Surg Endosc (2007) 21: 418–421 DOI: 10.1007/s00464-006-9051-5 Ó Springer Science+Business Media, Inc. 2006

Integrating simulation into a surgical residency program Is voluntary participation effective? L. Chang, J. Petros, D. T. Hess, C. Rotondi, T. J. Babineau Department of Surgery, Boston University Medical Center, 88 East Newton Street, Boston, Massachusetts 02118, USA Received: 12 April 2006/Accepted: 27 April 2006/Online publication: 16 December 2006

Abstract Objective: Surgical training programs nationwide are struggling with the integration of simulation training into their curriculum given the constraints of the 80-h work week. We examine the effectiveness of voluntary training in a simulation lab as part of the surgical curriculum. Methods: The ProMISTM simulator was introduced into the general surgery residency at Boston University Medical Center. All categorical residents (28) and noncategorical residents (23) were offered a 2-h training session and curriculum review. After the introductory session, time spent in the lab was encouraged, but voluntary. Use of the simulator was tracked for all residents. Participation in the simulation curriculum was defined as three or more uses of the simulator. After 3 months, all residents completed a survey regarding the simulation lab and their simulator usage. Results: Twenty-six (93%) categorical residents and three (6%) non-categorical residents completed the introductory simulator training session. Over a 3 month period, use of the simulator at least once was 31% among all eligible residents; 80% of postgraduate year (PGY)1, 40% of PGY2, 60% of PGY3, and 0% of PGY4 and PGY5. Four residents (14%) participated in the simulation curriculum. Overall, 70% of simulator usage was during working hours, and 30% was completed post-call or when the resident was off duty. Most residents agreed that the simulator was easy to use and that its use improved their operative skills, but they did not think it was a good substitute for actual operative experience. Reported reasons for not using the simulator included off-site rotation (44%), no time (30%), and no interest (11%). Conclusions: Voluntary use of a surgical simulation lab leads to minimal participation in a training curriculum.

This work was presented in a Poster Session at the SAGES Conference on April 28, 2006 Correspondence to: L. Chang

Participation should be mandatory if it is to be an effective part of a residency curriculum. Key words: Simulation — Curriculum — Surgical training — ProMISTM simulator — Resident participation

Surgeons, trainees, and patients appreciate the concept that basic surgical skills can be learned and practiced outside the operating room. Intuitively, it seems logical that training on a plastic, animal, or virtual model would improve intraoperative skills. With the recent development of virtual reality simulation, these types of systems have been brought to the forefront of resident education. Simulators offer trainees the ability to practice a particular exercise at their own pace and even experience failure without risk. In addition, challenging situations can be practiced as the level of difficulty with a simulated task can be adjusted to the individual user. Most computer-based simulators can provide objective feedback analysis for each exercise with calculated metrics such as time or path length. This allows teachers and trainees to monitor performance and progress. In recent years, many studies have shown the benefits of surgical simulation for improving technical skills [3, 10]. There is also evidence to show that skills learned in the simulated environment are transferable to the operating room with real patients [3, 6, 9, 11]. As a result, many programs are trying to incorporate simulation into their resident curriculum to supplement the hands-on experience gained in the operating room. Our institution recently adopted the ProMISTM surgical simulator into our resident educational curriculum. This system has been shown to have construct validity with its ability to distinguish between novices and experts [12]. It is a hybrid simulator that offers both virtual exercises and tasks involving physical models that provide the force feedback lacking from the virtual

419 Table 1. ProMIS resident curriculum PGY-1 Module 1: Laparoscopic Orientation Task 1: Investigation (levels 1–3) Task 2: Tracking (levels 1–3) Module 2: Instrument Handling Task 1: Locating and Coordinating (levels 1–3) PGY-2 Module 2: Instrument Handling Task 2: Object Positioning (levels 1–3) Task 3: Tissue Manipulation (levels 1–3) Module 6: Diathermy Task 1: Diathermy (levels 1–3) PGY-3 Module 3: Dissection Task 1: Clip Application (levels 1–3) Task 2: Sharp Dissection (levels 1–3) PGY 4–5 Module 5: Suturing and Knot-tying Task Task Task Task

1: 2: 3: 4:

Needle Handling and Passage (levels 1–3) Knot-tying (levels 1–3) Ligature (levels 1–3) Wound closure (levels 1–3)

PGY: postgraduate year

environment. The system allows trainees to practice basic laparoscopic skills, and it also has an open module that can be used as a platform for any laparoscopic task. This effort to increase surgical simulation training in residency coincides with the restriction of each residentÕs work week to 80 h or less. By the ACGME Program Requirements, any educational activity that is mandatory regardless of location is counted as duty hours [12]. Thus, time spent performing patient care and clinical cases may potentially be sacrificed for simulator training if it were considered mandatory. However, voluntary participation would not be counted as duty hours, allowing residents the opportunity to benefit from both simulation and clinical activities. The aim of the present study was to determine if voluntary participation would be an effective method for integrating simulation into the resident curriculum.

Materials and methods Participants All residents in the general surgery residency program at Boston University Medical Center from March 2005 through May 2005 participated in this study. There were 28 categorical residents and 23 noncategorical residents during this time period.

Curriculum In February of 2005, the ProMIS surgical simulator developed by Haptica, Inc. (Dublin, Ireland) was introduced into the general surgery residency at Boston University Medical Center. The simulator incorporates both virtual and physical models to teach users laparoscopic skills. Core training modules include laparoscopic orientation, instrument handling, dissection, diathermy, and suturing. After the completion of each exercise, a performance summary is provided to the trainee based upon four measures: time, path length, smoothness, and errors. For each postgraduate year (PGY) level (1–5), an appropriate curriculum using the ProMIS simulator was outlined to compliment

the complexity of each task. The specific modules and tasks for each level resident are outlined in Table 1.

Procedure A 2-h introductory session and curriculum review was offered to all residents at various times over a 3-week period. This introduction was mandatory for categorical residents and optional for non-categorical residents. For those residents who attended, the additional 2 h spent were counted toward their duty hours for that week. Each session had a standardized agenda taught by a single instructor, and there were no more than three trainees per session. During the introduction, system set-up was explained, and several tasks were demonstrated. Each participant used the simulator for two separate tasks, one virtual and one physical. Confidential login passwords were also established. For the residents who completed the introductory session, time spent in the lab was encouraged but deemed voluntary. Residents who did not complete the initial session were not allowed to use the system. The simulation lab was accessible any time including nights and weekends, and it was located two floors above the operating room of the hospital. Voluntary use of the simulator was monitored using a sign-in sheet to document each userÕs name, date, and call status (i.e., on-call, post-call, off duty). The opportunity for individual proctoring on the simulator was also offered to all residents by request. Participation in the simulation curriculum was defined as three or more uses of the simulator within the recommended curriculum during a 3-month period. At the end of the study period, all residents completed a short survey to obtain their perspective about the qualities of the simulator as well as usage of the system.

Results Introductory session There were 28 eligible categorical general surgery residents: five residents in each PGY 1–5 level and three residents in research their research year. Of these, 26 (93%) categorical residents completed the 2-h introductory simulator training session and curriculum review. Of the 23 non-categorical PGY-1 residents, only 3 (6%) completed the introductory training session.

420 Table 2. Surgical simulation survey results Statements regarding surgical simulation

Strongly disagree

Disagree

Agree

Strongly agree

Easy to use Enjoyed using the simulator Introduction was sufficient Proctoring not needed Would use more if work week