Orthopaedic education in the era of surgical simulation: Still at the crawling stage

Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulationbased curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.     

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??Problems and strategies faced by training model and education of general surgeon YANG Zhen. Department of Surgery, Tongji Hospital, Tongji Medical College,Huazhong University of Science and Technology,Wuhan430030,China
Abstract At present, chinese general surgery should improve residency and subspecialty residencies training utilized global standards which is consisted of 3 overlapping phases.Fundamentals of surgery curriculum and surgical skills curriculum are an effective way to enhance the students' basic surgical skills and would obtain the global standards for postgraduate medical education. Working-hour restrictions and a heightened awareness of patient safety has changed resident education and training. Specialization and the current practices of general surgeons are a important problem.Postgraduate medical students program should be combined with resident training.Interprofessional education and service learning is a model for the future of health professions education. Simulation-based surgical education and simulator center has completely revolutionized the training process,especially in the laparoscopic and robotic surgery curriculum for resident training. Virtual realicy is the application of the computer aid technique in recent years, which shows its dominant position in medical education. E-learning will play an important role in the near future.     

Proficiency-Based Training Using Simulator-Based Tools Could be Validated for Certification of Surgical Procedural Proficiency

Airline pilots can learn how to fly without ever leaving the ground, and pilots are required to pass proficiency checks using simulator-based tools to ensure they are competent, and remain competent, to fly specific types of planes under specific circumstances. In contrast, generally, surgical training is based on an apprenticeship model, and surgical certification does not require demonstration of hands-on skills in performing basic, advanced, or subspecialized procedures. Proficiency-based training, or PBT, also known as proficiency-based progression or PBP, is a tool that can be used to train surgeons to safely and efficiently perform surgical procedures. Moreover, PBT, simulators, and similar tools can be used to evaluate a surgeon’s proficiency. Ultimately, in the interest of quality, value, and patient safety, objective evaluation of hands-on surgical skill using simulators should be implemented. In the interest of fairness to surgeons, certification must be developed with a goal of not only testing but supporting development of procedural proficiency. As we follow our peers in the airline industry, pathways chosen to validate surgical competence must be evidence-based, fair, and valid.     

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training(box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon's performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.     

Surgical simulation in orthopaedic skills training

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

Simulation-based education for cardiac, thoracic, and vascular anesthesiology

Simulation has been used for medical teaching and testing for at least four decades in some form, such as that used for cardiopulmonary resuscitation training; however, new technology applied to medical and procedural training has recently led to a marked increase in the use of simulation-based instruction. Educational theory has further supported simulation for medical education and procedural training. Simulation-based testing to demonstrate competence with new procedures is already required by the US Food and Drug Administration for one angiographically-placed device, and it is likely that simulation-based credentialing for procedures will be increasingly prevalent. Anesthesiologists, like other physicians, may be credentialed or certified based on their performance in a simulated environment in the future. This review describes some of the current simulation-based education techniques related to cardiovascular and thoracic anesthesiology. Additional discussion covers some of the applicable educational theory and the expected future uses of simulation modalities in healthcare education, testing, and practice.     

怎样培训优秀的消化外科医师

培训一名优秀的消化外科医师,要求做好以下5个阶段：（1）医学本科学习。一名优秀的本科毕业医师,要求具有：①良好的医德医风和专业操守;②良好的医学知识和治病能力;③良好的其他能力,包括沟通、决策、协作、领导、健康倡导、教学能力和拥有专业精神。（2）外科基础培训。在国际上,先进国家已发展到系统性的外科基础培训。培训完毕和考试合格后,可进入不同科目的高级外科培训。（3）普通外科的专业培训。香港的普通外科培训和英国的制度相近,培训结束后参加香港统一考试,通过后可获得香港外科医学院和英国爱丁堡皇家外科医学院的专业医师资格。香港外科医学院和英国爱丁堡皇家外科医学院已认同我国大陆14个培训中心为培训基地,经过这些培训基地培训出来的医师,可参加香港外科医学院和英国爱丁堡皇家外科医学院举行的联合考试,合格后可获得这两所学院的外科专业资格。（4）消化外科小专科培训。消化外科是普通外科培训后其中一个小专科。中国香港和很多先进国家均没有建立一个系统性的培训制度。在香港是否发展普通外科的小专科系统性培训尚在商议中。（5）终生继续学习。终生学习非常重要。在国际上,已经有继续医学教育、持续专业发展、持续专业教育、重新验证和重新认证等讨论。总之,培训优秀的消化外科医师,要从打好根基开始。此外,建立一个国家性的系统外科培训,才能培训出好的外科专业人才。     

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。     

Editorial Commentary: Virtual Reality Simulation Can Help Arthroscopic Hip Preservation Surgeons at All Levels of Training and Practice—This is How

