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DUCATION

o the point: medical education reviewf the role of simulators in surgical trainingaya M. Hammoud, MD; Francis S. Nuthalapaty, MD; Alice R. Goepfert, MD; Petra M. Casey, MD; Sandra Emmons, MD;

ve L. Espey, MD; Joseph M. Kaczmarczyk, DO, MPH; Nadine T. Katz, MD; James J. Neutens, PhD; Edward G. Peskin, MD;

or the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee

nt

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n this article, the seventh in the ongo-ing To the Point series produced by

he Association of Professors of Gyne-ology and Obstetrics Undergraduate

edical Education Committee, we re-iew the different types of surgical simu-ators that are available currently andummarize the key concepts that are

rom the Department of Obstetrics andynecology, Weill Cornell Medical College

n Qatar, Doha, Qatar (Dr Hammoud);epartment of Obstetrics and Gynecology,reenville Hospital System, Universityedical Center, Greenville, SC (Druthalapaty); Department of Obstetrics andynecology, University of Alabama atirmingham, Birmingham, AL (Droepfert); Department of Obstetrics andynecology, Mayo Medical School,ochester, MN (Dr Casey); Departmentbstetrics and Gynecology, Oregon Health

nd Sciences University, Portland, OR (Drmmons); Department of Obstetrics andynecology, University of New Mexico,lbuquerque, NM (Dr Espey); Departmentf Obstetrics and Gynecology, Uniformedervices University, Bethesda, MD (Draczmarczyk); Department of Obstetricsnd Gynecology and Women’s Health,lbert Einstein College of Medicine, Bronx,Y (Dr Katz); Department of Obstetrics andynecology, University ofennessee–Knoxville, Knoxville, TN (Dreutens); Department of Obstetrics andynecology, University of Massachusetts,orcester, MA (Dr Peskin).

eceived Dec. 31, 2007; accepted May 14,008

eprints not available from the authors.

he views expressed in this article are those ofhe authors and do not reflect the official policyr position of the Department of Defense, theepartment of Health and Human Services, or

he US government.

002-9378/$34.002008 Mosby, Inc. All rights reserved.

moi: 10.1016/j.ajog.2008.05.002

eeded to use surgical simulators effec-ively for teaching and assessment.

The goal of surgical simulator-basedraining (SBT) is to help trainees acquirend refine the cognitive and technicalkills that are necessary to perform bothimple and complex surgical procedures.imilar to applications in the militarynd in the airline industry, surgical SBTan be used to train and evaluate therainee in complex decision-making, inime-sensitive and rare scenarios, and inkilled tasks. An excellent review of theistory, rationale, and potential for SBT

aboratories in obstetrics and gynecologyas published by Macedonia et al in003.1 These authors focused mainly onraining in obstetrics and described theirurriculum at the Uniformed Servicesniversity of the Health Sciences that in-

luded SBT in procedures such as spon-aneous vaginal delivery, perineal lacera-ion repair, assisted vaginal breechelivery, and low forceps delivery.With ongoing advances in surgical

echniques, the content of surgical train-ng in obstetrics and gynecology is be-oming increasingly complex. For exam-le, as compared with laparotomy,

Simulation-based training (SBT) is becomresidents and medical students develop gopatients. SBT seems ideal because it provifor practice with immediate feedback and caHowever, various forms of SBT and assevidence-based data to support their validwith high-tech simulators is more sophissuperior to SBT with low-tech (and lower ctypes of surgical simulators and appropriteaching and assessment modality is appliekey concepts that are needed to use surassessment.

Key words: assessment, medical educatio

inimally invasive laparoscopic surgery s

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equires the trainee to develop spatial re-ationship skills and associated psy-homotor skills to be able to manipulateurgical instruments in a 3-dimensionalperative field while looking at a 2-di-ensional video screen. Therefore, ef-

ective training in obstetrics and gyne-ology requires skills acquisition in basicnd complex surgical techniques and ob-tetric procedures. All of these skills po-entially can be taught and assessed withBT.

ypes of surgical simulatorshere are many types of simulators thatre available for surgical skills training.imulators can be broken down into 2ifferent groups: high fidelity and low fi-elity. These models vary widely with re-pect to their level of fidelity or realism,s compared with a living human pa-ient. The fidelity of a simulator is deter-

ined by the extent to which it providesealism through characteristics such asisual cues, tactile features, feedback ca-abilities, and interaction with therainee.

