Defining areas in need of simulation-based skills training
Simulation-based training should aim to hasten the process of learning surgical skills in a safe environment that is away from the stress of the OR and also allows the opportunity to both make and learn from mistakes without causing harm to patients. Because orthopaedic surgery encompasses the broadest human anatomy, simulated orthopaedic procedures need to be defined carefully so that both basic and advanced orthopaedic surgical skills can be improved outside the OR effectively.
Currently, the majority of the educational programs in United States have already integrated simulated training of basic surgical skills in to their first postgraduate year (PGY1) either as a one-time intensive course (i.e., boot camp) or as longitudinal training sessions throughout the year since this training is required by the American Board of Orthopaedic Surgery (ABOS) and Residency Review Committee (RRC) in orthopaedic surgery. However, the content of these courses is not well-defined. In addition, there is no consensus among orthopaedic training programs as to what type of advanced procedures need simulator training. Almost all advanced orthopaedic surgical skills’ courses that are presently available are limited in terms of both procedure types and practiced surgical tools due to their commercial nature. As one of the first steps forward, priority will need to be given to the definition of both basic and advanced surgical skills to be trained on simulators in orthopaedic education.
Another important issue is the use of simulators for training and certification or recertification of orthopaedic surgeons already in practice. Simulation-based training might offer a valuable opportunity for practicing orthopaedic surgeons who have completed residency or fellowship training to learn new procedures and/or update their existing skills. Further, simulations may have a future role to assess surgical skills as benchmarks for certification or recertification of practicing orthopaedic surgeons. Likewise, simulators can be beneficial in selecting students for specialty training in orthopaedic surgery based on their aptitude in simulated performance of basic surgical skills. Nevertheless, all these potential areas in which simulators could have benefits need to be further identified and studied rigorously before simulators can be used in certification/recertification and trainee selection processes.
Arthroscopic surgery is an area where orthopaedic simulation is more advanced and that simulation-based training can be very effective in improving skills of orthopaedic trainees[5-7]. During the past few decades, there have been dramatic improvements in arthroscopic surgery of the knee, shoulder, hip, elbow, wrist and ankle joints. However, the amount of time that the trainees could spend for practicing arthroscopic surgery skills is limited because the duration of residency training is still the same as it was decades ago. Further, there are different arthroscopic procedure types for each joint, which makes it nearly impossible for trainees to become truly proficient in this field. Hence, simulated arthroscopic skills training could be an important learning opportunity for residents and fellows.
Current simulators are limited to mainly the knee and shoulder modules and do not include some of the commonly performed operations such as meniscectomy, rotator cuff repair, or even loose body removal. It is clear that simulation-based arthroscopic skills training needs to be integrated into the educational curriculum. However, the types of simulator devices and software, joints on which to focus, and procedures to be practiced using arthroscopy simulators are still waiting to be defined and standardized. Cost factors will be another limitation. As an example, the cost of a high-fidelity simulator can be as high as 100000 USD including the device, software, and maintenance.
After defining the skills for which training with simulators will be most effective, programs to educate and certify simulation lab instructors to supervise trainees during simulation-based skills training could be of value. Although such an initiative could only become relevant after a standard simulation based curriculum is established, this may also aid in achieving uniformity among educational programs nationwide.
Time, duration, and frequency of simulation-based skills training
Although surgical simulation in orthopaedic skills training has been recognized as a necessity, and the Accreditation Council on Graduate Medical Education recommends simulation training during residency education, specifics with regard to time, duration, and frequency of practicing with simulators are left to program directors to determine what they think is best for their residents[2,8]. Since July 2013, orthopaedic residency programs in the United States have been required to incorporate laboratory-based surgical skills training into the curriculum during the first year of residency. Currently, some orthopaedic residency programs have included a one-month period of an intensive skills training course, or boot camp, into their curriculum before interns begin their training. There are existing concerns regarding the effectiveness of short-term intensive skills training, and the degree to which skills learned in these courses are retained and achieve the goal of improved integration into the actual OR is uncertain. Hence, some residency programs in the United States have decided to spread these skills training courses throughout the entire internship year via one or two days of simulation-based training every week. Further research is required to prove the superiority of either method in surgical skills training during residency.
Due to the tremendous number of surgical skills and procedures that must be learned after the first year of residency, incorporation of simulation-based skills training into the latter years of residency should positively influence the development of trainees’ skills. Choosing the time and duration of simulation-based training as well as determining the optimal time period for reinforcing the learned skills by repeating the simulated courses are of primary concern. Although more simulation-based surgical skills training may result in better learning for residents, this would also require more time spent in education and thus away from clinical service, which might be an obstacle to conducting lab-based training for extended periods during residency. The fellowship period might be a convenient time for practicing skills that are more advanced and specific to subspecialties and offer greater opportunities for dedicated time. However, fellowship programs may vary in terms of their goals and objectives for training, and standardized educational curriculum adjustments for simulation-based training during the fellowship period do not appear to be realistic at this stage. Also more advanced skills training is necessary at the fellowship level requiring higher fidelity simulations which may be cost prohibitive for many fellowship programs.
A notable simulation-based surgical skills training approach, which was recently proposed, is proficiency-based-progression (PBP). This approach can be defined as training based on a benchmark that has been established by expert performance. The benchmark that the novice must achieve is set by the mean performance scores of experts who undergo the same course (curriculum). Thus, the training is not completed in a given amount of time but rather continues until the benchmark scores are met for two consecutive trials. In addition, tasks are presented in a progressively increasing level of difficulty. The trainees are allowed to proceed to the next step only after the previous and easier task is accomplished proficiently. This notion also matches the Dreyfus and Dreyfus model of progression of skills performance from novice to master. In a prospective randomized blinded study, Angelo et al demonstrated that the PBP protocol, when coupled with the use of a shoulder model simulator and validated metrics, produces superior arthroscopic Bankart repair skills when compared with traditional and simulator-enhanced training methods. It is evident that the integration of simulation-based surgical skills training into educational curriculum using such novel approaches will be more beneficial if certain factors, such as which skills require focus and at what point during the training they should be implemented, could be determined and organized beforehand.