How to develop a simulation programme in urology

What's known on the subject? and What does the study add? Inanimate trainers and simulators have been shown to facilitate the skill acquisition of urologists. However, there are significant challenges to integrating standalone simulation programmes into mainstream urology curricula. This study provides a framework to overcome these challenges and discusses the advantages of centralised urology simulation centres and their potential to serve as key adjuncts in the certification and validation process of urologists. Fixed performance‐based outcomes of inanimate trainers and simulators have been praised as useful adjuncts in urology for reducing the learning curve associated with the acquisition of new technical and non‐technical skills without compromising patient safety. Simulators are becoming an integral part of the urology training curriculum and their effectiveness is totally dependent on the structure of the programme implemented. The present paper discusses the fundamental concepts of centralized urology centres and their potential to serve as key adjuncts in the certification and validation process of urologists. In summary, proficiency‐based curricula with well structured endpoints and objective tools for validating proficiency are critical in developing a simulation programme in urology. We concludes that more educational research into the outcomes of integrated urology curricula followed by trainee/trainer opinion surveys will help address some of these criteria.     

Establishing milestones in urology training: A survey of the Canadian Academy of Urological Surgeons

Background:

At the current time, technical skills are not directly evaluated by the Royal College of Physicians and Surgeons of Canada (RCPSC) as part of the certification process in urology. Rather, the RCPSC relies on the evaluation of Program Directors to ensure that trainees have acquired the necessary surgical skills.

Methods:

An electronic survey was sent out to the members of the Canadian Academy of Urological Surgeons (CAUS), including the 13 Canadian urology program directors, to assess the teaching and evaluation of technical skills of urology trainees.

Results:

The response rate was 37% (33/89), including 8 of the 13 (62%) Program Directors from across Canada. For the teaching of technical skills, most programs had access to live animal laboratories (69%), dedicated teaching time in simulation (59%) and physical training models (59%). Most relied on voluntary faculty. There was a wide variety of structured evaluations for technical skills used across programs, while 36% of respondents did not use structured evaluations. For trainees with deficiencies in technical skills, 67% of programs offered extra operative time with designated faculty, 26% offered additional simulation focused on the deficiency and 19% offered faculty tutorial sessions.

Conclusion:

Among Canadian urology residency programs, there is considerable variability in the assessment of technical skills of trainees. Standardized objective assessment tools would help ensure that all trainees have acquired adequate surgical proficiency to operate independently.     

Development and initial validation of a cost-effective,re-usable,ultrasound-compatible suprapubic catheter insertion training simulator

IntroductionSuprapubic catheterization (SPC) is a fundamental skill required of urology trainees. A lack of affordable simulation models and unpredictability of bedside SPCs limit experiential learning opportunities. Our objective was to develop and initially validate a re-usable, low-cost, ultrasound (US)-compatible SPC simulator for acquiring skills that transfer to the bedside.MethodsThe model was constructed using six components. Staff urologists and interventional radiologists (IRs) conducted a SPC and rated the model on three domains with multiple subcategories on a five-point Likert scale: anatomic realism; usefulness as a training tool; and global/overall reaction. Participants in our first-year urology “boot camp” received SPC training, practiced, and were evaluated via an objective structured clinical examination (OSCE). Staff ratings and OSCE scores determined the model’s initial face and content validity.ResultsTwelve staff physicians participated in the study. The mean scores for urologists and IRs, respectively, were: anatomical realism: 4.10 and 3.70; usefulness as a training tool: 4.23 and 4.24; and overall reaction: 4.40 and 4.44. Staff strongly agreed that the model should be incorporated into the residency curriculum. Over the past four years, 25 boot camp participants scored a mean of 99.7% (±1.8) on the OSCE, with high technical performance and entrustment scores (4.8 and 4.7, respectively). The model cost $55 CAD.ConclusionsThis novel, multiple-use, low-cost, easily reproducible US-compatible SPC simulator demonstrated initial face and content validity via high staff urologist and IR ratings and OSCE scores of first-year urology residents. Additional research is required for construct validation.     

Decision making in urological surgery

Context

Non-technical skills are important behavioural aspects that a urologist must be fully competent at to minimise harm to patients. The majority of surgical errors are now known to be due to errors in judgment and decision making as opposed to the technical aspects of the craft.

