Training cardiothoracic surgeons of the future: The UK experience

The Boot Camp Model in Urology: Preparing PGY1 Urology Interns for Practice

PURPOSE OF REVIEW

The purpose of this review is to highlight literature regarding resident boot camps published across surgical specialties with a focus on urology. Herein, we discuss different boot camp iterations, their results, and the integration of simulation into their curriculum. We review program elements such as curriculum, course length, and efficacy as well as areas for continued investigation.

RECENT FINDINGS

The field of urology has grown in both the breadth of knowledge and the complexity of procedures. With urology now being an integrated surgical subspecialty, interns often start on the urology service despite limited experience navigating this unique specialty. The boot camp model is one method by which interns and junior residents participate in consolidated training programs to best prepare them for a patient-facing role and the day-to-day demands of residency. Urology programs, both in the USA and abroad, have begun integrating boot camps into their training programs with positive results. Urology boot camps can be a valuable part of training programs for interns to quickly establish medical knowledge, skills, and efficiency. Boot camps should be easily accessible, have sufficient support from institutions, and provide effective training through various methods such as didactics and simulation.

Simulation-based training in cardiac surgery: a systematic review

OBJECTIVES

The increase in the complexity of operations, the rising quest for improved outcomes and the scrutiny of surgical practice and its associated complications have led to a decreased educational value of in-patient surgical training within cardiac surgery. Simulation-based training has emerged as an adjunct to the apprenticeship model. In the following review, we aimed to evaluate the currently available evidence regarding simulation-based training in cardiac surgery.

METHODS

A systematic database search was conducted as per PRISMA guidelines, of original articles that explored the use of simulation-based training in adult cardiac surgery programs in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to 2022. Data extraction covered the study characteristics, simulation modality, main methodology and main outcomes.

RESULTS

Our search yielded 341 articles, of which 28 studies were included in this review. Three main areas of focus were identified: (i) validity testing of the models; (ii) impact on surgeons' skills; and (iii) impact on clinical practice. Fouteen studies reported animal-based models and 14 reported on non-tissue-based models covering a wide spectrum of surgical operations. The results of the included studies suggest that validity assessment is scarce within the field, being carried out for only 4 of the models. Nonetheless, all studies reported improvement in trainees' confidence, clinical knowledge and surgical skills (including accuracy, speed, dexterity) of trainees both at senior and junior levels. The direct clinical impact included initiation of minimally invasive programmes and improved board exam pass rates, and creating positive behavioural changes to minimize further cardiovascular risk.

CONCLUSIONS

Surgical simulation has been shown to provide substantial benefits to trainees. Further evidence is needed to explore its direct impact on clinical practice.

Objective psychomotor laparoscopic skills evaluation using a low-cost wearable device based on accelerometry: construct and concurrent validity study

BACKGROUND

Motion analysis of surgical maneuvers provides useful quantitative information for the objective evaluation of the surgeons. However, surgical simulation laboratories for laparoscopic training do not usually integrate devices that help quantify the level of skills of the surgeons due to their limited resources and the high costs of new technologies. The purpose of this study is to present the construct and concurrent validity of a low-cost motion tracking system, based on a wireless triaxial accelerometer, employed to objectively evaluate psychomotor skills of surgeons during laparoscopic training.

METHODS

An accelerometry system, a wireless three-axis accelerometer with appearance of wristwatch, was placed on the dominant hand of the surgeons to register the motion during the laparoscopy practice with the EndoViS simulator, which simultaneously recorded the motion of the laparoscopic needle driver. This study included the participation of 30 surgeons (6 experts, 14 intermediates and 10 novices) who performed the task of intracorporeal knot-tying suture. Using 11 motion analysis parameters (MAPs), the performance of each participant was assessed. Subsequently, the scores of the three groups of surgeons were statistically analyzed. In addition, a validity study was conducted comparing the metrics between the accelerometry-tracking system and the EndoViS hybrid simulator.

RESULTS

Construct validity was achieved for 8 of the 11 metrics examined with the accelerometry system. Concurrent validity demonstrated that there is a strong correlation between the results of the accelerometry system and the EndoViS simulator in 9 of 11 parameters, showing reliability of the accelerometry system as an objective evaluation method.

CONCLUSION

The accelerometry system was successfully validated. This method is potentially useful to complement the objective evaluation of surgeons during laparoscopic practice in training environments such as box-trainers and simulators.

Congenital Heart Surgery Skill Training Using Simulation Models: Not an Option but a Necessity

Congenital heart surgery (CHS) is technically demanding, and its training is extremely complex and challenging. Training of the surgeon's technical skills has relied on a preceptorship format in which the trainees are gradually exposed to patients in the operating room under the close tutelage of senior staff surgeons. Training in the operating room is an inefficient process and the concept of a learning curve is no longer acceptable in terms of patient outcomes. The benefits of surgical simulation in training of congenital heart surgeons are well known and appreciated. However, adequate surgical simulation models and equipment for training have been scarce until the recent development of three-dimensionally (3D) printed models. Using comprehensive 3D printing and silicone-molding techniques, realistic simulation training models for most congenital heart surgical procedures have been produced. Newly developed silicone-molded models allow efficient CHS training in a stress-free environment with instantaneous feedback from the proctors and avoids risk to patients. The time has arrived when all congenital heart surgeons should consider surgical simulation training before progressing to real-life operating in a similar fashion to the aviation industry where all pilots are required to complete simulation training before flying a real aircraft. It is argued here that simulation training is not an option anymore but should be a mandatory component of CHS training.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

The use of objective assessments in the evaluation of technical skills in cardiothoracic surgery: a systematic review

OBJECTIVES

With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula.

