The Intratheater Latest Pre-Operative Discussion: Advocacy for Patient Safety, Procedural Optimization, and Surgical Education

The Intratheater Latest Pre-Operative Discussion: Advocacy for Patient Safety, Procedural Optimization, and Surgical Education | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Intratheater Latest Pre-Operative Discussion: Advocacy for Patient Safety, Procedural Optimization, and Surgical Education Robin T. Wu, Nidal Al Deek, Fu-Chan Wei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6951271/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background In the operating theater, surgeons must harness preparatory tools for quality assurance and team convergence. This study aims to evaluate perceptions of the latest pre-operative discussion, a presentation showcasing patient information, literature discussion, and team dialogue held with the entire operative team. Methods A prospective, anonymous survey was distributed to all trainees who participated in the latest pre-operative discussion at the Chang Gung Memorial Hospital microsurgical reconstruction department between January 2016 - December 2022. Survey questions evaluated patient safety/decision-making, operative flow, and education of the latest pre-operative discussion. Secondary outcomes were gathered from review of all discussions held in 2022, including number of manuscripts reviewed and changes in operative plan following team deliberation. Results Of sixty fellows and residents, fifty respondants (60% fellows, 40% residents) completed the survey, with a 83% response rate. At least 90% strongly agreed or agreed with all positive statements; 94% stated they will/have implemented the practice. An average of 2.3 projects were initiated in response to each discussion. Fellows more often strongly agreed that the discussion helped critique the quality of literature (78% vs 46%; p = 0.028), find gaps in currently knowledge (88% vs 66%; p = 0.044), and generate research topics (90% vs 74%; p = 0.028). Of seventy-one discussions in 2022, an average of 5.1 manuscripts were reviewed in each presentation, and 10.7% of final plans were changed as a result. Conclusions Trainees widely reported benefit of the latest pre-operative discussion in patient safety, operative flow, and education, with disparity amongst training levels in educational value. Formalized discussion may benefit surgical team decision-making and review contemporary literature, while allowing all operative staff to perform in congruity. Pre-Operative Discussion Intra-Operative Discussion Surgical Decision Making Surgical Team Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The operating theater relies on the concert of surgeons, anesthesiologists, trainees, nurses, and dedicated staff. Demands include selection of a correct operative plan, minimization of anesthetic risk, facilitation of student education, maintenance of efficiency, and above-all, gaurantee of patient safety. Universal mandates for operative checklists have driven great strides in surgical preparedness. 1 – 3 Unfortunately, surgical team involvement in decision making and education are regularly left to the wayside. 4 – 6 Efforts to improve team-based care, decision making, and learning have been few but fruitful. Glance et al. proposed a multi-disciplinary dialogue from all members of the pre-, intra-, and post-operative teams, providing full-spectrum care. 7 Sharma et al. depicted their elegant yet simple whiteboard technique: a written presentation of the full patient history and physical, the planned operation, sequence, and an “addendum” of needed supplies prior to every case. 8 Their survey-based quality assessment boasted improved flow, efficiency, involvement, and preparedness from all operating room staff. The international microsurgery fellowship at Chang Gung Memorial hospital, led by the senior author (FCW), has long been heralded for its didactic value. 9 – 11 Prior to every microvascular free flap reconstruction, the senior author (FCW) conducts a pre-operative discussion for all members of the operating theater (Fig. 1 ). As multiple discussions are held at the time of patient presentation, at the last clinic visit, and just prior to the operative day, this final dialogue is termed the latest pre-operative discussion. The team deliberates the patient history, operative plan, anatomy, and alternatives, followed by a review of the recent literature. We believe this interchange improves final surgical harmony and enriches team dynamics as well as education (Video 1). Video 1 (mp4). Demonstration of the latest-pre-operative discussion. Methods The study protocol was conducted in compliance with the institutional review board of Chang Gung Memorial Hospital in Linkou, Taiwan. The Latest Pre-Operative Discussion The latest pre-operative discussion was initiated at the nascent of the Chang Gung microsurgery fellowship in 1984. 