Identifying Technical Procedures in Orthopaedic Surgery and Traumatology That Should Be Integrated in a Simulation-Based Curriculum: A National General Needs Assessment in Denmark

Setting proficiency standards for simulation-based mastery learning of short antegrade femoral nail osteosynthesis: a multicenter study

BACKGROUND AND PURPOSE

Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with haptic feedback has been unavailable. We explored a novel simulator, with the aim of gathering validity evidence for an embedded test and setting a credible pass/fail standard allowing trainees to practice to proficiency.

PATIENTS AND METHODS

The research, conducted from May to September 2020 across 3 Danish simulation centers, utilized the Swemac TraumaVision simulator for short antegrade femoral nail osteosynthesis. The validation process adhered to Messick's framework, covering all 5 sources of validity evidence. Participants included novice groups, categorized by training to plateau (n = 14) or to mastery (n = 10), and experts (n = 9), focusing on their performance metrics and training duration.

RESULTS

The novices in the plateau group and experts had hands-on training for 77 (95% confidence interval [CI] 59-95) and 52 (CI 36-69) minutes while the plateau test score, defined as the average of the last 4 scores, was 75% (CI 65-86) and 96% (CI 94-98) respectively. The pass/fail standard was established at the average expert plateau test score of 96%. All novices in the mastery group could meet this standard and interestingly without increased hands-on training time (65 [CI 46-84] minutes).

CONCLUSION

Our study provides supporting validity evidence from all sources of Messick's framework for a simulation-based test in short antegrade nail osteosynthesis of intertrochanteric hip fracture and establishes a defensible pass/fail standard for mastery learning of SBT. Novices who practiced using mastery learning were able to reach the pre-defined pass/fail standard and outperformed novices without a set goal for external motivation.

Crisis Scenarios for Simulation-Based Nontechnical Skills Training for Cardiac Surgery Teams: A National Survey Among Cardiac Anesthesiologists, Cardiac Surgeons, Clinical Perfusionists, and Cardiac Operating Room Nurses

BACKGROUND

Nontechnical skills in cardiac surgery are vital in ensuring patient safety in the operating room (OR). To train these skills in a simulation-based scenario, a collection of commonly accepted crisis scenarios is needed to serve as a framework for a simulation-based training program.

OBJECTIVE

The objective of this study was to identify and reach consensus on a collection of relevant crisis scenarios in cardiac surgery suitable for simulation-based team training focusing on nontechnical skills.

METHODS

Using the Delphi method, a national assessment was performed among cardiac surgeons, cardiac anesthesiologists, clinical perfusionists, and cardiac OR nurses in the Netherlands. In the first Delphi round, potential crisis scenarios for simulation-based team training in cardiac surgery were identified. In the second round, the identified scenarios were rated using a 5-point Likert scale. Finally, based on consensus (two-thirds majority), scenarios were prioritized and explored for feasibility.

RESULTS

One hundred fourteen experts participated in the study (26 cardiac anesthesiologists, 24 cardiac surgeons, 25 clinical perfusionists, and 39 OR nurses), representing all 16 cardiac surgical centers in the Netherlands. In the first round, 237 scenarios were identified. After eliminating duplicates and grouping similar scenarios, 44 scenarios were scored in round 2, which finally resulted in 13 relevant crisis scenarios with an expert consensus higher than 67%.

CONCLUSIONS

Thirteen crisis scenarios relevant to simulation-based team training were identified by an expert panel consisting of all members of the cardiac surgical team. Further research is needed to evaluate the educational value of the respective scenarios.

Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study

PURPOSE

Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture.

METHODS

International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results.

RESULTS

Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters.

CONCLUSIONS

Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool.

CLINICAL RELEVANCE

This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.

A mixed methods systematic review: Does computer-based simulation (CBS) in fracture surgery leads to better knowledge, skills and competencies than traditional preparation?

Objectives

To identify original research studies comparing CBS to traditional surgical preparation for fracture surgery and to analyse and synthesise the results to support the hypothesis that CBS is better than traditional methods in preparation for fracture surgery.

Methods

Four databases 'Web of Science', 'Embase', 'Medline' and 'OrthoSearch' were searched using the terms 'orthopaedic', 'fracture', 'simulation' and 'education'. Two relevant journals, two conferences and two registries were hand searched. All searches were between Jan 2010 and April 2022. Selected articles underwent a backwards and forwards citation search. 1,285 articles were identified and screened for selection. Two reviewers independently extracted outcome data and completed a risk of bias analysis. Selected studies were included in a direction of effect synthesis and appropriate studies were included in a meta-analysis.

