The paradigm of surgical education is changing. Surgical residencies are now required to have skills laboratories so that varying degrees of surgical training and skills acquisition can occur outside of the operating room. There is mounting evidence that surgeons can learn many fundamental skills and specific procedures with simulators. Evidence also supports the theory that surgeons trained initially with simulators perform better in the operating room than those who are not. Currently, there are many different simulators available for obstetrics/gynaecology procedures, both high and low fidelity. Less-expensive models are often as effective for training as low-fidelity models. Developing an effective surgical simulation programme requires a commitment to the concept and finding the time and space. Most importantly, it requires desire on the part of the trainees to devote the hours of practise needed to make themselves accomplished surgeons.
In the book Outliers , Malcolm Gladwell walks us through many different examples of famous sports figures, musicians and business leaders, who have achieved extraordinary success. Gladwell shows us that rather than being true outliers these individuals achieve their success through important opportunities, timing of birth and, most importantly, a great deal of practise and hard work. In each example of successful people, there is a pattern in which individuals are the beneficiaries of cultural opportunities followed by the intensive desire to work hard to achieve their goals. In the book, the studies of Ericsson are highlighted. In these studies, Ericsson evaluated musicians at an elite academy of music. When they compared those musicians who had the potential to become world-class soloists to those who were good but not exceptional musicians, what they found was that all students started playing around age 5 or 6 years and practised about the same amount, but at age 8–9 years, those destined to become exceptional musicians began practising significantly more than those who were merely good. Those elite performers were practising up to 30 h a week and by the age of 20 years, each of these performers had logged over 10 000 h of practise. There were similar findings with elite athletes and dancers. The merely good students had only totalled 8000 h of practise. What is striking about these studies is that there were no ‘naturals’ who were exceptionally talented but without practise, nor were there any ‘grinds’, who practised exceptionally hard but did not rise to the top ranks.
The theory that emerges as one evaluates successful athletes, dancers, musicians, writers and even surgeons is that to achieve mastery in any field, 10 000 h of practise is required to be a world-class expert. Studies in cardiac surgery show that complications and mortality decrease during the first 10 years of practise and then level off right about the time when these surgeons have logged 10 000 h in the operating room (OR). These studies provide a strong argument that, for surgical training, we need to provide opportunities for surgical skill training and to find adequate time for trainees to practise and master their skills.
While there are opportunities for residents and fellows to practise their skills in the OR, the OR is probably not the best place for trainees to complete the number of hours needed to achieve competence. First, in the OR, there are fiscal and time constraints that significantly limit physicians’ time to teach students. Maximising efficiency and use of OR time is essential for the viability of most academic surgical departments as the OR has become the financial engine of most hospitals. Second, with rapidly evolving technology, both instructors and students need a safe place to practise and master new instrumentation and techniques before clinical application. Third, it is very difficult to standardise teaching in the OR as there are significant variations in (1) patients (obesity, adhesions and extent of disease), (2) the procedures needed to treat the disease and (3) the skills of the resident or student which will affect what the attending surgeon can allow the trainee to do. Finally, with increasing focus on patient safety issues, we need to address the inherent conflict between the trainee’s right to learn how to perform surgery and the patient’s expectation to have high-quality surgery performed. In surgery, the teacher must always be focussed on the patient first and the student second. Because of all of these factors, the OR is where residents and students should come to perform what they are already competent in. As much as possible, teaching and practise should occur outside the OR.
Dedicated facilities or surgical training laboratories allow teachers to focus all of their attention on the student. This allows students to get more out of their training and make practise sessions more valuable. However, other factors also must be considered when teaching surgical skills. First, inadequate sleep significantly impairs learning and increases errors in technical skills. At the University of Washington when we do our resident simulation surgical training sessions, we try, if at all possible, not to have residents on call the night before, since being fatigued makes the training sessions less valuable for residents. Second, feedback from experts is superior to computers, videos or other non-directed feedback. In our training sessions, we have a faculty member assigned to two residents so that the faculty member can provide feedback to the resident who is acting as primary surgeon and the resident who is acting as the assistant. While residents are encouraged to practise on their own whenever possible, we like some practise to be supervised so that what is being done correctly as well as incorrectly can be commented on. Studies have shown that this type of observed practise will lead more quickly to the development of competence. Third, high levels of motivation and low levels of anxiety enhance the ability to learn motor skills. This is another reason why training outside the OR is a good idea. Finally, imagery and mental practise enhance performance of technical skills. It is important for residents to rehearse the surgical procedure in their minds, similar to the way musicians will mentally rehearse a piece of music before a performance. Repetitive practise in a low-stress environment where mistakes are permissible and immediate feedback is given allows for more rapid development of muscle memory. When trainees no longer have to focus principally on how to accomplish a technical task, it frees them to focus on avoiding errors, deal with complications and become more efficient.
