Framework for incorporating simulation into urology training

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Simulation‐based training can provide urology trainees with the opportunity to develop their technical and non‐technical skills in a safe and structured environment. Despite its promised benefits, incorporation of simulation into current curricula remains minimal. This paper provides a comprehensive review of the current status of simulation for both technical and non‐technical skills training as it pertains to urology. It provides a novel framework with contextualised examples of how simulation could be incorporated into a stage‐specific curriculum for trainees through to experienced urologists, thus aiding its integration into current training programmes.

OBJECTIVES

? Changes to working hours, new technologies and increased accountability have rendered the need for alternative training environments for urologists. ? Simulation offers a promising arena for learning to take place in a safe, realistic setting. ? Despite its benefits, the incorporation of simulation into urological training programmes remains minimal. ? The current status and future directions of simulation for training in technical and non‐technical skills are reviewed as they pertain to urology. ? A framework is presented for how simulation‐based training could be incorporated into the entire urological curriculum.

MATERIALS AND METHODS

? The literature on simulation in technical and non‐technical skills training is reviewed, with a specific focus upon urology.

RESULTS

? To fully integrate simulation into a training curriculum, its possibilities for addressing all the competencies required by a urologist must be realized. ? At an early stage of training, simulation has been used to develop basic technical skills and cognitive skills, such as decision‐making and communication. ? At an intermediate stage, the studies focus upon more advanced technical skills learnt with virtual reality simulators. ? Non‐technical skills training would include leadership and could be delivered with in situ models. ? At the final stage, experienced trainees can practise technical and non‐technical skills in full crisis simulations situated within a fully‐simulated operating rooms.

CONCLUSIONS

? Simulation can provide training in the technical and non‐technical skills required to be a competent urologist. ? The framework presented may guide how best to incorporate simulation into training curricula. ? Future work should determine whether acquired skills transfer to clinical practice and improve patient care.     

SE01THE EMERGING ROLE OF SIMULATION IN SURGICAL TRAINING

Traditionally, surgical trainees have acquired their technical skills whilst working in the operating theatre alongside more senior surgeons in an apprenticeship model. Recently, changes in surgical practice have challenged this traditional approach, including reduced working hours, decreased availability of operating theatre time, increased cost of operating theatre time and increasing complexity of surgical procedures. Most importantly, public opinion is increasingly resistant to having patients used as teaching material. Moving forward in the 21st century, we need to develop a new model of technical skills acquisition. Surgical simulation offers a means of practicing surgical skills in a laboratory environment with no risk to patients. Simulators range from simple bench models, which are relatively inexpensive, to high tech virtual reality simulators. The Royal College of Surgeons in Ireland has developed a syllabus for operative surgery which is based on simulation and all trainees attend the National Surgical Training Centre on a regular recurrent basis, six times each year, for concentrated skills training. Simulation allows the standardisation of teaching technical skills and, most importantly, standardisation of assessment of technical skills. Furthermore, simulation offers trainees “permission to make mistakes”– a valuable learning exercise. Our trainees are assessed in the laboratory setting and must demonstrate proficiency before moving to the next stage of training (proficiency based progression). Simulation has played a key role in this process.     

Surgical simulators in urological training--views of UK Training Programme Directors

What's known on the subject? and What does the study add? The role of surgical simulators is currently being debated in urological and other surgical specialties. Simulators are not presently implemented in the UK urology training curriculum. The availability of simulators and the opinions of Training Programme Directors' (TPD) on their role have not been described. In the present questionnaire‐based survey, the trainees of most, but not all, UK TPDs had access to laparoscopic simulators, and that all responding TPDs thought that simulators improved laparoscopic training. We hope that the present study will be a positive step towards making an agreement to formally introduce simulators into the UK urology training curriculum. To discuss the current situation on the use of simulators in surgical training. To determine the views of UK Urology Training Programme Directors (TPDs) on the availability and use of simulators in Urology at present, and to discuss the role that simulators may have in future training. An online‐questionnaire survey was distributed to all UK Urology TPDs. In all, 16 of 21 TPDs responded. All 16 thought that laparoscopic simulators improved the quality of laparoscopic training. The trainees of 13 TPDs had access to a laparoscopic simulator (either in their own hospital or another hospital in the deanery). Most TPDs thought that trainees should use simulators in their free time, in quiet time during work hours, or in teaching sessions (rather than incorporated into the weekly timetable). We feel that the current apprentice‐style method of training in urological surgery is out‐dated. We think that all TPDs and trainees should have access to a simulator, and that a formal competency based simulation training programme should be incorporated into the urology training curriculum, with trainees reaching a minimum proficiency on a simulator before undertaking surgical procedures.     

