Simulation‐based surgical education

The reduction in time for training at the workplace has created a challenge for the traditional apprenticeship model of training. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs. Recent technological advances have led to the development of various simulators, which have already been introduced in surgical training. The complexity and fidelity of the available simulators vary, therefore depending on our recourses we should select the appropriate simulator for the task or skill we want to teach. Educational theory informs us about the importance of context in professional learning. Simulation should therefore recreate the clinical environment and its complexity. Contemporary approaches to simulation have introduced novel ideas for teaching teamwork, communication skills and professionalism. In order for simulation‐based training to be successful, simulators have to be validated appropriately and integrated in a training curriculum. Within a surgical curriculum, trainees should have protected time for simulation‐based training, under appropriate supervision. Simulation‐based surgical education should allow the appropriate practice of technical skills without ignoring the clinical context and must strike an adequate balance between the simulation environment and simulators.     

Exploring the challenges of task-centred training in obstetric anaesthesia in the operating theatre environment

BackgroundTask-centred learning forms the basis of procedural training in obstetric anaesthesia. We observed that our residents were not building their competence from experiential practice in the operating theatre. We used a broad-based framework to explore the challenges encountered by the residents and clinical supervisors in the learning and teaching of obstetric anaesthesia.MethodsThe study was conducted at the KK Women’s and Children’s Hospital, Singapore, from 1 December 2016 to 30 June 2017. A semi-structured interview format was used in the focus group and individual interviews. Information collection continued until data saturation was reached. The interviews were analysed and the challenges were identified. Fourteen residents and five clinical supervisors participated in the focus group and individual interviews respectively.FindingsThe operating theatre constituted a stressful learning and teaching environment for the participants. Five categories of challenges were identified: (1) clinical conditions, (2) concerns about maternal risk and outcomes, (3) reluctance of the residents to vocalise their learning needs, (4) poor feedback, and (5) lack of opportunities for inter-professional practice. These collective challenges reduced the quality of task-centred learning and the effectiveness of supervisor teaching. We described some strategies to overcome these challenges (dedicated trainee lists, obstetric anaesthesia reflective diary, active mentoring system and in-situ simulation).ConclusionsOur study described the challenges of obstetric anaesthesia training in the operating theatre environment in an Asian healthcare setting. Research is needed on the influence of supervisors’ concern about maternal risks and their teaching behaviours.     

Umfrage zur aktuellen Situation der Regionalanästhesie im deutschsprachigen Raum

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The first part of the trilogy contains the presentation and evaluation of the data about quality assurance and training concepts. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia and 384 hospitals participated (51.2%). The overall proportion of regional anaesthesia was 23% and in Switzerland it was significantly higher (adults: 48%; children: 31%). Of the hospitals 19% had no person who was responsible for quality assurance. The number of puncture attempts was unlimited in 59% of the hospitals. The first training steps were observed closely (complete observation: 81%). The exact beginning (48%) and end (15%/13%) of the training were often not fixed, 80% of all anaesthesia departments requested an improvement in the training for peripheral and 53% for neuroaxial regional anaesthesia techniques. Regional anaesthesia plays a highly important role. Concepts of training and quality assurance that are backed up by evidence-based medicine should be worked out to improve the training and further education in regional anaesthesia.     

