Simulation
Surgical skills training: time to start early Karim Hamaoui, Department of Surgery and Cancer, Imperial College London, UK Munir Saadeddin, Department of Orthopaedic Surgery, King Saud University, Riyadh, Saudi Arabia Hazim Sadideen, Department of Plastic & Reconstructive Surgery, University Hospitals Birmingham NHS Foundation Trust, UK
SUMMARY Background: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there are limited formal basic surgical skills programmes integrated into UK undergraduate curricula. Context: Early skills targeting is valuable for students entering
surgical, related allied specialties and even traditionally non-surgical specialties, such as General Practice. Such experience can make students more confident and subsequently competent future junior doctors and trainees. Innovation: The integration of skills training through the use of simple low-fidelity training models can bridge the gap between undergraduate skills education and postgraduate training, whereas approaches involving more recent advances in simulation may
prepare students further by making available more contextualised and scenario-based learning environments. Implications: We suggest that it is an ideal time for the introduction of dedicated basic surgical skills programmes into UK undergraduate medical curricula. Training will benefit all students. Importantly, training can inspire confidence, clinical interest, and can also provide a solid foundation of skills that can support and enable junior doctors’ further postgraduate training.
Currently there are limited basic surgical skills programmes integrated into UK undergraduate curricula
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183 179
tct_12128.indd 179
4/29/2014 5:01:21 PM
Medical students learn best through hands-on practical experience
INTRODUCTION
T
he adage of ‘see one, do one, teach one’ has become increasingly unacceptable to clinicians, students and patients alike. Dedicated undergraduate skills training improves students’ confidence and interest in clinical rotations. Learning occurs in a risk- and pressurefree setting, where the trainee has permission to ‘fail, reflect and learn’ prior to encountering real patients. Medical students learn best through hands-on, practical experience, with motivation stemming from the relevance of the subject matter to their daily routine. Integration with the dissection room provides a contextualised and memorable way for undergraduates to learn both surgical skills and clinically oriented anatomy. Immersive simulation training enables students to practise technical skills in a clinically realistic environment, as well as develop both teamwork and communication skills. Such training can aid in preparing students for their role as junior doctors, particularly those at the start of their surgical careers.
The UK undergraduate medical curriculum has undergone numerous changes.1 There is now a greater emphasis on ethics, law and community medicine, with less time spent on traditional attachments, such as surgery.2 Demands of surgical training programmes have made it important that graduates entering residency or core training bring with them greater surgical skill experience, so as to more quickly and efficiently progress in a time-constrained and European Working Time Directive (EWTD)-limited training environment. One key area where students are exposed to surgical skills is in the operating room (OR). Students cannot profit fully from
these occasions if they do not have a basic knowledge of theatre etiquette and surgical skills. Historically these were acquired in the field, by trial and error, under the supervision of a mentor; however, this has become increasingly difficult. In busy surgical firms with theatre time constraints students can perceive themselves as a burden, whereas surgeons may not actively encourage student teaching. Furthermore, it is not appropriate, nor ethically acceptable, to involve students in patient care without prior appropriate surgical skills training. The lack of comprehensive undergraduate basic surgical training may have repercussions in terms of the efficiency of postgraduate acquisition of basic surgical skills and also career choices. The landmark Temple report has suggested that the delivery of surgical education in the UK needs to be addressed in order to provide adequate training within EWTD constraints.3
DEFICIENCIES OF CURRENT CURRICULA The General Medical Council (GMC) document for undergraduate education, Tomorrow’s Doctors, made a number of training recommendations that highlighted the importance of the acquisition of both generic and several surgically-related skills, such as suturing and scrubbing.1 These recommendations, however, may not prepare students sufficiently to gain the most from their initial postgraduate surgical posts, especially if they have an interest in surgery. At present formal basic surgical skills in the UK are taught only through the Royal College of Surgeons (RCS) licensed Basic Surgical Skills (BSS) courses, 12–24 months after completing medical school. In general the spectrum of skills taught in undergraduate training is limited in comparison. This is in contrast to the international ‘arena’, however, as integrated undergraduate basic skills programmes are well developed in
180 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183
tct_12128.indd 180
4/29/2014 5:01:23 PM
students to become more confident and able future junior doctors.
