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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?
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.
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.
At the Vascular Annual Meeting, he reiterated his support for simulator training, and discussed the success of the aviation model of simulation in detail.
The Case for Simulation
If adopting simulation is all but inevitable, how best to do it? The dainty morsels vs. pig-in-a-python approach was at the crux of a debate held at the Vascular Annual Meeting session. On the pro-simulation side, Dr. Alan B. Lumsden of the Methodist DeBakey Heart and Vascular Center, Houston, saw simulation as "the wave of the future."
Dr. Lumsden was adamant in saying that the costly, high-fidelity virtual reality systems are not what simulation training for residents should be about. He used CPR dummies as an example of one of the most effective simulators. These cost "about a hundred bucks a pop," compared with some $250,000 systems, he noted, adding that almost every senior vascular surgeon beside him on the podium learned how to do endovascular procedures on foam rubber iliac and aortic stenosis models (including his debate adversary, Dr. Michael S. Makaroun).
"The question is not whether simulation is valid, but the question is whether we as vascular surgeons can figure out how to take what we have learned and learn how to apply that [to simulations]." His major point was that there should be a focus on simulation and how to standardize its use. He indicated that in single tasks, simulation could be made ideal, such that eventually "we should be all doing the procedure in the exact same way," and he gave the example of groin puncture to access a femoral vessel as one good place to start.
Dr. Lumsden also pointed out the critical validity of simulation for team training. He used the example of extracorporeal membrane oxygenation (ECMO) training simulation, and said that much could be learned from the Fundamentals of Laparoscopic Surgery program, a simulation program required in order to get certification and graduate in a general surgery residency. The system includes a kit that allows surgeons to practice at home and online to learn skills, he said.
"We need to build ‘Fundamentals of Endovascular Surgery,’ " he asserted. "We can do this and do it relatively easily and relatively cheaply. ... It’s not debatable as to whether this is of value. It’s debatable whether we can figure out how to do it and institute it into vascular surgery on a daily basis."
A Global Concern
Just what level of simulation is appropriate is an international question, and a recent analysis of how best to expand the use of simulation in open vascular surgical training was presented by Dr. Vikas A. Pandey and Dr. John H.N. Wolfe of the Imperial College Healthcare NHS Trust, London. In a recent article, they discussed one major issue in simulation that has created considerable concern in the vascular community especially – the comparative ease of simulating endovascular and laparoscopic approaches (which can be simulated using a two-dimensional imaging approach, and is one of the driving forces behind the simulation movement) as compared with open surgery, which requires a three-dimensional field to be representative of the procedure and is much more difficult to simulate effectively (J. Vasc. Surg. 2012 [doi: 10.1016/j.jvs.2012.04.015]).
Dr. Pandey and Dr. Wolfe indicated that a wide range of simulators exist for all aspects of vascular surgical training, and that these vary in complexity and price, from simulators suitable for use at home or in a local skills laboratory to those that can only be practically implemented at a regional skills center.
But even the latter are not the highest levels of simulation required. The authors suggested that higher levels of simulation training require more stringent considerations. "Where surgical procedures are not commonly performed or expertise is required for a new innovation, it is more appropriate to have national or internationally based workshops under the auspices of surgical boards or societies," they wrote.
Finding consensus on the best method for implementing simulation-based training in a surgical curriculum also remains a thorny subject. Dr. Zevin and his colleagues from the United States reported on their attempt to achieve international consensus. They used an iterative, online Delphi survey to develop a consensus among 24 international experts with training ranging from general surgery to vascular surgery. The final framework agreed upon for resident training was the need for predevelopment analysis of trainees; cognitive, psychomotor, and team-based simulation training; and methods of curriculum validation, evaluation, and improvement. A consensus was also reached by greater than 80% on the need for simulation for maintenance of training.
But Does It Work?
Dr. Lumsden’s position, and that of all strong proponents of simulation, was called into question in the Vascular Annual Meeting debate by Dr. Makaroun of the University of Pittsburgh Medical Center, who stated that it is a waste of time and money.
