Surgical Simulation - Hardcover

Hardcover

ISBN 10: 1783081562 ISBN 13: 9781783081561

Publisher: Anthem Press, 2014

Synopsis

Now widely recognized as one of the most effective methods for training future surgeons, simulation has become an integral part of the multidimensional landscape that makes up a surgical education curriculum. This book provides an overview of the current status of simulation-based training in various surgical disciplines and explains the science of surgical education, from developing a simulation programme to properly assess surgeons-in-training, to transferring the skills acquired through simulation into real-life settings. As such, the book can be used as a guide for understanding the basics of surgical education.

About this title

About the Author

Prokar Dasgupta is the professor of robotic surgery and urological innovation at King’s College London and hon. consultant urological surgeon at Guy’s and St Thomas’ Hospitals. He is the editor-in-chief of the ‘British Journal of Urology International’.

Kamran Ahmed is an academic clinical lecturer at King’s College London and specialist registrar in urology at Guy’s Hospital.

Peter Jaye is a consultant in emergency medicine at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) and the director of simulation at GSTT, and leads simulation for King’s Health Partners.

Mohammed Shamim Khan is a consultant urologist at Guy’s Hospital and honorary reader at King’s College London. He is the director of the BAUS Office of Education.

Excerpt. © Reprinted by permission. All rights reserved.

Surgical Simulation

By Prokar Dasgupta, Kamran Ahmed, Peter Jaye, Mohammed Shamim Khan

Wimbledon Publishing Company

Copyright © 2014 Prokar Dasgupta, Kamran Ahmed, Peter Jaye and Mohammed Shamim Khan
All rights reserved.

ISBN: 978-1-78308-156-1

Contents

1. Surgical Simulation: An Overview, 1, 
2. Simulation in Historical Perspective: The History of Medical and Surgical Simulation, 15, 
3. The Role of Animal Models in Surgical Training and Assessment, 23, 
4. Full Procedural Surgical Simulation, 41, 
5. Developing Non-technical Skills, 51, 
6. Learning Curves for Simulators, 63, 
7. Developing a Simulation Programme, 73, 
8. Patient Safety and Simulation, 85, 
9. Psychometrics, 95, 
10. Future of Surgical Simulation, 111, 
Author Details, 123, 

CHAPTER 1

SURGICAL SIMULATION: AN OVERVIEW

Jason Y. Lee and Elspeth M. McDougall

Simulation-Based Surgical Training

Definitions

Assessment – a process of documenting an individual's knowledge, skills and attitudes or beliefs on a given topic or content

Certification – confirming a specific or pre-determined level of knowledge, skills or attitudes through a formal assessment process

Credentialing – an objective process of establishing the qualifications of individuals or organisations through a formal assessment or evaluative process

Curriculum – any planned educational experience that involves goals, objectives, teaching methods and assessment or evaluation of individuals

Simulation – a person, device, or set of conditions that attempts to imitate a real environment

Virtual reality – a computer-based simulation of a real environment that allows for immersive interaction

As a result of advancements in science and technology, the field of surgery has witnessed significant changes and growth over the past few decades. The introduction of new surgical technologies has also been accompanied by more challenging surgical procedures for a more complex patient population. In addition, factors such as legislated limitations on resident work hours, an increased emphasis on safety and patient-centred care and increasing pressures to utilise costly operating room (OR) resources more efficiently have mandated significant changes to surgical training curricula.

The traditional residency training paradigm established by Dr William Halsted placed a strong emphasis on structured apprenticeships, with trainees developing surgical expertise in a supervised clinical setting over a prolonged training period consisting of increasing levels of responsibility (1). However, the current surgical landscape has required significant modifications to this model, including the development of specific learning objectives outside of the clinical setting and an increased utilisation of simulation-based educational strategies. This repetitive practice of difficult surgical skills in a risk-free environment away from the patient provides the trainee with immediate feedback and the opportunity to train to a predetermined expert proficiency, and seems intuitively, therefore, more efficacious and efficient for both the patient and the healthcare system. This type of surgical education both allows trainees to meet the learning objectives necessary to achieve surgical competency and ensures that they and their surgical educators are able to focus on the development of surgical judgement during the OR experience.

The training of a competent surgeon is, without a doubt, a complex, multi-dimensional process. It is key to any learning activity, however, that the process address three main learning domains relevant to each individual trainee: cognitive, psychomotor and affective objectives (2). In order to meet these learning objectives, it is important to select educational strategies or tools that are congruent with the curricular goals, referred to by educators as a 'goals–tools match'. Simulation-based training is but one such strategy and should be integrated into an overall, well-developed surgical training curriculum. Proponents of simulation must be careful not to anoint it as the panacea for all surgical training issues or deficiencies. For some surgical training objectives, simulation may not provide the requisite experience needed by trainees to achieve competency, no matter how high its fidelity. For other objectives, there may be much simpler and more cost-effective instructional methods that can be utilised to achieve the same educational outcome. It is critical that educators understand the benefits and advantages of simulation-based training over other teaching strategies and implement such methods accordingly, thereby ensuring the 'goals–tools match' so strongly emphasised by contemporary educators (3).

