Why we need open simulation to train surgeons in an era of work-hour restrictions

Expert performance

Surgical training in the United States and Europe has undergone radical changes in terms of work pattern over the past five years. The European Working Time Directive (EWTD), introduced in 2004 for countries in the European Union, mandates a working week of not more than 48 hours at the time of writing. ¹ In the United States, a similar trend has been seen with the Accreditation Council for Graduate Medical Education enforcing an 80 hours of duty per week standard.

These changes have caused a seismic shift in the way physicians are trained, with respect to the duties performed during the hours worked. These changes have brought some significant benefits, for example, an increase in medical providers, such as nurse practitioners and physician assistants and around-the-clock phlebotomy and patient transport services, allow more clinical contact and educational time. However, it has been argued that less time spent in the hospital will ultimately lead to less experienced and less competent surgeons than in the era preceding work-hour restrictions.

Studies of operative experience and educational outcomes shortly after the introduction of the work-hour restrictions demonstrated no difference in either measured variable. As the number of years from the inception of the work-hour restrictions increases, however, so do the number of reports demonstrating a diminishing operative exposure, not captured by absolute case number, with a reduction in the number of residents participating in an operation either in a teaching or learning capacity. ² In surgical specialties, such as vascular surgery, where minimally invasive therapies are becoming more prevalent, this decrease in operative experience may turn out to have a dramatic effect on operative competency.

Psychological correlates of performance as a function of the duration of time spent engaging in a particular activity have been well studied in many domains of performance-based professions, including surgery. One of the authors of seminal work on expert performance describes a period of deliberate practice that defines ‘experts’ in the field from their peers, quantifying this time of necessary preparation as 10,000 hours or approximately 10 years. ³ With a reduced opportunity for ‘deliberate practice’, as has occurred with reduced work hours, it is likely that current surgical training restrictions may result in a delay in expert skill acquisition.

Role of simulation in training

Simulation is not a new tool in educational methodology. Studies from the military, airline, astronautical and mining industries have suggested an important role for rigorously designed simulation programs in skills training. These fields utilize simulation as a routine introduction to skills training and integrate the transition from simulators to reality. In a similar educational paradigm, research in relatively new minimally invasive laparoscopic procedures has shown the value of simulation training, demonstrating transference of these skills to the operating room with a shorter and flatter learning curve.

Efforts to reduce preventable error rates, particularly during and immediately after training, have led to consideration of the use of simulation as a tool not only for imparting surgical skills, but also as a means to assess competency. In addition, simulation has been used to screen applicants prior to training; during vascular fellowship applications at Stanford University, applicants are expected to perform a renal artery angioplasty and stent simulation on the day of the interview. This approach is yet to be fully evaluated since predictive validity and transferability of skills to the operating room has not, to our knowledge, been demonstrated.

This approach has been adopted by those in the highest echelons of surgical education in a collaborative effort between the Society of American Gastrointestinal and Endoscopic Surgeons and the American College of Surgeons resulting in the recently mandated Fundamentals of Laparoscopic Surgery (FLS) certification that must be completed before sitting for the American Board of Surgery examinations. The course is a two-part assessment, focusing entirely on laparoscopic skills using simulation trainers. The first part is a cognitive assessment of 75 multiple choice questions regarding the clinical application of basic laparoscopic skills. The second part is the manual skills component comprising measured competencies that must be attained before the participant can gain the FLS certification. The components range from simple tasks such as laparoscopic peg-transfer to more complex tasks such as intracorporeal knot-tying with time-to-completion and accuracy as the target competencies.

Outside the well-established field of simulation in minimally invasive surgery, there has been movement within other subspecialties toward simulation-based training and competency. Endovascular simulation as a mode of training has already been embraced by the vascular surgical community and continues to gain acceptance as a credible means of attaining endovascular skills that are transferable to the operating room, a phenomenon known as isoperformance. ⁴ Recognizing the impact of simulation on future vascular skills training, the Association for Program Directors in Vascular Surgery recently formed a Simulation Committee specifically designed to address the need for a vascular simulation curriculum for trainees. In an era of high-volume endovascular interventions and greater trainee familiarity with catheter-based therapies, the question that now arises is: should the focus of simulation now be upon the increasingly more challenging open vascular operations?

Future directions in simulation training

Since the widespread introduction of catheter-based therapy for vascular disease three decades ago, there has been a shift from open vascular operations to more endovascular interventions. Although quick to be accepted in the clinical arena, endovascular training techniques were relatively delayed in their incorporation into vascular education. Not until 2000 did the Vascular Residency Review Committee (RRC) respond to input from training programs and agree that one year of fellowship training was inadequate preparation for independent vascular practice given the burgeoning and diverse field of endovascular intervention and approve the first two programs for a second year of fellowship training. Since then, endovascular training has become a standard part of vascular fellowships, occupying an entire year of dedicated interventional education in the majority of programs.

While vascular trainees are becoming more adept at performing endovascular interventions, however, the open vascular volume of non-complex cases is decreasing, particularly for general surgical trainees, while the complexity of those remaining open cases conversely increases. ⁵ The introduction of the EWTD further reduced the exposure to complex cases for surgeons in Europe and led to a European multi-institutional collaboration, which was formed to train vascular surgeons on high-fidelity open vascular simulators. The European Vascular Masterclass (colloquially known as the Pontresina course) has 20 years of experience at teaching vascular trainees open vascular techniques with a demonstrable increase in skills competence on post-training analysis. ⁶

The Division of Vascular Surgery at UCLA has recently reported a high-fidelity open vascular simulation program aimed at novice general surgeons with a view to addressing the potential skills gap in open vascular surgical training. Surgical residents are trained and then tested using the standardized and well-validated Objective Structured Assessment of Technical Skills tool designed to provide a global and technical evaluation of surgical skill. ⁷ During the open simulation course, it was possible to study the effect of standardization of vascular skill instruction adhering to a rigorously defined teaching protocol versus a ‘traditional’ teaching model involving idiosyncratic instruction by different vascular attending surgeons. ⁸ Further study from this initial course will focus on the transferability of simulation-acquired vascular skills to the operating room using performance measures to rate skills proficiency in the same group of residents.

Conclusions

With the advent of work-hour restrictions there is concern that future generations of surgeons will have less opportunity and exposure to complex open surgical cases. In vascular surgery, endovascular interventions are increasingly used, while there is a decrease in open vascular cases. Simulation training is mandatory in high-risk industries such as the military, astronautical and airline industries and has been proposed as a means to bridge the skills gap in various branches of medicine, with increasing recognition of the benefit in surgery in an era of performance-based practice. The role for continued traditional skills training in real-life clinical situations, however, must be emphasized and it should be recognized that simulation should be applied as an adjunct to rather than as a replacement for skills training in the operating room.

Open vascular surgical simulation is an area that has been utilized successfully in European training systems for two decades and has been slow to gain acceptance in the United States. The benefits of simulation programs similar to the European Masterclass are being increasingly acknowledged and may soon be a mandatory part of surgical education in the United States.