Simulation training has great appeal as it has been used effectively in the airline industry and in the military. Cockpit simulators are an integral part of training and certifying pilots. In anaesthesia and many endoscopic procedures, trainees will train to competence in a simulator prior to progressing to procedures in patients. In the surgical literature, there are multiple studies which show that laboratory-based training with simulators more rapidly leads to improvement of technical skills. There are fewer studies which show that improvement of technical skills in a laboratory setting translates into improved clinical skills in the OR. However, several studies, especially in minimally invasive surgery, show simulator-based training translates into improved surgical skills in the OR. For example, two studies both randomised 16 residents to standard or virtual reality training before performing a laparoscopic cholecystectomy. When the experimental group was assessed by blinded examiners, they performed fewer errors despite being faster. Other investigators have used live simulation models, principally porcine, to observe similar reductions in completion times and errors after simulation training. The conclusion of a recent critical review of this issue supports the finding that skills are transferred to the OR after simulation training, but the quality of the studies available limited the strength of the conclusion. Given all of the evidence, in 2008 the Residency Review Committee (RRC) for surgery, which is a body of the Accreditation Council for Graduate Medical Education (ACGME), required that all general surgical training programmes establish a skills training programme for both minimally invasive and open procedures.
A significant number of surgical procedures can be performed on in inanimate models. These models range from low-tech, inexpensive, homemade types to very expensive virtual-reality models that can provide haptic feedback. In an era of shrinking budgets, expensive high-fidelity training models must be critically evaluated. In a study undertaken at the University of Toronto, trainees were randomised to three types of training for extracting a ureteral stone. The first group received didactics only, the second group was trained in a high-fidelity virtual-reality model and the third was trained in a low-tech model using Styrofoam cups and straws placed in the anatomic orientation of a normal bladder. All participants were subsequently tested in the high-fidelity videoendoscopy trainer. The two groups with hands-on teaching in either trainer did significantly better than the group that received didactic instruction only, but training in the low-fidelity model conferred as much benefit as training in a high-fidelity model. The authors concluded that the key constructs need to be faithful to reality, but the models do not have to look real to be effective. Significantly, some of the high-tech trainers cost tens of thousands of dollars. We recently reported that with respect to assessment of hysteroscopic skills, assessment in the inexpensive low-tech trainer was actually better than assessment in the $50 000 virtual reality trainer. We found that even teenagers with no medical background could perform the hysteroscopic video game. Other investigators have had similar findings with virtual-reality laparoscopic simulators. Many programmes have shown significant improvements in technical skills with low-cost low-fidelity models. Animal models provide the best fidelity for most procedures; however, animal laboratories are very expensive and in some countries cannot be used for surgical training as the practise is considered unethical.
Another important issue in surgical education is the training schedule. Extensive research was conducted to determine the effects of practise schedules on the acquisition of technical skills. A study from the University of Toronto, Ontario, Canada, evaluated the effectiveness of a 2-year surgical curriculum. One group of surgical residents was given seven 2-h surgery laboratories every 2 weeks during which a different procedure was reviewed at each session. Formal assessment was done with an objective structured assessment of technical skills (OSATS) for the different procedures. The intervention group ( n = 19) was compared with a control group ( n = 31) trained without the surgical laboratory. These investigations found no difference in performance on the OSATS between the two groups, suggesting that simply being shown how to do a procedure with limited practise does not enhance competency. As a result, some educators are focussing on proficiency-based training as learning curves vary significantly for individual surgeons. For example, one group showed a 100% pass rate for the fundamentals of laparoscopic surgery skills programme when trainees were provided weekly training sessions and unlimited self-practise of the five proficiency-based skills. This underscores the importance of repetitive practise with constructive feedback whether directly by experts or using proficiency levels, similar to how musicians or highly trained athletes prepare for a performance or sporting event. Other investigators have compared massed practise (long session) with interval practise (multiple short sessions), and interval practise consistently results in more improvement of skills. For example, a group showed that when surgical residents were randomised to a single comprehensive or weekly distributed practise regimen, those in the distributed group performed significantly better on a procedure when tested 1 month later.