The continuing medical education needs of anaesthetists

Learning needs assessment is the term applied to the process of identifying or diagnosing a learner's educational needs. It is the foundation of a systematic continuing medical education (CME) programme. Needs assessment has been identified as the most pressing problem of medical education directors in North America. Furthermore, the CME learning needs, interests or motivations of anaesthetists have never been studied. The amount of time and effort required for needs assessment is probably a major deterrent to this activity. The investigators adopted simple and straightforward means of assessing the "perceived learning needs" and topic interests of anaesthetists. Questionnaires were sent by mail to anaesthetists practicing in teaching and non-teaching hospitals in the Toronto area. The questionnaire presented a list of CME content areas. The respondents were asked to indicate on scale of 1 to 10 their Current Expertise, Ideal-Desired Expertise, and Interest-Motivation levels for each content area. Need Score for each content area was calculated by taking the difference between Ideal and Current Expertise responses. A total of 101/305 anaesthetists (29%) responded to the survey. Most of the respondents had been in anaesthesia practice for less than ten years. Regional nerve block, acute pain control, and medicolegal considerations received high overall ranks in both the need and interest categories. Paediatric anaesthesia, anaesthesia for trauma surgery and thoracic anaesthesia had top ranks among the subspecialty fields. Regional anaesthesia techniques received higher need and interest ranks than intravenous and inhalational techniques. The learning needs of anaesthetists of a large urban centre have been identified, and this information is useful to CME planners.     

Training in obstetric general anaesthesia: a vanishing art?

General anaesthesia in obstetric practice has largely been replaced by the use of regional techniques. We have studied this phenomenon and the subsequent impact on training in this technique both retrospectively and with a prospective audit. There has been a decline in the use of general anaesthesia for Caesarean section such that trainee anaesthetists are getting less practical exposure to this important procedure. Audit revealed a deficit with consultant involvement in training and heightened awareness has resulted in improved supervision. Possible implications for future consultant working practices are discussed.     

Validation of surgical simulators

Although apprenticeship served surgeons in training well a hundred years ago, the complexity of surgical technology in the 21st Century has exponentially increased the demands on surgical education. Pelvic trainers can provide the necessary basic training for endoscopic and laparoscopic surgeons, but it usually is necessary to incorporate live-animal or cadaver practice or both to train fully in today's complex procedures. Advances in computer and materials technology have allowed the development of realistic simulators, but validation studies are required. Reliability is the reproducibility and precision of the test or testing device. Validity measures whether the simulator actually is teaching or evaluating what it is intended to teach or measure. Face validity relates to the realism of the simulator; content validity is a judgment of the appropriateness of the simulator as a teaching modality. Criterion validity compares the evaluation results from the new simulator with those of the old technique. The two types of criterion validity are concurrent - the extent to which the simulator correlates with the "gold standard" - and predictive - the extent to which the simulator predicts future performance. Construct validity indicates whether the simulator is able to distinguish the experienced from the inexperienced surgeon. For competency assessment, performance on a simulator should predict, or at least correlate with, an individual's performance in the operating room. A variety of endourologic models and simulators have been described, but only a few have been subjected to validity testing. An even greater number of simulators has been developed for laparoscopic skills training, but none is dedicated to training for laparoscopic urology. Surgical simulation must be used within an effective learning environment, underpinned by knowledge and professional attitudes.     

The training and careers of regional anesthesia fellows--1983-2002

BACKGROUND AND OBJECTIVES: The education and subsequent careers of regional anesthesia fellows have not been examined but may provide insight into improving future fellowship training and/or the future of the subspecialty. METHODS: Regional anesthesia fellows educated during a 20-year period (1983-2002) were asked to complete a comprehensive survey that detailed their training, current professional setting, and use of regional anesthesia, and how they foresee the future of regional anesthesia. A separate survey of academic anesthesiology chairs assessed the role of and need for regional anesthesiologists in teaching departments. RESULTS: Twelve regional anesthesia fellowship programs in the United States and Canada provided contact information on 176 former fellows. The survey response rate from those practicing in North America was 49% (77/156). Two of the 12 responding institutions have trained 68% of regional anesthesia fellows. Of respondents, 61% are or have been in academic practice. Regional anesthesia remains an integral part of most respondents' current practice, as evidenced by significant use of regional techniques, active involvement in subspecialty societies, and participation in continuing medical education programs. Academic chairs indicate that fellowship-trained regional anesthesiologists play important roles in resident education and are in demand by academic departments. CONCLUSIONS: This report details how regional anesthesia fellows from 1983 to 2002 were trained and how they currently practice and examines their insights regarding the strengths and weaknesses of past and future regional anesthesia education.     

