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.     

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.     

The changing face of surgical education: simulation as the new paradigm

Surgical simulation has evolved considerably over the past two decades and now plays a major role in training efforts designed to foster the acquisition of new skills and knowledge outside of the clinical environment. Numerous driving forces have fueled this fundamental change in educational methods, including concerns over patient safety and the need to maximize efficiency within the context of limited work hours and clinical exposure. The importance of simulation has been recognized by the major stake-holders in surgical education, and the Residency Review Committee has mandated that all programs implement skills training curricula in 2008. Numerous issues now face educators who must use these novel training methods. It is important that these individuals have a solid understanding of content, development, research, and implementation aspects regarding simulation. This paper highlights presentations about these topics from a panel of experts convened at the 2008 Academic Surgical Congress.     

Improving Surgical Training

Improving Surgical Training is a programme piloting an innovative, evidence-based approach to training. It was developed in response to the Shape of Training report which reviewed postgraduate training and recommended changes in medical education to meet the demands of the modern NHS. A series of initiatives have been developed to enhance the experience for surgical trainees not only to encourage a more focussed and supported method, but also to improve their job satisfaction. The initiatives have combined a greater emphasis on time for training provided by trainers with allocated time for training with multidisciplinary teamworking and the use of technology enhanced learning with simulation of both technical and non-technical skills. The pilot started in 2018 with core training in general surgery and has been expanded to include vascular surgery, urology and trauma and orthopaedics over the last 2 years. Initial feedback from both trainees, trainers and schools of surgery have identified different challenges to aid implementation. The programme is being very carefully evaluated by an independent company as well as careful oversight by the General Medical Council which are paramount to its success.     

Improving surgical training

Improving Surgical Training is a programme piloting an innovative, evidence-based approach to training. It was developed in response to the Shape of Training report which reviewed postgraduate training and recommended changes in medical education to meet the demands of the modern NHS. A series of initiatives were developed to enhance the experience for surgical trainees not only to encourage a more focussed and supported method, but also to improve their job satisfaction. The initiatives combined a greater emphasis on time for training provided by trainers with allocated time for training with multidisciplinary teamworking and the use of technology enhanced learning with simulation of both technical and nontechnical skills. The pilot started in 2018 with core training in general surgery and was expanded to include vascular surgery, urology and trauma and orthopaedics. An independent evaluation has described that the project proved to be more of a developmental programme than a pilot. Nevertheless a number of lessons have been highlighted to inform future approaches. These include issues of governance of training, dedicated and resourced training time for trainers and greater availability of simulation at both basic and more advanced levels.     

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.     

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.     

Novel method for assessment and selection of trainees for higher surgical training in general surgery

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty-two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short-listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree's or diplomas that had been obtained through part-time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short-listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post-graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability alpha = 0.89 and good statistical power (range 0.95-0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.     

Technology-enhanced learning for surgeons

Modern surgical education is a rapidly changing field with the development of new and more accessible technology creating the opportunity to enhance a learner's experience. The appropriate use of technology within a structured learning programme that has educational principles embedded can result in safe and effective development for learners. This article aims to highlight some of the available and more innovative technology that can be utilized to develop a learner's knowledge, technical and non-technical skills and attitudes as they progress in surgical training.     

Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training

SUMMARY BACKGROUND DATA: To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision METHODS: A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. RESULTS: VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. CONCLUSIONS: VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.     