9 As of 2015, the pre-operative discussion was shifted from the whiteboard to digital Powerpoint (Microsoft, Washington, United States) presentations. The latest pre-operative discussion consists of four sections: Patient information : A detailed description of the patient’s chief complaint, history of present illness, medical history, workup, laboratory data, imaging, and anatomy. Surgical plan : The anticipated resection plan followed by anatomy-specific reconstructive goals, and at least three alternative reconstructive options with rationale. Literature review : A topic of inquiry is chosen, related to the current patient. Contemporary literature is then presented with critical review and summative conclusion. Final decision : After judicious discussion, the final reconstructive plan is agreed upon by all members of the team and documented in the presentation. The senior author then reviews the surgical steps in detail and assigns roles to each member of the team. The final presentation is uploaded into Professor Wei’s patient database for future reference. All pre-operative Powerpoint presentations were organized from January 1st, 2022 until December 31th, 2022. Presentation data collected included primary operative plan, alternatives, literature discussion topics, and final surgical decision. Survey An anonymous survey was created, based on that by Sharma et al. 8 Special emphasis was placed on patient safety, surgical decision making, intra-operative fluency, and education. Surveys were distributed to all sixty prior microsurgery fellows and plastic surgery residents who rotated with Professor Wei at Chang Gung Memorial hospital from 2015 onwards. Statistics Statistical analysis was performed using Stata software (Stata Corporation, College Station, Texas). Data was reported in percentages for categorical and averages for continuous data. Comparisons were performed with Fischer exact tests for categorical survey responses. Pearson correlation was performed for number of papers published by respondants each year. Results The Latest Pre-Operative Discussion From January 1st 2022 until December 31st, 2022, seventy-one latest pre-operative discussions were completed. An average of 5.1 manuscripts were reviewed for each discussion, with a total of 363 papers reviewed in 2022. The preliminary surgical plan was changed in 10.7% of cases after discussion. Survey Participants Of the 60 initial recipients of the survey request, 50 responses were recorded, indicating an 83.3% response rate. Respondents were 60% fellows and 40% residents at the time of rotation, and the majority were now attending surgeons in practice (78%; Fig. 2 ). 94% of respondents stated they will/have implemented the latest pre-operative discussion in their own practices. Survey Results Final survey results are illustrated in Fig. 3 . No respondents strongly disagreed with any survey remarks. 100% of respondents strongly agreed or agreed with “I understood the surgical plan”. The least number of respondents (90%) strongly agreed or agreed with the statements “The operative flow was efficient” and “All team members had clear roles in surgery”. There was a non-significant trend towards increasing research projects initiated by respondents as a result of the latest pre-operative discussion (mean 2.3 projects; R = 0.21, p = 0.15; Fig. 4 ). In 2022, an average of 3.1 project were begun by each respondent after discussion. In the educational section, responses differed significantly between residents and fellows in regard to “I was able to critique the quality of literature” (78% vs 46%; p = 0.028), “I was able to find gaps in current knowledge” (88% vs 66%; p = 0.044), and “The latest pre-operative discussion helps to generate potential research topics” (90% vs 74%; p = 0.028). More fellows strongly agreed with all three statements compared with residents (Fig. 5 ). Survey Free Responses Twenty participants completed the optional free response section of the survey. Of these, 65% mentioned benefits of the surgical planning and patient safety, 55% referenced educational benefits, and 35% stated improvements in operative flow. Three participants cited shortcomings, including “it was quite stressful to prepare for all the discussions”, “the downside is that it is a relatively time-consuming process”, and “to include otolaryngology surgeons into discussion would have been an additional benefit”. Discussion We advocate our 40-year experience with the Chang Gung Memorial microsurgery latest pre-operative discussion as a pivot for improving surgical care. This discussion enhances three pillars consisting of patient safety/decision making, intra-operative procedure, and education. Patient safety and decision making Decision-making in surgery has evolved substantially. Shared decision-making alongside the patient represented a culture-shift to paternalistic treatment. 12 , 13 Advances in artificial intelligence and computer algorithms augment risk-benefit analyses. 14 Tumor boards for complex cancer cases result in more accurate diagnoses, treatment, and superior patient outcomes. 15 – 17 Still, most surgical decisions are made during the initial consultation. On the day of surgery, the remainder of the operative team shepherding the surgery, are not involved in the final plan. The latest pre-operative discussion supplements decision-making with current literature review and round-table type dialogue. Importantly, this allows the final plan to be formulated by all members of the operative team who are present on the day of surgery. As a result, 10.1% of surgical decisions were changed after the pre-operative discussion. This is analogous to an 11% change in surgical management after breast cancer tumor board discussions reported by Newman et al. 17 Many 18 Operative Flow Modern integration of artificial intelligence into surgery concentrates on workflow optimization. 