Simulation in surgical education

Simulation is becoming an important tool in surgical education. Surgical faculty have been forced to modify how they teach technical skills. Instead of a complete reliance on teaching in the operating room, a structured curriculum and dedicated time in the simulation center are being used in many centers. Some of the advantages of this approach include the ability to learn and practice new procedures in a safe and nurturing environment. The disadvantages include the significant cost of virtual reality simulators and the competition, between various training programs, to gain access to simulation.     

How does French initial osteopathic training value relational competency,patient education,and the competency-based approach? A cross-sectional survey

BackgroundDespite the promotion of international osteopathic recommendations and registration guidelines, relational competencies and patient education practices present a challenge in the clinical setting due to lack of training. In France, the latest national osteopathic standards for education and practice defined a relational competency that includes patient education. Little is known about its integration in curricula and how French osteopathic practitioners are subsequently trained for relational competency.ObjectiveTo determine teaching, learning, and assessment methods related to relational competency in French initial osteopathic training programs and identify the role of patient education in this relational competency.MethodsAn online questionnaire was designed and sent to all initial training institutes in France (n = 28). Eight institutes answered the survey.ResultsThe relational competencies appeared in various courses, enhanced by clinical learning. However, the courses were not specific to this competency and the volume of hours was relatively low. Patient education was seen as part of relational competency but was poorly implemented. This competency-based approach is still considered an emerging practice in these institutes.ConclusionsThere is a misalignment among intended learning outcomes, teaching, and assessment. Current educational practices are not sufficient to support relational competency, specifically regarding patient education. Further research is needed on how French standards are understood, how they are assimilated by educators, and how they are translated into educational practice. In addition, the adequacy of educators' training for effective implementation of the competency-based approach should be questioned.     

The experiential curriculum: an alternate model for anaesthesia education

The shift to direct entry into residency training from medical school for all graduates will offer new challenges for anaesthesia training programmes. In this paper we argue that it also offers us an opportunity to re-evaluate our current approach to anaesthesia education. Emphasis in the residency programmes should be to provide trainees with clinical experiences and stimulation that will develop the required traditional competencies. It should also cultivate competency in clinical decision-making, intuition and judgement. Our purpose is to generate discussion by proposing an alternate curriculum model, the experiential curriculum. The basic premise is that learning is a process and outcome is to a large extent related to what the learner does. The process begins with an experience that provides for observation and reflection. Integration of the thoughts provides the basis for executing either existing or new actions. In the experiential curriculum residency training and learning are enhanced by documenting and critically evaluating the experiences to which the resident is exposed. Included within such a structured programme are the methodologies of problem-based and evidence-based learning. Faculty development will be required to help the resident pursue these skills of self-evaluation and efficient learning. We believe that incorporation of an experiential curriculum into the residency training programme will achieve the goals listed above and allow maturation of the process of lifelong learning. It will also allow greater achievement of the application of new information to one’s practice.     

Anaesthesia and education

A literature review was undertaken to document the status of anaesthetic education in both the peer-reviewed anaesthesia and medical education literature. A search was performed using Silver Platter for the period 1983-91, and the most widely circulated medical education and anaesthesia journals in North America were reviewed in detail. Although anaesthetists are involved in many educational activities, the literature is oriented towards postgraduate training. Common issues include the assessment and selection of residents. Newer methods of evaluation, for example, daily assessment by preceptors, have been described, but work continues to be needed on these and older methods, such as oral examinations. Selection processes may be improved by incorporating psychological and psychomotor measures in the assessment process. A limited number of teaching methods, especially simulators, have been the focus of much interest, while other methods, such as bedside teaching, have received little attention. Programs of recertification or maintenance of competence, which have been announced by certifying bodies, may place new emphasis on the study of the design, effectiveness, and outcome of continuing medical education. In conclusion, the review revealed that there are many opportunities for anaesthetists to conduct educational research into many traditional and new areas of medical education.     

