Simulation builds skills

Dr. Levine is a clinical fellow at the Ronald O. Perelman & Claudia Cohen Center for Reproductive Medicine at the Weill Cornell Medical College at New York Presbyterian Hospital.

Dr. Goldschlag is an assistant professor of Clinical Obstetrics and Gynecology and Assistant Professor of Clinical Reproductive Medicine at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at the Weill Cornell Medical College at New York Presbyterian Hospital.

In 1999, the Institute of Medicine (IOM) issued the report To Err Is Human. In it, the IOM’s Committee on Quality of Health Care in America stated that not only did preventable medical errors cause more deaths than such feared threats as motor-vehicle accidents, breast cancer, and AIDS, but also that errors with serious consequences were most likely to occur in intensive care units, emergency departments, and operating rooms.¹ Although some operating room-associated complications can be attributed to wrong-site surgeries and equipment malfunctions, countless patients are harmed because of physician skill deficiencies.

It is sad but true that many ob/gyn residents are still trained using a Halstedian approach that can be boiled down to the infamous "See one, do one, teach one." Contrary to this philosophy of surgical education, surgery is not something that is  best taught by seeing, or best mastered by attempting on live subjects. There is an unavoidable practical element to effective surgical education, but no patient wants to be the “one" for a resident attempting to master a surgical procedure, especially in a fast-paced, high-stress clinical learning environment.

Even though surgery is a key part of ob/gyn training, a survey of residency programs found that only 74% formally evaluate surgical skills, with the majority reporting subjective faculty evaluations as the primary method of assessing skill proficiency. This occurs despite the availability of thoroughly vetted measures such as the objective structured assessment of technical skills (OSATS), the observational clinical human reliability assessment (OCHRA), and the operative performance rating system (OPRS).²

Surgical simulation products are now in wide use to address the critical need for new approaches to surgical education. In 2011, the Association of American Medical Colleges (AAMC) published a survey on medical simulation in medical education. One finding was that most medical schools and teaching hospitals own simulation facilities but that they are generally used for undergraduate medical education. That separation means that residents are unlikely to use the equipment, because a resident’s life revolves around the labor floor, with little time for much else.³

Gala and colleagues performed a multicenter, randomized controlled trial evaluating the performance of a laparoscopic bilateral mid-segment salpingectomy in which participants were randomized to either traditional teaching (no simulation) or faculty-directed training sessions in a simulation laboratory.⁴ The researchers found that the simulation-trained group became more competent with the technique in less time than the traditional teaching cohort. Ultimately, they concluded that proficiency-based simulation offers additional benefits for residents at all levels, and that making simulation available is likely one of the key drivers of resident surgical competency and mastery.

In a systematic review of the quality of medical simulators, Michael et al. found a lack of standardization of simulator quality metrics.⁵ But if there is proper faculty oversight, does the actual model matter? As long as the simulation is realistic and helps to teach requisite skills, the physical model can almost be ignored. For example, ACOG has a simulations consortium tool kit site where medical students, residents, and training programs can learn how to teach and refine their skills in knot-tying and suturing, vaginal laceration repair, colposcopy and loop electrosurgical excision, and even cold knife cone, among other techniques.⁶

Read: Group compares morcellation techniques for evidence of tissue spillage 

The Association of Professors of Gynecology and Obstetrics also has endorsed simulation and recommended learning strategies to help hone the experiences of medical students that are problem-, discovery-, experiential-, and task-based, and based on peer evaluation.^7,8 But what about residents, fellows, and attendings?

For example, the Practice Committee of the American Society for Reproductive Medicine (ASRM) recommends that "each physician performing oocyte retrievals and embryo transfers should have performed an adequate number of aspirations and transfer procedures under direct supervision that demonstrates proficiency within a practice that meets these standards." Goldman and colleagues sought to investigate whether the number of oocytes retrieved can be used as a marker for proficiency, in light of the fact that some fellowships provide ample opportunities for retrievals and others have smaller IVF volume.⁹ The researchers found that the majority of individual fellows in training demonstrate proficiency in follicular aspirations by the time they have performed 20 procedures; however, a minority may require 50 procedures to achieve the proficiency of an attending physician, numbers that are likely to be attainable in nearly every program.¹⁰