19 – 22 As such, in its most elementary form, surgical flow is based upon timely anticipation of the next step. The latest pre-operative outlines all surgical steps for all team members, thus optimizing surgical congruency. As discussions are limited to twenty minutes, we believe ultimate operative time is saved with improved team efficiency. In combined cases, discussions are held as the resection team begins, as reconstructive flap harvest generally finishes well before the ablative team is complete. While survey responses were overall positive, 10% of respondents did not agree that the operative flow was efficient or that team members had clear roles, of which 80% were residents. As the visiting fellows are newer to the surgical customs, instruction of surgical steps and roles is more focused on fellow understanding. We take this important reflection to focus more on resident instruction going forward. The surgical team is a well-recognized fundamental. The landmark study by Mazzocco et al. pinpointed poor information sharing, handoff briefing, and general teamwork measures as risk factors for complications or even death in the operating room. While measures of teamwork in the induction phase did not result significant, all values had an odds ratio greater than one for risk of complications or death. 23 Future efforts must focus on not just the surgical steps, but the role of each teach member within this construct. Education The field of medicine is ever-changing. Therefore, all surgical decisions should include a review of the most-recent information. While continued education is required for board certification, it is often difficult for busy surgeons to synthesize an endless number of publications. 24 , 25 In this study, we reviewed 363 manuscripts in the last year via the latest pre-operative discussion. With extensive literature review, surgeons can identify gaps for future study. In the last year alone, trainees reported an average 3 research projects initiated in response to the latest pre-operative discussion. Intraoperative instruction can prolong surgical times, often discouraging proper teaching. 26 This can be circumvented with dedicated time for pre-operative teaching. Even a simple four item pre-operative and post-operative briefing improved resident autonomy, performance, and the Objective Structured Assessment of Technical Skills scores. 27 , 28 This features yet another benefit enjoyed by the pre-operative discussion. Compared to fellows, residents experienced less educational benefit from the latest pre-operative discussion. Indeed, a higher training level can facilitate quicker synthesis and greater appreciation for didactic literature reviews. However, resident duty verses education continues to be a dilemma for residency programs. 29 – 31 It is unsurprising that “time-consuming” and “stressful” (as indicated by survey responses) preparation of this discussion may negatively impact trainee experience. Such feedback prompted efforts to standardize the presentation format, limit number of articles reviewed, and split the workload among all team members. Despite mention of difficulties, all negative responses universally mentioned the eventual appreciation of the value of such hard work. Limitations We are limited by retrospective survey measures for evaluating case improvements, decision-making, and education. Future direction should focus on prospective collection and comparison of operating staff experiences. While the pre-operative discussion was lead for 40 years, only the last 8 years have involved recorded Powerpoint-style presentations for review. In reference to survey feedback, we endeavor to actively include the ablative team in the discussion and to lessen the workload in preparation for trainees. As the Chang Gung Microsurgery Fellowship continues to cultivate future leaders in the field, we hope the pre-operative discussion will become commonplace in the operating room. Conclusion The latest pre-operative discussion promotes patient safety, team decision making, operative efficiency, and education for all team members. As the Chang Gung Reconstructive Microsurgery fellowship and residency continue to cultivate future leaders in the field, we hope the latest pre-operative discussion will become commonplace in the operating room. Abbreviations FCW: Fu Chan Wei Declarations Declarations of interest: none This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethics Approval and Consent to Participate Approved by the Chang Gung institutional review board. Informed consent to participate in this study was obtained from all the participants in the study. This research study adhered to the Declaration of Helsinki. Consent for Publication Not Applicable. Availability of Data and Materials All data and materials can be provided upon reasonable request Competing Interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ Contributions All authors contributed to the conception, drafting, and critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors have no additional acknowledgements to declare. References Nilsson, L., Lindberget, O., Gupta, A. & Vegfors, M. Implementing a pre‐operative checklist to increase patient safety: a 1‐year follow‐up of personnel attitudes. Acta anaesthesiologica Scandinavica 54 , 176–182 (2010). Haynes, A. B. et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England journal of medicine 360 , 491–499 (2009). Treadwell, J. R., Lucas, S. & Tsou, A. Y. Surgical checklists: a systematic review of impacts and implementation. BMJ quality & safety 23 , 299–318 (2014). Jensen, A. R., Wright, A. S., Kim, S., Horvath, K. D. & Calhoun, K. E. Educational feedback in the operating room: a gap between resident and faculty perceptions. The American journal of surgery 204 , 248–255 (2012). Kanashiro, J., McAleer, S. & Roff, S. Assessing the educational environment in the operating room—a measure of resident perception at one Canadian