SIMULATION AS A VIABLE TOOL FOR UNDERGRADUATES Competency-based training seeks to improve the learning of key clinical skills, but can only be achieved if the appropriate skills are first identified, taught, practised and then assessed. We believe further integration of basic surgical skills into undergraduate education can be strengthened through the specific use of simulation training to introduce and allow practise of these identified surgical competencies, prior to their performance in a clinical setting.
the USA. Several institutions have intensive month-long ‘Boot Camps’ to prepare students for their surgical rotations: these involve both the acquisition of surgical knowledge and also tuition and regular practise of surgical skills.4,5 Current educational theory dictates that skill acquisition is based on receiving expert assistance and supervision, supplemented with regular repeated practise in a safe environment, which is necessary for technique re-enforcement and skill retaining.6 The acquisition of surgical skills in the OR has become more difficult in light of the EWTD and decreased working hours, the implementation of standards to use theatre time more efficiently to deal with high case loads and with ethical concerns of ‘non-competent’ novices performing procedures on patients. This has resulted in non-standardised teaching, with a large variation in the quantity
and quality of learning experiences. The OR is thus not an ideal setting for students to acquire and retain basic surgical skills. Students often feel unprepared to competently involve themselves in OR procedures, and can perceive themselves as a burden on the surgical team.7 This lack of confidence in students may also be carried through to newly qualified doctors who believe that they are ill prepared to perform the procedures expected of them as junior surgical trainees. In addition to improving confidence, prior exposure to select skills at an undergraduate level may have an enhanced effect on early postgraduate skill acquisition, and enable more time-efficient training.8 Targeting skills that would be useful for surgical and allied specialties – namely suturing, knot tying, tying at depth and chest drain insertion – in the form of a dedicated teaching programme can help prepare
Learning from mistakes is an important educational experience, and simulation provides a safe arena for this
One option available is to provide students with a BSS course prior to or during their surgical rotations. Medical students learn best though hands-on, practical experience, with motivation related to the relevance of the subject matter to their daily routine.9 Surgical simulation in the form of skills courses is selectively used in US medical curricula to equip students with the techniques and confidence in an unpressurised environment.10 This preparation allows them to integrate with surgical teams during their clerkships, and prepare them for surgical residency. In addition, using ‘dry’ skill laboratories to train trainees has demonstrated a positive effect on technical skills, clinical outcomes and patient safety.11 Low-fidelity simulation programmes, such as a BSS course, not only have a positive impact on skills training, but are also accessible and inexpensive.12 Such a BSS course could also be integrated into anatomy teaching in the dissection room in preclinical years, where both
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183 181
tct_12128.indd 181
4/29/2014 5:01:24 PM
Development of surgical skills as undergraduates would be beneficial for the majority of students
technical and practical aspects could be combined and emphasised using cadavers.13,14 This would increase the clinical and surgical perspective of anatomy teaching, as well as provide a more contextualised approach to the skills imparted and their practise. Such experiences could be revisited prior to clinical rotations to reinforce training on anatomical plastic models, and would serve as reminders allowing as near ‘real’ skills practise as possible. This could then be complemented by performing the procedures in a clinical setting under direct supervision by surgical faculty members.
enclosure containing different types and numbers of ‘props’ to create a sense of realism within the DS environment. DS seeks to ‘provide simulation facilities that are “good enough” to engage participants and achieve learning goals, yet is low-cost, portable and able to be erected in a variety of clinical or non-clinical locations’, such as the inflatable operating theatre.12 DS aims to balance clinical realism with the functionality of a simulation centre, which can be tailored to multiple scenarios and learning needs, at a relatively affordable cost compared with static facilities.15
High-fidelity simulation programmes, on the other hand, can benefit from recreated clinical environments, patient actors and life-like prosthetic manikins to replicate clinical scenarios. Such training provides an immersive environment and allows students and trainees to rehearse key clinical scenarios in an authentic setting: mistakes are made in the training lab and not at the bedside.12 Learning from mistakes is an important educational experience, and simulation provides a safe arena for this. Simulation enables the student to be the centre of the educational experience, and receive dedicated feedback that could otherwise not be generated in a clinical setting, where the patient is the centre of any interaction and learning is a secondary by-product. Running such realistic simulations has drawbacks, however: it is resource intensive, normally only available in academic centres of excellence and, because of economic and organisational issues, is limited to high-end users.12
Distributed simulation (DS) training is still in its infancy, and interest so far has been in training clinicians, with no formal input into medical undergraduate curricula. The concept of DS resonates remarkably with the needs of undergraduate education, however, providing realistic training and preparing students for clinical rotations, with high impact at feasibly low economic cost. Recent work by the Kneebone group has explored the integration of DS with the dissection room.16 If successfully introduced into the undergraduate (and perhaps even early postgraduate) domain, students and trainees could conceivably rehearse how to assist a surgeon in theatre, for example, and then ‘close up’ a skin incision on a cadaveric model. Previously, such a ‘near-true’ experience could only be provided by participation in the OR.17 The role that DS may play in the future is fascinating, and long-term studies on its application and take-up are awaited.