"Simulation makes sense. ... It is safe and can’t hurt patients, it should improve education and learning, and it should improve clinical performance; it should help in the evaluation of competency. ... It has already been adopted by everybody ... and everywhere I look, simulation is there," he acknowledged. However, he said, "it is crucial that we recognize that the success of the flight simulator [the example always touted as a key triumph for simulation] does not translate well in simulating everything – in particular, not in highly complex, highly indeterminate situations such as human biology and behavior."
For effective simulation, he stated, you need an effective teacher, you need repetition, you need to measure the performance and get feedback, and thus you need the accessibility of local simulation facilities – meaning hundreds, if not thousands, of simulators nationwide.
Major simulation centers have cost between $20 million and $40 million to build, and the simulators in those facilities can cost in the hundreds of thousands of dollars, he added. Perhaps the priciest commodity of all is the time of a faculty trainer, he suggested.
Dr. Makaroun complained that industry is actively promoting this entire area and that the ultimate price tag is in the billions. So the case against simulation is that it is too expensive.
"So far, there is absolutely no data to indicate that it has improved the surgical skills of graduates who trained on simulators vs. those who did not," said Dr. Makaroun. There are also "absolutely no data" indicating a link between simulator use and improved patient outcomes and safety.
In fact, he said, most simulator studies being reported in the literature simply show that somebody who practiced a task on a simulator was better at doing that same task on the simulator after practice than before. "Are we really surprised that vascular residents can learn something after 2 days?" he asked. Studies are needed to assess whether surgeons trained on simulators performed actual procedures better at 6 months after training than did those who had received standard training.
Some general surgery residents also are still conflicted about the value of simulation training. In the in-depth survey cited above, 25 general surgery residents, all of whom were exposed to simulation training at the Texas A&M Health Science Center College of Medicine, were almost equally divided as to whether "ACGME should require a simulation curriculum in surgery residency" (52.1%, yes; 47.8%, no). Further questioning elicited concerns about whether there was any evidence of efficacy of simulation in surgical residency training beyond the traditional approach, and how simulation could not replace "real experience" on patients.
So, despite the growing consensus that simulation has a role in surgical education and training, there is less consensus as to how to evaluate the effectiveness (if any) of such training when the rubber (or plastic model) meets the operating room.
And if effectiveness cannot be proven, how can the tremendous investments in technology, time, and facilities be justified?
What Next?
In the end, the problems of cost, level, and effectiveness of simulation remain to be resolved. "Unfortunately, the promise of patient-specific, high-fidelity, virtual reality vascular surgical simulation remains largely unfulfilled due to the enormous development costs and the computational complexity associated with mimicking the response of tissue to deformation," Dr. Eidt said during his presidential address at the annual meeting of the Southern Association for Vascular Surgery (J. Vasc. Surg. 2012;55:1801-9).
He added that "low-fidelity, low-cost simulation is effective for teaching basic surgical skills such as suturing or knot-tying, or the sequence of steps in an operation to novice surgeons, but is remarkably ineffective for advanced learners where fidelity is critical."
Dainty morsels may apply for early trainees, but are pig-in-a-python meals required for the more advanced?
The lines are drawn, with seemingly the majority of educators, government regulators, and the general public convinced that the logic of simulators is undeniable, and that enough data from fields outside of surgery exist to justify the wide adoption of simulators in surgical training.
Given the trajectory of modern medicine, it seems that more rather than less technology is likely to be the answer – or at least the answer most acceptable to device-driven societies such as the United States and Western Europe, where these approaches are being pioneered. Hence, the continued use and expansion of simulation in surgical training seem inevitable.
Dr. Lumsden reported that he had no conflicts of interest other than working at the DeBakey Institute, where simulation training was of great importance. Dr. Zevin, Dr. Eidt, Dr. Makaroun, and Dr. Pandey reported no relevant disclosures. Dr. Wolfe reported receiving funding from Limbs & Things.