What about embryo transfers (ET)? Shah and colleagues performed a retrospective cohort study to assess pregnancy rates before and after a training intervention in which reproductive endocrinology and infertility fellows were required to perform 100 intrauterine inseminations (IUIs) before performing ETs. The researchers found that the pregnancy rate for the first 100 embryo transfers performed by fellows was unchanged after implementing the IUI training requirement, but the substantial variation noted among individual fellows decreased as more procedures were performed.¹¹

Given the aforementioned experience-based variation in technique and that fact that in many training programs, fellows still do not have the opportunity to perform ample "real live" ETs, ASRM and VirtaMed, a manufacturer of other ob/gyn products, recently announced the development of an ET simulation product. Said Owen Davis, MD, President-elect of ASRM, “the evidence is clear that simulation is the best training modality for new physicians. Embryo transfer is an absolutely foundational part of modern infertility treatment. With the development of a virtual reality simulator for embryo transfer, we are bringing an outstanding training tool to bear on one of the most vital procedures in the field.”¹²

Although the VirtaMed simulator is expensive, it ideally will provide residents and fellows with a set of skills previously available only to those who were in programs that were fortunate enough to have either a sufficiently high ET volume or supervising physicians who were comfortable with allowing trainees to perform this sensitive procedure.

While Halsted made an enduring contribution to the field of surgical education, the statistics cited at the start of this article illustrate the need for products that allow trainee physicians at every level to acquire skills before “practicing” surgery on patients. Happily, it seems as if this need will soon be met by a variety of new products, and we must hope that clerkship, residency, and fellowship directors will see the benefits of adopting simulation technology, and will integrate it into their training curricula.

One question that remains is how to procure simulator training experience in the current environment. As the AAMC survey revealed, many hospitals and medical schools have simulation core facilities. Scheduling training time may be as simple as calling the administrator of education in your ob/gyn department. For clinicians in community or private practices who do not have access to academic centers, national and district meetings such as those of ACOG and AAGL offer wonderful training sessions that are taught by our nation’s leading teachers using realistic simulators. Many surgical instrument sales representatives have access to simulation facilities. Simulation is an important part of surgical training and maintenance of skills and for those who want the training, the resources are available.

References                                        

1. Kohn, LT, Corrigan, JM, Donaldson, MS, Eds. To Err Is human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999.

2. Mandel LP, Lentz GM, Goff BA. Teaching and evaluating surgical skills. Obstet Gynecol. 2000;95:783–785.

3. Passiment M, Sacks H, Huang G. Medical simulation in medical education: results of an AAMC survey. https://www.aamc.org/download/259760/data/. Accessed April 8, 2015.

4. Gala R, Orejuela F, Gerten K, et al. Effect of validated skills simulation on operating room performance in obstetrics and gynecology residents: a randomized controlled trial. Obstet Gynecol. 2013;121(3):578-584.

5. Michael M, Abboudi H, Ker J, Shamim Khan M, Dasgupta P, Ahmed K. Performance of technology-driven simulators for medical students--a systematic review. J Surg Res. 2014;192(2):531–543.

6. The American Congress of Obstetricians and Gynecologists Simulations Consortium "Tool Kit." http://www.acog.org/About-ACOG/ACOG-Departments/Simulations-Consortium/Simulations-Consortium-Tool-Kit/. Accessed April 8, 2015.

7. Spencer JA, Jordan RK. Learner centered approaches in medical education. BMJ. 1999;318:1280–1283.

8. Association of Professors of Gynecology and Obstetrics. APGO clinical skills curriculum. Crofton, MD: Association of Professors of Gynecology and Obstetrics; 2008.

9. Practice Committee of the American Society for Reproductive Medicine; Practice Committee of the Society for Assisted Reproductive Technology; Practice Committee of the Society of Reproductive Biology and Technology. Revised minimum standards for practices offering assisted reproductive technologies: a committee opinion. Fertil Steril. 2014;102(3):682–686.

10. Goldman KN, Moon KS, Yauger BJ, Payson MD, Segars JH, Stegmann BJ. Proficiency in oocyte retrieval: how many procedures are necessary for training? Fertil Steril. 2011;95(7):2279–2282.

11. Shah DK, Missmer SA, Correia KF, Racowsky C, Ginsburg E. Efficacy of intrauterine inseminations as a training modality for performing embryo transfer in reproductive endocrinology and infertility fellowship programs. Fertil Steril. 2013;100(2):386–391.

12. VirtaMed. ASRM and VirtaMed to create embryo transfer simulator. http://www.virtamed.com/en/news/asrm-and-virtamed-create-embryo-transfer-simulator/. Accessed April 8, 2015.