Surgical Education and Training in Australia and New Zealand

Surgical education for medical students in Australia and New Zealand is provided by 19 universities in Australia and 2 in New Zealand. One surgical college is responsible for managing the education, training, assessment, and professional development programs for surgeons throughout both countries. The specialist surgical associations and societies act as agents of the college in the delivery of these programs, the extent of which varies among specialties. Historically, surgical training was divided into basic and specialist components with selection required for each part. In response to a number of factors, a new surgical education and training program has been developed. The new program incorporates a single merit-based national selection directly into the candidate's specialty of choice. The existing curriculum for each of the nine specialties has been remodeled to a competence-based format in line with the competence required to undertake the essential roles of a surgeon. New standards and criteria have been produced for accreditation of health care facilities used for training. A new basic surgical skills education and training course has been developed, with simulation playing an increasing role in all courses. Trainees' progress is assessed by workplace-based assessment and formal examinations, including an exit examination. The sustained production of sufficient competent surgeons to meet societal needs encompasses many challenges including the recruitment of appropriate graduates and the availability of adequate educational and clinical resources to train them. Competence-based training is an attractive educational philosophy, but its implementation has brought its own set of issues, many of which have yet to be resolved.     

我国普通外科医师培养模式及教学面临的问题及对策

当前,我国普通外科要以国际标准完善住院医师和专科培训,涵盖医学教育连续统一体的3个阶段。外科基础课程和外科技能课程能有效地提升学生的基本手术技术和能达到全球医学教育最基本要求。医师工作时间的限制和病人安全意识的加强改变了住院医师教育和培训的模式。普通外科医师的专业化与当前的临床实践是重要问题。研究生的教育应与专科医师培训相结合。跨专业教育和学习服务是对未来医疗卫生教育的一种模式。基于虚拟技术的外科培训和模拟中心完全改变了教育的程序,特别是住院医师培训的腹腔镜和机器人外科课程。虚拟现实技术是近年出现的计算机辅助应用技术,在医学教育领域展显优势。电子学习系统将发挥重要作用。     

Towards a hybrid philosophy of surgical education

BACKGROUND: Surgical training involves a complex amalgam of skills. This publication seeks to incorporate concepts about higher education into a philosophy of surgical education. METHODS: The core of the present review is derived from a literature search of a computer database (Medline). The notion of competence is used to illustrate the concept of a philosophy of surgical education. CONCLUSION: A predefined philosophy of surgical education may serve as a useful reference point when choices arise during the development of surgical training.     

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.     

The Development of a Novel Perfused Cadaver Model With Dynamic Vital Sign Regulation and Real-World Scenarios to Teach Surgical Skills and Error Management

The landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model.The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance.Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.     

Virtual reality laparoscopic skill assessment in microgravity

BACKGROUND: The objective of the study was to assess if performance of basic laparoscopic skills on a virtual reality (VR) simulator is impaired in microgravity relative to normal gravitational influences. MATERIALS AND METHODS: Fourteen subjects with various educational backgrounds underwent basic laparoscopy skill training for five consecutive days on the ground before flying aboard NASA's KC-135 zero-gravity laboratory. The participants performed basic laparoscopic exercises (clip applying, grasping, cutting, and suturing) on a VR laparoscopy simulator, both on the ground and during 25-s microgravity windows in parabolic flight. Skill levels after ground training were compared with skill levels in performing the same tasks in microgravity. Blinded reviewers measured the number of tasks successfully completed, tissue damage number, left and right hand path lengths during task execution, and percentage of task attempts that resulted in successful completion. RESULTS: A significant increase in tissue injury (t test, P < 0.05) and task erosion were seen in clip applying, cutting, and grasping in microgravity (45%, 20% and 57% decrease in task attempts that resulted in a successful completion, respectively). However, there was no significant difference in the left and right hand path lengths, and the total number of tasks successfully completed on the ground versus in microgravity, for any of the four laparoscopic exercises (t test, P > 0.05). CONCLUSION: This study demonstrates decreased efficiency and increased injury to the simulated tissues in performing laparoscopic skills during microgravity as compared to performing these skills in standard gravitational influence. Additional experiments are indicated to further develop and validate VR microgravity surgical simulation.     

Burns education: The emerging role of simulation for training healthcare professionals

Burns education appears to be under-represented in UK undergraduate curricula. However current postgraduate courses in burns education provide formal training in resuscitation and management. Simulation has proven to be a powerful modality to advance surgical training in both technical and non-technical skills. We present a literature review that summarises the format of current burns education, and provides detailed insight into historic, current and novel advances in burns simulation for both technical and non-technical skills, that can be used to augment surgical training. Addressing the economic and practical limitations of current immersive surgical simulation is important, and this review proposes future directions for integration of innovative simulation strategies into training curricula.     

