical activities through rigorous methods to ultimately help establish national and international best practices. The ultimate goal is to improve surgical training in order to improve surgeon performance and surgical care.

We take a highly multidisciplinary approach, drawing on work in many areas, including health services research, simulation, education, cognitive psychology, anthropology, econometrics, data science and engineering.

Assessing Teaching and Learning in the Operating Room

This research area leverages a core expertise of C-STAR researchers, psychometrics, to investigate the many ways in which faculty teach and residents learn as they progress toward the goal of becoming competent, independent surgeons. Much of this type of work focuses specifically on establishing the validity and reliability of assessment tools in order to identify highly reliable, valid measures that can be used in other research and improvement domains.

Demonstrating Trust and Entrustable Behaviors

Trust is a critical factor among teachers and learners in the OR, impacting how attending surgeons safely grant increasing autonomy to residents and, similarly, how residents safely demonstrate behaviors worthy of greater independence. Ongoing work is related to role of trust in residents' progression to autonomy and independence, including identifying entrustable behaviors and specialty-specific procedural milestones.

Learning Curves for Core Procedures

Another initiative in the Center focuses on establishing learning curves for all Core General Surgery procedures. The project, in collaboration with the Procedural Learning and Safety Collaborative (PLSC) uses educational data science approaches to establish these learning analytic models. Much of the data generated has come from SIMPL, a novel mobile assessment app maintained by researchers at the University of Michigan, now used by many training programs across the United States.

Precision Education

Additional Center efforts aim to develop measures and resident-specific models of current and predicted future trainee performance. Such models can be used to individualize the curriculum and coaching for each trainee, ensuring optimal educational outcomes. These data-intensive methods may serve as the basis for ushering residency training toward "precision" surgical educational practice.

Connecting Assessment Outcomes with Patient Outcomes

With unique access to key data, including several major national patient outcomes and trainee performance data sets, U-M investigators are delving into the connections between surgical trainee assessment measures and patient outcomes data. Identifying these connections enables surgical education leaders to develop evidence-based policies, a critical opportunity.

Culture and Leadership Development

Efforts in this domain center on physician wellness, the impact of personality and gender on entrustment in the operating room, and diversity, equity and inclusion (DEI) in surgical education. For example, Dr. Sandhu has played a major role in the Doctors of Tomorrow program designed to increase diversity in surgical education. The experientially-based program brings underrepresented minority high school students to U-M, where they shadow and are mentored by medical students and faculty. C-STAR faculty also are developing a two-year Residents as Educators curriculum, designed to help residents entering academic careers develop the skills needed to train medical students.

Strategies

C-STAR aims to shape new competency- and outcomes-based models and evidence-based policies. To achieve our vision of a high-reliability surgical education system, we use the following strategies:

  • Discovery: This includes using traditional educational tools and methodologies as well as mixed methods and quantitative research approaches to generate knowledge to improve surgical education quality and healthcare learning.
  • Application: Using the insights gained, C-STAR develops novel surgical education and training models and interventions, such as new curricula, new modes of assessment, and new policies to improve the practice of surgical education.
  • Dissemination: Center investigators disseminate surgical education research to inform policy through publications, collaborations, and an annual national symposium held at U-M.
  • Development: Center investigators also have an eye on training future leaders in surgical education research and quality improvement. Mentoring and training a cohort of scholars will occur through several fellowships for residents, medical students, undergraduate student, and graduate students.

Results

In work published in 2017 in the Annals of Surgery, Dr. George and co-authors collected performance ratings from over 10,000 directly observed operations and found significant gaps in general surgery resident performance. For example, in their last six months of residency residents were found to be competent in only 80% of their cases and, even in these later-stage trainees, only reached the maximum degree of autonomy for a few core procedures. These results underscore the need for better competency-based performance standards for surgical trainees.

Clinical Relevance & Impact

Today’s surgical trainees will become integral parts of tomorrow’s healthcare system. The assessment tools developed and/or validated by C-STAR investigators have been adopted at institutions around the country, changing the interactions between faculty and residents. OpTrust has been in use at U-M and is about to be adopted at several other institutions. The SIMPL app has been used by more than 50 surgical training programs, encompassing thousands of faculty and residents.

Resulting data from these tools will provide the insights needed to assess surgical education in the context of patient outcomes — for example, how much better do the patients of high-performing surgeons fare? The data will help us develop high-reliability, evidence-based methods for educating surgeons. These improvements will ultimately lead to better patient care.

Future Directions

There are many opportunities to apply rigorous, data-intensive scientific methods to surgical education research. One of the most exciting opportunity is to personalize surgical training based on individual trainee needs – their educational genome, in a sense. We also will continue to look toward the particular behaviors that demonstrate and earn trust in the operating room and the connections among trust, autonomy and patient outcomes.

Collaborations

C-STAR investigators are part of several active collaborations, including with:

  • Other sites as part of an American Board of Surgery (ABS) pilot project to assess the use of key Entrustable Professional Activities as a framework for assessing surgical trainee performance
  • The American Board of Surgery (ABS) and the Accreditation Council for Graduate Medical Education (ACGME) on the Milestone Project to develop and validate specialty-specific frameworks to assess trainee development
  • The American Board of Surgery to examine the predictive validity of the initial and continuing certification exams for early career risk-adjusted patient outcomes
  • The Accreditation Council for Graduate Medical Education (ACGME) to examine the predictive validity of the Milestones and Case Logs for early career risk-adjusted patient outcomes
  • The Accreditation Council for Graduate Medical Education (ACGME) to examine the relationship between SIMPL assessments and Milestones ratings
  • A consortium of 25-institutions who are sharing trainee performance data to establish learning curves for core general surgery procedures
  • The Procedural Learning and Safety Collaborative, a national consortium of over 80 surgical training programs who collectively research, develop, and share best practices about surgical education
  • University of Michigan Department of Surgery
  • The Josiah Macy, Jr. Foundation Graduate Medical Education Innovations Program
  • National Board of Medical Examiners (NBME) Stemmler Fund
  • Association of Program Directors in Surgery
  • American Board of Medical Specialties
  • American Board of Surgery
  • American Board of Family Medicine
  • Association for Surgical Education
  • University of Michigan Graduate Medical Education Innovations Fund
  • Elizabeth Crosby Foundation