Laying the foundation of surgical skills for trainees (Residents)

The role of the surgical skills laboratory is becoming increasingly important as surgical service needs evolve and educational processes seek to become more robust. The skills laboratory offers an opportunity to better prepare residents for their clinical rotations and to accelerate their clinical effectiveness. The Royal Australasian College of Surgeons has developed and introduced a new standardised basic surgical skills curriculum that can be delivered sustainably in centres throughout Australia and New Zealand. A technical skill set required by all surgical disciplines was compiled, and each skill was deconstructed into cognitive steps. Models were devised to simulate an application of each skill, and standardized demonstrations were created and recorded to ensure uniform teaching. Extensive resource material supports the course programme, with information for tutors, technicians, course directors and participants. Currently, clinical rotations offer inconsistent opportunities for trainees to practise their skills after the course. Recruitment and retention of tutors remains a key challenge.     

Workplace‐based assessment: assessing technical skill throughout the continuum of surgical training

The Royal Colleges of Surgeons and Surgical Specialty Associations in the UK have introduced competence‐based syllabi and curricula for surgical training. The syllabi of the Intercollegiate Surgical Curriculum Programme (ISCP) and Orthopaedic Curriculum and Assessment Programme (OCAP) define the core competencies, that is, the observable and measureable behaviours required of a surgical trainee. The curricula define when, where and how these will be assessed. Procedure‐based assessment (PBA) has been adopted as the principal method of assessing surgical skills. It combines competencies specific to the procedure with generic competencies such as safe handling of instruments. It covers the entire procedure, including preoperative and postoperative planning. A global summary of the level at which the trainee performed the assessed elements of the procedure is also included. The form has been designed to be completed quickly by the assessor (clinical supervisor) and fed‐back to the trainee between operations. PBA forms have been developed for all index procedures in all surgical specialties. The forms are intended to be used as frequently as possible when performing index procedures, as their primary aim is to aid learning. At the end of a training placement the aggregated PBA forms, together with the logbook, enable the Educational Supervisor and/or Programme Director to make a summary judgement about the competence of a trainee to perform index procedures to a given standard.     

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.     

Pediatric surgical training: an historic perspective, a formula for change

Background/purpose

American pediatric surgical education has more than a 65-year history of formalizing the organization and the curriculum of the training process. However, never before have so many simultaneous internal and external forces appeared on the horizon that have the collective potential of influencing the quality of future pediatric surgeons. It is the purpose of this study to identify and detail these opportunities, compare them with the historical past, and propose the beginnings of a strategy to control the destiny. The ultimate goal should be to continue to assure that pediatric surgeons are of the highest attainable quality that will optimize the surgical health of America’s children.

Methods and results

Using a current literature review, 7 specific influencing forces have been identified: a declining applicant pool, the generation-X factor, medical economics, early specialization of training, restricted residency work hours, pediatric surgical manpower, and competency-based surgical education. An effective response to these forces is multifactorial, but a first need might be consideration of a new educational oversight organizational structure for pediatric surgery. Thereafter, specific curricular reform is needed to match the strengths of the candidates as well as the training programs. Finally, as a specialty field we must assert the leadership needed to define optimal educational outcomes.

Conclusions

This report defines the educational history and the contemporary influencing forces, and it proposes a strategy to assure that pediatric surgical education exceeds the needs of America’s children into the future.     

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.     

Role of simulation in surgical education and training

There are several challenges facing surgical education and training that simulation may help to address. A conceptual framework is required to allow the appropriate application of simulation to a given level and type of surgical skill and this should be driven by educational imperatives and not by technological innovation. Simple simulation is required for core skills training. Cognitive simulation is introduced as a way in which procedural skills training can be achieved. Virtual world simulation opens up significant opportunities for team skills training. A role for simulation in surgical education and training appears assured, but its success will be determined by the extent to which it is integral to high quality curricula, its importance determined by its contribution to both learning and assessment, and its sustainability determined by evidence of its advantages and cost‐effectiveness.     

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.     

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.     

Australasian general surgical training and emergency medical teams: a review

Emergency medical teams (EMTs) have provided surgical care in sudden‐onset disasters in low‐ and middle‐income countries. General surgeons have been heavily involved in many EMTs due to their traditional broad set of surgical skills and experience. With the increased subspecialization of general surgical training in many high‐income countries, including Australia and New Zealand, finding general surgeons with adequately broad experience is becoming more challenging. Furthermore, it is now considered standard for EMTs deploying to a sudden‐onset disaster to have undergone credentialing, demonstrating sufficient training of their deployed members. The purpose of this review was to highlight the challenges and potential solutions facing those involved in training and recruiting general surgeons for EMTs in Australasia.     