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?
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.
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.
At the Vascular Annual Meeting, he reiterated his support for simulator training, and discussed the success of the aviation model of simulation in detail.
The Case for Simulation
If adopting simulation is all but inevitable, how best to do it? The dainty morsels vs. pig-in-a-python approach was at the crux of a debate held at the Vascular Annual Meeting session. On the pro-simulation side, Dr. Alan B. Lumsden of the Methodist DeBakey Heart and Vascular Center, Houston, saw simulation as "the wave of the future."
Dr. Lumsden was adamant in saying that the costly, high-fidelity virtual reality systems are not what simulation training for residents should be about. He used CPR dummies as an example of one of the most effective simulators. These cost "about a hundred bucks a pop," compared with some $250,000 systems, he noted, adding that almost every senior vascular surgeon beside him on the podium learned how to do endovascular procedures on foam rubber iliac and aortic stenosis models (including his debate adversary, Dr. Michael S. Makaroun).
"The question is not whether simulation is valid, but the question is whether we as vascular surgeons can figure out how to take what we have learned and learn how to apply that [to simulations]." His major point was that there should be a focus on simulation and how to standardize its use. He indicated that in single tasks, simulation could be made ideal, such that eventually "we should be all doing the procedure in the exact same way," and he gave the example of groin puncture to access a femoral vessel as one good place to start.
Dr. Lumsden also pointed out the critical validity of simulation for team training. He used the example of extracorporeal membrane oxygenation (ECMO) training simulation, and said that much could be learned from the Fundamentals of Laparoscopic Surgery program, a simulation program required in order to get certification and graduate in a general surgery residency. The system includes a kit that allows surgeons to practice at home and online to learn skills, he said.
"We need to build ‘Fundamentals of Endovascular Surgery,’ " he asserted. "We can do this and do it relatively easily and relatively cheaply. ... It’s not debatable as to whether this is of value. It’s debatable whether we can figure out how to do it and institute it into vascular surgery on a daily basis."
A Global Concern
Just what level of simulation is appropriate is an international question, and a recent analysis of how best to expand the use of simulation in open vascular surgical training was presented by Dr. Vikas A. Pandey and Dr. John H.N. Wolfe of the Imperial College Healthcare NHS Trust, London. In a recent article, they discussed one major issue in simulation that has created considerable concern in the vascular community especially – the comparative ease of simulating endovascular and laparoscopic approaches (which can be simulated using a two-dimensional imaging approach, and is one of the driving forces behind the simulation movement) as compared with open surgery, which requires a three-dimensional field to be representative of the procedure and is much more difficult to simulate effectively (J. Vasc. Surg. 2012 [doi: 10.1016/j.jvs.2012.04.015]).
Dr. Pandey and Dr. Wolfe indicated that a wide range of simulators exist for all aspects of vascular surgical training, and that these vary in complexity and price, from simulators suitable for use at home or in a local skills laboratory to those that can only be practically implemented at a regional skills center.
But even the latter are not the highest levels of simulation required. The authors suggested that higher levels of simulation training require more stringent considerations. "Where surgical procedures are not commonly performed or expertise is required for a new innovation, it is more appropriate to have national or internationally based workshops under the auspices of surgical boards or societies," they wrote.
Finding consensus on the best method for implementing simulation-based training in a surgical curriculum also remains a thorny subject. Dr. Zevin and his colleagues from the United States reported on their attempt to achieve international consensus. They used an iterative, online Delphi survey to develop a consensus among 24 international experts with training ranging from general surgery to vascular surgery. The final framework agreed upon for resident training was the need for predevelopment analysis of trainees; cognitive, psychomotor, and team-based simulation training; and methods of curriculum validation, evaluation, and improvement. A consensus was also reached by greater than 80% on the need for simulation for maintenance of training.
But Does It Work?
Dr. Lumsden’s position, and that of all strong proponents of simulation, was called into question in the Vascular Annual Meeting debate by Dr. Makaroun of the University of Pittsburgh Medical Center, who stated that it is a waste of time and money.