Simulation‐based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part‐task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three‐dimensional printing and computer‐based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.     

Simulation-based airway management training: application and looking forward

Within the airway management field, simulation has been used as a tool of training for over 40 years. Simulation training offers a chance of active involvement for the trainees. It can effectively enhance and upgrade the knowledge and skills of the trainees in airway management, and subsequently decrease medical errors and improve patients’ outcomes and safety through a variety of airway management training modalities, such as common airway skills, difficult airway management strategies, and crisis management skills. To perform simulation-based airway management training effectively, not only are task trainers and high-fidelity simulators required but also instructors with rich experience in airway management simulation training and optimal curriculum design are essential.     

Surgical Education and Surgical Simulation

The science of virtual reality provides an entirely new opportunity in the area of simulation of surgical skills using computers for training, evaluation, and eventually certification. A taxonomy of the types of simulators is proposed based upon the level of complexity of the task which is being simulated. These tasks are precision placement, simple manipulation, complex manipulation, and integrated procedure. Representative simulators in each category are illustrated and discussed in the context of their contribution to the education and training of a surgeon. The importance of a curriculum is to give content to the role of simulators as another advanced tool for education. Simulators must be integrated into a comprehensive curriculum and not considered as a stand-alone system. The current accomplishments as well as challenges are discussed.     

Simulation

Simulation is an established instrument for medical training and further education covering technical and non-technical skills. It provides a platform for training psychomotor skills and professional behavior. Various simulators have been developed for cardiac, thoracic, and vascular surgery. Skill trainers are described for heart valve surgery and coronary anastomoses. Even beating artificial hearts are commercially available for surgical training, besides classical animal models. Virtual reality provides an additional dimension for training in thoracoscopic and interventional surgery. Every simulator has to be embedded in a defined curriculum to achieve the optimal effect. Curricula in the form of courses may be more effective in teaching basic surgical skills than learning solely during patient treatment in the operating room. One popular method to facilitate simulators for education is scenario training in real time. International associations recommend the implementation of scenario simulation for emergency training and evaluation of surgical skills in various disciplines. Issues, such as communication, team leadership and decision making can be effectively trained by simulation scenarios. There are only a few but fundamental publications providing evidence that simulation has a positive effect on patient care during cardiac surgery and on intensive care units; however, simulation can never replace experience in real patient care. Especially inexperienced healthcare providers have a tendency to overestimate their competence after training by simulation. Simulation is therefore a valuable adjunct but not a substitute for medical training and further education.     

Primer: cognitive motor learning for teaching surgical skill--how are surgical skills taught and assessed?

As the practice of surgery evolves, the modalities by which future surgeons are trained must also develop. Traditionally, surgical trainees have learned through a mentorship model, with the majority of cognitive motor learning for surgical skill being initiated and practiced within the operating room. This, however, is no longer the ideal environment in which to acquire surgical skills and, subsequently, many surgical training programs are incorporating the use of other surgical models within their curricula. Training on simulators, ranging from low-fidelity bench models to complex, high-fidelity virtual reality models, seems to be transferable and might prove to be a crucial supplement to the traditional curriculum. Models that are reliable and valid, coupled with objective instruments that measure technical skill, might prove to be useful for evaluation. For a simulator to provide a good assessment of competency, it should either correlate to or predict the person's technical performance in the operating room. More research is, therefore, needed regarding the validity and transferability of various training models, particularly if they are to become a form of assessment for certification or licensure.     

Introduction, availability and role of simulation in surgical education and training: Review of current evidence and recommendations from the Association of Surgeons in Training

The utility of simulation in surgical training is now well-established, with proven validity and demonstrable transfer of skills to the clinical setting. Through a reduction in the technical learning curve, simulation can prepare surgeons for actual practice and in doing so it has the potential to improve both patient safety and service efficiency. More broadly, multi-disciplinary simulation of the theatre environment can aid development of non-technical skills and assist in preparing theatre teams for infrequently encountered scenarios such as surgical emergencies. The role of simulation in the formal training curriculum is less well-established, and availability of facilities for this is currently unknown. This paper reviews the contemporary evidence supporting simulation in surgical training and reports trainee access to such capabilities. Our national surgical trainee survey with 1130 complete responses indicated only 41.2% had access to skills simulator facilities. Of those with access, 16.3% had availability out-of-hours and only 54.0% had local access (i.e. current work place). These results highlight the paucity in current provision of surgical skills simulator facilities, and availability (or awareness of availability) varies widely between region, grade and specialty. Based on these findings and current best-evidence, the Association of Surgeons in Training propose 22 action-points for the introduction, availability and role of simulation in surgical training. Adoption of these should guide trainers, trainees and training bodies alike to ensure equitable provision of appropriate equipment, time and resources to allow the full integration of simulation into the surgical curriculum.     