Evidence acquisition

The authors reviewed the published literature regarding decision-making theory and in practice related to urology as well as the current tools available to assess decision-making skills. Limitations include limited number of studies, and the available studies are of low quality.

Evidence synthesis

Decision making is the psychological process of choosing between alternative courses of action. In the surgical environment, this can often be a complex balance of benefit and risk within a variable time frame and dynamic setting. In recent years, the emphasis of new surgical curriculums has shifted towards non-technical surgical skills; however, the assessment tools in place are far from objective, reliable and valid. Surgical simulators and video-assisted questionnaires are useful methods for appraisal of trainees.

Conclusion

Well-designed, robust and validated tools need to be implemented in training and assessment of decision-making skills in urology. Patient safety can only be ensured when safe and effective decisions are made.     

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.     

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.     

Objective Assessment of Small Bowel Anastomosis Skill in Trainee General Surgeons and Urologists

Introduction The object of this study was to compare the technical ability of general surgery and urology trainees to perform a small bowel anastomosis using a life-like bench model. Methods Forty subjects were divided into two groups based on the stage of their training. Specialist registrars (SpRs) trained for 1 to 3 years were defined as junior SpRs, and those with 4 to 6 years of training were defined as senior SpRs. They were asked to perform a small bowel anastomosis on a standard latex model using the same equipment, suture material, and standardized instructions. Trainees were assessed by three trained observers based on a global rating scale. Results Interrater reliability was 0.83 for the general surgical group and 0.88 for the urology group. The median scores obtained by the junior SpRs were lower than those achieved by the senior SpRs, and general surgical trainees consistently performed better than their matched urology group. This difference reached statistical significance for the senior group. Conclusions Global rating scores provide a reliable, valid method for assessing technical skills between specialties when performing a small bowel anastomosis. We provide reasons why general surgeons may be more proficient at this task than urologists. These findings have possible application to identifying trainees who need additional training and may also provide a mechanism to ensure competence in this task.     

First urology simulation boot camp in the United Kingdom

Objective

Simulation is now firmly established in modern surgical training and is applicable not only to acquiring surgical skills but also to non-surgical skills and professionalism. A 5-day intensive Urology Simulation Boot Camp was run to teach emergency procedural skills, clinical reasoning, and communication skills using clinical scenario simulations, endoscopic and laparoscopic trainers. This paper reports the educational value of this first urology boot camp.

A Review of the Available Urology Skills Training Curricula and Their Validation

BackgroundThe transforming field of urological surgery continues to demand development of novel training devices and curricula for its trainees. Contemporary trainees have to balance workplace demands while overcoming the cognitive barriers of acquiring skills in rapidly multiplying and advancing surgical techniques. This article provides a brief review of the process involved in developing a surgical curriculum and the current status of real and simulation-based curricula in the 4 subgroups of urological surgical practice: open, laparoscopic, endoscopic, and robotic.MethodsAn informal literature review was conducted to provide a snapshot into the variety of simulation training tools available for technical and nontechnical urological surgical skills within all subgroups of urological surgery using the following keywords: “urology, surgery, training, curriculum, validation, non-technical skills, technical skills, LESS, robotic, laparoscopy, animal models.” Validated training tools explored in research were tabulated and summarized.Results and ConclusionsA total of 20 studies exploring validated training tools were identified. Huge variation was noticed in the types of validity sought by researchers and suboptimal incorporation of these tools into curricula was noted across the subgroups of urological surgery. The following key recommendations emerge from the review: adoption of simulation-based curricula in training; better integration of dedicated training time in simulated environments within a trainee's working hours; better incentivization for educators and assessors to improvise, research, and deliver teaching using the technologies available; and continued emphasis on developing nontechnical skills in tandem with technical operative skills.     

Patient preferences and urologist recommendations among local-stage prostate cancer patients who present for initial consultation and second opinions

Objectives

This study describes urologist recommendations for treatment among local-stage prostate cancer patients presenting for initial management consultations versus second opinions. We hypothesized that urologists present a wider range of management recommendations and are less likely to consider the patient preference during the initial consultation.

