Perceptions About the Present and Future of Surgical Simulation: A National Study of Mixed Qualitative and Quantitative Methodology

Impact of the COVID-19 Pandemic on Surgical Education and Training: A Resident Survey in a Developing Country

Background The COVID-19 pandemic has adversely affected medical education and training programs worldwide. Early investigations have shown that surgical residents face a lot of challenges in these unprecedented times. This study aims to assess the impact of the COVID-19 pandemic on surgical education and training in a developing country. Methods This cross-sectional study was conducted in Allied Hospitals of Rawalpindi Medical University, Rawalpindi, Pakistan from June 2021 to July 2021. A structured questionnaire designed by the researchers was distributed to all surgery departments, and surgical residents who consented to participate in this study were included. Results A total of 152 residents participated in this study, of which 53 (34.9%) were in general surgery and 99 (65.1%) in various surgical allied specialties. Of the residents, 14.5% reported full transfer from the parent unit to the COVID-19 unit. An increase in emergency surgical procedures was reported by 52.8% of general surgery residents as compared to surgical allied specialties (P = 0.037). Of the residents, 90.1% reported increased stress and anxiety levels, with the number of allied residents significantly higher than general surgery residents (P = 0.031). A total of 125 (82.2%) respondents claimed that fear of contracting the virus affected proper patient evaluation. Conclusion The COVID-19 pandemic has severely impacted the training and psychological well-being of surgical residents.

Perspectives on simulation-based assessment of operative skill in surgical training

INTRODUCTION

The perspectives of the wider surgical community toward simulation-based assessment (SBA) in training is a gap in the literature. This study aims to explore the factors associated with the acceptable use of SBA in surgical training, through the perceptions and experiences of a broad range of stakeholder representatives, building on findings from a review of the published literature.

MATERIALS AND METHODS

Ten semi-structured interviews were conducted, using a sequential transformative qualitative methods approach, with representatives from identified key stakeholder groups; executive management, risk management, a practicing surgeon, an anaesthesiologist, a theatre-nursing representative, a representative from simulation industry, a patient, a medical student, a junior surgical trainee, and a senior surgical trainee. Interview transcripts underwent reflexive thematic analysis using an inductive and constructivist framework (NVIVO software, NVIVO 12, QSR International).

RESULTS

Four themes emerged: the 'need' for SBA, the concept of a 'minimum standard', the 'optimum design' of an SBA framework, and 'fairness'. SBA is a potential solution to challenges in the current training environment. It emerged that it should not replace trainer judgement, but could ensure that trainees meet a minimum operative competency standard. SBA should be used to identify underperforming trainees early in training to provide targeted remediation. The application of SBA in high-stakes settings such as trainee selection, autonomy granting, and end-of training certification has perceived benefits over current assessment methods.

CONCLUSIONS

This study builds on findings from prior research to explore factors regarding the acceptable use of simulation as an assessment method in surgical training, including perspectives from a broad range of stakeholder representatives. Findings can inform the development of simulation-based assessment curricula in surgical training.

Modified Larssen solution (MLS)-fixed cadaver model for transoral endoscopic thyroidectomy vestibular approach (TOETVA) education: a feasibility study

BACKGROUND

Training formats for transoral endoscopic thyroidectomy vestibular approach (TOETVA) are limited. Our aim was to create and investigate a TOETVA training model for general and ENT surgeons.

METHODS

A total of 15 modified Larssen solution (MLS) human cadavers were used in the study. A day duration TOETVA human cadaver workshops were offered in two years consecutive. Post-training verbal and online questionnaires were applied to all trainers to evaluate course structure and program, organoleptic characteristics of MLS-fixed human cadavers, and TOETVA training effectiveness. Cost assessment is included in the study.

RESULTS

Ninety-eight participants, i.e., 14 trainers and 84 hands-on (HO) and observer (OB) trainees, attended the workshops, completed the tasks assigned, and fulfilled the questionnaires. Implementation of all steps of TOETVA was approved positively by 89.8% of all participants, 94.4% of HO, and 83.3% of OB trainees. Regarding human cadaver and teaching quality, 10.8 ± 0.8 (10-12) human cadavers were "practical" by 13.2 (94.5%) of the trainers, and by 33.3 (92.5%) of the trainees for all steps of TOETVA. The cadavers were stored for 4.53 years and used 6.27 times repeatedly for endoscopic workshops and research studies. TOETVA workshop cost with repeatable use of MLS-fixed human cadaver is half of other performed TOETVA workshops.