A recent novel, versatile and low-cost concept in simulation training was described by Kneebone and colleagues: termed distributed simulation (DS).12 This consists of an inflatable
As a well-rounded doctor, awareness of the technical skills and activities of surgeons is important. Basic surgical skills are also useful for all students during their acute care rotations,
IMPLICATIONS
especially for those interested in allied surgical specialties (such as Accident & Emergency and Dermatology), and even in traditionally non-surgical specialties such as General Practice. Overall, according to the Royal College of General Practitioners, up to 50 per cent of medical students will choose a career in General Practice. In the current evolution of primary care medicine in the UK, the role of the general practitioner with specialty interest (GPwSI) in dermatology and skin surgery is becoming increasingly popular. This has been augmented in the UK by recent updated National Institute for Health and Care Excellence (NICE) and Department of Health (DOH) guidance on skin cancer that allow GPs and GPwSIs with the appropriate skill base to treat low-risk basal cell carcinomas without the need for referral to specialists. The development of surgical skills as undergraduates would thus be beneficial for the majority of students, regardless of their intended career. The low cost and high benefits of a low-fidelity programme would make it a logical addition to undergraduate training. It could be a simple yet effective and worthwhile tool in training students and preparing them for their role as junior doctors, particularly those at the start of their surgical careers. Introducing higher fidelity simulation modalities effectively will require a coordinated approach. This must involve surgical educators, trainees, educationalists and programme directors working together to produce a rational, affordable syllabus of basic surgical simulation training that can be integrated into programmes initially at undergraduate and then at early postgraduate levels, such as foundation year 1. It will then be the role of surgical educators and
182 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183
tct_12128.indd 182
4/29/2014 5:01:26 PM
undergraduate educationalists to collaboratively decide on the required degree of competency of the skills taught prior to students and trainees engaging in skill-specific clinical encounters with patients. Finally, such a course should augment rather than replace clinical learning in order to enhance the learning experience and ultimately patient care. REFERENCES 1. General Medical Council. Tomorrow’s Doctors. London: General Medical Council; 2009. 2. Wass V. Monitoring the medical education revolution. BMJ 2003;327:1362. 3. Temple J. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. Available at http://www.mee.nhs.uk/pdf/ JCEWTD_Final%20report.pdf. Accessed 3 April 2013.
G. A senior elective designed to prepare medical students for surgical residency. Am J Surg 2004;187:695–697.
Aggarwal R, Darzi A, Nestel D. Distributed simulation – accessible immersive training. Med Teach 2010;32:65–70.
6. Kneebone R. Evaluating clinical simulations for learning procedural skills: A theory-based approach. Acad Med 2005;80:549–553.
13. Nutt J, Mehdian R, Parkin I, Dent J, Kellett C. Cadaveric surgery: a novel approach to teaching clinical anatomy. Clin Teach 2012;9:148–151.
7. De SK, Henke PK, Ailawadi G, Dimick JB, Colletti LM. Attending house officer and medical student perceptions about teaching in the third year medical school general surgery clerkship. J Am Coll Surg 2004;199:932–942.
14. DiMaggio PJ, Waer AL, Desmarais TJ, Sozanski J, Timmerman H, Lopez JA, Poskus DM, Tatum J, Adamas-Rappaport WJ. The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship—a response to the economic pressures facing academic medicine today. Am J Surg 2010;200:162–166.
8. Sanfey H, Dunnington G. Verification of Proficiency: A Prerequisite for Clinical Experience. Surg Clin North Am 2010;90:559–567. 9. Subranabian A, Bakaeen F. Commentary: The Case for Teaching Basic Surgical Skills in Medical School. J Surg Res 2012;176:406–408. 10. Naylor RA, Hollett LA, Valentine RJ, Mitchell IC, Bowling MW, Ma AM, Dineen SP, Bruns BR, Scott DJ. Can medical students achieve skills proficiency through simulation training? Am J Surg 2009;198:277–282.