Virtual reality simulators: current status in acquisition and assessment of surgical skills

Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side-effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator--by passing control to a computer--may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine--by repeated trials--whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.     

腹腔镜基础技能模拟训练的量化研究

目的比较医学生和外科低年资住院医师在腹腔镜基础技能模拟训练中的差异,为腹腔镜基础技能训练提供客观的数据。 方法通过比较医学生和低年资医师在传递、精确定位、剪切、打结及缝合打结项目中的操作时间和失误情况得分的差异,建立各自的学习曲线。 结果经过10次训练后,A、B组参与者在传递、精确定位、剪切、打结及缝合打结5个项目的得分分别是(89.81±2.07) vs(93.91±3.46)、(89.00±6.39) vs(91.21±6.69)、(84.35±5.94) vs(86.69±6.46)、(93.88±3.01) vs(93.51±2.65)、(87.34±3.22)vs (92.09±4.10)。A、B组参与者的精确定位、剪切、打结的训练结果之间无差异(P >0.05),而传递和缝合打结的训练结果之间存在统计学差异(P<0.05)。A、B组参与者在同一训练项目中第1次与第10次的训练结果之间存在差异(P<0.05)。A、B组参与者在传递、打结和缝合打结项目中呈反曲线发展,而在精确定位和剪切两个项目中呈线性发展。 结论通过训练,A、B组参与者的腹腔镜基础技能均获得显著提高,重复性的训练可以使A组在精确定位、剪切、打结的训练中达到B组的水平,A、B组参与者在传递、打结和缝合打结项目中已达到平台期,而在精确定位和剪切两个项目中仍处于增长期。     

Acquiring surgical skills: the history of surgical teaching at the University of Sydney 1883–2014

There have been at least 10 major revisions of the medical curriculum since the inauguration of the Faculty of Medicine at the University of Sydney in 1883. This study traced the evolution of the teaching of surgery at our institution by examination of the set curriculum of each period; the expectations of student knowledge in the final examination as well as examining some of the insights provided by past students of their surgical experience through their writings. In the early years, medical graduates were qualified to perform operative surgery without any further training, whereas the modern postgraduate medical curriculum provides students with the basis for further surgical training.     

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.     

Validation of a novel robotic-assisted partial nephrectomy surgical training model

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic‐assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic‐assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training.

OBJECTIVE

• ? To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic‐assisted partial nephrectomy (RAPN).

METHODS

• ? We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (≥100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post‐study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey–kramer test.

RESULTS

• ? The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as ‘very realistic’ (median visual analogue score 7/10) (face validity). Experts also rated the model as an ‘extremely useful’ training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P= 0.0002) as well as individual metrics, including ‘depth perception,’‘bimanual dexterity,’‘efficiency,’‘tissue handling,’‘autonomy,’‘precision,’ and ‘instrument and camera awareness’ (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05).

CONCLUSION

• ? Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.

     

Reliability of a revised NOTECHS scale for use in surgical teams

BACKGROUND: Recent developments in the surgical literature highlight the need for assessment of nontechnical skills in surgery. We report a revision of the NOn-TECHnical Skills (NOTECHS) scale of the aviation industry for use in surgery and detailed analysis on its reliability. METHODS: The original NOTECHS scale assesses (1) Cooperation, (2) Leadership and Managerial Skills, (3) Situation Awareness and Vigilance, and (4) Decision Making. We added a Communication and Interaction dimension and adapted all subscales for use in surgical context. Reliability was assessed in simulation-based training for trainee clinicians. RESULTS: Satisfactory reliability (Cronbach's alpha) was obtained (1) across professional groups and trainers and trainees, (2) in separate analyses for trainers and trainees, (3) in successive administrations of the scale, and (4) in surgical, anaesthetic and nursing groups analyzed separately. In the operating department practitioners group, Situation Awareness and Vigilance and Cooperation and Team Skills exhibited lower reliability. CONCLUSIONS: Assessment of surgical nontechnical skills is becoming a training priority. The present evidence suggests that the revised NOTECHS scale exhibits good reliability. Further empirical research should assess the validity of the scale.