High-fidelity simulators use very real-stic materials and equipment to repre-

widely used in medical education to helpechnical skills before they practice on reala nonthreatening controlled environment

nclude objective performance assessment.ment often are being used with limitedand reliability. In addition, although SBTted and attractive, this is not necessarily) simulators. Therefore, understanding theapplications can help to ensure that thisost effectively. This article summarizes thel simulators effectively for teaching and

imulator, training

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orm. High-fidelity simulators provide therainee with additional real-life cues to im-

erse them in a more realistic interactivecenario and environment. Trainees arehallenged to apply correct interventionsr maneuvers to complete a surgical pro-edure successfully. Low-fidelity simula-ors use materials and equipment that areess similar to what is used in the true sur-ical environment. They typically serve toractice isolated procedures such as knotying or intravenous line insertion, instru-

ent handling, and hand-eye coordina-ion used in laparoscopy.

A variety of intermediate level simula-

TABLE 1Advantages and disadvantages ofType ofsimulator Description

Low Fidelity..........................................................................................................

BenchModels

Static Models such as kntying and tissue modelspracticing dissection andsuturing.

..........................................................................................................

Video BoxTrainers

Box with slits on theanterior surface for trocainsertion. Uses realsurgical instrumentsincluding camera andvideo screens.

...................................................................................................................

High Fidelity..........................................................................................................

VirtualRealitySimulators

System which providescomputer simulatedenvironment to practicesurgical skills. Consistsusually of a laparoscopicinstruments and a desktocomputer.

..........................................................................................................

ProceduralSimulators

Virtual reality simulatorswhich allow the learner tlearn the entire procedur

..........................................................................................................

AnimalModels

Live animals

Hammoud. To the point: role of simulators in surgical tra

ors are provided between the 2 ex- n

American Journal of Obstetrics & Gynecology MO

remes. Although high-fidelity simula-ors are more attractive to trainees, theyre more expensive and may not be op-imal for teaching more than basic skills.

e present more detailed descriptions ofome low- and high-fidelity surgical sim-lators and their uses, advantages, andisadvantages (Table 1).

ow-fidelity simulatorsench models. These simulators includeny models that are static. There is a wideariety of models that are available forraining of the medical student or theurgical resident. These include but are

- and high-fidelity surgical simulatoMethod ofmeasurement Advantage

.........................................................................................................................

Direct observation ● Inexpensi● Easily acc

made● Easly por

.........................................................................................................................

Direct observation ● Use real sinstrumenequipmen

● Provide etraining fbecausefeedback

● Moderate.........................................................................................................................

.........................................................................................................................

Performance measuredobjectively and dataare stored, so thelearner can monitorhis/her own progress.The learner also canset the level ofdifficulty.

● Objective● Learner c

his/her ow

.........................................................................................................................

● Helps witsurgical sacquisitio

● Enhancesand recoganatomytemporalthe proce

.........................................................................................................................

Direct observation ● Real prac

. Am J Obstet Gynecol 2008.

ot limited to knot tying trainers, tissue t

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odels for practicing dissection and su-uring, abdominal opening and closurerainers, episiotomy repair trainer, analphincter repair trainer, and urethralling procedure trainer.

These models can be purchased di-ectly from a commercial manufac-urer2,3; some can be made. Examples arevailable as outlined in the CREOGCouncil on Resident Education in Ob-tetrics and Gynecology) surgicalurriculum.4

ideo box trainers. These simulators useeal surgical instruments and equipment

Disatvantages

..................................................................................................................

ible or

e

● No feedback to thetrainee from the model

● Need direct observationfor assessment

..................................................................................................................

icaland

llentproscopy

ensory

expensive

● Limited feedback● Requires direct

observation for fullassessment

..................................................................................................................

..................................................................................................................

essmentpractice atpace

● Primarily visualexperience, few providetactile information

● Expensive

..................................................................................................................

sic

owledgeion oftheuence ofe..................................................................................................................

