Simulation-based Surgical Education Best practices across surgical specialties relating to simulation-based training Aimee K. Gardner, PhD,a Daniel J. Scott, MD,a Robert A. Pedowitz, MD, PhD,b Robert M. Sweet, MD,c Richard H. Feins, MD,d Ellen S. Deutsch, MD,e and Ajit K. Sachdeva, MD,f Dallas, TX, Cleveland, OH, Minneapolis, MN, Chapel Hill, NC, Philadelphia, PA, and Chicago, IL
Introduction. Simulation-based training is playing an increasingly important role in surgery. However, there is insufficient discussion among the surgical specialties regarding how simulation may best be leveraged for training. There is much to be learned from one another as we all strive to meet new requirements within the context of Undergraduate Medical Education, Graduate Medical Education, and Continuing Medical Education. Method. To address this need, a panel was convened at the 6th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes consisting of key leaders in the field of simulation from 4 surgical subspecialties, namely, general surgery, orthopedic surgery, cardiothoracic surgery, urology, and otolaryngology. Conclusion. An overview of how the 5 surgical specialties are using simulation-based training to meet a wide array of educational needs for all levels of learners is presented. (Surgery 2015;158:1395-402.) From the Department of Surgery,a UT Southwestern Medical Center, Dallas, TX; Fundamentals of Arthroscopic Surgery Training Program,b Cleveland, OH; University of Minnesota,c Minneapolis, MN; University of North Carolina at Chapel Hill,d Chapel Hill, NC; Children’s Hospital of Philadelphia,e Philadelphia, PA; and the American College of Surgeons,f Chicago, IL
SURGICAL EDUCATION is evolving faster than ever. Knowledge, skills and behaviors expected of students, residents, and surgeons are being defined, new methods are being pursued to assess core competencies, and expectations for documenting achievement of specific milestones are changing. For these and other reasons, simulation-based training is playing an increasingly important role in surgery. However, there is insufficient discussion among the surgical specialties regarding how simulation may best be leveraged for training. There is much to be learned from one another across the continuum of undergraduate medical education, graduate medical education, and continuing medical education. Presented at the Seventh Annual Meeting of the Consortium of ACS-accredited Education Institutes, March 21–22, 2014, Chicago, Illinois. Accepted for publication March 22, 2015. Reprint requests: Aimee K. Gardner, PhD, Assistant Professor of Surgery, Associate Director of Education, Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390. E-mail: [email protected]
0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2015.03.041
To address the need to cross-fertilize ideas across surgical specialties, a panel was convened at the 6th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes (ACS-AEIs), consisting of key leaders in the field of simulation from 5 surgical subspecialties, namely, general surgery, orthopedic surgery, cardiothoracic surgery, urology, and otolaryngology. What follows is an overview of how the 5 surgical specialties are using simulation-based training to meet a wide array of educational needs for all levels of learners. SIMULATION IN GENERAL SURGERY Dating back to the 1990s, several factors, including patient safety concerns, the need to introduce new procedures and technologies in practice, and the focus on the high costs of training in real environments, fueled the use of simulation-based training.1-4 By 2000, pioneering studies began to emerge affirming that structured skills lab training resulted in significant improvement in surgeon performance during actual operations.5,6 Over the ensuing years, additional regulations and imperatives, including duty-hour limitations, increased expectations for supervision, SURGERY 1395
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and greater demands on productivity, resulted in further emphasis on the use of simulation.7 In 2004, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in conjunction with the ACS launched the Fundamentals of Laparoscopic Surgery (FLS) program, which was the first major national simulation initiative in surgery and included both cognitive (web-based modules) and hands-on components (box trainer exercises). This program has received widespread acclaim because of its rigorous validation, and is now required by the American Board of Surgery (ABS) as a prerequisite for the initial certification.8-11 SAGES has created a similar offering with the introduction of the Fundamentals of Endoscopic Surgery program, focusing on competencies relating to performance of flexible endoscopy. It includes high-stakes cognitive and virtual reality simulator-based skills examinations, and is now also required by the ABS for initial certification, similar to FLS. SAGES has recently introduced the Fundamental Use of Surgical Energy program. The ACS established standards for accreditation of simulation centers that are called ACS-AEIs. This program was launched in 2005 and there are now >80 accredited centers both within the United States and abroad. Additional centers will be reviewed for accreditation on a continual basis. Ongoing activities of the network of these centers include sharing of best practices, pursuing simulation-based research, and developing new high-quality curricula.12 One of the most comprehensive initiatives has been a collaborative project between the ACS and the Association of Program Directors in Surgery (APDS) that has led to a standardized surgical skills curricula for residency programs to address a wide variety of skills.13 This national skills curriculum was launched in 2007 and now includes 20 part-task, 15 procedural, and 10 team training modules. This is currently undergoing revision. Simulation became a bona fide part of residency training in 2008 when the Residency Review Committee (RRC) for Surgery mandated that all programs include training in skills laboratories. Currently, there are strong motivators to continue embracing simulation in resident training, especially to verify achievement of specific competences.14 One metric of concern is that ABS pass rates are suboptimal; only 79% of graduates passed their written examination and only 78% passed the oral examination in 2014.15 The RRC introduced Milestones in 2014 to increase opportunities to verify that residents are achieving expected levels of performance with
