Simulation in Surgical Education: Lessons Learned from a Multi-Site Randomised Cohort Study

Abstract

Background Surgical proficiency requires expertise in both technical and non-technical (interpersonal) skills. Simulation-based education (SBE) provides a useful adjunct to traditional training methods. Studies show SBE to be effective for the development of both technical and nontechnical skills, however the best format for delivery of this training is not yet well understood. The purpose of the primary research detailed in this thesis was to determine the best format for the delivery of simulated laparoscopic skills training by investigating the efficacy and feasibility of a self-scheduled, self-directed skills course. Secondary projects utilised simulated theatre scenarios to assess the non-technical skills of surgeons to determine if level of professional surgical experience has an impact on non-technical skills, and if surgeons respond to harassment of a colleague. Methods Surgical and gynaecology trainees, junior doctors and medical students were randomised to undertake either self-directed learning (SDL) only, or a combination of supervised training in a Mobile Simulation Unit (MSU) as well as SDL. Three laparoscopic skills tasks were taught and assessed. Skills data was compared to assess the efficacy of SDL, and whether supervised training in the MSU accelerated skill acquisition. Qualitative pre- and post-course questionnaires were also conducted. In two separate studies, retrospective analyses of video-recorded simulated theatre scenarios were conducted. Firstly, the non-technical skills of surgical trainees and experienced surgeons were assessed and compared. Secondly, the participants’ response to harassment of a colleague (which was part of the scenario) was recorded and analysed, again comparing the response of trainees with that of experienced surgeons. Results A total of 207 participants enrolled, with 156 (75.4%) completing assessment requirements. The majority of participants’ skill improved, and some were able to reach expert proficiency standards in one or more tasks. In general, skills acquisition was dependent on the number of practice attempts performed, rather than where the training was undertaken. Overall efficacy of SDL was limited by poor practice session attendance. The greatest barrier to attending was lack of available time due to overriding clinical duties. Participants showed a preference for supervised training, scheduled fortnightly, after a shift. The mean scores of surgeons’ non-technical skills initially increased, peaking around the time of Fellowship, before decreasing roughly linearly over time. Harassment of a colleague was not always recognised, and the response from participants varied. The type of response depended on the nature of harassment being perpetrated and the seniority of the participant. Conclusions The efficacy of self-scheduled, self-directed laparoscopic skills training is limited by poor training attendance. To improve efficacy and feasibility of SBE, training should be conducted with a combination of supervised scheduled sessions, and SDL. Greater effort is needed by training providers to implement strategies that enable practice session attendance. Experienced surgeons are not immune to deficiencies in non-technical skills. Education and training in non-technical skills, including the recognition and management of bullying and harassment, needs to be better incorporated into the surgical training program as well as continuing professional development programs for qualified surgeons.