"Simulation makes sense. ... It is safe and can’t hurt patients, it should improve education and learning, and it should improve clinical performance; it should help in the evaluation of competency. ... It has already been adopted by everybody ... and everywhere I look, simulation is there," he acknowledged. However, he said, "it is crucial that we recognize that the success of the flight simulator [the example always touted as a key triumph for simulation] does not translate well in simulating everything – in particular, not in highly complex, highly indeterminate situations such as human biology and behavior."
For effective simulation, he stated, you need an effective teacher, you need repetition, you need to measure the performance and get feedback, and thus you need the accessibility of local simulation facilities – meaning hundreds, if not thousands, of simulators nationwide.
Major simulation centers have cost between $20 million and $40 million to build, and the simulators in those facilities can cost in the hundreds of thousands of dollars, he added. Perhaps the priciest commodity of all is the time of a faculty trainer, he suggested.
Dr. Makaroun complained that industry is actively promoting this entire area and that the ultimate price tag is in the billions. So the case against simulation is that it is too expensive.
"So far, there is absolutely no data to indicate that it has improved the surgical skills of graduates who trained on simulators vs. those who did not," said Dr. Makaroun. There are also "absolutely no data" indicating a link between simulator use and improved patient outcomes and safety.
In fact, he said, most simulator studies being reported in the literature simply show that somebody who practiced a task on a simulator was better at doing that same task on the simulator after practice than before. "Are we really surprised that vascular residents can learn something after 2 days?" he asked. Studies are needed to assess whether surgeons trained on simulators performed actual procedures better at 6 months after training than did those who had received standard training.
Some general surgery residents also are still conflicted about the value of simulation training. In the in-depth survey cited above, 25 general surgery residents, all of whom were exposed to simulation training at the Texas A&M Health Science Center College of Medicine, were almost equally divided as to whether "ACGME should require a simulation curriculum in surgery residency" (52.1%, yes; 47.8%, no). Further questioning elicited concerns about whether there was any evidence of efficacy of simulation in surgical residency training beyond the traditional approach, and how simulation could not replace "real experience" on patients.
So, despite the growing consensus that simulation has a role in surgical education and training, there is less consensus as to how to evaluate the effectiveness (if any) of such training when the rubber (or plastic model) meets the operating room.
And if effectiveness cannot be proven, how can the tremendous investments in technology, time, and facilities be justified?
What Next?
In the end, the problems of cost, level, and effectiveness of simulation remain to be resolved. "Unfortunately, the promise of patient-specific, high-fidelity, virtual reality vascular surgical simulation remains largely unfulfilled due to the enormous development costs and the computational complexity associated with mimicking the response of tissue to deformation," Dr. Eidt said during his presidential address at the annual meeting of the Southern Association for Vascular Surgery (J. Vasc. Surg. 2012;55:1801-9).
He added that "low-fidelity, low-cost simulation is effective for teaching basic surgical skills such as suturing or knot-tying, or the sequence of steps in an operation to novice surgeons, but is remarkably ineffective for advanced learners where fidelity is critical."
Dainty morsels may apply for early trainees, but are pig-in-a-python meals required for the more advanced?
The lines are drawn, with seemingly the majority of educators, government regulators, and the general public convinced that the logic of simulators is undeniable, and that enough data from fields outside of surgery exist to justify the wide adoption of simulators in surgical training.
Given the trajectory of modern medicine, it seems that more rather than less technology is likely to be the answer – or at least the answer most acceptable to device-driven societies such as the United States and Western Europe, where these approaches are being pioneered. Hence, the continued use and expansion of simulation in surgical training seem inevitable.
Dr. Lumsden reported that he had no conflicts of interest other than working at the DeBakey Institute, where simulation training was of great importance. Dr. Zevin, Dr. Eidt, Dr. Makaroun, and Dr. Pandey reported no relevant disclosures. Dr. Wolfe reported receiving funding from Limbs & Things.