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regard to knowledge, skills, and behaviors. Many educators expect that simulation will play an increasingly important role in this endeavor. Efforts are also underway to strengthen the preparation of medical students for surgery residency training. Most efforts have focused on students planning to enter surgery residencies and have included preparatory electives or ‘‘boot camps,’’ which have become well-developed and popular.16,17 A national initiative is underway to identify best practices and create a standardized offering for the fourth year of medical school, and to use simulation in several modules. This work is being pursued as a collaborative venture between the ACS, the APDS, and the Association for Surgical Education (ASE). The ABS has issued a statement that the board ‘‘recommends and endorses that all incoming surgical residents beginning with the 2014 year complete a preparatory course before beginning surgical training.’’18 To address the training needs of medical students regardless of their career goals, the ACS and ASE have also collaborated to launch the SimulationBased Surgical Skills Curriculum for Medical Students.19 On the other end of the spectrum, simulation activities for practicing surgeons are still in evolution. These endeavors may play a role in credentialing and maintenance of certification, but such practices have not been widely adopted in general surgery. Some data suggest that there may be a need for use of simulation for competency verification of practicing surgeons, because #33% of practicing surgeons may not initially pass the FLS examination, which is required for surgery residents.20 In fact, the ACS and SAGES issued a joint statement recommending that all surgeons practicing laparoscopic surgery be certified through the FLS program.21 Through the work performed to date, best practices have emerged for simulation-based training, including establishment of appropriate infrastructures, provision of protected time for learners and teachers, requirements for mandatory participation, and tracking of both attendance and performance. Additionally, skill acquisition is being optimized using deliberate practice to achieve specific goals22 and through distributed practice whereby sessions are spread out over time.23,24 Programs have also adopted a proficiency-based paradigm, in which educational experiences are tailored to the needs of the learner and training is deemed completed when individuals have reached performance goals rather than through use of time or repetition parameters.25
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SIMULATION IN ORTHOPEDIC SURGERY There are a number of factors propelling change that involve a greater role of simulation training in orthopedic surgery. These factors include increasing procedural and technical complexity, continuous introduction of new surgical methods and techniques, safety concerns of patients and the public, increased costs and logistical challenges associated with cadaver training, and greater international demands for state-of-the-art surgical education. Unfortunately, orthopedics has been challenged by a history of developing simulation devices without clear a priori development of curricula with well-defined educational objectives. More recently, however, initiatives in orthopedic surgery are favoring a more systematic approach, including use of educational needs assessments in the development of curricula and inclusion of relevant assessment tools. This scientific approach allows for refinement of the simulation strategy and more efficient creation of the specific simulation devices, ultimately optimizing the contribution of simulationbased training to educational endeavors. Acknowledging the value of simulation to orthopedic surgery, the American Academy of Orthopaedic Surgeons (AAOS) convened an orthopedic surgery simulation summit in 2011. The goal of the summit was to bring together key stakeholder organizations and representatives to achieve consensus on how simulation training can be implemented optimally in orthopedic surgery. A national survey26 preceding the summit indicated that only one-half of orthopedic programs in the United States have skills laboratories and associated programs, although 80% of the program directors thought that simulation should be a required part of residency training. Within a few months of the summit, the American Board of Orthopaedic Surgery (ABOS) and the Orthopaedic RRC passed new requirements that mandated integration of formalized motor skills training in all US residency training programs starting in July 2013. These new requirements focus on formal development and implementation of a postgraduate year (PGY)1 curriculum in basic surgical skills relating to the initial management of injured patients (ie, splinting, casting, application of traction devices, and other types of immobilization) and basic operative skills (ie, soft tissue management, suturing, bone management, arthroscopy, fluoroscopy, and use of basic orthopedic equipment).
