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Surgery_Schwartz. da Vinci Skills Simulator (Intuitive Surgical, Santa Clara, CA).124,125 The SEP-Robot is a desktop-like system for training robotic skills in a VR graphical interface. The da Vinci Skills Simulator, also called the “backpack,” is a hardware system that loads VR simulations into the actual da Vinci console.126 The RoSS and dV-Trainer systems are stand-alone devices with surgical controls resembling those of the da Vinci system.124 These simulators largely focus on hand-eye coordination, tissue manipulation, suturing and knot tying.127 The major benefit of VR simulators for training da Vinci robotic skills is that they produce performance metrics including time, error measures, and motion analysis.124 These simulators are increasingly being used for training novice surgeons in robotic skills for a variety of surgical specialties.When assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to the clinical environment and the learning


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Surgery_Schwartz. for a variety of surgical specialties.When assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to the clinical environment and the learning curve for initial console training for surgeons is significantly decreased.124,126 Unfortunately, the available robotic surgery simulators still come with a high sticker price and varying agreement on the level of fidelity that is currently present in these technologies.124 These deficiencies are likely due to the early stage of the robotic surgery approach, and it is likely that cheaper and more sophis-ticated systems will be available in the near future.128Fundamentals of Robotic SurgeryThe Fundamentals of Robotic Surgery (FRS) is a robotic surgi-cal skills training and assessment program designed to provide a proficiency-based curriculum of basic technical skills to prepare surgeons for performing robotic surgery procedures across a wide range of specialties. The FRS program was


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Surgery_Schwartz. designed to provide a proficiency-based curriculum of basic technical skills to prepare surgeons for performing robotic surgery procedures across a wide range of specialties. The FRS program was developed over a 2-year period by subject matter experts from multiple surgi-cal societies, surgical educational societies, surgical boards, and other governing organizations through a series of four consensus conferences, which included over 80 international robotic sur-gery experts, behavioral psychologists, medical educators, stat-isticians, and psychometricians.129 The multidisciplinary team of experts agreed upon the critical skills and tasks to be included in a comprehensive basic curriculum, and a task deconstruction was performed to identify the tasks, subtasks, and errors that needed to be measured. A modified Delphi methodology was then used to create a matrix of specific robotic surgery tasks, common errors, desired outcomes, and quantitative metrics to


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Surgery_Schwartz. and errors that needed to be measured. A modified Delphi methodology was then used to create a matrix of specific robotic surgery tasks, common errors, desired outcomes, and quantitative metrics to 6Brunicardi_Ch53_p2163-p2186.indd 217422/02/19 4:39 PM 2175SKILLS AND SIMULATIONCHAPTER 53Table 53-5The four online modules for the fundamentals of robotic surgery curriculumModule 1Introduction to Surgical Robotic Systems, includes an overview of minimally invasive surgery, advantages of robotic assisted surgery, components of robotic systems, and system functionalityModule 2Didactic Instructions for Robotic Surgery Systems, provides an overview of robotic surgery systems, as well as detailed information regarding the pre-, intra-, and postoperative phasesModule 3Psychomotor Skills Curriculum, consists of background and general principles of the psychomotor tasks, an introduction to the physical model on which the tasks are performed, and general scoring guidelines for all the tasks,


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Surgery_Schwartz. consists of background and general principles of the psychomotor tasks, an introduction to the physical model on which the tasks are performed, and general scoring guidelines for all the tasks, followed by detailed descriptions of each task, including the targeted primary and secondary skills and metricsModule 4Team Training and Communication Skills, includes background on the degradation of situation awareness and the TeamSTEPPS process followed by detailed content covering communication, situational awareness, mutual support, leadership, the preoperative phase, robotic docking, intraoperative phase, postoperative phase, and a review of five scenariossupport those outcomes. Finally, a second round classic Delphi anonymous rating was used to ensure concurrence, prioritize the task rankings, and eliminate low-scoring tasks.All trainees must first complete an online curriculum consisting of four modules. Each of the four online modules is followed by a short quiz, requiring a minimum of


