Jennifer Perone, MD; Nicholas E. Anton, MS; and Aimee K. Gardner, PhD
January 1, 2018
Simulation is increasingly being used throughout a physician’s career to prevent arrested skill development, refine new techniques, and improve teaching abilities and other important competencies. The goal of this brief article is to provide an overview of how simulation training has been implemented throughout the continuum of surgical education from preparing medical students for surgical training to maintenance of proficiency as a practicing surgeon.
Simulation is a particularly well-suited modality for medical students, as it allows them to learn and rehearse critical patient care skills without endangering real patients.1 Accordingly, the American College of Surgeons (ACS) and the Association for Surgical Education (ASE) developed a simulation-based surgical skills modular curriculum for medical students (ie, years one through three) to enable them to develop basic surgical examination and procedural skills.2 Using feedback from clerkship directors and fourth year medical students, the ACS/ASE task force developed a free and publicly available 25 model curriculum, spreading over three years, to focus on skills training in communication, basic examinations, and more advanced skills such as chest tube placement and laparoscopy.3,4
Simulation has also received increased interest as a potential screening tool for medical students planning on entering surgical training.5,6 Not only can simulation offer a unique opportunity for residency program decision makers to gain insight into applicant competencies and skills by placing them in scenarios or task environments that mimic those in residency, but participating in these simulations may also provide applicants with a realistic preview of what is expected of the specialty and/or program. For example, work conducted by a national organization7 has shown that both medical students and program directors see value in the use of simulation for selection as it allows an opportunity to assess critical nontechnical competencies, such as receptivity to feedback, communication, leadership, and decision making. With agreement on its value from stakeholders on both sides of the screening process, simulation is likely to play an increasing role in selection decisions in years to come.6
For those who do enter surgical training, simulation may also be able to reduce the learning curve from medical school to surgical residency. Okusanya et al. developed a pre-surgical internship “boot camp” that featured simulation-based technical skills training that emphasized the significance of patient safety and the consideration of treatment benefits, risks, and care alternatives, as well as team-based clinical scenario simulations increasing in difficulty over the course of five days.8 The ACS, ASE, and Association of Program Directors in Surgery (APDS) have developed a similar resident prep curriculum9 to ensure graduating students have adequate skills for entering their new roles as surgery residents. This robust, simulation-based curriculum focuses on teaching students about surgical patient care, technical skills (fpr example, basic laparoscopy, bedside procedures, open surgery, etc.), interpersonal skills and communication, professionalism, and systems-based practice (for example, utilizing the medical record).10 Others have utilized virtual-based simulation training programs, such as the ACS Fundamentals of Surgery Curriculum11 to ensure competency among first-year surgical residents. For example, in a 2013 study, Krajewski and colleagues implemented a two-month simulation-based boot camp with general surgery interns that combined the Fundamentals of Surgery curriculum with simulation, and demonstrated that interns who had participated in the boot camp were rated higher in several patient care areas by nursing staff and faculty and had significantly higher American Board of Surgery In-Training Examination (ABSITE) scores, compared to prior cohorts.12 This work shows the robustness of implementing structured curricula during this critical transition phase.
Throughout residency training, simulation continues to play a significant role in skill development and refinement. Whether curricula are developed for suturing,13 knot tying,14 central line placement,15-17 laparoscopy,18-24 endoscopy,25-27 robotics,28-30 or open surgery,31-34 there are a few key concepts that need to be at the core of curricular delivery and implementation. For example, development of curricula should include knowledge-based learning as well as deconstruction of the procedure into its various components accompanied by skills training.35-37 Stefanidis and colleagues have identified critical elements of curricular design for simulation-based training, including proficiency-based learning (ie, training to expert-level benchmarks), distributed training (ie, multiple training sessions over time), training to automaticity (ie, learning which results in reduced attentional demands during performance), and deliberate practice.38 Stakeholders developing or adopting existing curricula should consider these key concepts.
Simulation is also a critical methodology for surgeons in practice. Not only can simulation help surgeons engage in deliberate practice39 for continued skill development and refinement, but it can also aide in the development of advanced cognitive processes, such as problem solving and decision making. Most recently, simulation has been to aide coaching curricula for practicing surgeons. For example, Stefanidis et al. developed a coaching curriculum, which consisted of video review, peer mentoring, and simulated skills training, to enhance the performance of practicing general surgeons and gynecologists.40
Simulation is also being used as a modality for equipping surgeons with critical skills related to their role as educators. Recent attempts have been made to standardize the instruction provided to surgical trainees during procedural-based simulation training, to ensure that trainees are consistently exposed to the most effective instructional methods possible.41 For example, Mackenzie et al. studied the effectiveness of a two-day train-the-trainer course for expert colorectal laparoscopic surgeons teaching laparoscopic skills to learners through simulation training, and found that this course provided a structured training framework that the trainers took back to their native institutions, which ultimately reduced the learning curve of laparoscopic skills for the learners at their institution. This work and other work supports the concept that “how” to teach can be learned and that trainees may benefit from improved faculty training as well.42-43
Simulation has become a critical asset to the surgical community, impacting the entire lifecycle of a surgeon. As new technologies and techniques continue to expand and the variety of uses of simulation are further explored, it is expected that simulation will continue to play an increasingly important role in surgery.
Jennifer Perone, MD, is a resident physician and postdoctoral research fellow, department of surgery, University of Texas Medical Branch-Galveston, Galveston, TX.
Nicholas E. Anton, MS, is a surgical skills coach, department of surgery, Indiana University School of Medicine, Indianapolis, IN.
Aimee K. Gardner, PhD, is assistant dean of evaluation and research, department of surgery, School of Allied Health Sciences, Baylor College of Medicine, Houston, TX.