● Availability● High costs● Infection concerns● Moral and ethical

concerns

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ors to simulate various laparoscopicurgical skills and techniques. Box train-rs typically have slits on the anteriorurface for trocar insertions. The portolders are at waist level and are capablef accepting a camera and 2 instruments.he video output is visible on an operat-

ng room preview system monitor. Boxrainers are an excellent mechanism torain for eye-hand coordination, cameraandling, suturing techniques, graspingechanisms, point-to-point movement

lip applying, and cutting. Many drillsave been developed for use with theserainers that involve movement and co-rdination exercises with small objects.uturing skills can also be practiced withtandard sutures and needles. Perhaps 1f the most important attributes of theox trainer is the sensory feedback that itrovides to the trainee in terms of the feelf the instruments on the tissue surfacesnd the pressure of opening and closinghe instruments.

Low-fidelity synthetic bench andideo box models sacrifice realism forortability, lower costs, and the potential

or repetitive use. However, it is impor-ant to note that intensive training thatses bench and video box trainers can

mprove not only technical skills but alsoranslates into improved operativeerformance.5,6

igh-fidelity simulatorsirtual-reality simulators. The virtual-

eality surgical simulators are the latestnd most promising development inurgical simulation, especially in regardso laparoscopic simulations. Virtual re-lity is a technology that allows a user tonteract with a computer-simulated en-ironment, be it real or imagined. Mosturrent virtual-reality environments arerimarily visual experiences that are dis-layed either on a computer screen orhrough special stereoscopic displays.aptic systems are those that incorpo-

ate tactile information; generally, this isn the form of force feedback.

Virtual-reality surgical simulators in-orporate a number of unique featureshat enable them to provide a more be-ievable practice environment and moreocused assessment than low-fidelity box

rainers. These simulators record and l

ave objective data on individual perfor-ance on specific tasks, such as time

aken to complete the task, economy ofhe hand motion, dexterity, and instru-

ent path lengths. These data can besed by the educator to monitor therogress of the trainee or the data can besed by the trainee to monitor his or herwn progress while practicing indepen-ently. In addition, the trainee can sethe level of difficulty and move from 1evel to the next.

One of the most commonly used vir-ual-reality simulators is the LapSim sys-em.7 This simulator, which consists ofaparoscopic instruments and a desktopomputer, focuses on basic laparoscopickills. The system has numerous mod-les that simulate tasks in the abdominalavity, such as camera navigation, in-trument navigation, coordination,rasping, cutting, clip applying, and su-uring. Recent enhancements includeomplex diathermy and bowel manipu-ation. The simulator records data on-10 parameters per task that includeiming and tissue damage. Performancen the LapSim has been shown to distin-uish between novice and expert skillevels.8 In addition, basic skills that arechieved by systematic training with aaparoscopic simulator such as LapSiman be transferred to the operatingoom.9

rocedural simulators. Procedural simu-ators are virtual-reality simulators thatllow the trainee to perform an entirerocedure and not just its componentarts. Some of the available proceduralimulators include gastrointestinal en-oscopy, cholecystectomy, and ectopicregnancy. The advantage of this type ofimulator is that, in addition to aidingasic surgical skill acquisition, they alsonhance knowledge and recognition ofnatomy and the temporal sequence ofhe procedure. This combination oftructured cognitive and manual skillspplication potentially transfers to theperating room.10

nimal models. Live animal surgery mod-ls have been popular for many years as aethod of teaching, developing, and refin-

ng surgical techniques in both open and

aparoscopic approaches.11,12 They are g

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ost desirable when a trainer is teachingomplex laparoscopic techniques that areot best taught on patients for the first

ime.13 Although these models are consid-red to be of high fidelity, they are limitedy availability, high costs, potential forransmission of infectious disease, and

oral and ethical concerns.

imulator use for traininghe breadth of current simulator op-

ions presents educators with the chal-enge of deciding how to apply this tech-ology to achieve the most effectiveimulation-based learning opportuni-ies. The first step in the evaluation of anyBT is defining the capabilities of theimulator. The availability of surgicalimulators builds on the long-standingenet that basic surgical skills, such asnot tying and suturing, should be ac-uired outside the operating room. Sim-lators, however, have introduced theotential to dissect even the most com-lex procedure into its component partsnd provide opportunities for task-spe-ific practice. Ericsson14 acknowledgedhat the primary goal of practice is to im-rove some specific aspect of perfor-ance and that it should not be assumed

hat this training is transferable to a clin-cal context or the operating room.

