The Role of Simulation in Surgical Education

Abstract

The current healthcare environment demands optimization of patient outcomes in addition to maximal cost efficiency. Restrictions on resident work hours have placed limitations on the amount of time that trainee physicians can spend on patient care. For the surgery resident, the consequence is less time spent in the operating room under the supervision of a senior surgeon, the cornerstone of Halsted's approach to resident surgeon education. The use of simulation in graduate medical education has gained significant traction as a way to provide trainees with exposure to various techniques and procedures before use on the general patient population. This article describes simulation-based education with particular attention to surgical education. It proceeds to address competency-based education and mastery learning (ML) as key features of effective surgery education programs. A case study of ML in surgery is presented along with examples of translational medical education science from other medical specialties. The report concludes with a brief discussion about simulation-based surgical education today and prospects for the future.

Introduction

There is consistent pressure in healthcare toward increasing the quality of care by improving patient outcomes while simultaneously reducing costs. This condition exists across the spectrum of medicine. Surgery, in particular, is a specialty that faces unique challenges as it seeks to train the next generation of clinicians. Until recently, surgical training was governed by the teachings of William Halsted, MD, FACS,¹ and his Johns Hopkins colleague William Osler, MD,² who believed that the most effective method to train novice surgeons was the apprenticeship model, by which trainees were expected to learn necessary skills and techniques through direct patient care under the supervision of senior surgeons. The near-universal acceptance and incorporation of the Halsted and Osler ideology formed the foundation of surgical training and influenced generations of surgeons. Although these principles have guided the field for the past century, technological and educational advancements and limits placed on resident training in the modern era reduce the utility of apprenticeship education.

Problems with the traditional apprenticeship model of clinical education have been clearly documented.³ Of particular concern is the consistent finding that clinical experience alone yields biased and uneven caseloads among surgery residents.^4,5 Common operations are performed routinely, yet many procedures are done rarely, if at all. This led Bell et al. to observe, “Methods will have to be developed to allow surgeons to reach a basic level of competence in procedures which they are likely to experience only rarely during residency. Even for more commonly performed procedures, the numbers of repetitions are not very robust, stressing the need to determine objectively whether residents are actually achieving basic competency in these operations.”⁴

Implementation of work-hour restrictions placed on resident physicians beginning in 2003 has limited the time that trainees can spend on direct patient care, the cornerstone of the Halsted and Osler approach. However, the scope of surgical knowledge and practice continues to expand with biomedical scientific advancements. Continued technological advancements with corresponding expansion of the applications available for surgical patient care also place further demands on resident physicians. Trainees must acquire a growing volume of medical knowledge and become facile with an expanding range of surgical techniques despite limitations on the amount of time that can be spent in the hospital. Surgical educators must prepare residents to practice surgery in this new context, recognizing that traditional clinical education is likely insufficient. New approaches are needed to complement the apprenticeship model to produce the next generation of surgeons.

Simulation-Based Education

One strategy that has been identified by graduate medical education (GME) programs for meeting this challenge is the development and expansion of simulation-based education (SBE). Simulation has long been viewed as an attractive option for surgical resident education because it gives learners an opportunity to practice clinical skills in a low-stakes setting before operating room (OR) experience.^6–8 Advocates of SBE in surgical education point out the benefits of providing a practice environment where learners can master fundamental surgical skills such as knot tying, basic laparoscopy, and skin closure rather than learning these skills in the high-cost OR.^9,10 Surgical regulatory agencies have also embraced the use of SBE to train surgery residents. The American Board of Surgery now requires successful completion of two SBE initiatives, the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery courses, for graduating residents to become board eligible.^11–13 The clinical significance of these programs is seen from studies demonstrating a strong relationship between performance on simulated exercises and technical skill in the OR and endoscopy suite.^14–16 These results illustrate the utility of using simulation to complement the traditional apprenticeship model of surgical GME, especially in the early stages of resident training.

There needs to be a demonstration of improved patient-level outcomes in addition to cost savings as a result of SBE program implementation to advance cost-effective, patient-centered care. The term “medical education research as translational science”¹⁷ has been used to describe downstream, patient-level outcomes that derive from rigorous simulation-based medical education. Learning outcomes measured in the simulation laboratory (T1) are the foundation for measuring the effects of rigorous education on improved patient care practices (T2) and better patient outcomes (T3).¹⁷ Several recent reviews summarize this body of translational medical education research.^18–22 Effective SBE programs should be delivered in a standardized, evidence-based format and provide all learners an equal opportunity to succeed. Simulated exercises should be difficult and challenge learners.²³ This contrasts with passive clinical experience typical of the apprenticeship model that assumes skills will translate into effective performance when in the OR.