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?
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.
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.
At the Vascular Annual Meeting, he reiterated his support for simulator training, and discussed the success of the aviation model of simulation in detail.
The Case for Simulation
If adopting simulation is all but inevitable, how best to do it? The dainty morsels vs. pig-in-a-python approach was at the crux of a debate held at the Vascular Annual Meeting session. On the pro-simulation side, Dr. Alan B. Lumsden of the Methodist DeBakey Heart and Vascular Center, Houston, saw simulation as "the wave of the future."
Dr. Lumsden was adamant in saying that the costly, high-fidelity virtual reality systems are not what simulation training for residents should be about. He used CPR dummies as an example of one of the most effective simulators. These cost "about a hundred bucks a pop," compared with some $250,000 systems, he noted, adding that almost every senior vascular surgeon beside him on the podium learned how to do endovascular procedures on foam rubber iliac and aortic stenosis models (including his debate adversary, Dr. Michael S. Makaroun).
"The question is not whether simulation is valid, but the question is whether we as vascular surgeons can figure out how to take what we have learned and learn how to apply that [to simulations]." His major point was that there should be a focus on simulation and how to standardize its use. He indicated that in single tasks, simulation could be made ideal, such that eventually "we should be all doing the procedure in the exact same way," and he gave the example of groin puncture to access a femoral vessel as one good place to start.
Dr. Lumsden also pointed out the critical validity of simulation for team training. He used the example of extracorporeal membrane oxygenation (ECMO) training simulation, and said that much could be learned from the Fundamentals of Laparoscopic Surgery program, a simulation program required in order to get certification and graduate in a general surgery residency. The system includes a kit that allows surgeons to practice at home and online to learn skills, he said.
"We need to build ‘Fundamentals of Endovascular Surgery,’ " he asserted. "We can do this and do it relatively easily and relatively cheaply. ... It’s not debatable as to whether this is of value. It’s debatable whether we can figure out how to do it and institute it into vascular surgery on a daily basis."
A Global Concern
Just what level of simulation is appropriate is an international question, and a recent analysis of how best to expand the use of simulation in open vascular surgical training was presented by Dr. Vikas A. Pandey and Dr. John H.N. Wolfe of the Imperial College Healthcare NHS Trust, London. In a recent article, they discussed one major issue in simulation that has created considerable concern in the vascular community especially – the comparative ease of simulating endovascular and laparoscopic approaches (which can be simulated using a two-dimensional imaging approach, and is one of the driving forces behind the simulation movement) as compared with open surgery, which requires a three-dimensional field to be representative of the procedure and is much more difficult to simulate effectively (J. Vasc. Surg. 2012 [doi: 10.1016/j.jvs.2012.04.015]).
Dr. Pandey and Dr. Wolfe indicated that a wide range of simulators exist for all aspects of vascular surgical training, and that these vary in complexity and price, from simulators suitable for use at home or in a local skills laboratory to those that can only be practically implemented at a regional skills center.
But even the latter are not the highest levels of simulation required. The authors suggested that higher levels of simulation training require more stringent considerations. "Where surgical procedures are not commonly performed or expertise is required for a new innovation, it is more appropriate to have national or internationally based workshops under the auspices of surgical boards or societies," they wrote.
Finding consensus on the best method for implementing simulation-based training in a surgical curriculum also remains a thorny subject. Dr. Zevin and his colleagues from the United States reported on their attempt to achieve international consensus. They used an iterative, online Delphi survey to develop a consensus among 24 international experts with training ranging from general surgery to vascular surgery. The final framework agreed upon for resident training was the need for predevelopment analysis of trainees; cognitive, psychomotor, and team-based simulation training; and methods of curriculum validation, evaluation, and improvement. A consensus was also reached by greater than 80% on the need for simulation for maintenance of training.
But Does It Work?
Dr. Lumsden’s position, and that of all strong proponents of simulation, was called into question in the Vascular Annual Meeting debate by Dr. Makaroun of the University of Pittsburgh Medical Center, who stated that it is a waste of time and money.
