Original Research—General Otolaryngology

Simulation Activity in Otolaryngology Residencies Ellen S. Deutsch, MS, MD1, Gregory J. Wiet, MD2, Michael Seidman, MD3, Heather M. Hussey, MPH4, Sonya Malekzadeh, MD5, and Marvin P. Fried, MD6

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Abstract Objectives. Simulation has become a valuable tool in medical education, and several specialties accept or require simulation as a resource for resident training or assessment as well as for board certification or maintenance of certification. This study investigates current simulation resources and activities in US otolaryngology residency programs and examines interest in advancing simulation training and assessment within the specialty.

Otolaryngology– Head and Neck Surgery 2015, Vol. 153(2) 193–201 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815584598 http://otojournal.org

Keywords biological products, bronchoscopes, certification, cooperative behavior, curriculum, ear, education, medical, faculty, health care costs, health services research, humans, internship and residency, judgment, laparoscopy, manikins, operating rooms, otolaryngology, patient care, physicians, quality improvement, research, research personnel, schools, medical, simulation, simulators, temporal bone, United States, universities Received September 19, 2014; revised March 31, 2015; accepted April 8, 2015.

Study Design. Web-based survey. Setting. US otolaryngology residency training programs.

Introduction

Subjects and Methods. An electronic web-based survey was disseminated to all US otolaryngology program directors to determine their respective institutional and departmental simulation resources, existing simulation activities, and interest in further simulation initiatives. Descriptive results are reported.

Otolaryngology residency programs face many challenges as they prepare residents to become skilled, independent surgeons. The impact of work hour restrictions, resource limitations, and evolving societal expectations on educational and assessment opportunities have been the focus of much attention.1-7 Cost, infection, security, and other concerns related to training in cadaveric or animal laboratories also assert pressure to find complementary platforms for learning and practice.8 The concurrent rapid evolution of

Results. Responses were received from 43 of 104 (43%) residency programs. Simulation capabilities and resources are available in most respondents’ institutions (78.6% report onsite resources; 73.8% report availability of models, manikins, and devices). Most respondents (61%) report limited simulation activity within otolaryngology. Areas of simulation are broad, addressing technical and nontechnical skills related to clinical training (94%). Simulation is infrequently used for research, credentialing, or systems improvement. The majority of respondents (83.8%) expressed interest in participating in multicenter trials of simulation initiatives. Conclusion. Most respondents from otolaryngology residency programs have incorporated some simulation into their curriculum. Interest among program directors to participate in future multicenter trials appears high. Future research efforts in this area should aim to determine optimal simulators and simulation activities for training and assessment as well as how to best incorporate simulation into otolaryngology residency training programs.

1

Department of Anesthesiology and Critical Care Medicine, the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA 2 Department of Otolaryngology, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio, USA 3 Department of Otolaryngology–Head and Neck Surgery; Henry Ford Health System, Detroit, Michigan, USA 4 Department of Research and Quality Improvement, American Academy of Otolaryngology Head and Neck Surgery, Alexandria, Virginia, USA 5 Department of Otolaryngology–Head and Neck Surgery; MedStar Georgetown University Hospital, Washington, DC, USA 6 Department of Otorhinolaryngology–Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA This article was presented at the 2014 AAO-HNSF Annual Meeting & OTO EXPO; September 21-24, 2014; Orlando, Florida. Corresponding Author: Ellen S. Deutsch, MS, MD, the Children’s Hospital of Philadelphia, Main Building Room 9329, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA. Email: [email protected]

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contemporary simulation provides a range of tools that may mitigate these challenges. Simulation has become a valuable and effective instrument for both training and assessment in medical education within otolaryngology and in the broader field of medical education, with a growing body of evidence demonstrating its effectiveness.9-13 Simulation supports early acquisition of complex skills and is known to improve procedural skills, surgeon confidence, patient care practices, and outcomes as well as provide collateral benefits such as transfer of skills and knowledge to other trainees and reduced healthcare costs.6,14-17 Specific skills relevant to otolaryngology have been demonstrated to be transferrable from simulation to procedures on actual patients (in vivo).10,18 Residents trained on an endoscopic sinus surgery simulator, when compared with controls, showed decreased completion time, increased confidence, and fewer technical errors on basic surgical tasks done on patients.10 The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNS/F) established the Otolaryngology Surgical Simulation Task Force in 2011; the task force was charged with providing a review of the existing state of simulation activity within otolaryngology and within other specialties. In addition to developing this survey and participating in ASSET (the multispecialty Alliance for Surgical Simulation in Education and Training), the task force has held open meetings during every AAO-HNS/F Annual Meeting and Combined Otolaryngology Spring Meeting since its establishment, as vehicles for participants to exchange information about their simulation activities and to provide opportunities for collaboration. Development of an online community via the AAO-HNS’s online ‘‘ENTConnect’’ will expand opportunities for collaboration. To determine the extent to which simulation activities are currently used within otolaryngology training programs throughout the United States, a survey was developed. Our objectives were the following: 1. Determine the simulation resources available to US Otolaryngology-Head and Neck Surgery (ORL-HNS) training institutions. 2. Determine current involvement in simulation within US ORL-HNS training programs. 3. Gauge interest in advancing simulation for training and assessment.