Competency-Based Education

The Accreditation Council on Graduate Medical Education developed a set of six core competencies that define the key professional qualities that every physician should acquire to function effectively as an independent practitioner.²⁴ The six competencies have been broken down into discrete units, milestones, for use as progress metrics toward achievement of each core competency. A milestone is a “competency-based developmental outcome (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties.”²⁵ The ability of each resident to meet the defined milestones gives program directors a measure of each resident's readiness for independent practice.

Mastery Learning

The idea of mastery learning (ML) is growing in popularity in medical education. ML is founded on the principle of “excellence for all.” This means that all motivated learners can reach a predefined “mastery” standard, provided they are given time and resources to achieve the standard. This focus on universal achievement with variable learning time represents a radical departure from the traditional apprenticeship model by which some learners would fail in any given task. Learning time is fixed and educational outcomes vary. Table 1 outlines seven core features of the ML bundle.²⁶

Table 1.

Seven Core Principles of the Mastery Learning Bundle ²⁶

1. Baseline or diagnostic testing.

2. Clear learning objectives, sequenced as units usually in increasing difficulty.

3. Engagement in educational activities (e.g., skills practice, data interpretation, and reading) focused on reaching the objectives.

4. A set minimum passing standard (e.g., test score) for each educational unit.

5. Formative testing to gauge unit completion at the preset minimum passing standard for mastery.

6. Advancement to the next educational unit given measured achievement at or above the mastery standard.

7. Continued practice or study on an educational unit until the mastery standard is reached.

ML relies on the concept of “deliberate practice” (DP) originated by Ericsson.^27–29 DP describes the process whereby mastery can be attained by any motivated learner through a process of intensive, goal-directed practice with immediate feedback.³⁰ The dual concepts of ML and DP lend themselves well to the current focus on competency-based educational strategies and milestones in medical education because it provides an educational framework for ensuring high levels of achievement among all learners and aims to reduce variation in the outcome of the educational intervention. This is especially applicable for GME programs, in which the stated goal is to prepare resident physicians for independent practice based on previously determined standards of care.

Mastery Learning in Surgery: A Case Study

Simulation-based mastery learning (SBML) provides a unique opportunity in surgical education as a strategy to address training deficiencies while promoting GME responsibility. Applying the core concepts of ML with DP to SBE has resulted in the growth of many SBML curricula in medicine. SBML can be used to teach novices the techniques needed to perform a surgical procedure before transition to the OR. Another benefit of SBML is to teach residents how to perform surgical procedures not commonly encountered during clinical training.

Laparoscopic common bile duct exploration (LCBDE) is an example of an operation rarely encountered by current U.S. surgical residents. Multiple studies have demonstrated a decline in the use of LCBDE with a corresponding increase in the use of endoscopic retrograde cholangiopancreatography (ERCP).^31,32 A 2008 study assessing resident training in complex hepato-bilio-pancreatic procedures demonstrated a mean of 0.7 LCBDEs performed by U.S. graduating chief residents, with the mode being zero.³³ To address this deficiency, Santos et al. developed and evaluated a novel, low-cost LCBDE simulator and created a procedural rating scale for use with the simulator.³⁴ Teitelbaum et al. subsequently designed and implemented an educational curriculum at Northwestern University aimed at training senior surgical residents the essential steps for performing both a transcystic and a transcholedochal LCBDE.³⁵ A minimum passing score (mastery standard) was determined by 2 surgeons with previous experience performing LCBDE. None of the original 10 residents who participated in the study achieved the mastery standard during the initial pretest. However, all residents achieved mastery at post-test after a period of DP using the LCBDE simulator (10/10 for transcystic and 8/10 for transcholedochal). In addition to achieving the mastery standard, pre- and postsurveys completed by the participating residents demonstrated a significant improvement in their perceived ability to perform an LCBDE independently. Additional steps were taken to include OR nurses and staff in the simulator training sessions to increase OR staff awareness of the surgical equipment and to acquaint them with key procedural steps. Successful completion of the LCBDE mastery curriculum is now required for senior residents rotating on the minimally invasive surgery service.

Preliminary work looking at the clinical impact of the LCBDE curriculum has shown a significant increase in the use of LCBDE in addition to significant cost savings and reduced length of stay for patients admitted with a primary diagnosis of choledocolithiasis who underwent LCBDE compared with those who underwent ERCP. These not yet published results provide an example of how the targeted implementation of a comprehensive SBML curriculum designed to address a specific deficiency in clinical surgery can effectively complement the traditional apprenticeship model to produce improved patient-level outcomes.