The next step in the evaluation of SBTs defining the relationship between theimulator and the actual simulation. Aecent systematic review of surgical sim-lation evaluated 30 randomized con-

rolled trials that were published beforepril 2005.15 Included trials were those

hat assessed any training technique withurgical simulators vs no simulatorraining and standard training and thateported measures of surgical task per-ormance. The simulators that were usedn the included studies were similar tohose previously described. Although theuality of the randomized controlled tri-ls that were included in the review wasoted to be generally poor, the authorsoncluded that none of the methods ofBT has yet been shown to be superior tother forms of surgical training. In gen-ral, SBT was superior to no training.

In an accompanying editorial, facultyembers from the Departments of Sur-

ery and Anesthesia at Stanford Univer-

merican Journal of Obstetrics & Gynecology 3

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ity School of Medicine cautioned edu-ators and investigators to considerarefully the research questions when as-essing outcomes of SBT.16 They asserthat currently available surgical simula-ors are “tools that aim to train an iso-ated technical skill or set of skills.” Onhe other hand, simulation is a “set ofechniques for re-creating aspects of theeal world, typically to replace or amplifyctual experiences”. In essence, surgicalimulators are only as effective as theimulation scenario in which they aresed and how they are incorporated into

he medical curriculum for residents andtudents. Simulation and simulatorshould be seen to be complementaryools that accelerate the learning curvend that enhance the real-world patientncounters that remain the “cornerstonef medical education.”In this context, once a commitment

o SBT is made, educators should con-ider 4 criteria when designing, imple-

enting, evaluating, or purchasingimulation-based training programsor procedural skills (as described byneebone17):

1. Simulations should allow for sus-tained, deliberate practice within asafe environment, ensuring that re-cently acquired skills are consoli-dated within a defined curriculumthat assures regular reinforcement.

2. Simulations should provide access

TABLE 2Advantages and disadvantages ofAssessment Tool

Clinical evaluation by directobservation in the operating room

...................................................................................................................

Recording number of procedures

...................................................................................................................

Virtual simulators

...................................................................................................................

Objective Structured Assessmentof Technical Skills (OSATS)

Hammoud. To the point: role of simulators in surgical tra

to expert tutors when appropriate, t

American Journal of Obstetrics & Gynecology MO

assuring that such support fadeswhen no longer needed.

3. Simulations should map to real-lifeclinical experience, ensuring thatlearning supports the experiencethat is gained within communitiesof actual practice.

4. Simulation-based learning envi-ronments should provide a sup-portive, motivational, and trainee-centered milieu that is constructiveto learning.

he last 2 of these 4 criteria are especiallymportant and worthy of emphasis. Ac-ual clinical practice encompasses multi-le competencies, which is a point thatay be neglected when surgical simula-

ion exercises focus too narrowly on apecific surgical task. Therefore, whenossible, simulation exercises should in-orporate components such as commu-ication and teamwork.

sing simulators for assessmentny tool that is used for assessment of

urgical skills must be both reliable andalid. Reliability refers to the ability of aest to generate the same results if re-eated at multiple points in time. Valid-

ty refers to the ability of a test to measurehat it was designed to measure. Fur-

hermore, construct validity refers tohether the test can differentiate be-

ween different levels of experience in aarticular factor (eg, whether a simula-

ious assessment methods of surgicavantages

ssess performance of technical skillsn real patients

.........................................................................................................................

asy to recordsed for accreditation purposesvaluated by applicants whenonsidering a residency program

.........................................................................................................................

rovide a reliable and valid method ofask specific skills assessment

.........................................................................................................................

ses checklists specific to the operationr task and a global rating scalerovides a reliable and valid method ofssessment. Am J Obstet Gynecol 2008.

or can differentiate between a novice S

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nd an expert level). The traditionalethod for surgical assessment has been

uantification of procedural volume. Al-hough procedural volume is consideredn important benchmark for residencyccreditation and is a key characteristichat is evaluated by applicants who con-ider programs for training, this methodacks both reliability and validity as a

easure of surgical competency. In con-rast, simulators have the potential torovide a reliable and valid method ofask-specific skills assessment when usedn combination with Objective Struc-ured Assessment of Technical SkillsOSATS).

