Interview with Dr. Don Bae-Surgical Simulation Training

Q:   Why do you feel that there has a transition from residents simply gaining procedural experience in the OR to new alternative  teaching methods like surgical simulation training?

A:   Surgical simulation does not replace the invaluable experience obtained in the OR during residency training, but does improve skills acquisition and education by responding to a number of emerging trends, including opportunities lost with duty-hour restrictions; challenges associated with rapidly emerging technology, instrumentation, and minimally invasive techniques; and “top heavy” training programs in which operative experience is often delayed until more senior years of residency or fellowship.

Q:   How does simulation training improve patient safety?

A:   Simulation training improves patient safety on many levels.  At the most fundamental level, by providing trainees the opportunity to acquire and practice technical skills in simulated settings, surgical errors and suboptimal technical performance can be avoided during the care of actual patients.  At higher levels, simulation training in team performance and crisis resource management allows for improved communication and efficiencies, particularly in high-stakes but uncommon clinical scenarios.

Q:   What are some of the barriers to implementation of simulation at individual programs?

A:   A number of barriers to implementation exist.  Initiation of any simulation curriculum requires investment of resources (e.g. equipment, physical space, simulation models, and supervising personnel) which present challenges for training programs and hospitals/institutions in an increasingly resource-scarce health care environment.  In addition, though many institutions and programs have begun exciting and innovative simulation programs, little consensus has been reached amongst all stakeholders regarding the specific kind of simulation training that should be pursued within orthopedics.  Finally, further work needs to be done to establish validated metrics that can be followed to demonstrate how simulation improves clinical outcomes, increases patient safety, and ultimately reduces cost.

Q:   The ABOS has developed recommended modules for intern surgical simulation training. Most centers have utilized these to help develop their programs.  However, there is a lack of uniformity in the implementation of curriculum.  How do we standardize training amongst residency programs?

A:   While mandates and requirements can improve implementation -- as has been seen to some degree with how many training programs have responded to the ABOS Milestones Initiative-- the barriers mentioned above also need to be addressed to promote widespread adoption.  In pediatric orthopedics -- thanks to the commitment of the POSNA leadership to improving education, care, and safety-- the Simulation in Pediatric Othopaedics Taskforce (SPORT) has been created to address some of these barriers.  This multi-center collaborative is working toward developing education curricula, practical simulation models, validated assessment tools, and scientific research protocols to allow for improved simulation training in fundamental pediatric orthopaedic procedures.

Q:   What pediatric orthopaedic simulation have you incorporated into the curriculum at your institution?

A:   Currently, all residents rotating through Boston Children’s Hospital are enrolled in a simulation curriculum in fundamental pediatric procedures (e.g. distal radius fracture reduction and cast application, supracondylar humerus fracture pinning, in situ fixation of SCFE, and arthroscopic knot tying, etc).  This curriculum presents didactic material in the form of articles, lectures, and videos.  After reviewing the didactic material, residents perform simulation exercises at the beginning of their rotation.  During their rotation, residents are given the opportunity to practice skills on their own time in our simulation facility, and a final assessment is performed at the end of the clinical rotation. Along the way, performance in the simulation exercises is measured with standardized assessment tools as well as video review, and research is being done to correlate simulation training with clinical results and patient safety. Soon additional simulation modules will be rolled out in clubfoot casting and pedicle screw insertion as well.

Q:   How do we objectively evaluate our residents during simulation training?

A:   Evaluations should be performed with Objective Standardized Assessments of Technical Skill (OSATS), many of which are currently being developed and validated.  These tools may consist of procedural checklists or global rating scales focused on essential steps of each procedure being evaluated.  In addition to these evaluations, providing both real-time and summative feedback is critical for performance improvement.

Q:   What do you see as the future role for simulation training in orthopaedics?

A:   It is unclear what the future education, be it at regional centers or individual institutions.  There are also great opportunities to leverage this simulation training to others outside of orthopaedic residency training (medical students, fellows, mid-level providers, etc).  The opportunity to improve care, optimize patient safety, and reduce cost is too great to pass up. 
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