Simulation in pediatric anesthesiology

Simulation‐based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer‐based simulations to mannequins. Computer‐controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in‐situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task‐training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients.     

Is it time to incorporate hands-on simulation into the cardiothoracic surgery curriculum?

The COVID pandemic has had huge implications for training in cardiothoracic surgery. The reduction in training opportunities has led to concerns from trainees globally regarding the impact on their learning and their training progression. Surgical simulation is effective in the development of technical skills in cardiothoracic surgery with numerous examples of low and high-fidelity simulators. Despite this the incorporation of such methods into training curricula worldwide is seldom. Core fundamentals are required to successfully implement surgical simulation into training programmes, which includes; commitment from trainers, regular sessions and structured feedback. Few programmes have demonstrated the successful incorporation of surgical simulation and there is a growing acceptance of its place in the speciality. As we recover from this challenging period it may be the right opportunity to evolve how we train our current and future trainees by incorporating hands-on simulation as a fundamental part of the cardiothoracic curriculum.     

Surgical simulation in orthopaedic skills training

Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.     

Accomplishments and challenges of surgical simulation

For nearly a decade, advanced computer technologies have created extraordinary educational tools using three-dimensional (3D) visualization and virtual reality. Pioneering efforts in surgical simulation with these tools have resulted in a first generation of simulators for surgical technical skills. Accomplishments include simulations with 3D models of anatomy for practice of surgical tasks, initial assessment of student performance in technical skills, and awareness by professional societies of potential in surgical education and certification. However, enormous challenges remain, which include improvement of technical fidelity, standardization of accurate metrics for performance evaluation, integration of simulators into a robust educational curriculum, stringent evaluation of simulators for effectiveness and value added to surgical training, determination of simulation application to certification of surgical technical skills, and a business model to implement and disseminate simulation successfully throughout the medical education community. This review looks at the historical progress of surgical simulators, their accomplishments, and the challenges that remain.     

Virtual reality training for endoscopic surgery: voluntary or obligatory?

Introduction Virtual reality (VR) simulators have been developed to train basic endoscopic surgical skills outside of the operating room. An important issue is how to create optimal conditions for integration of these types of simulators into the surgical training curriculum. The willingness of surgical residents to train these skills on a voluntary basis was surveyed. Methods Twenty-one surgical residents were given unrestricted access to a VR simulator for a period of four months. After this period, a competitive element was introduced to enhance individual training time spent on the simulator. The overall end-scores for individual residents were announced periodically to the full surgical department, and the winner was awarded a prize. Results In the first four months of study, only two of the 21 residents (10%) trained on the simulator, for a total time span of 163 minutes. After introducing the competitive element the number of trainees increased to seven residents (33%). The amount of training time spent on the simulator increased to 738 minutes. Conclusions Free unlimited access to a VR simulator for training basic endoscopic skills, without any form of obligation or assessment, did not motivate surgical residents to use the simulator. Introducing a competitive element for enhancing training time had only a marginal effect. The acquisition of expensive devices to train basic psychomotor skills for endoscopic surgery is probably only effective when it is an integrated and mandatory part of the surgical curriculum.     

Open Surgical Simulation—A Review

BackgroundSurgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation.Current State of Open Surgical SimulationOpen surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment.Future of Open Surgical SimulationThe skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient’s safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools.     

Training opportunities and the role of virtual reality simulation in acquisition of basic laparoscopic skills

BACKGROUND: Within the past decade, there has been increasing interest in simulation-based devices for training and assessment of technical skills, especially for minimally invasive techniques such as laparoscopy. The aim of this study was to investigate the perceptions of senior and junior surgeons to virtual reality simulation within the context of current training opportunities for basic laparoscopic procedures. METHODS: A postal questionnaire was sent to 245 consultants and their corresponding specialist registrar (SpR), detailing laparoscopic surgical practice and their knowledge and use of virtual reality (VR) surgical simulators. RESULTS: One hundred ninety-one (78%) consultants and 103(42%) SpRs returned questionnaires; 16%(10/61) of junior SpRs (year 1-4) had performed more than 50 laparoscopic cholecystectomies to date compared with 76% (32/42) of senior SpRs (year 5-6) (P < 0.001); 90% (55/61) of junior SpRs and 67% (28/42) of senior SpRs were keen to augment their training with VR (P = 0.007); 81% (238/294) of all surgeons agreed that VR has a useful role in the laparoscopic surgical training curriculum. CONCLUSIONS: There is a lack of experience in index laparoscopic cases of junior SpRs, and laparoscopic VR simulation is recognized as a useful mode of practice to acquire technical skills. This should encourage surgical program directors to drive the integration of simulation-based training into the surgical curriculum.     