4. Parent RJ, Plerhoples TA, Long EE, Zimmer DM, Teshome M, Mohr CJ, Ly DP, Hernandez-Boussard T, Curet MJ, Dutta S. Early, intermediate, and late effects of a surgical skills “boot camp” on an objective structured assessment of technical skills: a randomized controlled study. J Am Coll Surg 2010;210:984–989.
11. Lossing AG, Hatswell EM, Gilas , Reznick RK, Smith LC. A technical-skills course for 1st-year residents in general surgery: a descriptive study. Can J Surg 1992;35:536–540.
5. Boehler ML, Rogers DA, Schwind CJ, Fortune J, Ketchum J, Dunnington
12. Kneebone R, Arora S, King D, Bello F, Sevdalis N, Kassab E,
Such a course should augment rather than replace clinical learning
15. Kassab E, Tun JK, Arora S, King D, Ahmed K, Miskovic D, Cope A, Vadhwana B, Bello F, Sevdalis N, Kneebone R. “Blowing up the barriers” in surgical training: exploring and validating the concept of distributed simulation. Ann Surg 2011;254:1059–1065. 16. Harris A. Distributed Simulation and soft-preserved cadavers in surgical simulation. 17th Annual Meeting of the Society in Europe for Simulation Applied to Medicine (SESAM 2011). Available at http:// www.iavante.es/descargas/pdf/ SESAM%202011%20-%20Book%20 of%20Abstracts.pdf. Accessed on 10 May 2013. 17. Harris A, Tang J, Maroothynaden J, Bello F, Kneebone R. Plus ça change, plus c’est la même chose. Lancet 2012;380:1058.
Corresponding author’s contact details: Hazim Sadideen, Specialty Registrar, Department of Plastic & Reconstructive Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. E-mail: [email protected]
Funding: This work received no funding. Conflict of interest: None to declare. Ethical approval: Not applicable. doi: 10.1111/tct.12128
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183 183
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Surgical skills training: time to start early Karim Hamaoui, Department of Surgery and Cancer, Imperial College London, UK Munir Saadeddin, Department of Orthopaedic Surgery, King Saud University, Riyadh, Saudi Arabia Hazim Sadideen, Department of Plastic & Reconstructive Surgery, University Hospitals Birmingham NHS Foundation Trust, UK
SUMMARY Background: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there are limited formal basic surgical skills programmes integrated into UK undergraduate curricula. Context: Early skills targeting is valuable for students entering
surgical, related allied specialties and even traditionally non-surgical specialties, such as General Practice. Such experience can make students more confident and subsequently competent future junior doctors and trainees. Innovation: The integration of skills training through the use of simple low-fidelity training models can bridge the gap between undergraduate skills education and postgraduate training, whereas approaches involving more recent advances in simulation may
prepare students further by making available more contextualised and scenario-based learning environments. Implications: We suggest that it is an ideal time for the introduction of dedicated basic surgical skills programmes into UK undergraduate medical curricula. Training will benefit all students. Importantly, training can inspire confidence, clinical interest, and can also provide a solid foundation of skills that can support and enable junior doctors’ further postgraduate training.
Currently there are limited basic surgical skills programmes integrated into UK undergraduate curricula
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183 179
tct_12128.indd 179
4/29/2014 5:01:21 PM
Medical students learn best through hands-on practical experience
INTRODUCTION
T
he adage of ‘see one, do one, teach one’ has become increasingly unacceptable to clinicians, students and patients alike. Dedicated undergraduate skills training improves students’ confidence and interest in clinical rotations. Learning occurs in a risk- and pressurefree setting, where the trainee has permission to ‘fail, reflect and learn’ prior to encountering real patients. Medical students learn best through hands-on, practical experience, with motivation stemming from the relevance of the subject matter to their daily routine. Integration with the dissection room provides a contextualised and memorable way for undergraduates to learn both surgical skills and clinically oriented anatomy. Immersive simulation training enables students to practise technical skills in a clinically realistic environment, as well as develop both teamwork and communication skills. Such training can aid in preparing students for their role as junior doctors, particularly those at the start of their surgical careers.