Methods

Newly diagnosed local-stage prostate cancer patients and their urologists participated in a survey at urology practices in three states. The urologist??s survey included questions about the patient??s clinical status, treatments discussed and recommended, and factors that influenced the urologist??s recommendations.

Results

Of the 238 eligible patients, 95 men presented for an initial consultation, and 143 men presented for a second opinion. In multivariate analysis, urologists recommended 0.52 more treatments (standard error 0.19, P?Conclusions In second opinion settings urologists discussed fewer treatment options and recommended surgery more often. These findings also applied to men with low-risk prostate cancer.     

Evidence‐based medicine training in residency: a survey of urology programme directors

OBJECTIVE

To investigate whether and in what format urology residents receive formal training in evidence‐based clinical practice.

METHODS

In 2007 we conducted a survey of the Accreditation Council for Graduate Medical Education (ACGME)‐accredited urology residency programmes in the USA. The survey instrument was sent to all programmes, using postal mailing, e‐mail and a web–based interface. Programme director and coordinator names and basic demographic information such as programme size and length were retrieved from the institutions’ websites and the ACGME database.

RESULTS

Of 117 ACGME‐accredited urology programmes, 108 responded (92.3%). Most respondents either agreed or strongly agreed with statements that formal evidence‐based medicine (EBM) training was valuable to urology residents (97, 89.8%) and should be part of all residency programme curricula (91, 84.3%). Eighty‐four programmes (77.8%) indicated that their curricula included formal educational activities related to EBM. These programmes provided a median (interquartile range) of 10 (4.8–25.0) h of EBM teaching per academic year. Most programmes (65.9%) provided fewer hours of EBM training than programme directors perceived as ideal. Asked what would make it easier to integrate EBM into the programme, respondents identified urology‐specific educational materials (33.3%), a formal curriculum (24.4%) and faculty development (16.3%) as central needs.

CONCLUSION

In this survey we found that most programme directors recognize formal EBM teaching as an important aspect of urology residency training. However, most programmes devote less time to EBM training than they would like, and urology‐specific resources have been lacking. These findings support increased efforts to provide urology residents with opportunities to learn EBM‐related knowledge and skills in a variety of educational formats.     

An assessment of urologists' training and knowledge of energy-based surgical devices

OBJECTIVE

To assess surgeons’ training and current understanding of existing energy‐based surgical instrumentation (ESI), we disseminated an online questionnaire to urology residents, fellows and attending urologists.

SUBJECTS AND METHODS

A two part 24‐question survey was disseminated to 1000 urology residents, fellows and attending physicians. The first part of the questionnaire assessed the respondents’ demographics and education about ESI; the second part evaluated the respondent’s knowledge of surgical energy methods and ESI, and was stratified into nine basic‐ and six advanced‐knowledge questions.

RESULTS

In all, 136 people (13.6%) viewed the survey and it was completed by 63 (6.3%). Respondents comprised 27 (43%) attending physicians, 14 (22%) minimally‐invasive urology fellows and 22 (35%) urology residents. Among participants, 41 (64%) had received no formal didactic training on ESI, and a further 14% of respondents’ didactic experience was limited to one lecture. Of the respondents, 70% said that monopolar energy was the mode most often used in surgery. Overall, the participants correctly answered 41% of the questions. Of the nine questions classified as ‘basic’ knowledge, respondents correctly answered 49%. Of the six questions classified as ‘advanced’ knowledge, 29% were answered correctly. The highest percentage score was obtained by the attending urologists, with a mean (range) score of 41 (29–86)%, followed by the fellows, with a mean score of 39.5 (29–57)%, and then the residents, at 34 (14–64)%.

CONCLUSION

Despite widespread and growing use of ESI, there is currently minimal formal training on energy modes and current energy devices being provided to urological surgeons. Both practising and training urologists have a limited understanding of surgical energy modes and of existing ESI.     

Comprehensive proficiency-based inanimate training for robotic surgery: reliability, feasibility, and educational benefit

Background

We previously developed a comprehensive proficiency-based robotic training curriculum demonstrating construct, content, and face validity. This study aimed to assess reliability, feasibility, and educational benefit associated with curricular implementation.