CONCLUSIONS

A TOETVA human cadaver workshop model has not been reported yet. Our findings suggest the feasibility of MLS-fixed human cadaver model for training of TOETVA, preserve the organoleptic properties necessary for the implementation of surgical steps, and reduce the cost.

The Impact of COVID-19 on Surgical Training: the Past, the Present and the Future

The COVID-19 pandemic and infection control measures had an unavoidable impact on surgical services. During the first wave of the pandemic, elective surgery, endoscopy, and 'face-to-face' clinics were discontinued after recommendations from professional bodies. In addition, training courses, examinations, conferences, and training rotations were postponed or cancelled. Inadvertently, infection control and prevention measures, both within and outside hospitals, have caused a significant negative impact on training. At the same time, they have given space to new technologies, like telemedicine and platforms for webinars, to blossom. While the recovery phase is well underway in some parts of the world, most surgical services are not operating at full capacity. Unfortunately, some countries are still battling a second or third wave of the pandemic with severely negative consequences on surgical services. Several studies have looked into the impact of COVID-19 on surgical training. Here, an objective overview of studies from different parts of the world is presented. Also, evidence-based solutions are suggested for future surgical training interventions.

Surgical Simulation in East, Central, and Southern Africa: A Multinational Survey

BACKGROUND

High-income countries have increased the use of simulation-based training and assessment for surgical education. Learners in low- and middle-income countries may have different educational needs and levels of autonomy but they and their patients could equally benefit from the procedural training simulation provides. We sought to characterize the current state of surgical skills simulation in East, Central, and Southern Africa and determine residents' perception and future interest in such activities.

METHODS

A survey was created via collaboration and revision between trainees and educators with experiences spanning high-income countries and low- and middle-income countries. The survey was administered on paper to 76 trainees (PGY2-3) who were completing the College of Surgeons of East, Central, and Southern Africa (COSECSA) Membership of the College of Surgeons examination in Kampala, Uganda in December 2019. Data from paper responses were summarized using descriptive statistics and frequencies.

RESULTS

We received responses from 43 trainees (57%) from 11 countries in sub-Saharan Africa who participated in the examination. Fifty-eight percent of respondents reported having dedicated space for surgical skills simulation training, and most (91%) had participated in some form of simulation activity at some point in their training. However, just 16% used simulation as a regular part of training. The majority of trainees (90%) felt that surgical skills learned in simulation were transferrable to the operating room and agreed it should be a required part of training. Seventy-one percent of trainees felt that simulation could objectively measure technical skills, and 73% percent of respondents agreed that simulation should be integrated into formal assessment. However, residents split on whether proficiency in simulation should be achieved prior to operative experience (54%) and if nontechnical skills could be measured (51%). The most common cited barriers to the integration of surgical simulation into residents' education were lack of suitable tools and models (85%), funding (73%), and maintenance of facilities (49%).

CONCLUSIONS

Residents from East, Central, and Southern Africa strongly agree that simulation is a valuable educational tool and ought to be required during their surgical residency. Barriers to achieving this goal include availability of affordable tools, adequate funding and confidence in the value of the educational experience. Trainees affirm further efforts are necessary to make simulation more widely available in these contexts.

Beef Tongue Surgical Simulation Model for Posterior Vaginal Repair

BACKGROUND

This surgical simulation model for vaginal posterior repair is designed to enhance vaginal surgical training.

METHODS

A beef tongue simulation model was previously described and validated to practice the repair of obstetric laceration. The model was modified for surgical simulation of vaginal posterior repair. Chicken skin was used to simulate the anal canal. The model was secured in a PVC (polyvinyl chloride) pipe attached to a wooden base to simulate operating within the vaginal canal.

EXPERIENCE

Materials can be obtained from the local supermarket and hardware store. The total cost of the model is $35.47 for initial setup and $7.11 per use. Residents performing on the model felt it was realistic and useful for practicing the steps and skills for this procedure.

CONCLUSION

The beef tongue simulation model of vaginal posterior repair is realistic, easy to construct, and affordable. It can be incorporated into a vaginal surgery curriculum to augment resident surgical education.

Highly realistic cadaveric trauma simulation of the multiply injured battlefield casualty: an international, multidisciplinary exercise in far-forward surgical management

INTRODUCTION

We designed an ultra-high-fidelity military cadaveric surgical simulation course to train military medical teams for specific battlefield injuries. Our aim was to deliver a highly realistic, immersive simulation training experience, teaching both technical and non-technical skills necessary for the management of war-injuries in the austere environment of a far forward surgical facility. We designed an educational cohort study around the course to measure its learning impact.