The UK undergraduate medical curriculum has undergone numerous changes.1 There is now a greater emphasis on ethics, law and community medicine, with less time spent on traditional attachments, such as surgery.2 Demands of surgical training programmes have made it important that graduates entering residency or core training bring with them greater surgical skill experience, so as to more quickly and efficiently progress in a time-constrained and European Working Time Directive (EWTD)-limited training environment. One key area where students are exposed to surgical skills is in the operating room (OR). Students cannot profit fully from
these occasions if they do not have a basic knowledge of theatre etiquette and surgical skills. Historically these were acquired in the field, by trial and error, under the supervision of a mentor; however, this has become increasingly difficult. In busy surgical firms with theatre time constraints students can perceive themselves as a burden, whereas surgeons may not actively encourage student teaching. Furthermore, it is not appropriate, nor ethically acceptable, to involve students in patient care without prior appropriate surgical skills training. The lack of comprehensive undergraduate basic surgical training may have repercussions in terms of the efficiency of postgraduate acquisition of basic surgical skills and also career choices. The landmark Temple report has suggested that the delivery of surgical education in the UK needs to be addressed in order to provide adequate training within EWTD constraints.3
DEFICIENCIES OF CURRENT CURRICULA The General Medical Council (GMC) document for undergraduate education, Tomorrow’s Doctors, made a number of training recommendations that highlighted the importance of the acquisition of both generic and several surgically-related skills, such as suturing and scrubbing.1 These recommendations, however, may not prepare students sufficiently to gain the most from their initial postgraduate surgical posts, especially if they have an interest in surgery. At present formal basic surgical skills in the UK are taught only through the Royal College of Surgeons (RCS) licensed Basic Surgical Skills (BSS) courses, 12–24 months after completing medical school. In general the spectrum of skills taught in undergraduate training is limited in comparison. This is in contrast to the international ‘arena’, however, as integrated undergraduate basic skills programmes are well developed in
180 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183
tct_12128.indd 180
4/29/2014 5:01:23 PM
students to become more confident and able future junior doctors.
SIMULATION AS A VIABLE TOOL FOR UNDERGRADUATES Competency-based training seeks to improve the learning of key clinical skills, but can only be achieved if the appropriate skills are first identified, taught, practised and then assessed. We believe further integration of basic surgical skills into undergraduate education can be strengthened through the specific use of simulation training to introduce and allow practise of these identified surgical competencies, prior to their performance in a clinical setting.
the USA. Several institutions have intensive month-long ‘Boot Camps’ to prepare students for their surgical rotations: these involve both the acquisition of surgical knowledge and also tuition and regular practise of surgical skills.4,5 Current educational theory dictates that skill acquisition is based on receiving expert assistance and supervision, supplemented with regular repeated practise in a safe environment, which is necessary for technique re-enforcement and skill retaining.6 The acquisition of surgical skills in the OR has become more difficult in light of the EWTD and decreased working hours, the implementation of standards to use theatre time more efficiently to deal with high case loads and with ethical concerns of ‘non-competent’ novices performing procedures on patients. This has resulted in non-standardised teaching, with a large variation in the quantity
and quality of learning experiences. The OR is thus not an ideal setting for students to acquire and retain basic surgical skills. Students often feel unprepared to competently involve themselves in OR procedures, and can perceive themselves as a burden on the surgical team.7 This lack of confidence in students may also be carried through to newly qualified doctors who believe that they are ill prepared to perform the procedures expected of them as junior surgical trainees. In addition to improving confidence, prior exposure to select skills at an undergraduate level may have an enhanced effect on early postgraduate skill acquisition, and enable more time-efficient training.8 Targeting skills that would be useful for surgical and allied specialties – namely suturing, knot tying, tying at depth and chest drain insertion – in the form of a dedicated teaching programme can help prepare
Learning from mistakes is an important educational experience, and simulation provides a safe arena for this
One option available is to provide students with a BSS course prior to or during their surgical rotations. Medical students learn best though hands-on, practical experience, with motivation related to the relevance of the subject matter to their daily routine.9 Surgical simulation in the form of skills courses is selectively used in US medical curricula to equip students with the techniques and confidence in an unpressurised environment.10 This preparation allows them to integrate with surgical teams during their clerkships, and prepare them for surgical residency. In addition, using ‘dry’ skill laboratories to train trainees has demonstrated a positive effect on technical skills, clinical outcomes and patient safety.11 Low-fidelity simulation programmes, such as a BSS course, not only have a positive impact on skills training, but are also accessible and inexpensive.12 Such a BSS course could also be integrated into anatomy teaching in the dissection room in preclinical years, where both
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183 181
tct_12128.indd 181
4/29/2014 5:01:24 PM
Development of surgical skills as undergraduates would be beneficial for the majority of students
technical and practical aspects could be combined and emphasised using cadavers.13,14 This would increase the clinical and surgical perspective of anatomy teaching, as well as provide a more contextualised approach to the skills imparted and their practise. Such experiences could be revisited prior to clinical rotations to reinforce training on anatomical plastic models, and would serve as reminders allowing as near ‘real’ skills practise as possible. This could then be complemented by performing the procedures in a clinical setting under direct supervision by surgical faculty members.