institution. Surgery 139 , 150–158 (2006). O’Neill, R., Shapiro, M. & Merchant, A. The role of the operating room in medical student education: differing perspectives of learners and educators. Journal of surgical education 75 , 14–28 (2018). Glance, L. G., Osler, T. M. & Neuman, M. D. Redesigning surgical decision making for high-risk patients. The New England journal of medicine 370 , 1379 (2014). Sharma, K., Morgan, A. L., Stroud, J. & Mackinnon, S. E. The whiteboard technique: Personalized communication to improve operating room teamwork. Annals of surgery 268 , 225–227 (2018). Abdelrahman, M. The microsurgery fellowship at Chang Gung Memorial Hospital: blossom of caterpillars. Plastic and Reconstructive Surgery Global Open 3 , (2015). Aljaaly, H. A. The Chang Gung Memorial Hospital Microsurgery Fellowship: A Review of 1 Year of Experience. Plastic and Reconstructive Surgery Global Open 4 , (2016). Deek, N. F. A. & Lalonde, D. H. Fu-Chan Wei—Surgeon, Innovator, and Leader of the Legendary Chang Gung Microsurgery Center. Plastic and Reconstructive Surgery Global Open 4 , (2016). De Mik, S., Stubenrouch, F., Balm, R. & Ubbink, D. Systematic review of shared decision-making in surgery. Journal of British Surgery 105 , 1721–1730 (2018). Légaré, F. et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane database of systematic reviews (2018). Loftus, T. J. et al. Artificial intelligence and surgical decision-making. JAMA surgery 155 , 148–158 (2020). Specchia, M. L. et al. The impact of tumor board on cancer care: evidence from an umbrella review. BMC Health Services Research 20 , 1–14 (2020). El Saghir, N. S., Keating, N. L., Carlson, R. W., Khoury, K. E. & Fallowfield, L. Tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer worldwide. American Society of Clinical Oncology Educational Book 34 , e461–e466 (2014). Newman, E. A. et al. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer 107 , 2346–2351 (2006). Bierle, D. M., Raslau, D., Regan, D. W., Sundsted, K. K. & Mauck, K. F. Preoperative evaluation before noncardiac surgery. in vol. 95 807–822 (Elsevier, 2020). Kitaguchi, D. et al. Automated laparoscopic colorectal surgery workflow recognition using artificial intelligence: experimental research. International Journal of Surgery 79 , 88–94 (2020). Nakawala, H. et al. “Deep-Onto” network for surgical workflow and context recognition. International journal of computer assisted radiology and surgery 14 , 685–696 (2019). Padoy, N. Machine and deep learning for workflow recognition during surgery. Minimally Invasive Therapy & Allied Technologies 28 , 82–90 (2019). Colborn, K., Brat, G. & Callcut, R. Predictive Analytics and Artificial Intelligence in Surgery—Opportunities and Risks. JAMA surgery (2022). Mazzocco, K. et al. Surgical team behaviors and patient outcomes. The American Journal of Surgery 197 , 678–685 (2009). Moellhoff, N. et al. ESPRAS Survey on Continuing Education in Plastic, Reconstructive and Aesthetic Surgery in Europe. Handchirurgie· Mikrochirurgie· Plastische Chirurgie 54 , 365–373 (2022). Sachdeva, A. K. Continuing professional development in the twenty-first century. Journal of Continuing Education in the Health Professions 36 , S8–S13 (2016). Vinden, C. et al. Teaching surgery takes time: the impact of surgical education on time in the operating room. Canadian Journal of Surgery 59 , 87 (2016). Zhou, N. J. et al. The Role of Preoperative Briefing and Postoperative Debriefing in Surgical Education. Journal of surgical education 78 , 1182–1188 (2021). Zhou, N. J. et al. Preoperative briefings and postoperative debriefings to increase resident operative autonomy and performance. Journal of surgical education 78 , 1450–1460 (2021). Aziz, F., Talhelm, L., Keefer, J. & Krawiec, C. Vascular surgery residents spend one fifth of their time on electronic health records after duty hours. Journal of vascular surgery 69 , 1574–1579 (2019). Ellis, R. J. et al. Comprehensive characterization of the general surgery residency learning environment and the association with resident burnout. Annals of surgery 274 , 6–11 (2021). Maloney, S. R. et al. Surgery resident time consumed by the electronic health record. Journal of Surgical Education 77 , 1056–1062 (2020). Additional Declarations No competing interests reported. Supplementary Files ThePreOperativeDiscussionVideo.mp4 Video 1 (mp4). Demonstration of the latest-pre-operative discussion. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 08 Aug, 2025 Editor assigned by journal 06 Aug, 2025 Editor invited by journal 17 Jul, 2025 Submission checks completed at journal 16 Jul, 2025 First submitted to journal 16 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6951271","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":500122404,"identity":"3ae7b047-03f1-4eae-97f6-dafe0a9ef35e","order_by":0,"name":"Robin T. 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Sections were separated based on pertinence to patient safety/surgical decision making, intraoperative procedure, or education.