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Additionally, the ABOS and AAOS formed a taskforce to develop approximately 20 curriculumbased modules that can equip orthopedic training programs with solid implementation solutions to the new simulation mandates. Each of these modules follows a structured curriculum template that was modified from the ACS Division of Education basic surgical skills template. The modules incorporate a variety of laboratory-based simulation strategies, ranging from simple bone models to sophisticated, computer-based virtual reality training. One of the key challenges is definition and validation of solid proficiency metrics for each of these simulation strategies. Although relatively little research has been done in the orthopedic domain along these lines,27 validated metrics and proficiency-based training curricula are being developed. For example, the Arthroscopy Association of North America (AANA) has launched the ‘‘Copernicus Project,’’ which focuses on the fundamental cognitive and psychomotor skills that are required for arthroscopic stabilization of the shoulder (a common and technically challenging operative procedure). Another example of the paradigm shift in orthopedic surgery is the Fundamentals of Arthroscopic Surgery Training Program, a collaborative project of AANA, AAOS, and ABOS that focuses on the most fundamental motor skills that are required for arthroscopic surgery. A final example is an ongoing collaborative effort that was initiated by the AAOS in conjunction with the Orthopaedic Trauma Association, which focuses on development of basic fluoroscopy skills among junior orthopedic residents. There is a variety of potential applications of surgical simulation across the continuum of professional development in orthopedic surgery. Simulation methods may enhance medical student career counseling, as students explore their own psychomotor aptitudes. Simulation has already been mandated for PGY1 by the ABOS and Orthopaedic RRC and is expected to have a more robust and integrated role in the subsequent training years, as programs leverage their dedicated simulation facilities. Additionally, as assessment methodologies improve, surgical simulation may become an important part of the certification/re-certification cycle and may also facilitate reentry into the orthopedic workforce after an extended leave of absence. These are more controversial areas that may be explored after a solid simulation foundation has been established at the residency education level.
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Clearly, surgical simulation is becoming a fundamental part of orthopedic training and assessment. One of the greatest challenges will be development and validation of relevant, reliable, and objective proficiency models. This process will require substantial diligence and dedicated resources. SIMULATION IN UROLOGY As in many other surgical specialties, the interest and application of simulation in postgraduate education in urology continues to expand. The rapid advances in technology, increased scrutiny on how best to adopt new technologies in clinical practice, limited work hours, patient safety concerns, increasing health care costs, and new device training regulations are all driving forces in regard to this movement. Despite these factors, urology has not integrated simulation fully into educational endeavors. For example, although encouraged, implementation of simulation-based training and assessment requirements with regard to technical skills have yet to be mandated by governing bodies. Other reasons delaying this integration include lack of validity evidence, insufficient evidence of impact of such training in patient outcomes, and insufficient dedicated funding to cover simulation-based training costs. In hopes of demonstrating the value of simulation in urology training, a group of leading academic minimally invasive surgeons, under the aegis of the American Urological Association (AUA) Office of Education, created a curriculum that includes the core learning objectives, tasks, conditions, metrics, errors, and standards for basic laparoscopic skills. Leveraging the work from general surgery, FLS was presented and evaluated by the AUA Laparoscopic/Robotics Committee for its application to urology. It was determined that the peg transfer, pattern cut, needle driving, and knot tying psychomotor skills exercises could be translated directly to laparoscopic urology, but extracorporeal knot tying and endo-loop tasks were not considered basic skills necessary for urologists at that time. The didactic component of FLS was deemed to be too focused on general surgery, and would need to be redesigned for urology. Experts also agreed that clip application is an important additional task. Thus, the University of Minnesota designed a dynamic clip-applying exercise. The exercise includes a small, low-cost (<$5), disposable dynamic ‘‘beating’’ organosilicate vessel filled to mean arterial pressure that trainees are instructed to clip and divide in a clearly defined area. Metrics such as clip accuracy, coaptation, leakage, and crossing clips are measured.