Virtual reality (VR) simulation has enormous potential utility in technically demanding manual activities. Hip arthroscopy is a perfect example of a challenging surgical technique with an extensive learning curve. The literature has recently consistently demonstrated that both career and annual maintenance case volume significantly influences patient-reported outcomes and risk of revision surgery and complications. Current residency and fellowship programs do not sufficiently prepare trainees to meet or exceed experience thresholds, so augmentation of training is necessary. A significant strength of VR simulation includes its ability to practice without limits. Unfortunately, hip models are limited to simple tasks, without full surgery models yet available simulating routine arthroscopic hip preservation procedures like labral repair, cam and pincer correction, capsular repair. Advanced techniques like labral reconstruction or augmentation, protrusio acetabulae, extensive cam morphology, revision surgery, peritrochanteric space endoscopy, and deep gluteal space endoscopy are not yet available for simulation. VR simulation can probably achieve competence for most, if not all, surgeons; possibly achieve proficiency; and unlikely to achieve mastery. The use of machine learning and artificial intelligence can process vast quantities of photo and video data to generate high-fidelity, lifelike surgical simulation. The near future will incorporate and assimilate these technologies cost-effectively for training programs and surgeons. Our patients will benefit.     

Assessing the skills of surgical residents using simulation

Much is still to be learned about the assessment of simulation-based surgical skills training. However, assessing surgery skills through simulation is a new horizon in medical education. Providing a safe environment for surgical residents to assess their performance rigorously without placing patients in jeopardy is valuable. Using simulators (both warm and cold) as a means to assess trainees has been established. However, also problems concerning the validity and reliability of such simulation-based assessment tools exist, particularly in surgery, that may need to be investigated even more to decide whether to use them as a tool for assessing the performance of surgical residents.     

The Human Umbilical Cord: a Model for Microsurgical Training

Microsurgery continues to be a fundamental technique in many surgical subspecialties. In the past, many models have been utilized for microsurgery training. We are proposing the human umbilical cord as a training model, which is cheap, available and practical. This model can be used both for junior trainees to achieve good microsurgical skills before operating on human being and it can also help surgeons to maintain their skills.     

Current Issues in Dermatologic Office-Based Surgery

Dermatologists and dermatologic surgeons have played major roles in the development and refinement of many office-based cutaneous surgical procedures. The comprehensive scientific education in the structure and function of skin that dermatologists receive during formal residency training programs has contributed directly to these advances. This long tradition of comprehensive training and strong basic research activities in skin biology has supported a scholarly approach to cutaneous surgery. As a result, many pioneering cutaneous surgical techniques have been created by dermatologists and dermatologic surgeons. One example of this creativity can be seen in the field of laser surgery where techniques to effectively treat tattoos, benign pigmented lesions, port-wine stains and other vascular conditions, premalignant and malignant skin lesions, wrinkles and sun-damaged skin, and excess or unwanted hair were developed by dermatologists. Some of the most innovative procedures, like tumescent liposuction, have focused primarily on improving patient safety while preserving the highest standards of care. Virtually every aspect of cutaneous surgery, including Mohs micrographic surgery for the treatment of skin cancers, hair replacement surgery, sclerotherapy of leg veins, the correction of scars and sun-damaged skin with the injection of filler materials, dermabrasion or chemical peels, and new anesthesia techniques, have been favorably impacted by the unique education and skills of many dermatologists and dermatologic surgeons. This article reviews the important historic role that has been played by dermatologists and dermatologic surgeons in developing and improving outpatient cutaneous surgical procedures and examines current issues and future directions in credentialing, privileging, and accreditation.     

Teaching Pediatric Hand Surgery in Vietnam

BACKGROUND: International volunteering missions are becoming an important focus of plastic surgeons in the United States. The purpose of this paper is to describe the teaching of pediatric hand surgery in Vietnam to share the lessons learned from this project. METHODS: Two medical education trips were conducted to the no. 1 Children's Hospital in Ho Chi Minh city (Saigon) to teach pediatric hand and burn reconstructive surgery to the surgeons and therapists. This is the main referral children's hospital for the country, and pediatric hand surgery expertise is not available. RESULTS: Structured education programs were conducted over two trips to introduce congenital hand surgery and burn reconstructive procedures using flap techniques. The education programs included lectures and surgical demonstrations of selected procedures. Their proficiency was verified by supervised conduct of these operations. CONCLUSIONS: A well-conceived medical education program can introduce complex surgical discipline to a country. Through two trips, the surgeons at this referral center will have the capability to take care of many children requiring reconstructive hand surgery.     