Formal evaluation of skills is another important factor in achieving competence. Evidence suggests trainees have different learning curves and using repetition thresholds or performance plateaus may not be reliably substituted as training end points. Like practise, assessment should be done in a setting where trainees are allowed to perform the procedure or task completely independently and to make mistakes. Summative skills evaluation gives trainees objectively established goals that they need to meet before progressing to the next level or being allowed to operate on patients. Increasing evidence suggests that goal-directed training specifically improves laparoscopic skill acquisition. In our own residency programme, formal evaluation of surgical skills in a laboratory setting is valuable for both residents and faculty. For residents, it allows for self-assessment. Is the resident able to complete a task that other residents at his/her level are performing successfully? For faculty, a formal assessment at the end of each year allows the identification of those residents whose skills are falling behind their peers. In addition, it allows faculty to assess the surgical curriculum and to determine whether the curriculum is meeting the needs of the residents.
Although, to date, most surgical simulation assessment and curriculum development were performed by and for general surgery, many have significant application to the field of gynaecology. In addition, several specific simulators, curricula and objective assessments have been shown to be effective for resident training in gynaecological procedures. One group showed that residents randomised to laboratory-based laparoscopic skills training perform laparoscopic salpingostomy on patients significantly better, as graded by an OSATS than those residents receiving routine surgical training. Their laboratory skills training curriculum took place over 10 days with 30-minsessions daily and principally involved low-fidelity block movements, running string and a bean drop, for example. One group also randomly assigned residents to a single laboratory-based curriculum for laparoscopic tubal ligation versus routine surgical training. Their training consisted of didactics, pigs’ feet suturing, knot tying and a laparoscopy simulator (Limbs and Things, Bristol, UK). At baseline, there were no differences in skills between the two groups. After completion of the curriculum, all residents were assessed in the OR as to their ability to perform a laparoscopic tubal ligation by faculty members blinded to knowledge of which training the resident had received. Residents assigned to the laboratory training had significantly higher scores compared with the control group. Others found that a virtual-reality ectopic pregnancy simulator might benefit residents with minimal laparoscopic experience. They compared total time to perform a salpingectomy by novice trainees to experienced surgeons and found that after nine repetitions the novices reached the same plateau as the experienced surgeons after two. Furthermore, authors found that a warm-up exercise improved subsequent laparoscopic performance in randomised obstetrics/gynaecology (ob/gyn) residents and medical students. One study also used a group of novice, intermediate and expert surgeons to validate a procedure-specific rating scale for laparoscopic salpingectomy.
For teaching hysteroscopic surgical skills and cystoscopy, several studies indicate the benefit of simulation training for gynaecology residents. One study found residents receiving a laboratory-based curriculum subsequently tested 4–6 months later performed significantly better, as measured by an OSATS and checklist, on a simulated uterine resection than a control group from another institution. Their curriculum included a 1-h didactic session and a 2-h hands-on session during which the residents were allowed to assemble and use the scope on a hysteroscopy model (Simulation, Prior Lake, MN, USA). Furthermore, their model and assessment demonstrated good construct validity. A group showed that a cohort of residents trained with a hysteroscopy simulator (Ethicon Women’s Health and Urology, Somerville, NJ, USA) had persistent improvement in their understanding of the procedure and reduction in their resection time 6 months following training. In urogynaecology, a study showed that a curriculum and training session for diagnostic cystoscopy and Burch colposuspension, similar to that described for hysteroscopy , is an effective way to teach diagnostic cystoscopy to junior residents. The curriculum included didactics and hands-on sessions with models for the Burch colposuspension (Limbs & Things, Bristol, UK) and cystoscopy (Simulations). In addition, researchers have developed a cystoscopy model that uses much simpler materials to simulate the bladder and which should make this model more readily available to training programmes. In summary, several models and curricula are available specifically for training residents in gynaecological procedures and more continue to be developed. At this point, no one system appears to meet the needs of all resident years; therefore, a developing programme will likely need to invest in several approaches to comprehensively train its residents.