Methods Survey questions were developed by the 5 members of the task force, all of whom have expertise in simulation, in collaboration with an analyst from the AAO-HNS/F Research and Quality Improvement department (H.M.H.). Topics included access and availability of simulation resources, the types of simulation used, the purpose of the simulation activities, and whether simulation was incorporated generally within the institution or specifically within the otolaryngology program. Simulator and simulation were broadly

defined within the introductory text of the survey to provide context for respondents. Cadaveric or other biological tissue models were not specifically included as examples of simulation in the survey instructions. A list of all survey questions can be found in Figure 1. Institutional review board (IRB) approval was not required as per the Children’s Hospital of Philadelphia’s IRB because the analysis was conducted on a deidentified data set. The task force sent an electronic survey to program directors and coordinators of otolaryngology residencies in the United States (n = 104) via email on March 13, 2013, with a reminder sent on April 5, 2013, and results collected on April 11, 2013. Recipients were asked to share the survey with the person in the program most familiar with simulation. Potential respondents were provided with the following instructions: Consider simulation as encompassing a variety of technologies as well as nontechnical approaches, allowing us to learn, refresh, or test our skills or our practices by using models and replicating patient conditions and care situations. ‘‘Simulators’’ are broadly defined; they may be virtual and computer-screen based, physical with electronic interfaces, full-body high-tech manikins, home-made models, or people ‘‘acting.’’ Simulators are then incorporated into simulations that may focus solely on otolaryngology skills, or they may address interpersonal as well as technical skills.

Other than these instructions, and the choices embedded in the survey, no additional definitions or instructions were provided. It is assumed that all training programs have, or at least have access to, cadaveric temporal bone dissection. Although not explicitly stated, the purpose of the survey was to inquire about less widely distributed, unique types of simulation activities, as this would be more novel, informative, and of greater interest to the otolaryngology–head and neck surgery community at large.

Results Survey responses were received from 43 (43/104, 41%) residency training programs. Responses were provided by the program director (35/43, 81.4%), chair (3/43, 7%), or another individual such as associate program director or research director (5/43, 11.6%). The majority of respondents (39/42, 92.9%) had a simulation center or program at their institution; institutional resource availability is displayed in Figure 2. Descriptions ranged from ‘‘small, internally supported’’ to ‘‘several thousand square feet, institutional funding.’’ Six respondents reported that simulation programs were primarily focused on medical students, anesthesiologists, surgeons, or other specific groups. Primary funding sources included hospital, medical school, alumni, private industry, grant, and departmental funds. One otolaryngology program reported access to simulation resources without charge, while about a fourth of respondents reported that they must pay a fee or fund the simulation activities internally. Many responses did not directly address or clearly describe funding.

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1. What is your role in the Otolaryngology program at your institution? Chair / Program Director / Other 2. Which of the following simulation resources are available to your institution? (Select all that apply) Simulation center – onsite / simulation center – offsite / simulation capabilities – in situ / simulation curriculum / simulation staff / simulation models, mannequins, and/or devices / funding for training / other/none of these 3. Does your institution have a “simulation center” or a simulation program? Yes/No; If so please describe size, source of funds to support the center or program (philanthropic, internal etc) 4. Do you have simulation activity involving otolaryngology at your institution? Yes, extensively at my institution/Yes, to a limited extent at my institution/ Yes, to a limited extent outside my institution/Yes, extensively outside my institution/No 5. If you do not have simulation activity, do you have plans to incorporate simulation into your program? Yes/No 6. If you do not currently have plans to incorporate simulation into your program, would you like to? Yes/No 7. If you have simulation activity in your program, to what area of otolaryngology is it applied (check all that apply): Interpersonal, professional skills (patient interaction, team communication, etc.) / Bronchesophagology / Laryngology / Facial plastics-reconstruction / Head and neck / Otology / Sinus / Emergency management / Team training / Other, please specify 8. How are you using your simulation resources (select all that apply): Clinical training / Proficiency / Mastery of a particular technique / Other, please specify 9. If you are incorporating simulation, are the simulation events (select all that apply): Single participant / Single specialty (e.g. ORL residents) / Interprofessional / Other, please specify 10. Are you using simulation in a research capacity? Yes/No 11. Are you using simulation for physician credentialing? Yes/No 12. Are you using simulation for systems improvements in your organization? Yes/No 13. Have you developed any simulators and/or simulation-based curriculum? Yes/No 14. Would you be willing to participate in the future in any of the following ways? Share simulators / share curriculum / participate in multi-center trials of simulation initiatives Figure 1. Survey questions. The possible responses to each question are listed; additionally, each question offered the opportunity to add free-text comments.