Methods

Over an 11-month period, 55 residents, fellows, and faculty (robotic novices) from general surgery, urology, and gynecology were enrolled in a 2-month curriculum: online didactics, half-day hands-on tutorial, and self-practice using nine inanimate exercises. Each trainee completed a questionnaire and performed a single proctored repetition of each task before (pretest) and after (post-test) training. Tasks were scored for time and errors using modified FLS metrics. For inter-rater reliability (IRR), three trainees were scored by two raters and analyzed using intraclass correlation coefficients (ICC). Data from eight experts were analyzed using ICC and Cronbach’s α to determine test-retest reliability and internal consistency, respectively. Educational benefit was assessed by comparing baseline (pretest) and final (post-test) trainee performance; comparisons used Wilcoxon signed-rank test.

Results

Of the 55 trainees that pretested, 53 (96?%) completed all curricular components in 9–17?h and reached proficiency after completing an average of 72?±?28 repetitions over 5?±?1?h. Trainees indicated minimal prior robotic experience and “poor comfort” with robotic skills at baseline (1.8?±?0.9) compared to final testing (3.1?±?0.8, p?p?p?p?Conclusion This curriculum is associated with high reliability measures, demonstrated feasibility for a large cohort of trainees, and yielded significant educational benefit. Further studies and adoption of this curriculum are encouraged.     

Can medical students achieve skills proficiency through simulation training?

Background

The purpose of this study was to determine whether third-year medical students can become proficient in open technical skills through simulation laboratory training.

Methods

A total of 204 students participated in a structured curriculum including bladder catheterization, breast examination, and knot-tying. Proficiency was documented using global rating scales and validated, objective, model-based metrics.

Results

For catheterization and breast examination, all trainees showed proficiency, and self-rated comfort increased in more than 90%. For knot-tying, 83% completed the curriculum; 57% and 44% of trainees showed proficiency for 2- and 1-handed tasks, respectively. Objective performance scores improved significantly for 2- and 1-handed knot-tying (62.9-94.4 and 49.2-89.6, respectively; P < .001) and comfort rating also increased (28%-91% and 19%-80%, respectively; P < .001).

Conclusions

Objective scores and trainee self-ratings suggest that this structured curriculum using simulator training allows junior medical students to achieve proficiency in basic surgical skills.     

Efficacy of simulation‐based trauma team training of non‐technical skills. A systematic review

Trauma resuscitation is a complex situation, and most organisations have multi‐professional trauma teams. Non‐technical skills are challenged during trauma resuscitation, and they play an important role in the prevention of critical incidents. Simulation‐based training of these is recommended. Our research question was: Does simulation‐based trauma team training of non‐technical skills have effect on reaction, learning, behaviour or patient outcome? The authors searched PubMed, EMBASE and the Cochrane Library and found 13 studies eligible for analysis. We described and compared the educational interventions and the evaluations of effect according to the four Kirkpatrick levels: reaction, learning (knowledge, skills, attitudes), behaviour (in a clinical setting) and patient outcome. No studies were randomised, controlled and blinded, resulting in a moderate to high risk of bias. The multi‐professional trauma teams had positive reactions to simulation‐based training of non‐technical skills. Knowledge and skills improved in all studies evaluating the effect on learning. Three studies found improvements in team performance (behaviour) in the clinical setting. One of these found difficulties in maintaining these skills. Two studies evaluated on patient outcome, of which none showed improvements in mortality, complication rate or duration of hospitalisation. A significant effect on learning was found after simulation‐based training of the multi‐professional trauma team in non‐technical skills. Three studies demonstrated significantly increased clinical team performance. No effect on patient outcome was found. All studies had a moderate to high risk of bias. More comprehensive randomised studies are needed to evaluate the effect on patient outcome.     

Education and training in evidence-based urology

Objectives  

Urologists believe evidence-based clinical practice improves patient care. Competence in critical appraisal skills is necessary to successfully implement evidence-based practice. However, practicing urologists, urology program training directors, and residents have identified the need for urology-specific resources to promote competence in evidence-based practice. The objective of this review is to identify urology-specific educational resources for critical appraisal skills.     