Translational Science Examples

Given the financial and time restraints placed on GME programs in the successful design and implementation of SBML, it is reasonable to assume that administrators will increasingly demand evidence that the interventions are having an impact at the patient level (T2 outcomes) and beyond (T3 outcomes). SBML is, by its nature and design, intended to provide learners with the opportunity to practice and master skills in a neutral setting. However, there usually comes a time when it is necessary for the learner to apply the learned knowledge and skills to the clinical arena. Although there are a number of studies looking at the beneficial effects of SBML on the ability of learners to meet the mastery standard in the form of improved knowledge and various technical performance metrics, there are far fewer studies that attempt to analyze the downstream effects of these educational interventions. So, although SBML has been proven to have significant impact on individual learner performance, what effect do these programs have on patient-level outcomes and beyond?

An example of the longitudinal benefits of a well-designed SBML procedural skills curriculum on higher level outcomes (T2 and above) can be found in the work of Barsuk et al., who studied the effect of SBML on central venous catheter (CVC) placement. After initial work evaluated the use of a CVC simulator and associated rating scale, a group of 41 SBML-trained internal medicine residents were studied in comparison with a preintervention group that performed CVC insertion in a medical intensive care unit (MICU) without prior practice on the CVC simulator. The investigators found that SBML-trained residents produced significantly fewer arterial punctures, had less need for CVC adjustments, and had a higher insertion success rate with real patients than traditionally trained residents.³⁶ A follow-up study demonstrated a significant reduction in the central line-associated blood stream infection (CLABSI) rate in the MICU after the SBML-trained residents began their rotations. In addition, CLABSI rates in the MICU were noted to be significantly less than those in the surgical intensive care unit located in the same university-affiliated academic medical center, where residents performing CVC insertions had not been exposed to the curriculum.³⁷ Investigators then quantified the cost savings associated with the reduction in CLABSI rate as compared with the cost of implementing the curriculum and demonstrated a 7:1 rate of return.³⁸ Finally, to demonstrate the transferability of a rigorous, well-designed SBML intervention, the curriculum was implemented at a local community hospital and again showed a significant decrease in that hospital's CLABSI rate after eligible residents completed the SBML curriculum.³⁹ As pointed out by the authors, sustained progress after implementation of these types of curricula demand continued effort and vigilance on the part of key stakeholders (hospital administrators, faculty, and nursing leadership) to ensure that complacency does not result in a reversal of earned gains.

Summary and Conclusions

The expansion of SBE in the recent surgical literature has been profound. Although GME programs should be applauded for their use of SBE to address deficiencies in the current surgical education environment imposed by external considerations such as resident duty hour restrictions, it should be remembered that any effective SBE intervention is unlikely to achieve its goals unless it is grounded in solid, evidence-based educational theory with evidence of positive translational outcomes. SBML is one such approach that results in improved patient care outcomes when curricula are designed in accordance with the core principles of ML, including DP. In addition, any well-designed ML-based curriculum should have a robust mechanism in place to identify learners in need of assistance to help them achieve mastery, even if that requires additional training time. Reliable outcome measurement is an integral part of any SBE curriculum to ensure that learners have achieved the mastery standard. Learner participation alone without rigorous outcome measurement will not translate into improved learner outcomes and improved patient outcomes.

Any discussion of SBE would be incomplete without stressing the need for institutional support to achieve the ultimate goal of any clinical educational intervention—improved patient outcomes. There is a growing body of evidence in the surgical and medical literature demonstrating that such achievements are feasible provided learners are given adequate support as protected educational time. Surgical educators must have financial and logistical support to design and implement effective curricula that have the clinical impact. There is a definite value proposition for any healthcare system that encourages and supports rigorous, evidence-based educational programs that result in improved patient care outcomes and cost savings.

We argue that surgical simulation should be viewed as a complement to, not a replacement for, the traditional system where resident physicians practice and refine their skills under the watchful eyes of a senior surgeon. The fidelity of medical simulation will continue to improve as computing power and materials science progress. However, there is no substitute for teaching split-second decision-making in the face of unexpected, potentially life-threatening scenarios in the high stakes OR environment. Simulation has an important role to play in surgical education by providing GME programs with an effective tool for supplementing the clinical education of the next generation of surgeons and beyond.

Footnotes

Disclosure Statement

No competing financial interests exist.

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