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6951271/v1/f7852f12857eeb041bb30a09.jpeg"},{"id":89231319,"identity":"608a3feb-f229-4fb8-be59-13044a6d691f","added_by":"auto","created_at":"2025-08-17 14:18:51","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":114571,"visible":true,"origin":"","legend":"\u003cp\u003eFrom 2015 to 2022, there was an increasing trend in the number of research projects initiated due to the latest pre-operative discussion\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6951271/v1/390c8d8f302012f9d6d0ad99.jpeg"},{"id":89231328,"identity":"34d0af2b-7854-4042-a5d3-dbcb097d5e04","added_by":"auto","created_at":"2025-08-17 14:18:52","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":181921,"visible":true,"origin":"","legend":"\u003cp\u003eDifference between resident and fellow responses to the educational value of the latest pre-operative discussion. *p\u0026lt;0.05\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6951271/v1/1202f17c34fde3920c52ad14.jpeg"},{"id":89233325,"identity":"21789ce0-5cb7-4a71-8910-9fd507a230f3","added_by":"auto","created_at":"2025-08-17 14:34:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2206787,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6951271/v1/87d685ac-10f6-435d-805a-e4c0ad8bd029.pdf"},{"id":89232585,"identity":"bd47fdbb-e6c8-4eda-8503-5f025318121e","added_by":"auto","created_at":"2025-08-17 14:26:52","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17853182,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo 1 (mp4). \u003c/strong\u003eDemonstration of the latest-pre-operative discussion.\u003c/p\u003e","description":"","filename":"ThePreOperativeDiscussionVideo.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6951271/v1/5b8e99e6a51e18d6f152fa26.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Intratheater Latest Pre-Operative Discussion: Advocacy for Patient Safety, Procedural Optimization, and Surgical Education","fulltext":[{"header":"Background","content":"\u003cp\u003eThe operating theater relies on the concert of surgeons, anesthesiologists, trainees, nurses, and dedicated staff. Demands include selection of a correct operative plan, minimization of anesthetic risk, facilitation of student education, maintenance of efficiency, and above-all, gaurantee of patient safety. Universal mandates for operative checklists have driven great strides in surgical preparedness.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Unfortunately, surgical team involvement in decision making and education are regularly left to the wayside.\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eEfforts to improve team-based care, decision making, and learning have been few but fruitful. Glance et al. proposed a multi-disciplinary dialogue from all members of the pre-, intra-, and post-operative teams, providing full-spectrum care.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Sharma et al. depicted their elegant yet simple whiteboard technique: a written presentation of the full patient history and physical, the planned operation, sequence, and an “addendum” of needed supplies prior to every case.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Their survey-based quality assessment boasted improved flow, efficiency, involvement, and preparedness from all operating room staff.\u003c/p\u003e\u003cp\u003eThe international microsurgery fellowship at Chang Gung Memorial hospital, led by the senior author (FCW), has long been heralded for its didactic value.\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Prior to every microvascular free flap reconstruction, the senior author (FCW) conducts a pre-operative discussion for all members of the operating theater (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). As multiple discussions are held at the time of patient presentation, at the last clinic visit, and just prior to the operative day, this final dialogue is termed the latest pre-operative discussion. The team deliberates the patient history, operative plan, anatomy, and alternatives, followed by a review of the recent literature. We believe this interchange improves final surgical harmony and enriches team dynamics as well as education (Video 1).\u003c/p\u003e\u003cp\u003e\u003cb\u003eVideo 1 (mp4).\u003c/b\u003e Demonstration of the latest-pre-operative discussion.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The study protocol was conducted in compliance with the institutional review board of Chang Gung Memorial Hospital in Linkou, Taiwan.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe Latest Pre-Operative Discussion\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe latest pre-operative discussion was initiated at the nascent of the Chang Gung microsurgery fellowship in 1984.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e As of 2015, the pre-operative discussion was shifted from the whiteboard to digital Powerpoint (Microsoft, Washington, United States) presentations.\u003c/p\u003e\u003cp\u003eThe latest pre-operative discussion consists of four sections:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003ePatient information\u003c/em\u003e: A detailed description of the patient’s chief complaint, history of present illness, medical history, workup, laboratory data, imaging, and anatomy.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eSurgical plan\u003c/em\u003e: The anticipated resection plan followed by anatomy-specific reconstructive goals, and at least three alternative reconstructive options with rationale.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eLiterature review\u003c/em\u003e: A topic of inquiry is chosen, related to the current patient. Contemporary literature is then presented with critical review and summative conclusion.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eFinal decision\u003c/em\u003e: After judicious discussion, the final reconstructive plan is agreed upon by all members of the team and documented in the presentation. The senior author then reviews the surgical steps in detail and assigns roles to each member of the team.