Novellierung der Musterweiterbildungsordnung

Defining the curriculum for the training of medical specialists is the central structural element for the future of a medical discipline. This is not only important for defining the essential skills and knowledge elements of future urologists but also defines the position of urology as a speciality within the healthcare system, sets the rules for the interaction and separation of urology from other specialities and very often sets the limits for medical and surgical charges by urologists. The revision of the federal curriculum for medical specialists which is currently being prepared will therefore be instrumental in defining the future of urology in the German healthcare system.     

Urological litigation in the UK National Health Service (NHS): an analysis of 14 years of successful claims

What’s known on the subject? and What does the study add? There are no previous studies for urology in the UK but several studies from physician insurance groups in North America. There is anecdotal evidence of common reasons for litigation, e.g. missed testicular torsion. This is the first analysis of the claims data compiled by the NHS litigation authority for the speciality of urology; it provides realistic insight into the areas and procedures of the speciality most commonly affected by litigation. The article identifies areas of high risk, both clinical and medico‐legal.

OBJECTIVES

? To present a summary of the collected data on urological litigation within the UK National Health Service (NHS). ? Knowledge of the main areas of litigation is essential for maintaining good clinical practice as well as risk management procedures in any specialty.

MATERIALS AND METHODS

? Details of all claims closed with indemnity payment pertaining to the specialty of urology as practiced by urologists, general surgeons and paediatric surgeons was obtained from the NHS Litigation Authority (NHSLA) for the years since its creation in 1995 to 2009. ? The data was then classified and analysed.

RESULTS

? In all, 493 cases were closed with indemnity payment with a total of £20 508 686.18 paid. The average payment per claim was £41 599.77. ? Most of the claims were related to non‐operative events (232), followed by postoperative events (168) and intraoperative events (92). ? The most common reason for non‐operative‐related claims was failure to diagnose/treat cancer (69), perforation/organ injury (38) was the highest intraoperative‐related claim and a forgotten ureteric stent (23) was the most frequent postoperative‐related claim. ? The five most commonly implicated procedures were ureteroscopy/ureteric stenting (45), transurethral resection of the prostate (30), nephrectomy (26), vasectomy (19) and urethral catheterisation (15).

CONCLUSIONS

? The present study once again emphasizes the importance of thorough clinical assessment, record keeping and follow‐up as well as informed consent and good communication with patients. ? Recognising the areas of highest risk and improving practice should limit future claims.     

Significant transfer of surgical skills obtained with an advanced laparoscopic training program to a laparoscopic jejunojejunostomy in a live porcine model: feasibility of learning advanced laparoscopy in a general surgery residency

Background

Simulation may provide a solution to acquire advanced laparoscopic skills, thereby completing the curriculum of residency programs in general surgery. This study was designed to present an advanced simulation-training program and to assess the transfer of skills to a live porcine model.

Methods

First-year residents were assessed in a 14-session advanced laparoscopic training program followed by performing a jejunojejunostomy in a live porcine model. Previous and after training assessments at the bench model were compared to a single performance of six expert laparoscopic surgeons. Results obtained by trainees at the porcine model assessment were compared to those of 11 general surgeons without any laparoscopic lab-simulation training and 6 expert laparoscopic surgeons. In all assessments, global and specific OSATS scores, operative time, and covered path length of hands were registered.

Results

Twenty-five residents improved significantly their global and specific OSATS score median at the bench model [7 (range, 6?C11) vs. 23 (range, 21?C24); p?<?0.05 and 7 (range, 4?C8) vs. 18 (range, 18?C19); p?<?0.05, respectively] and obtained significantly better scores on the porcine model compared with general surgeons with no lab-simulation training [21 (range, 20.5?C21) vs. 8 (range, 12?C14); p?<?0.05]. The results were comparable to those achieved by expert certificated bariatric surgeons. Total path lengths registered for trainees were more efficient post-training and significantly lower compared with general surgeons on the porcine model [7 (range, 6?C11) vs. 23 (range, 21?C24); p?<?0.05] with no statistical difference compared with experts.

Conclusions

Trainees significantly improved their advanced laparoscopic skills to a level compared with expert surgeons. More importantly, these acquired skills were transferred to a more complex live model.     

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

INTRODUCTION

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees'' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool.

METHODS

An electronic literature search was performed, restricted to the English language, of MEDLINE®, Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session.

RESULTS

Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training.

CONCLUSIONS

Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.