enclosure containing different types and numbers of ‘props’ to create a sense of realism within the DS environment. DS seeks to ‘provide simulation facilities that are “good enough” to engage participants and achieve learning goals, yet is low-cost, portable and able to be erected in a variety of clinical or non-clinical locations’, such as the inflatable operating theatre.12 DS aims to balance clinical realism with the functionality of a simulation centre, which can be tailored to multiple scenarios and learning needs, at a relatively affordable cost compared with static facilities.15
High-fidelity simulation programmes, on the other hand, can benefit from recreated clinical environments, patient actors and life-like prosthetic manikins to replicate clinical scenarios. Such training provides an immersive environment and allows students and trainees to rehearse key clinical scenarios in an authentic setting: mistakes are made in the training lab and not at the bedside.12 Learning from mistakes is an important educational experience, and simulation provides a safe arena for this. Simulation enables the student to be the centre of the educational experience, and receive dedicated feedback that could otherwise not be generated in a clinical setting, where the patient is the centre of any interaction and learning is a secondary by-product. Running such realistic simulations has drawbacks, however: it is resource intensive, normally only available in academic centres of excellence and, because of economic and organisational issues, is limited to high-end users.12
Distributed simulation (DS) training is still in its infancy, and interest so far has been in training clinicians, with no formal input into medical undergraduate curricula. The concept of DS resonates remarkably with the needs of undergraduate education, however, providing realistic training and preparing students for clinical rotations, with high impact at feasibly low economic cost. Recent work by the Kneebone group has explored the integration of DS with the dissection room.16 If successfully introduced into the undergraduate (and perhaps even early postgraduate) domain, students and trainees could conceivably rehearse how to assist a surgeon in theatre, for example, and then ‘close up’ a skin incision on a cadaveric model. Previously, such a ‘near-true’ experience could only be provided by participation in the OR.17 The role that DS may play in the future is fascinating, and long-term studies on its application and take-up are awaited.
A recent novel, versatile and low-cost concept in simulation training was described by Kneebone and colleagues: termed distributed simulation (DS).12 This consists of an inflatable
As a well-rounded doctor, awareness of the technical skills and activities of surgeons is important. Basic surgical skills are also useful for all students during their acute care rotations,
IMPLICATIONS
especially for those interested in allied surgical specialties (such as Accident & Emergency and Dermatology), and even in traditionally non-surgical specialties such as General Practice. Overall, according to the Royal College of General Practitioners, up to 50 per cent of medical students will choose a career in General Practice. In the current evolution of primary care medicine in the UK, the role of the general practitioner with specialty interest (GPwSI) in dermatology and skin surgery is becoming increasingly popular. This has been augmented in the UK by recent updated National Institute for Health and Care Excellence (NICE) and Department of Health (DOH) guidance on skin cancer that allow GPs and GPwSIs with the appropriate skill base to treat low-risk basal cell carcinomas without the need for referral to specialists. The development of surgical skills as undergraduates would thus be beneficial for the majority of students, regardless of their intended career. The low cost and high benefits of a low-fidelity programme would make it a logical addition to undergraduate training. It could be a simple yet effective and worthwhile tool in training students and preparing them for their role as junior doctors, particularly those at the start of their surgical careers. Introducing higher fidelity simulation modalities effectively will require a coordinated approach. This must involve surgical educators, trainees, educationalists and programme directors working together to produce a rational, affordable syllabus of basic surgical simulation training that can be integrated into programmes initially at undergraduate and then at early postgraduate levels, such as foundation year 1. It will then be the role of surgical educators and
182 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183
tct_12128.indd 182
4/29/2014 5:01:26 PM
undergraduate educationalists to collaboratively decide on the required degree of competency of the skills taught prior to students and trainees engaging in skill-specific clinical encounters with patients. Finally, such a course should augment rather than replace clinical learning in order to enhance the learning experience and ultimately patient care. REFERENCES 1. General Medical Council. Tomorrow’s Doctors. London: General Medical Council; 2009. 2. Wass V. Monitoring the medical education revolution. BMJ 2003;327:1362. 3. Temple J. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. Available at http://www.mee.nhs.uk/pdf/ JCEWTD_Final%20report.pdf. Accessed 3 April 2013.
