Assimilating Simulation in Surgical Training: Dainty Morsels or Pig in a Python?


Simulation is an increasing part of surgical training and a critical component in producing the next generation of surgeons – but it is also the focus of questions and controversy, as evidenced by a spate of recent journal articles and by views expressed at a special session of the 2012 Vascular Annual Meeting.

Reasons for the interest in simulation include duty hour restrictions, more complex and automated procedures, and stricter quality assurance programs such as pay for performance – all of which mandate the need to practice and perfect difficult techniques. The push toward simulation is projected to affect not only residents in early training but also established surgeons pursuing Maintenance of Certification (MOC).

Questions seem to have moved beyond simply whether simulation is needed to how much simulation training is needed and how to pay for it. Can simulation training be administered as dainty morsels nibbled over time, or does it need to be swallowed all at once – the pig-in-a-python approach?

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It all depends on what level of simulation is necessary. Suturing can be practiced on rubber tubing or on the latest synthetic bioskin products, which mimic multiple skin layers. Arterial procedures can be mimicked by operating on tubing in plastic see-through dummies, or by using robotic simulators to operate on virtual patients generated as three-dimensional CT scans. And the standard of performing simulated operations in the cadaver lab still exists.

Everything ranging from relatively simple, individual technique simulators that cost comparatively little to massive, regional simulation centers that cost hundreds of thousands of dollars are now being used in surgical training. Highly visible examples of what is possible (if you can afford it) are the Goodman Simulation Center at Stanford (Calif.) University, the Stony Brook Medicine Surgical Skills Center at the State University of New York at Stony Brook, the Methodist DeBakey Heart and Vascular Center in Houston, and the University of South Florida Center for Advanced Medical Learning and Simulation in Tampa.

Photos courtesy Eric Younghans/University of South Florida

At the surgical skills laboratory at the USF Health Center for Advanced Medical Learning and Simulation (CAMLS), medical students and surgical residents practice together. Two learners to each life-sized operating room table, they focus on honing their suturing techniques using cryopreserved aortas.

Since 2008, the Accreditation Council for Graduate Medical Education (ACGME) has required, for general surgical training, that resources "include simulation and skills laboratories. These facilities must address acquisition and maintenance of skills with a competency-based method of evaluation." But the extent to which simulation should play a role in training, how much simulation should be required, and how it should be evaluated are subject to debate. The only consensus seems to be that something is needed, and simulation is here to stay, like it or not.

Why Now?

The need for simulation training appears to be driven by several intersecting forces – social and economic problems for which simulation claims to be the solution.

"During the past 100 years, time-based apprentice-type surgical training programs have produced many superb surgeons. However, with restrictions in residency work hours, increasing emphasis on patient safety, and rising costs for training in the operating room, trainees now have fewer opportunities to train in the operating room," according to Dr. Boris Zevin of the University of Toronto and his colleagues.

"The major driving force behind the call to incorporate simulation into surgical training comes from the need to improve patient safety and to shorten the learning curve in the operating room," Dr. Zevin, leader of an international survey that assessed simulation-based training in surgery, and his colleagues wrote in the Journal of the American College of Surgeons (2012 [doi: 10.1016/j.jamcollsurg.2012.05.035]).

In a recent survey, residents in a single surgical simulation training program expressed concern that the need for simulation wasn’t being driven by the health care system or from within the surgical community. Two candid opinions in the survey stated that simulation is "filling this public thirst for there being a uniform, regulated – on a national level – program by which we are all practicing on, basically, objects, before practicing on people," and "a core component of just some way for the health care industry to prove that there are competent people and this is what they are competent in" (Surgery 2012;151:815-21).

Ultimately, one of the strongest pressures to alter resident education may well be financial. According to Dr. John F. Eidt of the University of Arkansas for Medical Sciences, Little Rock, a leading voice for simulation training in vascular surgery education, "The federal government is the primary source of funding for graduate medical education (GME) through supplementation of hospital reimbursement. Recent events threaten to drastically alter GME funding. ... The Medicare Payment Advisory Commission has stated that up to 50% of indirect GME reimbursement is not ‘empirically justified’ by actual hospital costs associated with education," Dr. Eidt said during his presidential address at the annual meeting of the Southern Association for Vascular Surgery.


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