OSATS was introduced by Martin et aln 1997.18 This assessment tool is com-osed of several stations at which train-es perform procedures on simulators inxed time periods. Task performance isssessed with checklists that are specifico the operation or task and a global rat-ng scale. Martin et al showed that thisormat is a reliable and valid method forhe assessment of surgical skills and thatench model simulation gives equivalentesults to the use of live animals for thisest format. It appears that the task-spe-ific checklists add little value to the as-essment process above that obtainedrom global rating scales.19 These find-ngs were confirmed in obstetric and gy-ecology resident training by investiga-

ors at the University of Washington in

killsDisadvantages

● Questionable reliability and validity as it issurgeon dependent and not based onspecific checklists

..................................................................................................................

● Lacks validity and reliability

..................................................................................................................

● Expensive tool● Transferability to the operating room not

fully understood..................................................................................................................

● Requires significant investment of facutlyresources to administer

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www.AJOG.org Education ReviewARTICLE IN PRESS

urgical laboratory curriculum usingoth inanimate and animal (porcine)odels. The surgical skills that were

valuated by OSATS significantly im-roved over time both individually ands a cohort by resident year.20 Thesendings suggest that simulators areest used for assessment when they cane incorporated into an objectivetructured clinical examination andre used to assess individual perfor-ance and progress over time.Unlike low-fidelity simulators com-

ined with OSATS that require a signifi-ant investment of faculty resources todminister, virtual-reality simulatorsan provide automatic “objective” as-essment by recording metrics. A num-er of investigations regarding the reli-bility and validity of virtual-realityimulators for the assessment of surgicalkills have confirmed that both the Lap-imGyn VR and the minimally invasiveurgical trainer–virtual reality systemsonfirm that these simulators provide andequate means of psychomotor skillsssessment for various laparoscopic pro-edures.21-24 It remains to be deter-ined, however, whether performance

n these trainers translates into im-roved surgical competency in the oper-ting room. Thus far, 2 randomized con-rolled trials have demonstrated theenefits of using the minimally invasiveurgical trainer–virtual reality for train-ng for a laparoscopic cholecystec-omy.25,26 Therefore, it appears that sim-lators can play a well-defined role inurgical assessment and can be a usefuldjunct to the global performance as-essment that happens during the con-uct of real procedures in the operatingoom. Table 2 presents a summary of theools that are available for assessment ofurgical skills with advantages and disad-antages of each, along with a compari-on to the traditional method that is usedor the assessment of competence, forlinical evaluation by direct observationn the operating room, and for recordinghe number of surgical procedures thatre performed.

The critical question for contempo-ary surgical educators to consider ishether the apprenticeship model for

urgical skills training is still adequate for a

raining competent surgeons in today’snvironment. Educational technology inhe form of low- and high-fidelity surgi-al simulators provides an opportunityo supplement and even enhance surgi-al teaching and learning. This article hasrovided a summary of the key conceptshat are needed to utilize surgical simu-ators effectively for teaching and assess-

ent. However, simply providing accesso simulators is no guarantee that theyill be used effectively for either trainingr assessment. Such interventions muste developed with a stepwise approach.ne such approach is the ADDIE frame-ork27: analyze (analyze relevant trainee

haracteristics and tasks to be learned),esign (define objectives and outcomes;elect an instructional approach), de-elop (create the instructional materi-ls), implement (deliver the instruc-ional materials), evaluate (ensure thathe instruction achieved the desiredoal).A recent qualitative systematic review

ummarized the 10 features that character-ze effective, high-fidelity medical simula-ion.28 Key among these features is the in-egration of the simulation into theroader educational program rather thanffering it as an extraordinary activity. Ad-itionally, it is important to keep in mindhat there is no proven positive relation-hip between simulator fidelity and its ef-ectiveness and that lower levels of fidelity

ay reduce costs without compromisingutcomes.29 Finally, a more robust assess-ent program for surgical skills poten-

ially can be achieved with a combinationf OSATS, performance assessments fromirtual-reality simulators, and global rat-ng scales from observation of a trainee op-rating on a real patient. f

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