Abstract
In this issue of the Scottish Medical Journal, Mervyn et al. describe a clay model for teaching and training of medical students in laryngeal anatomy. The results were not statistically significant due to low numbers, but we certainly perceive this as a progress towards exploration of future simulation models in comparison to traditional prosections in teaching anatomy in complex areas such as larynx. Surgical simulation has gathered significant evidence to support its role in surgical training curricula.1,2 Human cadavers embalmed in different ways remain standard for the past many years as the anatomy resembled to what they trained surgeons would encounter in their clinical practice (level of realism) but have certain limitations in their availability and cost effectiveness. Furthermore, their preservation using formalin makes them less useful for many modern interventional techniques. Theil preservation has been an innovation recently and has been reported to be extremely good in laparoscopic, endoscopic and interventional procedures but not widely adoptable due to cost barriers.3–5
Simulation-based teaching and assessment of technical surgical skills is essential part of surgical curricula and future safe surgical workforce development. Psychomotor performances (technical skills) of surgical trainees are measured by various metrics such as motion analysis, stepwise progression, eye–hand co-ordination, number of errors and overall performance to complete a surgical procedure. Anatomical simulation models provide backbone to this assessment and overall delivery of surgical training. The future progress in simulation model technology needs to address as how these models can be made flexible to demonstrate or assess various degrees/levels of progression during the surgical training. Each procedure needs to be deconstructed into various tasks and proficiency should be tested for the performance of each task. We are not sure how clay model described by Mervyn and colleagues in this issue would accommodate flexibility on this pointing the future.
Simulation-based skills training can enhance skills acquisition in surgery and provide support to achieving a higher number of trained surgical personnels for the future.6–8 The latter is a huge challenge due to limited resources to train a increased number of surgical workforces in order to meet universal healthcare for all by 2030 (one of the goals set by the WHO) and limited number of years a trainee can spend in a residency programme. 9 We do hope that innovations in low-cost simulation models would help meeting the challenge.
Innovations in surgical simulation models should also consider the fact that 75% of performance of a procedure depends on cognition and it is only 25% which is dependant on technical ability. Cognition of a procedure has three components knowledge, awareness within, and judgment during the performance of a task. 10 Cognition for a procedure will change in accordance with the level of difficulty in the performance of a procedure. The clay model described in this issue of SMJ would add to the teaching of cognition in complex laryngeal anatomy only in understanding of anatomy. Further modifications may be needed to complete the development of model addressing all components of training.
Due to international readership of the journal, one must mention the existing inequity to the access of simulation model technology and training. Upfront investment cost remains a significant barrier for the dissemination and adoption of simulators in low and middle income countries (LMICs). 11 For example, cost of 3D-printed based high-fidelity models may be of great educational benefits to the western population but may not be affordable in low-income group of counties. 12 Future research should not only focus on the design and creation of low-cost models but also co-create sustainable global partnerships for innovation in model technology. The technology should focus on global training of surgeons and surgical workforce and bring in efficient and effective ways of incorporating these in teaching and training programmes. Ongoing evaluation and assessment of models with aim to improve their use would be a huge benefit for the practice of safe surgery by reducing surgical errors – which are often irreversible in contrast to the drug errors.