Development of a valid, cost-effective laparoscopic training program

BACKGROUND: Practical programs for training and evaluating surgeons in laparoscopy are needed to keep pace with demand for minimally invasive surgery. METHODS: At the University of Kentucky five inexpensive simulations have been developed to train and assess surgical residents. Residents are videotaped performing laparoscopic procedures on models. Five surgeons assess the taped performances on 4 global skills. RESULTS: Creating mechanical models reduces training costs. Trainees agreed procedures were well represented by the simulations. Blinded assessment of performances showed high interrater agreement and correlated with the trainees' level of experience. Nonclinician evaluations on checklists correlated with evaluations by surgeons. CONCLUSIONS: Inexpensive simulations of laparoscopic appendectomy, cholecystectomy, inguinal herniorrhaphy, bowel enterotomy, and splenectomy enable surgical residents to practice laparoscopic skills safely. Obtaining masked, objective, and independent evaluations of basic skills in laparoscopic surgery can assist in reliable assessment of surgical trainees. The simulations described can anchor an innovative educational program during residency for training and assessment.     

Who are today’s bariatric surgeons and which ones join the ASBS?

BACKGROUND: This study was undertaken to describe bariatric surgeons in the United States today and to determine whether those who are members of a major bariatric surgery specialty society differ from nonmembers. METHODS: We performed a national survey of a 50% cross-sectional random sample of all general surgeons in the United States to determine how many performed bariatric procedures. Through record linkage, we identified which surgeons were members of the American Society of Bariatric Surgeons (ASBS). We used bivariate tests of association (Pearson's chi2, Fisher's exact test, and the Student t-test) to compare demographic, training, and surgical practice characteristics of ASBS members and nonmembers. RESULTS: Of the 2906 survey respondents, 359 (12%) were bariatric surgeons. We estimated response rates of 55% among bariatric surgeons and 27% among others; 46% (n = 163) of those performing bariatric procedures were ASBS members. Members were more likely to be board-certified in general surgery, to perform newer surgical techniques, and to have a higher procedural volume. The years of bariatric experience were similar in the two groups. CONCLUSIONS: Continuing medical education opportunities afforded by specialty society membership allow surgeons to remain abreast of the most recent advances in bariatric surgery technique and effectively address the complex health and psychosocial issues associated with morbid obesity. However, we found that only about half of all surgeons performing bariatric procedures in the United States are ASBS members. Standardization in the form of mandatory involvement in education and training activities or even specialty board certification in bariatric surgery might be necessary to ensure bariatric surgery skills and qualifications across the United States.     

Editorial Commentary: Simulation-Based Training in Orthopaedic Surgery: Current Evidence and Limitations

Simulation-based training has been widely adopted by surgical educators and is now an essential component of the modern resident’s skills acquisition pathway and career progression. The challenges faced by residents because of lack of exposure as a result of working-time directives—and now the COVID-19 (coronavirus disease 2019) pandemic limiting nonurgent and elective operating—reinforce the need for evidence-based simulation training. Although a wide range of training platforms have been developed, very few have shown transfer of skills. Simulation is thought to enhance the initial phase of the procedural learning curve; however, this hypothesis is yet to be tested in a high-quality study. Nevertheless, in light of the current evidence, simulation-based procedural curricula should be developed using the strengths of multiple different training platforms while incorporating the essential concept of nontechnical skills.     

Surgical simulation: a current review

Background Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.     

Predictors of Technical Skill Acquisition Among Resident Trainees in a Laparoscopic Skills Education Program

BACKGROUND: Administrative and financial pressures on surgical education have created a need for efficient training curricula. Predictors of innate technical ability, which would guide the optimization of such a curriculum, are not well described. The goal of this study was to identify student characteristics predictive of innate pretraining skill level and response to training during the course of a four-week laparoscopic skills development program. METHODS: Laparoscopic skills in 35 first-year surgical residents were assessed with the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) before and after a four-week skills training program and after an interval of approximately 1 year. The correlation between trainee characteristics, including age, sex, designated surgical specialty, and laparoscopic skill level was assessed by using Pearson's correlation and paired t-test studies. RESULTS: Intake MISTELS scores showed no significant correlation to age, sex, or designated field. Interns designated for the general surgery training program had significantly higher final scores than those entering other fields (p = 0.02). There was a negative correlation between trainee age and both degree of improvement during training and final scores (p = 0.02 and 0.05). A history of video game use correlated with significantly higher initial scores and better skills retention (p = 0.03 and 0.04). CONCLUSIONS: A laparoscopic technical curriculum can achieve basic proficiency even when taught to a diverse group of trainees. Older residents beginning their surgical careers may be slower to develop technical skills. Choice of subspecialty seems to predict higher level of proficiency after completion of a skills training program among resident students.     

SE01THE EMERGING ROLE OF SIMULATION IN SURGICAL TRAINING

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