Given the trends in surgical education described, establishing a surgical skills laboratory or simulation centre appears to be not only prudent for resident education and patient safety but also may, at some point, become necessary for residency accreditation as it is for general surgery and possibly board certification. While developing a laboratory and training programme is a substantial undertaking, fortunately, the resources and research behind establishing an effective programme are readily available and are becoming plentiful. The training philosophy guiding the establishment and development of our surgical simulation programme at the University of Washington is that residents are first provided with clear objectives for their education. Second, the opportunity to repeatedly learn and practise skills in a low-stress, non-competitive environment, where the faculty they work with are available to provide immediate feedback, was one of the goals. Unlike in the OR, we believe that it is of paramount importance that in the skills laboratories residents are allowed the opportunity to make their own mistakes in an environment in which they are not punished but rather glean the maximum education benefit from those errors of judgement or technique.
Currently, our institution has invested heavily in a centre for the entire institution (Institute for Simulation and Interprofessional Studies (ISIS)), with dedicated staff and ample space for classes. Not only has this made scheduling, set-up and clean-up far more efficient but it has also allowed for more collaboration with other surgical departments. For example, we are beginning to work with general surgery to test a self-directed proficiency-based system of introducing, practising and evaluating basic surgical skills. The ISIS also allows for sharing the cost burden of expensive trainers across several departments. Having a permanent physical space for practise is giving us the opportunity to modify our curriculum by developing self-directed rotation-specific education. Without dedicated space such as at ISIS that would be nearly impossible.
There are some challenges in designing a laboratory-based curriculum. Probably the most significant obstacle has been scheduling for both residents and faculty. We schedule our laboratories during the usual resident didactic time; both residents and faculty are relieved of their clinical duties, and colleagues provide coverage for those in the laboratory. The other significant obstacle is the faculty time commitment to do these training sessions. In general, we have found that faculty really enjoy the laboratories, and participation in these sessions has been helpful for the teaching portfolio requirement for promotion. In addition, many faculty members have been able to conduct research projects that have led to scholarly publications. Ideally, it would be best if universities or medical centres provided funding to cover faculty teaching time.
In conclusion, as we develop surgical training programmes for our residents, we need to adopt the principles of adult learning, embrace simulation as a major component of our surgical education and focus on training each individual to proficiency. As a speciality, we need to adopt a model where trainees practise and become competent in a laboratory and then graduate to the OR. This is very similar to the model used for training in aviation. It promotes patient safety and is ultimately a much more efficient way to train residents and fellows. The major challenge for surgical educators is how to fund the laboratories, equipment and faculty to conduct this type of training. This must not come from the clinical dollars generated by surgical departments. Coordinated effort is needed with all surgical departments to develop a laboratory that is used by all surgical disciplines, and both hospitals and medical schools must participate in the funding of these programmes to be successful.
In addition, it is important for trainees to understand that there are probably no naturally gifted surgeons. The biggest predictor of surgical success is motivation and a passion for being a technically excellent surgeon. Students with high levels of motivation will have the ability to engage in the type of sustained practise that is needed to become a proficient surgeon. The importance of training laboratories and simulators is that it provides the critical opportunity for extensive practise. Many of these simulators can also provide metrics such as time, accuracy and even force that can be used for self-assessment and improvement by trainees. These simulators provide opportunities for motivated individuals to devote the number of hours needed to practise their surgical skills. Now that residents are currently limited in the number of clinical hours that they can work, the available time for practising surgical skills with patients has been substantially cut. This makes the need for simulators, either low or high fidelity, important for our current and future trainees.