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One hundred nine practicing urologists and trainees participated in the initial validation studies of the psychomotor aspects of what was called the AUA BLUS or ‘‘Basic Laparoscopic Urologic Surgery’’ curriculum. This study demonstrated acceptable face, content, and construct validity evidence for the psychomotor tests for a cohort of urologists.28 The BLUS working group has also designed an online cognitive test based on the principles of the AUA BLUS Handbook of Laparoscopic Fundamentals.29 This online test is administered through the AUA website. A multiinstitutional trial examining the cognitive component and the performance on BLUS psychomotor exercises using a new surgical training robot is now underway. Other simulation-based initiatives have been pursued through the AUA, including a robotics curriculum that includes cognitive training, psychomotor training, and team training on both physical and virtual models. Additionally, accreditation relating to the use of ultrasonography in urology practice has been implemented and includes both didactic and hands-on requirements with standardized patients and phantom models. Specifically, guidelines for facilities, training (12 hours if graduated before 2009), case review, and case volume (100 initial per year then 150 per 3 years for recertification) were established. New training curricula have been developed around virtual reality simulation as well. The GreenLight Photovaporization simulator, based on backward design and task deconstruction principles, has been developed to help treat benign prostatic hyperplasia.30 Other technologies for hands-on training include the University of Minnesota SimPORTAL ureteroscopy models and the MIMIC dv-trainer and its intuitive ‘‘back-pack’’ counterpart for robotic skills training.31,32 Individual institutions have established comprehensive simulation skills labs to address endoscopic, laparoscopic/robotic, communication, and open skills in urology. As empirical work continues to validate the use of these training curricula, it is anticipated that the use of simulation in urology will continue to expand. SIMULATION IN CARDIOTHORACIC SURGERY Cardiothoracic surgery is a high-stakes specialty where even minor adverse events can result in devastating consequences for the patient. Over the last 8 years, the specialty has embraced simulationbased education and training as a means to further enhance the knowledge and skills of its residents and practicing surgeons. A variety of low-cost but
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highly effective simulators and related curricula have been developed and have transformed education and training within cardiothoracic surgery. A real issue for cardiothoracic surgery involves inadequate patient volume to teach cardiac surgery skills.33 Thus, educators have sought to identify ways to complement clinical training with simulation. A common approach is to identify an animal organ with relevant anatomy, animate it to a living state, place it in a human mannequin, and preserve it for extended periods of time. This method has resulted in a variety of low-cost simulators developed for both cardiac and general thoracic procedures. Other simulators are more robust, like the Ramphal simulator,34 which uses a porcine heart animated with a computer-controlled pneumatic system in each ventricle allowing for the full simulation of the beating heart. The ‘‘high-end’’ general thoracic surgery equivalent to the Ramphal Cardiac Surgery Simulator is the UNC Lung Surgery Simulator, which uses a perfused, animated porcine heart–lung block for performing thoracoscopic and open lobectomies. Resident boot camps to maximize simulationbased education and training in cardiothoracic residencies have also been implemented. For example, the Thoracic Surgery Directors Association (TSDA) created the first specialty oriented national Resident Boot Camp in 2008. This program brings together first-year cardiothoracic residents and faculty from throughout the country for 3 days of intensive simulator-based education. Thus far, 206 residents have attended. Skills such as vessel anastomosis, open lung hilar dissection, rigid and flexible bronchoscopy, mediastinoscopy, and cardiopulmonary bypass are taught using a 2:1 student to faculty ratio. The TSDA Boot Camp35 has been very successful in demonstrating the advantages of simulation-based training and in creating a national faculty capable of providing that education at their own institutions. The average cost per participant has been $1,800 (residents and faculty). Residents and faculty who have attended the boot camp have been unanimously in favor of the centralized boot camp program with 100% stating they would recommend the boot camp to others. Additionally, post boot camp surveys of thoracic surgery program directors have reported improvement in resident confidence (70%), preparation for cases (54%), technical skills (77%), and enthusiasm for the specialty (75%). The clinical and financial demands on academic faculty have made allocating time to teach using simulation exceedingly difficult. To address this problem, the Cardiothoracic Surgeon’s ‘‘Senior
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Tour’’ was established in 2010 as a unique organization of retired cardiothoracic surgeons with part of its mission being to support simulation-based training. Members undergo formal training and then serve as teachers at the TSDA Boot Camps and at their home institution’s simulation centers. The group presently numbers about 30 retired cardiothoracic surgeons and offers the opportunity for still very capable teachers and surgeons to participate in a critical role for the specialty. In addition to identifying the appropriate simulators, curricula, and faculty with which to train the residents, research is ongoing to demonstrate that simulation will produce a safer cardiothoracic surgeon. Under a 3-year grant from the Agency for Healthcare Research and Quality, 8 centers in the United States are using component task simulators and the Ramphal Cardiac Surgery Simulator to train first-year cardiothoracic residents in the performance of cardiopulmonary bypass, coronary artery bypass, and aortic valve replacement and in the intraoperative crisis management of acute aortic dissection, air embolism, and sudden cardiac collapse. A comprehensive curriculum has been developed along with extensive assessment tools. All major components of the training are also being video recorded. It is expected that the study results will create the framework upon which this training will be conducted in all cardiothoracic surgery residencies. It is expected that simulation will also be adopted for specialty board certification, maintenance of certification, and hospital and state licensing board credentialing in the future. With major initiatives in curriculum development, simulator development, faculty recruitment and training, and ongoing research, cardiothoracic surgery is well-positioned to produce the best trained and safest surgeons possible. SIMULATION IN OTOLARYNGOLOGY Training in otolaryngology involves integration of complex anatomy and associated pathology of the temporal bone with refined microsurgical technical skill. Unfortunately, otolaryngology faces the same barriers to training as many other surgery specialties, including less time available for teaching and learning, limitations of instructional resources, and the lack of uniform objective assessment of technical skills.36 However, simulation in otolaryngology has a rich history and continues to evolve as advances in technology, changing societal expectations, resource availability, and improved understanding of adult learning continue to impact training in the specialties.