Perception and use of minimal access surgery simulators in pediatric surgery training programs

Background/Purpose

In the current time-restricted training environment, simulator use in surgical teaching is receiving increasing attention. A large body of literature addresses simulators' effectiveness in surgical education. No prior studies assess how widely simulators are actually being used or attitudes about their effectiveness of those involved in training.

Methods

Surveys were e-mailed to all current pediatric surgery trainees and training directors. Queries examined respondents' perceptions about surgical simulators' usefulness and to what extent they are used in their programs. Other questions assessed obstacles to simulator use.

Results

Response rates were high (47% of program directors and 67% of current fellows). Nearly all respondents felt laparoscopic simulators improve training efficiency (88%). About half (55%) report regular simulator availability to trainees. Only 21% of programs have current or planned simulation curricula. Less than half of the training directors (32%) and about half of the fellows (55%) felt they have actually significantly improved trainees' skills.

Conclusions

Trainees and training directors placed significant importance on simulator use in pediatric surgery training. However, most did not feel that simulators had actually improved the trainees' laparoscopic skills. Wider availability of simulation laboratories and protected time for using them would enhance the impact of simulators on pediatric surgery training.     

Training and assessment of trauma management: the role of simulation-based medical education

Simulation-based medical education (SBME) offers a safe and "mistake-forgiving" environment to teach and train medical professionals. The diverse range of medical simulation modalities enables trainees to acquire and practice an array of tasks and skills. SBME offers the field of trauma training multiple opportunities to enhance the effectiveness of the education provided in this challenging domain. In this article, the authors describe the possible roles of simulated patients, skills trainers, computerized patient simulators, and web-based teaching in trauma training, and describe some practical aspects of using simulation for trauma training.     

Simulators and difficult airway management skills

Although difficult airway management remains one of the leading factors in anaesthetic deaths, there have been tremendous advances in the field in the last few decades. The question is, are advanced airway management skills being taught and used? Of the numerous training tools available, simulators have the advantages of providing whole‐task learning with the potential to change behaviour and, when applied to large groups of trainees, the possibility of achieving standardized application of the safest practices for a range of scenarios limited only by the creativity of the program designers. Partial‐task trainers include computer‐based software programs and simulators. Full‐scale simulators include a variety of products from several manufacturers. To take full advantage of simulators as educational tools, curricula should be designed around a set of educational objectives that address the objectives of learning in all three skill domains (cognitive, psychomotor, and affective). Simulation experiences using partial‐task or whole‐task trainers should be coupled whenever feasible with a structured clinical experience in airway management. This can best be achieved through a dedicated airway management rotation. Monitored procedure logs may also be used. Whether using a simulator or in a clinical rotation, experiences should be graded, for example, gaining experience in an adult population before gaining experience in paediatrics and in each population mastering airway management skills for common scenarios before advancing to more complicated techniques such as fibreoptic bronchoscopy.     

Identification of skills common to renal and iliac endovascular procedures performed on a virtual reality simulator.

INTRODUCTION: There is a learning curve in the acquisition of endovascular skills for the treatment of vascular disease. Integration of Virtual reality (VR) simulator based training into the educational training curriculum offers a potential solution to overcome this learning curve. However evidence-based training curricula that define which tasks, how often and in which order they should be performed have yet to be developed. The aim of this study was to determine the nature of skills acquisition on the renal and iliac modules of a commercially-available VR simulator. METHOD: 20 surgical trainees without endovascular experience were randomised to complete eight sessions on a VR iliac (group A) or renal (group B) training module. To determine skills transferability across the two procedures, all subjects performed two further VR cases of the other procedure. Performance was recorded by the simulator for parameters such as time taken, contrast fluid usage and stent placement accuracy. RESULTS: During training, both groups demonstrated statistically significant VR learning curves: group A for procedure time (p<0.001) and stent placement accuracy (p=0.013) group B for procedure time (p<0.001), fluoroscopy time (p=0.003) and volume of contrast fluid used (p<0.001). At crossover, subjects in group B (renal trained) performed to the same level of skill on the simulated iliac task as group A. However, those in group A (iliac trained) had a significantly higher fluoroscopy time (median 118 vs 72 secs, p=0.020) when performing their first simulated renal task than for group B. CONCLUSION: Novice endovascular surgeons can significantly improve their performance of simulated procedures through repeated practice on VR simulators. Skills transfer between tasks was demonstrated but complex task training, such as selective arterial cannulation in simulators and possibly in the real world appears to involve a separate skill. It is thus suggested that a stepwise and hierarchical training curriculum is developed for acquisition of endovascular skill using VR simulation to supplement training on patients.