Simulation Won't Fix Surgical Education
Simulation (as practiced today) is incredibly lacking. It is low fidelity to the point of questionable benefit, extremely resource intensive in terms of money, location, and time, and lacks attending guidance.
“Just spend more time in the sim lab.”
Many residents have heard this line.
Surgical residency programs across the country have created simulation centers at significant expense. Usually available 24/7 for resident access, they nonetheless are rarely used outside of formal scheduled skills sessions, or occasional cramming for skills exams such as FLS or FES.1
Why is that? Are residents inherently lazy? Do they not care about learning surgery? If you read our previous post about holding surgical educators to a higher standard, you know our answer.
If residents aren’t using a resource provided to them, it is probably because the resource isn’t providing value.
So why might the sim lab be falling short at helping train surgical residents?
1. Low fidelity
Imagine if you told Roger Federer that, for one month, instead of playing tennis on a normal court he could only play Wii Tennis. Do you think he would be diligently logging hours in his living room?
I remember doing a simulation of an open inguinal hernia repair. It involved cutting through “skin” that resembled a leather car seat, and then “opening the hernia sac” which consisted of clear plastic wrap over top of colored yarn that was supposed to represent nerves and blood vessels. Needless to say, I was underwhelmed.
I was disappointed because I was desperate to learn how to actually do an open inguinal hernia repair. These cases are difficult to master—there are complex layers of planes that need to be identified and carefully dissected. Your ability to define these planes is often the difference between a smooth, elegant case vs a painful struggle with high risk of recurrence. The infantilized anatomy and movement skills provided by the simulation did not come close to replicating the aspects of the surgery that actually caused me to struggle. If someone offered me the opportunity to do this simulation again, I would skip it for a more useful activity.
Obviously, there are levels to simulation fidelity, and some are better than others. However, the point of this section is that a simulation can be so low fidelity that it is either useless (best case) or actively builds bad habits (worst case).
2. Resource Intensive
So we just need high-enough fidelity simulations, right? Then all problems with surgical education will be resolved?
First of all, for anyone unfamiliar with the current status of simulation in surgery, we are far closer to Wii Tennis than some sort of incredibly lifelike VR surgery. I would estimate that we are at least 50 years away from technologically being to really simulate surgery, the feel of surgical tissue, etc.
But, even if we weren’t, we must take into account the intense resource requirements of simulation-focused learning, both in terms of money, convenience, and TIME before declaring it the solution to all our woes.
Let’s take a hypothetical situation: You are a 4th year general surgery resident. It’s 7:30pm. You’ve had a busy clinical day and it is finally time to go home, eat, recover, and prepare for your early start tomorrow. You have a whipple at 7am, and you are definitely unprepared. Right as you are ready to leave, your simulation center calls you. Since you live in a utopian world with unlimited resources (including simulation staff willing to work at night) they tell you that they have a perfect-fidelity whipple simulator set up for you in the sim lab. It will work just like the real thing. In just 6-8 hours you can do a whipple by yourself and be ready for your case tomorrow. When you’re done at 2am. Without seeing your family or eating anything.
Who is signing up for that? What if you’re also on call that night? What about when it is time to prepare for your big case the next night? And the next?
The problem with perfect simulation is that it must, by definition, take as long as real life. In our current system, surgery residents wouldn’t even have time to take advantage of a perfectly designed simulation for consistent preparation for cases.
The ideal tool to help residents prepare for cases should be easy, cheap, convenient to access, and high-yield per unit time spent.
3. Lacks Attending Guidance
Okay, so you don’t really need to do the whole whipple to prepare the night before to prepare. Maybe you isolate a skill you want to work on, spend some time in this hypothetical utopian sim lab, and then get home at 10:30pm. Laying aside the very real financial, convenience, and wellness implications of such a system, it is still missing a crucial detail: the attending.
Back to sports analogies: you can go ‘hammer tennis balls against a wall’ in the sim lab by yourself, but if no one has ever taught you how to swing, you’re not going to get very far. In surgery, we would tell this hypothetical tennis player that they just didn’t read enough—if they would just find a good tennis textbook and read more about what makes a good forehand, they would get to do more in the case.
Yeah right. Let me know when you find even a slightly competent tennis player that learned that way.
Surgical trainees need direct, attending guidance on how to do a surgery before they could ever start to hone those skills on their own using a simulator.
And just doing a case, or even a handful of cases doesn’t mean a resident is ready to go off and teach themselves doing simulated surgery. Due to the difficult learning environment of the OR, only a fraction of the information residents are taught sticks, and by the time you’ve done enough cases to start really critiquing your own performance, you have probably already rotated to the next service.
Of course, no two attendings operate exactly the same either. So you might do 1 whipple with Dr. X, 3 with Dr. Y, and 2 with Dr. Z, but that certainly isn’t the same as doing 6 cases the same way.
“Well, simulation is the best we have!”
We agree with the fundamental premise of simulation—the OR is a bad learning environment, and more learning and teaching outside of the OR will make each case a much more valuable/productive learning opportunity.
However, simulation (as practiced today) is incredibly lacking. It is low fidelity to the point of questionable benefit, extremely resource intensive in terms of money, location, and time, and lacks attending guidance.
At Edu-rrhaphy, we believe that an ideal methodology for learning and teaching outside the OR would be:
- affordable
- convenient (able to be performed at a time and place of your choice)
- fast
- easily repeated/reviewed
- decentralized (attending specific)
Simulation in its current form meets none of these requirements. But other strategies for out-of-OR learning do. We will explore some in future posts.
1Glass et al., “A National Survey of Educational Resources Utilized by the Resident and Associate Society of the American College of Surgeons Membership.”