Simulation activity specific to otolaryngology is displayed in Figure 3. Several respondents specifically identified activity related to temporal bone simulation, using either cadaveric or virtual simulators. Of the 8 respondents

with no simulation activity, 2 indicated a desire to incorporate simulation within the next year, 2 wanted to incorporate within the next 2 to 5 years, and 3 had no plans to incorporate simulation into their program (1 respondent did not

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respondents (%)

196 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

78.6%

73.8% 57.1% 28.6%

26.2%

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28.6% 11.9%

Figure 2. Simulation resources available at the respondents’ institutions (more than 1 response could be selected; n = 42 respondents).

curriculum. Finally, 56.8% of respondents reported that they would be willing to share simulators; 62.2% would be willing to share curriculum; and 83.8% would be willing to participate in multicenter trials of simulation initiatives.

100% 90%

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Discussion

50% 40% 30% 20%

19%

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Yes, extensive, inside

Yes, extensive, outside

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Figure 3. Presence and extent of simulation activity at respondents’ institutions. Extensive versus limited refers to otolaryngology simulation activity; inside or outside references the respondent’s institution (n = 43 respondents).

answer this question). Of the 3 respondents who had no plans to incorporate simulation, 2 said they would like to incorporate simulation but that it was not a high priority; the third did not want to incorporate simulation. Of the 31 respondents who specified areas of otolaryngology simulation, the most common applications of simulation within otolaryngology were emergency management (22/31, 71%) and otology (20/31, 64.5%; Figure 4). Most respondents who used simulation were using it for clinical training (30/32, 93.8%; Figure 5); 87.1% (27/31) of respondents were incorporating simulation in events with singlespecialty participation (eg, ORL-HNS residents); 29.0% of respondents said they conducted single-participant simulations; and 41.9% of respondents provide interprofessional simulation events. The majority of respondents were not using simulation for research, credentialing, or systems improvement (Figure 6). Also, 29.4% of respondents reported that they had developed their own simulators; 38.2% reported that they had developed their own curriculum; and 52% reported that they had not developed either their own simulators or simulation-based

Health systems and medical schools around the United States are increasing their use of simulation opportunities to enhance training, improve patient care, foster and enhance quality, and improve skills of the health care provider. There is a growing trend by certifying bodies to use simulation to gauge skills and ensure competency. The purpose of this manuscript was to assess the use of simulation in ORLHNS residency training programs in the United States. Accreditation Council for Graduate Medical Education (ACGME) program requirements for several specialties, including otolaryngology, accept or may even require the use of medical simulation as a mechanism for education and assessment of trainees, and several American Board of Medical Specialties (ABMS)–affiliated professional certification boards accept or require simulation as a component of board certification or recertification (Figure 7). A few surgical specialties are exploring and even requiring widespread application of simulation into their educational paradigms. Successful completion of the simulation-based Fundamentals of Laparoscopic Surgery is among the requirements for board certification in (general) surgery.19 Supported by an Agency for Healthcare Research and Quality (AHRQ) R-18 grant, cardiac surgeons are developing a comprehensive simulation-based training program that includes deconstructing and reconstructing operative procedural tasks, creating component task simulators, and developing a comprehensive syllabus.20 Gasco et al21 described a comprehensive neurosurgery curriculum implemented in a single institution, addressing all 7 years of training, which they conclude is feasible and favorably regarded and had a positive impact on trainees, particularly in junior years. A curriculum with 68 core exercises per academic year was distributed in individualized sets of 30 simulations assigned to each resident each year. Skills ranged from basic to advanced; physical, cadaveric, and haptic/ computerized simulators were used. The simulation laboratory

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71% 70%

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45% 42%

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40% 32% 30%

26%

26%

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Figure 4. Knowledge areas addressed in simulations (more than 1 response could be selected; n = 31 respondents).