METHODS

25 personnel participated in 15 non-continuous hours of simulation that included 12 patient scenarios. Participants were given previously piloted questionnaires pre- and post-simulation to assess their confidence with managing battlefield injuries by body area, their views on the realism of the simulation, and their perceptions of training benefit. All questions were assessed using a Likert scale of 1-10 (10=best).

RESULTS

The response rate for complete questionnaires was 95%. Baseline confidence scores were; abdomen (5.5), pelvis (5.7), chest (6.2), airway (6.3), extremity (7.3). Confidence gains following training were; abdomen (+1.7), pelvis (+ 1.6), chest (+1.6), airway (+1.2), extremity (+0.8). The most realistic aspects of the simulation were; injury replication (9.1), the cadaver as a multiply injured casualty (9.1) and the multidisciplinary team (9.2). The mean ratings for technical and non-technical skill acquisition were 9.1 and 9.0 respectively. Cadaveric simulation was reported to be ideal for learning military medical skills (9.3), and participants strongly recommended that provision should be increased (9.7).

CONCLUSION

We have demonstrated an ability to recreate highly realistic injuries in an ultra-high-fidelity simulation of a multiply injured military casualty. There was a measurable increase in confidence for both technical skills in all major body areas, and non-technical skills. Multinational and multidisciplinary working strongly enhanced learning.

Perceptions and experiences of simulation-based assessment of technical skill in surgery: A scoping review

INTRODUCTION

The introduction of simulation-based assessment raises questions as to its role in trainee selection, progression, certification and credentialing. This study sought to review and critique the available research regarding the perceptions and experiences of residents and their trainers towards simulation-based assessment of technical skills in surgery.

METHODS

A comprehensive literature review of the Medline (PubMed), Embase, Cochrane and Web of Science databases was performed in accordance with the Joanna Briggs Institute 2020 protocol for scoping reviews in July 2020, for all original research articles, abstracts and conference proceedings assessing the attitudes, perceptions, opinions and experiences of residents and surgical trainers toward simulation-based assessment of technical or operative skill.

RESULTS

A total of 1869 studies were identified on database searching. Quantitative, qualitative and mixed-methodology publications reporting the attitudes and experiences of surgical trainers and residents were identified, with 21 articles ultimately meeting the inclusion criteria for (qualitative) thematic analysis. Results were charted and categorized into broad themes: 1) Perceptions of simulation-based assessment in principle, 2) Entrustment, 3) Credentialing and certification, and 4) Resident selection and recruitment, identifying both positive perceptions and key areas of concern from residents and trainers alike regarding the current and future application of simulation-based assessment.

CONCLUSION

There is broadly positive agreement amongst residents and surgical trainers in the published literature regarding the validity of simulation-based assessment. Perceptions of the broader application and implications of simulation-based skill assessment has been identified as a gap in the literature. Future studies should aim to record comprehensive data from key stakeholders prior to implementation of a simulation-based assessment curriculum to ensure acceptability.

Training outcomes for audiology students using virtual reality or traditional training methods

Due to limited space and resources, it can be difficult to train students on audiological procedures adequately. In the present study, we compared audiology training outcomes between a traditional approach and a recently developed immersive virtual reality (VR) approach in audiology students. Twenty-nine first-year audiology students participated in the study; 14 received traditional training (“TT group”), and 15 received the VR training (“VRT group”). Pre- and post-training evaluation included a 20-item test developed by an audiology educator. Post-training satisfaction and self-confidence were evaluated using Likert scales. Mean post-training test scores improved by 6.9±9.8 percentage points in the TT group and by 21.1±7.8 points in the VRT group; the improvement in scores was significant for both groups. After completing the traditional training, the TT group was subsequently trained with the VR system, after which mean scores further improved by 7.5 points; there was no significant difference in post-VR training scores between the TT and VRT groups. After training, the TT and VRT groups completed satisfaction and self-confidence questionnaires. Satisfaction and self-confidence ratings were significantly higher for the VR training group, compared to the traditional training group. Satisfaction ratings were “good” (4 on Likert scale) for 74% of the TT group and 100% of the VRT group. Self-confidence ratings were “good” for 71% of the TT group and 92% of the VRT group. These results suggest that a VR training approach may be an effective alternative or supplement to traditional training for audiology students.