Development and decay of procedural skills in surgery: A systematic review of the effectiveness of simulation-based medical education interventions

ContextChanges to surgical training programmes in the UK has led to a reduction in theatre time for trainees, and an increasing reliance on simulation to provide procedural experience. Whilst simulation offers opportunity for repetitive practice, the effectiveness of simulation as an educational intervention for developing procedural surgical skills is unclear.MethodsA systematic literature review was undertaken to retrieve all studies describing simulation-based medical education (SBME) interventions for the development of procedural surgical skills using the MEDLINE, PsycINFO, CINAHL, EMBASE and PUBMED databases. Studies measuring skill retention or demonstrating transferability of skills for improving patient outcomes were included in the review.ResultsSBME is superior to no training and can lead to improvement in procedural surgical skills, such that skills transfer from simulated environments into theatre. SBME results in minimal skill degradation after 2 weeks, although more significant decay results after >90 days. Many studies recruited <10 participants, used a variety of methods and were restricted to endoscopic surgical techniques. All studies did not compare interventions with non-SBME teaching methods for developing procedural surgical skills. No studies compared the curriculum design of different surgical training programmes.ConclusionsSBME interventions are effective for developing procedural skills in surgery. SBME interventions are also effective for preventing the decay of procedural surgical skills. Although no studies demonstrate non-inferiority of SBME interventions compared to time in theatre developing skills, SBME interventions do enable the transfer of skills into theatre, and the potential for improving patient outcomes.     

A surgical virtual reality simulator distinguishes between expert gynecologic laparoscopic surgeons and perinatologists

Background:Concern regarding the quality of surgical training in obstetrics and gynecology residency programs is focusing attention on competency based education. Because open surgical skills cannot necessarily be translated into laparoscopic skills and with minimally invasive surgery becoming standard in operative gynecology, the discrepancy in training between obstetrics and gynecology will widen. Training on surgical simulators with virtual reality may improve surgical skills. However, before incorporation into training programs for gynecology residents the validity of such instruments needs to first be established. We sought to prove the construct validity of a virtual reality laparoscopic simulator, the SurgicalSim^TM, by showing its ability to distinguish between surgeons with different laparoscopic experience.Methods:Eleven gynecologic surgeons (experts) and 11 perinatologists (controls) completed 3 tasks on the simulator, and 10 performance parameters were compared.Results:The experts performed faster, more efficiently, and with fewer errors, proving the construct validity of the SurgicalSim.Conclusions:Laparoscopic virtual reality simulators can measure relevant surgical skills and so distinguish between subjects having different skill levels. Hence, these simulators could be integrated into gynecology resident endoscopic training and utilized for objective assessment. Second, the skills required for competency in obstetrics cannot necessarily be utilized for better performance in laparoscopic gynecology.     

Simulation for early years surgical training

The shift from traditional apprenticeship models to competency-based curricula, compounded by working hour restrictions and rapid advances in surgical technology, has altered the delivery of early years surgical training. Simulation has been widely incorporated in other high-risk, high-reliability industries, but it has only just begun to be embedded in surgical programmes over the last two decades. In this article, we review key concepts in surgical simulation. Using Scotland's Core Surgical Training Programme as an example, we demonstrate the implementation of these concepts into a national integrated simulation strategy for early years surgical training. We highlight other global examples of simulation use in surgical curricula. The key messages for all stakeholders in surgical training are: (i) simulation is an adjunct to clinical training; (ii) simulation is a tool; however, it is not the tool that should be the main object of interest, but the learning for which it is used; and (iii) in the absence of a constructively aligned and purposeful programme that is valued by trainees, trainers and the training system, it is not enough to issue the kit, no matter how good the simulators are.