Simulator education is essential to surgical training and it should be a requirement at all training programs across North America. Yet, in a survey of North American obstetrics and gynecology program directors (response rate 52%), we found that while 73% (n = 98) of programs teach laparoscopic skills, only 59% (n = 81) were satisfied with their curriculum. Most programs lacked standard setting in the form of theoretical examinations (94%, n = 127) or skills assessments (91%, n = 123) prior to residents performing surgery on patients in the operating room. Most programs (97%, n = 131) were interested in standardizing laparoscopy education by implementing a common curriculum. We present 3 core recommendations to ensure that gynecologists across North America are receiving adequate training in gynecologic laparoscopic surgery as residents: (1) uniform simulator education should be implemented at all training programs across North American residency programs; (2) a standardized curriculum should be developed using evidence-based techniques; and (3) standardized assessments should take place prior to operating room performance and specialty certification. Future collaborative research initiatives should focus on establishing the content of a standardized laparoscopy curriculum for gynecology residents utilizing a consensus method approach.
The Problem
Currently there is no standardized evidence-based laparoscopy program to teach gynecology residents laparoscopic surgery, resulting in considerable variability among residency training programs.
Recent progress
We recently queried accredited (Accreditation Council for Graduate Medical Education [ACGME] and Royal College of Physicians and Surgeons of Canada [RCPSC]) North American obstetrics and gynecology residency programs (n = 259) to establish the prevalence and characteristics of laparoscopy education and to collect opinions on the design of a standardized laparoscopy curriculum for gynecology residents. We used the principles of comprehensive curriculum design to enquire about the inclusion of cognitive, technical, and team-training components. We surveyed program directors because of their leadership role in academic obstetrics and gynecology, influence on surgical education in their institutions, and influence on departmental and divisional finances. We encouraged them to assign the survey to a department delegate responsible for laparoscopy education, if he or she was more equipped to answer the questionnaire.
In all, 135 responses were included for analysis (52% response rate). A majority of respondents (77%) performed laparoscopy as part of their obstetrics and gynecology practice. In all, 98 (73%) programs had some form of a laparoscopy training curriculum, which was a combination of didactic teaching and technical skills. A total of 129 (96%) programs had access to a skills laboratory, which could be accessed independently by residents at 84% of programs (n = 113). The available training modalities in the skills laboratory varied depending on the program ( Table 1 ). Residents in 89% (n = 120) of programs participated in nontechnical skills (team-based) training. The structure of nontechnical skills training varied depending on the program ( Table 2 ). Despite the presence of laparoscopy education in three quarters of programs, many programs were unsatisfied (41%, n = 54) with their current laparoscopy training.
| Characteristic | n (%) |
|---|---|
| Training modalities currently available in surgical skills laboratories at responding programs | |
| Box trainer | 124 (96) |
| Virtual reality simulator | 83 (63) |
| Live animal laboratory | 37 (29) |
| Cadaver, human | 24 (18) |
| Cadaver, animal | 11 (9) |
| Training modalities used by responding program directors for nontechnical skills curriculum | |
| Group exercises | 82 (68) |
| Simulation | 80 (67) |
| Lectures | 72 (60) |
| Role play | 54 (45) |
| Seminars | 31 (26) |
| Characteristic | n (%) |
|---|---|
| Lectures | 123 (91) |
| Video material | 120 (89) |
| E-Learning modules | 109 (81) |
| Box trainers | 124 (92) |
| VR simulators | 111 (81) |
| Animal courses | 55 (41) |
| Cadaver courses | 37 (27) |
| OR simulations | 57 (42) |
Core recommendations
We describe 3 core recommendations to remedy this issue:
Recommendation 1
Simulator education, essential to surgical training, should be implemented at all training programs across North America. When laparoscopic teaching is based on a structured and comprehensive curriculum, skills and outcomes improve. Initial learning and practice of laparoscopic surgical techniques should occur in a simulated environment prior to operating room experience. With the increasing emphasis on simulation by our governing bodies (ie, the ACGME Milestones project, the RCPSC maintenance of certification requirements), it is important to determine what is being used currently so we know how to move forward as a specialty.
Three-quarters of programs surveyed in our study had some form of a laparoscopy training curriculum, which was a combination of didactic teaching and technical skills. This has not changed significantly since Stovall et al published their survey of laparoscopy training in US obstetrics and gynecology residency programs in 2006, despite the increase in minimally invasive surgery volumes. As well, although most programs in the present study recognized the need to incorporate laparoscopy teaching and simulation into their curricula, there was no clarity on how to do so effectively. Numerous barriers include financial pressures, time constraints, medicolegal concerns, and the lack of qualified gynecologic surgeons available to teach and mentor residents.
Recommendation 2
Residency programs must adopt a uniform approach to simulator education to ensure that gynecology residents across North America are receiving adequate training in gynecologic laparoscopic surgery. Developing a standardized curriculum will optimize resources and help to overcome the barriers identified in Recommendation 1, as every site would not be expected to create their own design independently.
While all program directors believed that laparoscopy training was important for gynecology residents, only 59% (n = 81) of programs were satisfied with their current laparoscopy training program. This is concerning because laparoscopic surgery is the standard of surgical care in gynecology. Training during residency has been shown to be the most important predictor of the performance of advanced laparoscopic procedures in independent practice and the lack of training is commonly identified as a major barrier to incorporating laparoscopic procedures into practice. A survey of practicing gynecologists performed by Chen et al revealed that a significant portion (39%) did not feel adequately trained during residency to perform endoscopy, despite 78% of them having received endoscopic training during residency.
Almost all programs (n = 131) were interested in implementing a standardized curriculum. Table 2 illustrates the instructional methods recommended for a standardized curriculum. It shows the importance of multiple modalities as well as the inclusion of a knowledge component in addition to a technical component. We did not ask program directors to delineate what topics and skills should be included in a standardized curriculum. This could be determined using consensus methodology and a group of interested program directors or experts in surgical education. There is precedent in general surgery for curriculum development using Delphi consensus methodology. A standardized curriculum has the potential to enhance residency education by allowing residents to have access to equivalent basic theoretical, technical, and nontechnical skills knowledge regardless of training site. This could translate into better surgical care for gynecology patients.
Recommendation 3
Standardized assessments should take place prior to operating room performance and specialty certification to ensure certification of competent surgeons. Currently, standardized assessments either prior to real-time operating room experience or board certification are lacking. Most residency programs rely significantly on operating room mentorship for surgical education, which is both time-consuming and potentially problematic in an era of decreased resources and increased awareness of patient safety. This problem has been described over the last decade, but the field of gynecology has not addressed this concern.
In our survey, we found a majority of programs lacked any type of assessment (knowledge assessment, 94%, n = 127; and skills assessment, 91%, n = 123) prior to performing surgery on patients in the operating room. Despite this, program directors stated that their residents were well trained to perform basic (n = 135, tubal ligation, ovarian cystectomy, salpingo-oophorectomy) and advanced (n = 119, laparoscopic hysterectomy, laparoscopic myomectomy) laparoscopic procedures independently. This was a subjective assessment as objective formal skills assessments are not currently an ACGME or RCPSC requirement for certification.
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