G. A senior elective designed to prepare medical students for surgical residency. Am J Surg 2004;187:695–697.
Aggarwal R, Darzi A, Nestel D. Distributed simulation – accessible immersive training. Med Teach 2010;32:65–70.
6. Kneebone R. Evaluating clinical simulations for learning procedural skills: A theory-based approach. Acad Med 2005;80:549–553.
13. Nutt J, Mehdian R, Parkin I, Dent J, Kellett C. Cadaveric surgery: a novel approach to teaching clinical anatomy. Clin Teach 2012;9:148–151.
7. De SK, Henke PK, Ailawadi G, Dimick JB, Colletti LM. Attending house officer and medical student perceptions about teaching in the third year medical school general surgery clerkship. J Am Coll Surg 2004;199:932–942.
14. DiMaggio PJ, Waer AL, Desmarais TJ, Sozanski J, Timmerman H, Lopez JA, Poskus DM, Tatum J, Adamas-Rappaport WJ. The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship—a response to the economic pressures facing academic medicine today. Am J Surg 2010;200:162–166.
8. Sanfey H, Dunnington G. Verification of Proficiency: A Prerequisite for Clinical Experience. Surg Clin North Am 2010;90:559–567. 9. Subranabian A, Bakaeen F. Commentary: The Case for Teaching Basic Surgical Skills in Medical School. J Surg Res 2012;176:406–408. 10. Naylor RA, Hollett LA, Valentine RJ, Mitchell IC, Bowling MW, Ma AM, Dineen SP, Bruns BR, Scott DJ. Can medical students achieve skills proficiency through simulation training? Am J Surg 2009;198:277–282.
4. Parent RJ, Plerhoples TA, Long EE, Zimmer DM, Teshome M, Mohr CJ, Ly DP, Hernandez-Boussard T, Curet MJ, Dutta S. Early, intermediate, and late effects of a surgical skills “boot camp” on an objective structured assessment of technical skills: a randomized controlled study. J Am Coll Surg 2010;210:984–989.
11. Lossing AG, Hatswell EM, Gilas , Reznick RK, Smith LC. A technical-skills course for 1st-year residents in general surgery: a descriptive study. Can J Surg 1992;35:536–540.
5. Boehler ML, Rogers DA, Schwind CJ, Fortune J, Ketchum J, Dunnington
12. Kneebone R, Arora S, King D, Bello F, Sevdalis N, Kassab E,
Such a course should augment rather than replace clinical learning
15. Kassab E, Tun JK, Arora S, King D, Ahmed K, Miskovic D, Cope A, Vadhwana B, Bello F, Sevdalis N, Kneebone R. “Blowing up the barriers” in surgical training: exploring and validating the concept of distributed simulation. Ann Surg 2011;254:1059–1065. 16. Harris A. Distributed Simulation and soft-preserved cadavers in surgical simulation. 17th Annual Meeting of the Society in Europe for Simulation Applied to Medicine (SESAM 2011). Available at http:// www.iavante.es/descargas/pdf/ SESAM%202011%20-%20Book%20 of%20Abstracts.pdf. Accessed on 10 May 2013. 17. Harris A, Tang J, Maroothynaden J, Bello F, Kneebone R. Plus ça change, plus c’est la même chose. Lancet 2012;380:1058.
Corresponding author’s contact details: Hazim Sadideen, Specialty Registrar, Department of Plastic & Reconstructive Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. E-mail: [email protected]
Funding: This work received no funding. Conflict of interest: None to declare. Ethical approval: Not applicable. doi: 10.1111/tct.12128
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 179–183 183
tct_12128.indd 183
4/29/2014 5:01:26 PM