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94%

31% 19% 3%

6%

Figure 5. Applications of simulation (more than 1 response could be selected; n = 32 respondents). n/a, not applicable.

could be accessed 24 hours per day, 7 days per week for individual practice and weekly for organized teaching sessions during the academic year. Exercises conducted in the operating room were supported as quality improvement exercises with no additional cost to the neurosurgery department, and protected time was provided for faculty.21 Surgeons are often familiar with the use of simulation to improve procedural skills. With some creativity, diverse simulation experiences can be used to address each of the 6

ACGME core competencies (patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, systemsbased practice).7,22 For example, a simulation scenario could include the need for a trainee to obtain informed consent or deliver ‘‘bad news’’ to a confederate or standardized patient (a professional who is trained to represent a patient and to provide feedback), addressing professionalism. Another simulation scenario could include a real team (eg, surgeon, anesthesiologist, nurses) managing a medical or surgical condition, using real equipment (eg, bronchoscopes). Simulations can be conducted in situ (in real patient care areas) to enhance realism for the participants or to study the patient care environment, particularly with respect to identifying system factors that may affect healthcare delivery. The learning objectives and debriefing could be focused on assessing the care environment and looking for ways to improve the systems that affect how we work, thereby addressing systems-based practice.23 Finally, feedback and debriefing are essential components of learning from simulation-enhanced learning opportunities. The reflective skills developed during debriefing are relevant for practicebased learning and improvement. Survey respondents reported that simulation resources, including both simulators and staff, were widely available onsite within otolaryngology residency institutions, and most respondents were able to take advantage of these resources to at least a limited extent. Most respondents who did not currently include simulation within their otolaryngology program planned to incorporate it in the future. Only a few respondents reported extensive use of simulation. It is likely that most if not all programs incorporate temporal bone laboratories, but some respondents may not have

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respondents (%)

198 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Otolaryngology–Head and Neck Surgery 153(2) 91%

64% 50% 38%

Extensively To a limited extent

27%

No 9%

12% 3% 6%

Research (n=33) Credenaling (n=34)

Systems Improvement (n=34)

Figure 6. Use of simulation for research, credentialing, and/or systems improvement.

considered this to be simulation. There are several possible explanations limiting the widespread use of simulation in otolaryngology training programs: lack of familiarity or expertise in simulation, expense of time and resources required to develop in-house simulation activities, shortage of simulators or simulation support (eg, simulation staff), a perception of insufficient data demonstrating simulation efficacy within otolaryngology, or other factors. For programs that use simulation, the most common application is in emergency management (71%), and 43% of respondents also reported using simulation for team training, suggesting that many programs use simulation to develop nontechnical skills, which may include leadership

ACGME Program Requirements Selected program requirements which address the use of simulaon Program Requirement Anesthesiology Residents must parcipate in at least one simulated clinical experience each year.27 Emergency Medicine Each resident must maintain, in an accurate and mely manner, a record of all major resuscitaons and procedures performed throughout the enre educaonal program. The record must document each procedure type, adult or pediatric paent, and circumstances of each procedure (live or simulaon). 28 General Surgery Resources must include simulaon and skills laboratories. These facilies must address acquision and maintenance of skills with a competency-based method of evaluaon. 29 Internal Medicine The sponsoring instuon and parcipang sites must … provide residents with access to training using simulaon. 30 Otolaryngology Medical knowledge…[residents] must demonstrate knowledge of anatomy through procedural skills demonstrated in cadaver dissecon, temporal bone lab, and/or surgical simulator labs 31 ACGME Program Milestones Selected Programs which address simulaon as a possible or required method of training, assessment or evaluaon • Emergency Medicine32 • General Surgery33 • Internal Medicine and Internal Medicine Subspeciales34,35 • Ophthalmology36 • Pathology, Cytopathology, Forensic Pathology37-39 • Plasc Surgery40 • Prevenve Medicine (Occupaonal Medicine, Aerospace Medicine)41,42 • Radiology (Diagnosc, Nuclear, Neuroradiology, Vascular and Intervenonal, Musculoskeletal, Abdominal)43-48 • Urology49 ACGME CLER Requirements 50 Simulaon addressed as a mechanism to be considered in fulfilling CLER objecves • Paent Safety Pathway 7: Resident/fellow educaon and experience in disclosure of events • Care Transions Pathway 4: Faculty member engagement in assessing resident-/fellow-related paent transions of care • Supervision Pathway 1: Educaon on supervision ACGME Faculty development Simulaon as a mechanism to develop faculty skills • Developing Faculty Competencies in Assessment: A Course to Help Achieve the Goals of Competency-based Medical Educaon (CBME) 51 American Board of Medical Speciales Board Cerficaon or Recerficaon Using Simulaon The American Board of Surgery Requires successful compleon of skill achievement verified in simulaon as a component of eligibility for Board Cerficaon 52 The American Board of Allows and provides simulaon as a component of maintenance of cerficaon Internal Medicine in Intervenonal Cardiology 53 The American Board of Offers simulaon as a component of Maintenance of Cerficaon in Anesthesia 54 Anesthesiology