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe final presentation is uploaded into Professor Wei’s patient database for future reference. All pre-operative Powerpoint presentations were organized from January 1st, 2022 until December 31th, 2022. Presentation data collected included primary operative plan, alternatives, literature discussion topics, and final surgical decision.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurvey\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAn anonymous survey was created, based on that by Sharma et al.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Special emphasis was placed on patient safety, surgical decision making, intra-operative fluency, and education. Surveys were distributed to all sixty prior microsurgery fellows and plastic surgery residents who rotated with Professor Wei at Chang Gung Memorial hospital from 2015 onwards.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStatistics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using Stata software (Stata Corporation, College Station, Texas). Data was reported in percentages for categorical and averages for continuous data. Comparisons were performed with Fischer exact tests for categorical survey responses. Pearson correlation was performed for number of papers published by respondants each year.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eThe Latest Pre-Operative Discussion\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFrom January 1st 2022 until December 31st, 2022, seventy-one latest pre-operative discussions were completed. An average of 5.1 manuscripts were reviewed for each discussion, with a total of 363 papers reviewed in 2022. The preliminary surgical plan was changed in 10.7% of cases after discussion.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurvey Participants\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOf the 60 initial recipients of the survey request, 50 responses were recorded, indicating an 83.3% response rate. Respondents were 60% fellows and 40% residents at the time of rotation, and the majority were now attending surgeons in practice (78%; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 94% of respondents stated they will/have implemented the latest pre-operative discussion in their own practices.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurvey Results\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFinal survey results are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. No respondents strongly disagreed with any survey remarks. 100% of respondents strongly agreed or agreed with \u0026ldquo;I understood the surgical plan\u0026rdquo;. The least number of respondents (90%) strongly agreed or agreed with the statements \u0026ldquo;The operative flow was efficient\u0026rdquo; and \u0026ldquo;All team members had clear roles in surgery\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThere was a non-significant trend towards increasing research projects initiated by respondents as a result of the latest pre-operative discussion (mean 2.3 projects; R\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;=\u0026thinsp;0.15; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In 2022, an average of 3.1 project were begun by each respondent after discussion.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the educational section, responses differed significantly between residents and fellows in regard to \u0026ldquo;I was able to critique the quality of literature\u0026rdquo; (78% vs 46%; p\u0026thinsp;=\u0026thinsp;0.028), \u0026ldquo;I was able to find gaps in current knowledge\u0026rdquo; (88% vs 66%; p\u0026thinsp;=\u0026thinsp;0.044), and \u0026ldquo;The latest pre-operative discussion helps to generate potential research topics\u0026rdquo; (90% vs 74%; p\u0026thinsp;=\u0026thinsp;0.028). More fellows strongly agreed with all three statements compared with residents (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurvey Free Responses\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTwenty participants completed the optional free response section of the survey. Of these, 65% mentioned benefits of the surgical planning and patient safety, 55% referenced educational benefits, and 35% stated improvements in operative flow.\u003c/p\u003e\u003cp\u003eThree participants cited shortcomings, including \u0026ldquo;it was quite stressful to prepare for all the discussions\u0026rdquo;, \u0026ldquo;the downside is that it is a relatively time-consuming process\u0026rdquo;, and \u0026ldquo;to include otolaryngology surgeons into discussion would have been an additional benefit\u0026rdquo;.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e We advocate our 40-year experience with the Chang Gung Memorial microsurgery latest pre-operative discussion as a pivot for improving surgical care. This discussion enhances three pillars consisting of patient safety/decision making, intra-operative procedure, and education.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient safety and decision making\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDecision-making in surgery has evolved substantially. Shared decision-making alongside the patient represented a culture-shift to paternalistic treatment.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Advances in artificial intelligence and computer algorithms augment risk-benefit analyses.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Tumor boards for complex cancer cases result in more accurate diagnoses, treatment, and superior patient outcomes.