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Some of the simpler methods of simulation within otolaryngology involve use of basic household items. For example, simulators constructed from gelatin and other everyday items have been designed to teach instrument use and hand–eye coordination for sinus and rhinologic procedures.37 Similarly, basic otologic procedures, such as cerumen disimpaction, and insertion of myringotomy tubes, can be practiced on simple, inexpensive simulators that replicate the external ear canal, constructed from test tubes, or wood with holes drilled, and thin plastic sheets inserted to represent the tympanic membrane.38 Otolaryngologists also use cadaveric temporal bones for learning otologic procedures; otolaryngologists have used a variety of materials and methodologies to practice the skills necessary for head and neck procedures, but have not always labeled these methodologies as ‘‘simulation.’’ One of the most basic examples is the use of a board with 3 nails and a section of soft tubing, designed for novice surgeons and arranged so that suturing the tubing together results in increasing tension, requiring increasingly precise technique. Simulators developed from synthetic and biologic tissue have been designed to practice advanced microvascular skills.39 Other forms of simulation include partial or full-body manikins to develop technical endoscopic skills. High-technology manikins, controlled with computer interfaces, can demonstrate palpable pulses, normal and abnormal chest wall motion, stridor, laryngospasm. They can exhibit variable or progressive physiologic conditions, correlated with a dynamic display of vital signs on a standard monitor; and detect and respond to specific interventions. High-technology manikins can ‘‘desaturate’’ if an endoscopist becomes so engaged in removing an ‘‘aspirated’’ foreign body that he or she neglects to attend to ventilating the ‘‘patient.’’40-42 At a more advanced level of simulation, the Endoscopic Sinus Surgery Simulator (ES3), is a virtual reality simulator that incorporates handheld instruments, a physical interface, and responsive virtual anatomy with haptic feedback. Learners using this simulator have demonstrated mastery learning, which speaks to the potential use of simulators to achieve Accreditation Council for Graduate Medical Education (ACGME) Milestones.43-46 The value of this simulator has been demonstrated widely. Specifically, studies using this simulator have demonstrated that participants trained to criterion proficiency levels were equivalent to or outperformed subjects trained by conventional methodology and that
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this proficiency level is at least equal to that achieved by conventional training involving repetition of the live operative procedure.45 These unique simulators can be organized into trainee curricula and delivered in various formats, whether it be focused courses, weekly didactics, boot camps, or ‘‘just in time’’ training. Importantly, simulation offers opportunities for experts as well as surgeons in training. Practicing physicians can benefit by using simulators when a new technology becomes available, if they anticipate unique or complicated anatomy, and to optimize team dynamics and responses during crisis situations. For simulation to continue to thrive within this field and become an ingrained education and training methodology, educators need to support systematic curriculum development and develop standardized metrics for evaluation. These components are essential not only for proper development of training programs and proficiency levels, but to expand the value and acceptance of simulation-based training within otolaryngology. In conclusion, simulation continues to receive significant attention within the context of national imperatives relating to quality of care and patient safety, changes in surgical practice, new regulations that are impacting surgery training, and increasing demands for accountability from a variety of external entities and the public. Surgical specialties have adopted the use of simulation to address the aforementioned challenges and are at different stages of developing and implementing innovative simulation-based curricula for learners at various levels. Surgical specialties leading innovation in the development and use of cutting-edge, simulationbased curricula need to share their experiences with other specialties for the benefit of the patients. A few specialties have begun to use models developed by others; however, a broad national effort is needed to share best practices and advance this burgeoning field. The panel representing 5 different surgical specialties was convened at the Annual Meeting of the Consortium of ACS-AEIs and provided valuable information relating to the experiences from these specialties, and demonstrated similarities as well as some differences in the respective approaches used. The efforts of all 5 surgical specialties were directed principally at residents and medical students and the needs of the residents in early years were the focus of a number of major national endeavors. These efforts need to be expanded to encompass residents across all years of the curriculum with the ultimate goal of assessing the knowledge and skills of residents before