Figure 7. Acceptance, endorsement, or requirement for simulation by selected ACGME and ABMS programs. ACGME, Accreditation Council for Graduate Medical Education; CLER, Clinical Learning Environment Review. Downloaded from oto.sagepub.com by guest on November 15, 2015

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and judgment. As noted previously, this provides opportunities to use simulation to address each of the ACGME Core Competencies. The next most common application of simulation is in otology (65%), which may reflect the longstanding tradition of using cadaveric temporal bones for resident practice of otology, as well as the development of several low-cost, ‘‘homemade’’ simulators for middle ear procedures.24-26 Very few programs are using simulation for research, credentialing, or systems improvement. Research in particular can be difficult because otolaryngology residency programs typically include only a few residents in each postgraduate year. Efforts of organizations like the Society of University Otolaryngologists and the AAO-HNS, as well as the otolaryngology specialty societies, can be instrumental in providing ways for potential researchers connect with each other, unified direction for the development of simulation, and support to access sufficient study subjects to expand our understanding of the efficacy of simulators and simulation in learning and assessment for otolaryngology trainees. Respondents indicated great interest in collaborating with respect to participating in multicenter trials of simulation initiatives, sharing simulators and curriculum, and receiving updates. Simulation will become an increasingly important component of resident education and assessment, as well as faculty teaching portfolios. It is essential that we recognize the limitations of simulation as well as expand its capabilities. In the authors’ experience, successful simulation activities require expertise in simulation as well as in the specific subject matter; some individuals have expertise in both domains. Access to opportunities to develop simulation skills is becoming more widespread. In addition, the departmental chair and faculty need to perceive value to provide appropriate support. In the future, external mandates may affect resource allocation. Limitations of this study include voluntary participation, which can bias responses, and an overall response rate of 43% of solicited institution. The lack of response from 57% of programs could be related to lack of survey receipt, lack of interest in the survey, lack of opportunity to complete the survey in a timely fashion, or a lack of interest in simulation. Lack of standardized terms and definitions in the field of simulation may have affected how respondents interpreted questions and selection choices. Specifically, inclusion of cadaveric, temporal bone, or other living or nonliving biological tissue practice in the survey’s introduction would have clarified the authors’ intent to use a broad definition of simulation. Collection of demographic data might provide additional information about trends as well as the degree to which the respondents reflect a broad cross section of otolaryngology programs.

Conclusion Simulation is gaining acceptance as a component of resident education and board certification in multiple medical specialties. Most respondents from otolaryngology residency programs have incorporated simulation into their curriculum,

and most report availability of staff as well as models, manikins, or other devices. Although most respondents report that their programs participate in simulation only to a limited extent, there is widespread interest in participating in multicenter trials of simulation initiatives. Future research efforts in this area should take advantage of institutional collaborations to determine optimal simulators and simulation activities for training and assessment as well as how to best incorporate simulation into otolaryngology residency training programs. Author Contributions Ellen S. Deutsch, survey composition, data analysis, drafting, final edit and review, revision edit and review, approval, responsibility for manuscript content; Gregory J. Wiet, survey composition, data analysis, drafting, final edit and review, revision edit and review, approval, responsibility for manuscript content; Michael Seidman, survey composition, data analysis, drafting, final edit and review, revision edit and review, approval, responsibility for manuscript content; Heather M. Hussey, survey composition, data analysis, drafting, final edit and review, revision edit and review, approval, responsibility for manuscript content; Sonya Malekzadeh, survey composition, data analysis, drafting, final edit and review, revision edit and review, approval, responsibility for manuscript content; Marvin P. Fried, survey composition, data analysis, drafting, final edit and review, revision edit and review, approval, responsibility for manuscript content.

Disclosures Competing interests: Michael Seidman, NIH Grant Temporal Bone Simulation Work; ViSalus Sciences: royalty for off-label products developed by Dr Seidman; Body Language Vitamin: founder of small company; intellectual property rights: 7 patents and several more pending. Sponsorships: AAO-HNS provided administrative assistance and distribution of the study survey. Study authors maintained complete control of the study design, conduct, analysis, interpretation of the data, and writing the manuscript. Funding source: None.

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Simulation Activity in Otolaryngology Residencies.

Simulation has become a valuable tool in medical education, and several specialties accept or require simulation as a resource for resident training o...
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