Design and validation of a virtual reality trainer for ultrasound-guided regional anaesthesia

Virtual reality is a form of high-fidelity simulation that may be used to enhance the quality of medical education. We created a bespoke virtual reality trainer software using high resolution motion capture and ultrasound imagery to teach cognitive-motor needling skills necessary for the performance of ultrasound-guided regional anaesthesia. The primary objective of this study was to determine the construct validity between novice and experienced regional anaesthetists. Secondary objectives were: to create learning curves for needling performance; compare the virtual environment immersion with other high-fidelity virtual reality software; and compare cognitive task loads imposed by the virtual trainer compared with real-life medical procedures. We recruited 21 novice and 15 experienced participants, each of whom performed 40 needling attempts on four different virtual nerve targets. Performance scores for each attempt were calculated based on measured metrics (needle angulation, withdrawals, time taken) and compared between the groups. The degree of virtual reality immersion was measured using the Presence Questionnaire, and cognitive burden was measured using the NASA-Task Load Index. Scores by experienced participants were significantly higher than novices (p = 0.002) and for each nerve target (84% vs. 77%, p = 0.002; 86% vs. 79%, p = 0.003; 87% vs. 81%, p = 0.002; 87% vs. 80%, p = 0.003). Log–log transformed learning curves demonstrated individual variability in performance over time. The virtual reality trainer was rated as being comparably immersive to other high-fidelity virtual reality software in the realism, possibility to act and quality of interface subscales (all p > 0.06) but not in the possibility to examine and self-performance subscales (all p < 0.009). The virtual reality trainer created workloads similar to those reported in real-life procedural medicine (p = 0.53). This study achieved initial validation of our new virtual reality trainer and allows progression to a planned definitive trial that will compare the effectiveness of virtual reality training on real-life regional anaesthesia performance.     

Practical aspects of training in spinal anaesthesia (author's transl)

The current "renaissance" in regional anaesthesia finds many institutions poorly prepared. Since the various methods of conduction anaesthesia can not adequately be acquired from journals or lectures alone, the main responsibility for the dissemination of the necessary technical skills rests with the training programs. The standard of care available to our patients depends upon the quality of the residency training and the practically oriented postgraduate courses, which we are able to provide. Unfortunately, teaching methodology, especially in the area of conduction anaesthesia, has sofar not attracted much attention. Initial sporadic investigations [1, 2, 3] have shown, that even in centers with a long tradition of training residents in spinal anaesthesia the results largely fall short of reasonable expectations. Systematic work in this area appears urgently needed. Teaching methods used within the Department of Anaesthesiology at the University of Alabama are briefly outlined.     

Failed intubation in obstetrics

Failed intubation in obstetric practice is rare, however it can have a devastating impact on the mother and fetus if not managed appropriately.Over the last 20 years there have been significant changes in anaesthetic management and training; in addition The European Working Time Directive has led to a reduction in junior doctors' hours. As a result, trainees now have less exposure to airway management, specifically endotracheal intubation.Acquiring skills in obstetric general anaesthesia is increasingly difficult as the majority of women will be suitable for regional anaesthesia.Training must be targeted at the differences between the airway in the non-pregnant and pregnant woman, and it is essential that all training opportunities in obstetric general anaesthesia should be taken. Use of simulation and animal models is an effective way of improving teamwork and confidence to deal with emergency situations such as failed intubation.     