A Comparative Human-Centric Analysis of Virtual Reality and Dry Lab Training Tasks on the da Vinci Surgical Platform

There is a growing, widespread trend of adopting robot-assisted minimally invasive surgery (RMIS) in clinical care. Dry lab robot training and virtual reality simulation are commonly used to train surgical residents; however, it is unclear whether both types of training are equivalent or can be interchangeable and still achieve the same results in terms of training outcomes. In this paper, we take the first step in comparing the effects of physical and simulated surgical training tasks on human operator kinematics and physiological response to provide a richer understanding of exactly how the user interacts with the actual or simulated surgical robot. Four subjects, with expertise levels ranging from novice to expert surgeon, were recruited to perform three surgical tasks — Continuous Suture, Pick and Place, Tubes, with three repetitions — on two training platforms: (1) the da Vinci Si Skills Simulator and (2) da Vinci S robot, in a randomized order. We collected physiological response and kinematic movement data through body-worn sensors for a total of 72 individual experimental trials. A range of expertise was chosen for this experiment to wash out inherent differences based on expertise and only focus on inherent differences between the virtual reality and dry lab platforms. Our results show significant differences ([Formula: see text]-[Formula: see text]) between tasks done on the simulator and surgical robot. Specifically, robotic tasks resulted in significantly higher muscle activation and path length, and significantly lower economy of volume. The individual tasks also had significant differences in various kinematic and physiological metrics, leading to significant interaction effects between the task type and training platform. These results indicate that the presence of the robotic system may make surgical training tasks more difficult for the human operator. Thus, the potentially detrimental effects of virtual reality training alone are an important topic for future investigation.

Filling the gap between the OR and virtual simulation: a European study on a basic neurosurgical procedure

BACKGROUND

Currently available simulators are supposed to allow young neurosurgeons to hone their technical skills in a safe environment, without causing any unnecessary harm to their patients caused by their inexperience. For this training method to be largely accepted in neurosurgery, it is necessary to prove simulation efficacy by means of large-scale clinical validation studies.

METHODS

We correlated and analysed the performance at a simulator and the actual operative skills of different neurosurgeons (construct validity). We conducted a study involving 92 residents and attending neurosurgeons from different European Centres; each participant had to perform a virtual task, namely the placement of an external ventricular drain (EVD) at a neurosurgical simulator (ImmersiveTouch). The number of attempts needed to reach the ventricles and the accuracy in positioning the catheter were assessed.

RESULTS

Data suggests a positive correlation between subjects who placed more EVDs in the previous year and those who get better scores at the simulator (p = .008) (fewer attempts and better surgical accuracy). The number of attempts to reach the ventricle was also analysed; senior residents needed fewer attempts (mean = 2.26; SD = 1.11) than junior residents (mean = 3.12; SD = 1.05) (p = .007) and staff neurosurgeons (mean = 2.89, SD = 1.23). Scoring results were compared by using the Fisher's test, for the analysis of the variances, and the Student's T test. Surprisingly, having a wider surgical experience overall does not correlate with the best performance at the simulator.

CONCLUSION

The performance of an EVD placement on a simulator correlates with the density of the neurosurgical experience for that specific task performed in the OR, suggesting that simulators are able to differentiate neurosurgeons according to their surgical ability. Namely this suggests that the simulation performance reflects the surgeons' consistency in placing EVDs in the last year.

Cadaveric simulation: a review of reviews

BACKGROUND

Traditional surgical training, largely based on the Halstedian model "see one, do one, teach one" is not as effective in the era of working time restrictions and elaborate shift-patterns. As a result, contemporary surgeons turned to educational methods outside the operating theatre such as simulation. Cadavers are high fidelity models but their use has ethical and cost implications and their availability may be limited. In this review, we explore the role of cadaveric simulation in modern surgical education.

METHODS

All the Evidence-Based Medicine databases were searched for relevant reviews. The resulting studies were assessed for inclusion to this review, according to pre-determined criteria. Data extraction was performed using a custom-made spreadsheet, and the quality of included reviews was assessed using a validated scoring system (AMSTAR).

RESULTS

The literature review yielded 33 systematic reviews; five of which matched the inclusion criteria and were included in this review of reviews. Cadaveric simulation was found to have good face (subjective assessment of usefulness) and content validity (whether a specific element adds or retracts to the educational value) while trainees improved their surgical skills after practicing on cadavers. However, concerns have been raised about ethical issues, high cost and availability.

CONCLUSION

Cadavers are an effective medium for surgical teaching, and it may be appropriate for them to be used whenever surrounding conditions such cost and availability allow. Further research is required to provide evidence on whether there is equivalence between cadavers and other educational media which may not bear the same shortcomings.

"Take-home" box trainers are an effective alternative to virtual reality simulators

BACKGROUND

Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS.

METHODS

After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared.

RESULTS

The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups.

CONCLUSIONS

This study suggests that a basic "take-home" BT is a suitable alternative to VRS.