Simulation-based training has been defined as:

A person, device, or set of conditions which attempts to present evaluation problems authentically. The student or trainee is required to respond to the problems as he or she would under natural circumstances. (4)

While simulation can imitate reality, it does not duplicate real-life clinical situations. Rather than considering this a limitation, it should be viewed as the very reason that simulation-based education can be an effective teaching tool on today's surgical training programmes. One of the key conceptual frameworks relevant to the development of expertise, the theory of deliberate practice (5), espouses the need for multiple repetitions of a skill and the provision of constructive feedback to ensure the skill is being learned correctly. Surgical simulation provides the trainee with an opportunity to repeatedly perform a specific skill, or set of skills, in a low-risk environment away from actual patients, thus allowing for a safe environment where things can 'go wrong' many times over. When properly designed and implemented, simulation- based training methods can also allow for individualised learning that takes into consideration differences in baseline skill levels of the students. There is also the possibility of building different clinical variations into the simulated training sessions, allowing trainees to practise with cases of increasing difficulty and complexity as well as experiencing rare clinical scenarios (6–7). Surgical simulation-based training not only permits structured, comprehensive and immersive learning opportunities, but also allows the educator to provide timely and constructive formative or summative feedback based on trainee performance, ensuring acquisition of correct proficiency-based competency.

Assessment of Trainees Using Surgical Simulation

The ability to provide accurate assessments of students is an essential component of any educational curriculum and is critical to successful surgical residency training (3). Regardless of whether it is the assessment of acquired knowledge and skills, changes in trainee behaviour, modifications to trainee attitudes or the ideal outcome of improved patient care, the ability to provide reliable and valid assessments is of paramount importance, particularly in the case of summative assessments (8–9). Whether it be simulation 'devices' such as pelvic box trainers and virtual reality (VR) laparoscopic simulators, or simulated 'clinical scenarios' such as mock OR team training sessions, surgical simulation-based training methods must be objectively validated and rigorously evaluated if they are to be used for the assessment of trainee competence.

Reliability speaks to the reproducibility of an assessment and is strongly linked to the assessment's validity. It can be estimated by using correlation coefficients, such as Cronbach's alpha, and allows educators to quantify the amount of random error in the measured data, facilitating valid interpretations and the usage of trainee assessment scores. Repeated assessments of a trainee using validated surgical simulators should demonstrate internal consistency with reliability scores of 0.70–0.79 for lower-stake assessments and 0.80–0.89 for moderate-stake assessments, while high-stake assessments, such as certification exams, should demonstrate a reliability of at least 0.90 (10).

Validity evidence for surgical simulation is critical to support any interpretation of assessment data resulting from simulation-based training. Subjective validity evidence includes both face and content validity. While face validity speaks to the 'realism' of the simulator or simulated scenario as judged by non-experts, content validity evidence is provided by content experts who judge the appropriateness of the simulator as a teaching tool. Objective validity evidence is more difficult to obtain but also more robust. Construct validity speaks to the ability of the simulator or simulated scenario to discern the experienced from the novice surgeon. For instance, a robotic surgical simulator with construct validity would reliably discern expert robotic surgeons from novice robotic surgeons by comparing the performance scores of both groups. Concurrent validity is demonstrated if the simulation-based training assessment correlates strongly with assessment data obtained from the accepted 'gold standard' method of determining trainee competence on a particular learning objective. Predictive validity evidence refers to the ability of assessment data obtained during simulation-based training to predict future trainee performance during hands-on clinical surgery (9).

The use of various surgical simulation tools to assess competency, whether for the certification of trainees or the recertification of postgraduate surgeons, requires more than just robust reliability and validity evidence. One of the difficulties in the application of simulation-based tools for assessment purposes is the issue of standard setting: 'establishing credible, defensible, and acceptable passing or cut-off scores [...] in health professions education can be challenging' (11). What is the ideal performance score to discern the competent surgical trainee from the incompetent one? What level of performance should be required for certification? Or recertification? These questions must be asked whenever a simulation tool is to be used for assessment purposes.

Standards are usually categorised as either norm-based (relative) or criterion- based (absolute). Norm-based standards determine competency relative to the performance of a well-defined group (e.g., laparoscopic expert surgeons, the top quartile of the class, etc.) and are not ideally suited to high-stakes competency assessments. Criterion-based standards determine trainee competency based on some predetermined absolute level or performance score. As it implies a certain level of mastery of content or skill, criterion-based standards are preferred to assess competency (11). The passing scores for most national specialty certification examinations, for example the American Board of Urology Examinations, are criterion-based.

From De-contextualised to Contextualised Simulation

Along with significant advancements in surgical technology, surgeons have also witnessed considerable advancements in surgical simulation. Technological improvements in simulation fidelity, the increasing integration of valid assessment tools into VR simulators and the improved accessibility of simulation-based training resources have given surgical educators more opportunities to implement a variety of effective surgical simulation tools into contemporary urology training programmes.