Facilitating learning in the operating theatre and intensive care unit

Almost every aspect of anaesthetic and intensive care practice can be taught within the operating theatre and intensive care unit. This includes knowledge in the areas of medicine, anatomy, pharmacology, physiology, measurement and statistics, invaluable psychomotor and global skills and abilities, as well as the many important non-clinical aspects of anaesthesia and intensive care including effective communication, leadership, management, ethics and teaching. The operating theatre and intensive care unit offer many advantages and pose numerous challenges to education. This paper briefly discusses what can be taught in the operating theatre and intensive care unit, the educational challenges and benefits of teaching in these unique environments, implications for teaching and what consultants and trainees can do to positively influence the educational activity. The paper concludes with suggestions for facilitating learning in the operating theatre and intensive care unit including the Soldier's Five, practice vivas, skills training, endoscopic dexterity, interesting article exchange, in-service sessions, electronic resources and use out of hours.     

Invited manuscript poster on renal-related education American Society of Nephrology, Nov. 16-21, 2010. Nephrology teaching tool: anagrams

At our institution we have developed unique ways of teaching nephrology and attracting medical students and residents to the field of nephrology. One of the ways we have achieved this is doing talks and sessions using puzzles. This teaching tool was designed to enhance resident learning and to complement resident's role as a teacher, while they were on their nephrology elective. Here we present a sample "anagram" and how it was used to teach the medical residents.     

The computer as a teaching aid: with particular reference to anaesthesia

Computers have been used by a few anaesthetists for teaching purposes for a number of years. Well constructed programs have the capacity to realistically present material which would not be available by other teaching methods. The advent of small portable computers has made this powerful teaching aid potentially available to a much larger group. It is likely that computer aided learning has a significant future in anaesthetic training and, in particular, for continuing medical education.     

Education and teaching laparoscopic surgery in Europe: present constraints and role of the European Association for Endoscopic Surgery

As we move on to the second decade of the 21st century, many changes in education and, particularly, in training future surgeons, have come to pass. Several of these changes are the result of a natural evolution in teaching methods, but others have been dictated by global modifications in the educational and social systems reigning throughout the Western culture. The recent evolution to less aggressive therapy and, in particular, surgical techniques, attests to the desire to decrease patient harm. Laparoscopic surgery, based on less invasive parietal violation and insult, responding to the above-mentioned concerns, has rekindled the debate on patient safety but also has opened the debate on how to best teach the technique. This paper endeavors to describe the problems created by the social and economic changes in the last few decades, to assess the consequences on teaching and learning laparoscopic surgery for the surgeon and to review possible solutions.     

Undergraduate and postgraduate education

Education is a core activity of academic departments but pressure from universities to maximize research income and research productivity, and from hospitals to deliver a more efficient clinical service, has pushed the importance of education into third place in many departments. Academic departments of anaesthesia can make significant contributions to undergraduate teaching. Students appreciate the one-to-one teaching which they receive from anaesthetists and the range of practical skills which they can learn. The main teaching burden of an academic department of anaesthesia relates to education of clinical trainees. National curriculum requirements must be delivered. Organization of a structured training programme, together with the appraisal and assessment systems which are necessary to ensure satisfactory progress of each trainee, require supervision by a number of academic staff, as well as administrative support. Higher postgraduate degrees may be gained by teaching or a combination of teaching and research. Teaching methods are changing, and there are opportunities to exploit e-learning on Intranet sites, and anaesthesia simulators, in both undergraduate and postgraduate education. Clinical governance issues and increasing scrutiny by authorities which fund teaching or set professional standards have resulted in demands for evidence that educational objectives are being met and that assessment systems are robust. There is a recognition that education has a cost, and resources are available from universities and hospitals to support the teaching activities of academic departments of anaesthesia.     

A novel, cost effective escharotomy simulator and trainee assessment

Over the last two decades, virtual reality, haptics, simulators, robotics, and other “advanced technologies” have emerged as important innovations in medical learning and practice. In the 21st century, however, it is important to continue to develop simple teaching aids which are available to large audiences in low and middle-income countries. We present a simple ‘escharotomy simulator’ which has been well received, resulting in an increase in knowledge, and an increase in confidence to carry out the procedure.