\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Still, most surgical decisions are made during the initial consultation. On the day of surgery, the remainder of the operative team shepherding the surgery, are not involved in the final plan.\u003c/p\u003e\u003cp\u003eThe latest pre-operative discussion supplements decision-making with current literature review and round-table type dialogue. Importantly, this allows the final plan to be formulated by all members of the operative team who are present on the day of surgery. As a result, 10.1% of surgical decisions were changed after the pre-operative discussion. This is analogous to an 11% change in surgical management after breast cancer tumor board discussions reported by Newman et al.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Many\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eOperative Flow\u003c/em\u003e\u003c/p\u003e\u003cp\u003eModern integration of artificial intelligence into surgery concentrates on workflow optimization.\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e As such, in its most elementary form, surgical flow is based upon timely anticipation of the next step. The latest pre-operative outlines all surgical steps for all team members, thus optimizing surgical congruency. As discussions are limited to twenty minutes, we believe ultimate operative time is saved with improved team efficiency. In combined cases, discussions are held as the resection team begins, as reconstructive flap harvest generally finishes well before the ablative team is complete.\u003c/p\u003e\u003cp\u003eWhile survey responses were overall positive, 10% of respondents did not agree that the operative flow was efficient or that team members had clear roles, of which 80% were residents. As the visiting fellows are newer to the surgical customs, instruction of surgical steps and roles is more focused on fellow understanding. We take this important reflection to focus more on resident instruction going forward. The surgical team is a well-recognized fundamental. The landmark study by Mazzocco et al. pinpointed poor information sharing, handoff briefing, and general teamwork measures as risk factors for complications or even death in the operating room. While measures of teamwork in the induction phase did not result significant, all values had an odds ratio greater than one for risk of complications or death.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Future efforts must focus on not just the surgical steps, but the role of each teach member within this construct.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEducation\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe field of medicine is ever-changing. Therefore, all surgical decisions should include a review of the most-recent information. While continued education is required for board certification, it is often difficult for busy surgeons to synthesize an endless number of publications.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e In this study, we reviewed 363 manuscripts in the last year via the latest pre-operative discussion. With extensive literature review, surgeons can identify gaps for future study. In the last year alone, trainees reported an average 3 research projects initiated in response to the latest pre-operative discussion.\u003c/p\u003e\u003cp\u003eIntraoperative instruction can prolong surgical times, often discouraging proper teaching.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e This can be circumvented with dedicated time for pre-operative teaching. Even a simple four item pre-operative and post-operative briefing improved resident autonomy, performance, and the Objective Structured Assessment of Technical Skills scores. \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e This features yet another benefit enjoyed by the pre-operative discussion.\u003c/p\u003e\u003cp\u003eCompared to fellows, residents experienced less educational benefit from the latest pre-operative discussion. Indeed, a higher training level can facilitate quicker synthesis and greater appreciation for didactic literature reviews. However, resident duty verses education continues to be a dilemma for residency programs.\u003csup\u003e\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e It is unsurprising that \u0026ldquo;time-consuming\u0026rdquo; and \u0026ldquo;stressful\u0026rdquo; (as indicated by survey responses) preparation of this discussion may negatively impact trainee experience. Such feedback prompted efforts to standardize the presentation format, limit number of articles reviewed, and split the workload among all team members. Despite mention of difficulties, all negative responses universally mentioned the eventual appreciation of the value of such hard work.\u003c/p\u003e\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWe are limited by retrospective survey measures for evaluating case improvements, decision-making, and education. Future direction should focus on prospective collection and comparison of operating staff experiences. While the pre-operative discussion was lead for 40 years, only the last 8 years have involved recorded Powerpoint-style presentations for review. In reference to survey feedback, we endeavor to actively include the ablative team in the discussion and to lessen the workload in preparation for trainees. As the Chang Gung Microsurgery Fellowship continues to cultivate future leaders in the field, we hope the pre-operative discussion will become commonplace in the operating room.