Inanimate surgical simulation models range from part-task trainers (e.g., laparoscopic box trainers) to procedure-specific trainers (e.g., ureteroscopy trainers) (Figures 1.1 and 1.2). These synthetic models give trainees the opportunity to deliberately practise a specific surgical skill, or set of skills, in a low-risk environment. Such simulation tools are often ideal for the novice or intermediate trainee, however, due to the lack of clinical variability and the inability to provide individualised, proficiency-based variations in complexity, inanimate surgical simulation models often decrease in utility for advanced-level trainees. In addition, trainee assessments using such synthetic models require significant time and personnel resources from content and/ or education experts. Chapter 3 provides a more comprehensive discussion of the role of synthetic surgical simulation tools in urologic training, both for instructional and assessment purposes.

Animal and cadaveric surgical training models provide improved fidelity and allow the trainee to practise a complete set of technical skills or whole procedures in a context-rich environment. Improved contextual fidelity and the ability to provide procedure-specific training and assessment is offset by the incremental costs associated with these high-fidelity, non-reusable resources. For this reason, it is critical to ensure that the utilisation of animal and cadaveric training models appropriately matches learning objectives and is part of a well-designed, comprehensive curriculum. For example, using animal model training sessions to instruct or assess residents on the basic principles of laparoscopic camera navigation would be a gross misappropriation of resources. An in-depth review of the role of animal and cadaveric models in simulation-based training and assessment in urology is provided in Chapters 4 and 5.

VR flight simulators have been a mainstay of training in the aviation industry for decades, being utilised for instruction, assessment, certification and re-certification purposes. While VR surgical simulators are still relatively rudimentary in comparison to their aviation counterparts, improvements in graphics software, hardware sophistication and built-in performance metrics analytics have significantly improved the fidelity, reliability and validity of modern surgical simulators (Figures 1.3 – 1.5). Like other simulation-based training tools, VR surgical simulators have the benefit of providing trainees with an opportunity for deliberate practise in a low-risk environment. In addition, clinical variations can be built into the simulator, improving the training content delivered and allowing for individualised, proficiency-based training. The majority of VR surgical simulators currently available also have the advantage of providing instant feedback through analysis of various performance metrics (e.g., time to complete a task, errors committed during a task, instrument motion smoothness and path length or economy of motion). This built-in assessment functionality permits self-directed learning and proficiency-based training, and also removes the necessity of expert faculty presence during the entirety of the training. Despite the improved realism and fidelity of today's VR simulators, rigorous validity evidence is still required for each individual surgical simulator, particularly if it is to be used for competency assessments. The significant cost associated with most endourologic, laparoscopic and robotic surgical simulators also remains a significant obstacle for many training programmes, even further demonstrating the importance of rigorous validation. A detailed review of various VR surgical simulators is provided in Chapter 6.

Attention has increasingly been directed towards the improvement of the non-technical skills of surgical trainees in recent years, as they pertain to the management of crisis OR situations and the overall improvement of patient care. To this end, the development and utilisation of mock OR environments (Figure 1.6) to create high-fidelity simulated clinical scenarios for the purposes of high-reliability team training, crisis OR management training and non-technical skills training and assessment are becoming more commonplace (12, 13). A complete discussion of the use of surgical simulation for the instruction and assessment of interpersonal and communication skills is developed in Chapter 8.

Conclusions

Today's surgical training landscape would likely seem foreign to traditional surgical educators such as Dr William Halsted. Gone are the days of the 'see one, do one, teach one' training paradigm. In an effort to improve patient care outcomes and reduce the impact of surgical training on patient safety, a significant portion of surgical training today is best conducted outside of the clinical OR setting. The growing role of surgical simulation in urological training is supported by the emergence of increasingly robust validity evidence, but educators must be cognisant of the importance of the proper utilisation of surgical simulation as both an instructional and assessment tool. Even the most advanced, high-fidelity simulation tool cannot replace a well-designed, comprehensive training curriculum, nor can it take the place of a well-trained, dedicated surgical educator.

Take-Home Messages

1. Surgical simulation must be integrated into a comprehensive surgical training curriculum and is not a stand-alone training method.

2. Robust reliability and validity evidence is critical to surgical simulation, particularly for the purposes of summative assessment or determination of competency.

3. Surgical simulation provides an opportunity for deliberate practice in a low-risk environment, reducing the footprint of surgical training on patient care outcomes.

4. The ability to incorporate clinical variation and variable levels of difficulty into surgical simulation tools allows for proficiency-based training tailored to the individual trainee.

(Continues...)

Excerpted from Surgical Simulation by Prokar Dasgupta, Kamran Ahmed, Peter Jaye, Mohammed Shamim Khan. Copyright © 2014 Prokar Dasgupta, Kamran Ahmed, Peter Jaye and Mohammed Shamim Khan. Excerpted by permission of Wimbledon Publishing Company.
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Edition details

• Publisher: Anthem Press
• Publication date: 2014
• Language: English
• ISBN 10: 1783081562
• ISBN 13: 9781783081561
• Binding: Hardcover
• Number of pages: 132
• Editor: Dasgupta Prokar, Ahmed Kamran, Jaye Peter, Khan Mohammed Shamim