METHODS

Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity.

CONCLUSIONS

Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.

Higher Speciality Training Boot Camp in Otolaryngology: A Quantitative and Qualitative Analysis of the Northern National Formative Specialty Training 3 Induction Course

Background Opportunities for new otolaryngology trainees to develop their skills as they embark on specialty training can be limited. Our facility hosted a national simulation-based boot camp for new otolaryngology trainees in the UK. This study aimed to assess the effectiveness of the boot camp in improving trainee confidence as they transitioned from core surgical training (CST) to higher specialty training (HST) in otolaryngology. Methodology We conducted a prospective study on the effectiveness of the boot camp on trainee induction. The boot camp included hands-on simulation, small group teaching and didactic lectures addressing technical skills in the fields of otology, laryngology, rhinology, facial plastics, and paediatrics, as well as non-technical skills involving human factors, simulated ward round, and cognitive simulation. The boot camp curriculum reflected the competencies expected by the Joint Committee of Surgical Training (JCST) at this level of training. Participants completed a pre- and post-course questionnaire addressing their self-confidence for the technical and non-technical skills they developed during the boot camp. All participants were invited to participate in an interview 12 months after the boot camp. Results A total of 27 new otolaryngology trainees (approximately half of all new otolaryngology trainees in the UK) participated in the boot camp. A significant increase in median confidence was observed for all technical and non-technical stations (p < 0.0001). The increase in confidence observed was similar for participants regardless of prior experience in otolaryngology. Five candidates were interviewed a year after the boot camp. Analysis of the transcripts generated distinct comments that were grouped into five key themes. Conclusions A simulation-based boot camp mapped to the JCST curriculum can increase the confidence of new otolaryngology Specialty Training 3 trainees during their transition from CST to HST. It can provide valuable and durable technical and non-technical skills to aid trainees in the clinic, theatre environment, and when on-call during their inaugural year of training.

Recommendations for the use of coronary and valve simulators in cardiac surgical training: a systematic review

OBJECTIVES

The aim of this study was to systematically review the simulators that are currently available for coronary artery bypass graft and valve surgery and, in addition, to review the validation evidence supporting them and to recommend several simulators for training based on the analysis of results.

METHODS

A systematic literature search of the MEDLINE® (1946 to May 2021) and EMBASE® (1947 to May 2021) databases was performed to identify simulators for coronary artery and valvular procedures in cardiothoracic surgery. A selection of keywords and MeSH terms was used to execute the literature search. After identification of relevant articles, data were extracted and analysed.

RESULTS

Thirty-seven simulators were found in 31 articles. Simulators were found for coronary artery bypass graft (n = 24) and valve surgery (n = 13). The majority of models were either benchtop (n = 28) or hybrid (n = 8) modalities. Evidence of validity was demonstrated in 15 (40.5%) simulators. Twenty-two (59.5%) simulators had no validation evidence, and 1 (2.7%) simulator had 3 or more elements of validity established.

CONCLUSIONS

Two simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills' development whereas high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilized in early training, at which point the learning curve of trainees is steepest.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training

Objective

To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency.

Design

Prospective evaluation.

Setting

Simulation Center.

Patients

Forty REI fellows.

Interventions

Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice.

Main Outcome Measures

Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency.

Results

Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03).

Conclusions

An intensive surgical boot camp enhances surgical skill among REI fellows.

Cardiothoracic surgery training in South Korea: Challenges and new hopes

In this era when multiple challenges are surrounding the cardiothoracic surgery specialty, including an increase in procedural complexity and institutionalization of public reporting, it is rather paradoxical to have an unprecedentedly unfavorable condition for quality education while the level of proficiency and competency to be achieved during the course of training became more demanding. Cardiothoracic surgery in South Korea is also facing several challenges across multiple levels that includes a persistent low filling rate of residency positions, severe therapeutic deviation toward percutaneous transcatheter intervention in coronary artery disease, a social climate reluctant to cardiovascular surgery and consequent underestimation of surgical volume, and skewed health insurance reimbursement system. Meanwhile, some hopeful signs have been observed in our specialty because of ongoing efforts of our leaderships of the Society, including recent financial initiative and several educational platforms such as boot camp. We introduce our system internationally to share our experience for the purpose of promoting further discussions and encouraging persistent efforts toward education.

Simulation-based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part-task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three-dimensional printing and computer-based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.

Is live-tissue training ethically justified? An evidence-based ethical analysis

Trauma training is a crucial element of medical education in the civilian sector, as well as in the military sector. Its aim is to prepare physicians, medics and nurses for stressful and demanding emergency situations. Training methods include live-tissue training (LTT) on animal models and simulation-based trauma education. For LTT, blast, gunshot or stab wounds are inflicted on anaesthetised animals, mostly goats and pigs, but sometimes non-human primates. This training method raises ethical concerns, especially in the light of increasingly sophisticated simulation-based methods. Despite these non-animal alternatives, LTT is still widely used due to its presumed educational benefits. In this paper, the question of whether LTT can still be justified, is discussed. We developed a normative framework based on the premise that LTT can only be ethically justified when it yields indispensable benefits, and when these benefits outweigh those of alternative training methods. A close examination of the evidence base for the presumed advantages of LTT showed that it is not superior to simulation-based methods in terms of educational benefit. Since credible alternatives that do not cause harm to animals are available, we conclude that LTT on animal models is ethically unjustified.