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe latest pre-operative discussion promotes patient safety, team decision making, operative efficiency, and education for all team members. As the Chang Gung Reconstructive Microsurgery fellowship and residency continue to cultivate future leaders in the field, we hope the latest pre-operative discussion will become commonplace in the operating room.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFCW: Fu Chan Wei\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclarations of interest:\u003c/strong\u003e none\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Approval and Consent to Participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved by the Chang Gung institutional review board. Informed consent to participate in this study was obtained from all the participants in the study. This research study adhered to the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for Publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of Data and Materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data and materials can be provided upon reasonable request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception, drafting, and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no additional acknowledgements to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNilsson, L., Lindberget, O., Gupta, A. \u0026amp; Vegfors, M. Implementing a pre‐operative checklist to increase patient safety: a 1‐year follow‐up of personnel attitudes. \u003cem\u003eActa anaesthesiologica Scandinavica\u003c/em\u003e \u003cstrong\u003e54\u003c/strong\u003e, 176\u0026ndash;182 (2010).\u003c/li\u003e\n\u003cli\u003eHaynes, A. B. \u003cem\u003eet al.\u003c/em\u003e A surgical safety checklist to reduce morbidity and mortality in a global population. \u003cem\u003eNew England journal of medicine\u003c/em\u003e \u003cstrong\u003e360\u003c/strong\u003e, 491\u0026ndash;499 (2009).\u003c/li\u003e\n\u003cli\u003eTreadwell, J. 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R. \u003cem\u003eet al.\u003c/em\u003e Surgery resident time consumed by the electronic health record. \u003cem\u003eJournal of Surgical Education\u003c/em\u003e \u003cstrong\u003e77\u003c/strong\u003e, 1056\u0026ndash;1062 (2020).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pre-Operative Discussion, Intra-Operative Discussion, Surgical Decision Making, Surgical Team","lastPublishedDoi":"10.21203/rs.3.rs-6951271/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6951271/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn the operating theater, surgeons must harness preparatory tools for quality assurance and team convergence. This study aims to evaluate perceptions of the latest pre-operative discussion, a presentation showcasing patient information, literature discussion, and team dialogue held with the entire operative team.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e A prospective, anonymous survey was distributed to all trainees who participated in the latest pre-operative discussion at the Chang Gung Memorial Hospital microsurgical reconstruction department between January 2016 - December 2022. Survey questions evaluated patient safety/decision-making, operative flow, and education of the latest pre-operative discussion. Secondary outcomes were gathered from review of all discussions held in 2022, including number of manuscripts reviewed and changes in operative plan following team deliberation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf sixty fellows and residents, fifty respondants (60% fellows, 40% residents) completed the survey, with a 83% response rate. At least 90% strongly agreed or agreed with all positive statements; 94% stated they will/have implemented the practice. An average of 2.3 projects were initiated in response to each discussion. Fellows more often strongly agreed that the discussion helped critique the quality of literature (78% vs 46%; p\u0026thinsp;=\u0026thinsp;0.028), find gaps in currently knowledge (88% vs 66%; p\u0026thinsp;=\u0026thinsp;0.044), and generate research topics (90% vs 74%; p\u0026thinsp;=\u0026thinsp;0.028). Of seventy-one discussions in 2022, an average of 5.1 manuscripts were reviewed in each presentation, and 10.7% of final plans were changed as a result.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eTrainees widely reported benefit of the latest pre-operative discussion in patient safety, operative flow, and education, with disparity amongst training levels in educational value. Formalized discussion may benefit surgical team decision-making and review contemporary literature, while allowing all operative staff to perform in congruity.\u003c/p\u003e","manuscriptTitle":"The Intratheater Latest Pre-Operative Discussion: Advocacy for Patient Safety, Procedural Optimization, and Surgical Education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-17 14:18:47","doi":"10.21203/rs.3.rs-6951271/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-08-08T17:15:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-06T13:51:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-17T08:43:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-16T07:03:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-07-16T05:13:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b971a8ac-a0b2-45ba-86db-df2be94a2221","owner":[],"postedDate":"August 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-17T14:18:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-17 14:18:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6951271","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6951271","identity":"rs-6951271","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}