Results

15 studies totalling 350 participants, measuring the development of participants' knowledge, skills, and competencies, were included for direction of effect analysis. 86% (13/15) favoured CBS over traditional preparation. A meta-analysis of 4 studies, totalling 62 participants, measuring OSATS score favoured CBS, Standard Mean Difference = 1.06 (95% CI; -0.34, 2.45) (Z = 1.48)(P = 0.14).

Conclusion

Participants in this systematic review range from medical students to fellows; outcomes measure knowledge, skills and competencies and the control groups varied. Despite this heterogenicity CBS is favoured consistently, and the heterogenicity of these results means this evidence is generalisable to a wide educational context within orthopaedic fracture surgery.

Contemporary Issues in the Acquisition of Orthopaedic Surgical Skills During Residency: Competency-Based Medical Education and Simulation

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Orthopaedic education should produce surgeons who are competent to function independently and can obtain and maintain board certification.

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Contemporary orthopaedic training programs exist within a fixed 5-year time frame, which may not be a perfect match for each trainee.

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Most modern orthopaedic residencies have not yet fully adopted objective, proficiency-based, surgical skill training methods despite nearly 2 decades of evidence supporting the use of this methodology.

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Competency-based medical education backed by surgical simulation rooted in proficiency-based progression has the potential to address surgical skill acquisition challenges in orthopaedic surgery.

Development of an International Standardized Curriculum for Laparoscopic Sleeve Gastrectomy Teaching Utilizing Modified Delphi Methodology

BACKGROUND

The performance of laparoscopic sleeve gastrectomy has increased markedly to become the single-most performed bariatric surgical procedure globally. To date, a means of standardized trainee teaching has not been developed. The aim of this study was to design a laparoscopic curriculum for trainees of bariatric surgery utilizing modified Delphi consensus methodology.

METHODS

A panel of surgeons was assembled to devise an academic framework of technical, non-technical and cognitive skills utilized in the performance of laparoscopic sleeve gastrectomy. The panel invited 18 bariatric surgeons experienced in laparoscopic gastrectomy from 11 countries to rate the items for inclusion in the curriculum to a predefined level of agreement.

RESULTS

A consensus of experts was achieved for 24 of the 30 proposed elements for inclusion within the first round of the curriculum Delphi panel. All components pertaining to anatomical knowledge, peri-operative considerations and non-technical items were accepted. A second round further examined six statements, of which three were accepted. Agreement of the panel was reached for 27 of the cognitive, technical and non-technical components after two rounds. Three statements found no consensus.

CONCLUSIONS

Utilizing modified Delphi methodology, a curriculum outlining the most important components of teaching the procedure of laparoscopic sleeve gastrectomy, has been determined by a consensus of international experts in bariatric surgery. The curriculum is suggested as a standard in proficiency-based training of this procedure. It forms a generic template which facilitates individual jurisdictions to perform content validation, adapting the curriculum to local requirements in teaching the next generation of bariatric surgeons.

Identifying technical skills and clinical procedures in surgery for a simulation-based curriculum: a national general needs assessment

BACKGROUND

The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery.

METHODS

A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study.

RESULTS

Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list.

CONCLUSION

Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

Simulation Training in Fracture Surgery

The current surgical training environment has sparked a paradigm shift toward the use of surgical training simulation. An apprentice-based model has historically been used in surgical education, but current financial and practical constraints have led to a more variable training experience. Surgical simulation has demonstrated efficacy in many facets of orthopaedic training and has most recently been implemented to fine-tune surgical skill in reconstruction of traumatic skeletal injuries. Although some surgical skills learned during residency training are not fully used in later practice, most surgeons require a baseline level of competence in managing skeletal trauma. Fracture surgery is heavily dependent on technical skill. Trainee simulation use in skill acquisition has potential to improve proficiency during actual surgery. Furthermore, in a specialty where the standard axiom has been repetition matters, education augmentation with simulation provides overall benefit. Work remains to maximize the effectiveness of surgical simulation in fracture treatment through improved model integration and access.

Development and assessment of a simulation-based curriculum in pediatric surgical education: Conventional wisdom and lessons learned from the national training program in France

Traditional training in pediatric surgery has focused on knowledge acquisition and technical skills. Although recognized as important, the skills relating to communication, collaboration, leadership, management, health advocacy and professionalism have received less formal attention. Recognition of the importance of these softer skills in combination with the greater use of simulation in education prompted us to develop a national simulation-based curriculum in pediatric surgery. This paper describes the development, implementation and three-year follow-up of the mandatory, simulation-based curriculum for pediatric surgery residents in France. We review the available literature on the topic and present our results.