"Simulation makes sense. ... It is safe and can’t hurt patients, it should improve education and learning, and it should improve clinical performance; it should help in the evaluation of competency. ... It has already been adopted by everybody ... and everywhere I look, simulation is there," he acknowledged. However, he said, "it is crucial that we recognize that the success of the flight simulator [the example always touted as a key triumph for simulation] does not translate well in simulating everything – in particular, not in highly complex, highly indeterminate situations such as human biology and behavior."
For effective simulation, he stated, you need an effective teacher, you need repetition, you need to measure the performance and get feedback, and thus you need the accessibility of local simulation facilities – meaning hundreds, if not thousands, of simulators nationwide.
Major simulation centers have cost between $20 million and $40 million to build, and the simulators in those facilities can cost in the hundreds of thousands of dollars, he added. Perhaps the priciest commodity of all is the time of a faculty trainer, he suggested.
Dr. Makaroun complained that industry is actively promoting this entire area and that the ultimate price tag is in the billions. So the case against simulation is that it is too expensive.
"So far, there is absolutely no data to indicate that it has improved the surgical skills of graduates who trained on simulators vs. those who did not," said Dr. Makaroun. There are also "absolutely no data" indicating a link between simulator use and improved patient outcomes and safety.
In fact, he said, most simulator studies being reported in the literature simply show that somebody who practiced a task on a simulator was better at doing that same task on the simulator after practice than before. "Are we really surprised that vascular residents can learn something after 2 days?" he asked. Studies are needed to assess whether surgeons trained on simulators performed actual procedures better at 6 months after training than did those who had received standard training.
Some general surgery residents also are still conflicted about the value of simulation training. In the in-depth survey cited above, 25 general surgery residents, all of whom were exposed to simulation training at the Texas A&M Health Science Center College of Medicine, were almost equally divided as to whether "ACGME should require a simulation curriculum in surgery residency" (52.1%, yes; 47.8%, no). Further questioning elicited concerns about whether there was any evidence of efficacy of simulation in surgical residency training beyond the traditional approach, and how simulation could not replace "real experience" on patients.
So, despite the growing consensus that simulation has a role in surgical education and training, there is less consensus as to how to evaluate the effectiveness (if any) of such training when the rubber (or plastic model) meets the operating room.
And if effectiveness cannot be proven, how can the tremendous investments in technology, time, and facilities be justified?
What Next?
In the end, the problems of cost, level, and effectiveness of simulation remain to be resolved. "Unfortunately, the promise of patient-specific, high-fidelity, virtual reality vascular surgical simulation remains largely unfulfilled due to the enormous development costs and the computational complexity associated with mimicking the response of tissue to deformation," Dr. Eidt said during his presidential address at the annual meeting of the Southern Association for Vascular Surgery (J. Vasc. Surg. 2012;55:1801-9).
He added that "low-fidelity, low-cost simulation is effective for teaching basic surgical skills such as suturing or knot-tying, or the sequence of steps in an operation to novice surgeons, but is remarkably ineffective for advanced learners where fidelity is critical."
Dainty morsels may apply for early trainees, but are pig-in-a-python meals required for the more advanced?
The lines are drawn, with seemingly the majority of educators, government regulators, and the general public convinced that the logic of simulators is undeniable, and that enough data from fields outside of surgery exist to justify the wide adoption of simulators in surgical training.
Given the trajectory of modern medicine, it seems that more rather than less technology is likely to be the answer – or at least the answer most acceptable to device-driven societies such as the United States and Western Europe, where these approaches are being pioneered. Hence, the continued use and expansion of simulation in surgical training seem inevitable.
Dr. Lumsden reported that he had no conflicts of interest other than working at the DeBakey Institute, where simulation training was of great importance. Dr. Zevin, Dr. Eidt, Dr. Makaroun, and Dr. Pandey reported no relevant disclosures. Dr. Wolfe reported receiving funding from Limbs & Things.