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graduation from residency programs using valid and reliable methods. Also, these experiences need to be extended into the continuing education domain to impact surgeons through their many years of surgical practice. The use of simulation is key in helping surgeons acquire new skills, maintain existing skills, reenter surgical practice after a period of minimal or no clinical activity, and fulfill various regulatory needs. Documents affirming achievement of specific levels of knowledge and skills would be very helpful in the process of credentialing and privileging at the local level. The key to advancing the field as articulated is collaboration across the specialties, both at the level of the specialty societies as well as the certifying boards. The collaboration among the ACS, the APDS, and the ASE has been very fruitful and has resulted in the development and deployment of state-of-the-art national curricula. These efforts are being expanded. The collaboration between the ACS and SAGES in regard to the FLS curriculum has also yielded outstanding results. Dialogues between the ACS and the ABS have been aimed at advancing education and training through use of simulation. Articulation of the need to train and assess residents in simulated environments by the RRC for Surgery has been a major step in advancing simulationbased training, as well. The collaboration between the American Academy of Orthopaedic Surgery and the ABOS in regard to the simulation-based curriculum for early years of residency training is a great example of how a specialty society and a specialty board can work together to advance simulation-based training and assessment. The experiences of the surgical specialties relating to the use of high- and low-fidelity simulations and simulators have demonstrated the value of the use of both types of simulations and simulators to achieve optimal outcomes. The creativity used by the specialties in designing low-cost simulators based on hybrid models is an example of how issues relating to costs can be addressed. The panelists underscored the need for proficiency-based training models that can help individuals to reach defined levels of skills and affirm achievement of these levels. As simulationbased education and training are incorporated further into programs aimed at learners across the continuum of their professional careers, specific focus needs to be placed on the broad spectrum of cognitive skills, technical skills, and nontechnical skills. The host of challenges that various surgical specialties face include insufficient time, inadequate
resources, and difficulty in recruiting faculty members who are being pulled in various directions professionally. The ‘‘Senior Tour’’ program of cardiothoracic surgery is an excellent example of how retired surgeons or those near retirement may be recruited to train residents. The Consortium of ACS-AEIs should play a critical role in the development and dissemination of national curricula, articulation of curricular needs for new simulators that may then be developed by industry aligned with these needs, and definition of common terminology and uniform metrics. The metrics will be of great help in creating effective teaching and assessment models. A variety of surgical specialties should be encouraged to use the Consortium of ACS-AEIs, as needed, to address their education and training needs. This will help in cross-fertilization of ideas, exploration of collaboration between surgical specialties and other health care professions, and will foster effective teamwork. Effective collaboration across surgical specialties will benefit patient care and support training of residents in new and exciting ways. REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS. To Err is human: building a safer health system. Washington, DC: The National Academy of Sciences; 1999. 2. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003;290:1868-74. 3. Anonymous. A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club. N Engl J Med 1991;324:1073-8. 4. Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999; 77:28-32. 5. Scott DJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Valentine RJ, et al. Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 2000;191:272-83. 6. Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK, Andersen DK, et al. Virtual reality training improves operating room performance. Ann Surg 2002;236:458-64. 7. Mattar SG, Alseidi AA, Jones DB, Rohan JD, Swanstrom LL, Aye RW, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg 2013;258:440-9. 8. Peters JH, Fried GM, Swanstrom LL, Soper NJ, Sillin LF, Schirmer B, et al. Development and validation of a comprehensive program of education and assessment of the basic Fundamentals of Laparoscopic Surgery. Surgery 2004;135: 21-7. 9. Fried GM, Derossis AM, Bothwell J, Sigman HH. Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. Surg Endosc 1999;13: 1077-81. 10. Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R. Fundamentals of Laparoscopic surgery simulator training
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