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Surgery_Schwartz. and eliminate low-scoring tasks.All trainees must first complete an online curriculum consisting of four modules. Each of the four online modules is followed by a short quiz, requiring a minimum of 70% cor-rect to proceed in the training (Table 53-5). The curriculum also includes a cumulative, cognitive test following completion of all modules.ABFigure 53-7. A. The simulated abdominal cavity for training in the Fundamentals of Robotic Surgery. B. The 18-cm removable dome model featuring well-defined areas for executing each of the seven psychomotor exercises outlined in Table 53-6. (Used with permission from the Institute for Surgical Excellence.)Following online course completion, trainees must com-plete seven psychomotor exercises using a surgical robot, a simulated abdomen, and an 18-cm, removable dome model (Fig. 53-7).The psychomotor exercises consist of the following tasks: docking/instrument insertion, ring tower transfer, knot tying, railroad track, 3rd arm cutting, puzzle


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Surgery_Schwartz. removable dome model (Fig. 53-7).The psychomotor exercises consist of the following tasks: docking/instrument insertion, ring tower transfer, knot tying, railroad track, 3rd arm cutting, puzzle piece dissection, and ves-sel energy dissection (Table 53-6).NONTECHNICAL SKILLSFor surgeons, the term “nontechnical skills” refers to the cog-nitive knowledge and teamwork-related abilities that must be integrated with psychomotor skills and abilities. There are no sharp demarcations between these areas of skill, but different simulation methods are suitable for training each, and all should be addressed.High-Fidelity Patient Simulation and Team SkillsRecognition of the role of human factors in the occurrence of preventable errors has spawned various efforts to train behav-iors conducive to high-performing teams. Crew resource man-agement (CRM) training utilizing simulation has been credited with increased safety in aviation.130,131 Lessons learned from CRM have been adapted to medical


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Surgery_Schwartz. high-performing teams. Crew resource man-agement (CRM) training utilizing simulation has been credited with increased safety in aviation.130,131 Lessons learned from CRM have been adapted to medical training with simulators focusing on medical team performance in complex clinical situ-ations. This development came about in the 1990s driven pri-marily by anesthesiologists responsible for establishing the first high-fidelity simulation environments.132,133 These were devel-oped for simulation of crisis-level events where management could be practiced under realistic but safe conditions.134-136 Such training could be scaled to involve a single learner to focus on clinical management up to an entire care team able to practice team processes. Development of a program for such training requires an understanding of the principles underlying team effectiveness and the specific characteristics of an expert team. In a 2012 discussion paper on team-based health care emerging from the Best


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Surgery_Schwartz. an understanding of the principles underlying team effectiveness and the specific characteristics of an expert team. In a 2012 discussion paper on team-based health care emerging from the Best Practices Innovation Collaborative of the Institute of Medicine (IOM) Roundtable on Value & Science-Driven Health Care, such principles were clearly laid out following a careful analysis of effective medical teams across the country (Table 53-7).137 This document provides an excellent review of characteristics and values that surgical teams can aspire to. The necessity to train these skills has been widely accepted as Brunicardi_Ch53_p2163-p2186.indd 217522/02/19 4:39 PM 2176SPECIFIC CONSIDERATIONSPART IITable 53-6The seven psychomotor dome tasks for the fundamentals of robotic surgery curriculumTask 1: Docking/Instrument InsertionThe first psychomotor exercise provides training and assessment of proper docking and instrument insertion using the simulated abdomen.Task 2: Ring Tower


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Surgery_Schwartz. curriculumTask 1: Docking/Instrument InsertionThe first psychomotor exercise provides training and assessment of proper docking and instrument insertion using the simulated abdomen.Task 2: Ring Tower TransferThe trainee removes a ring from the right middle tower and places it on the lower left tower. Primary skills assessed include hand, eye, and instrument coordination, camera navigation, and use of the camera pedal.Task 3: Knot TyingThe trainee ties a surgeon’s knot to approximate two eyelets such that they touch each other. Primary skills assessed include appropriate handling of suture material and tying secure knots.Task 4: Railroad TrackThe trainee must perform horizontal mattress suturing through a series of target points to approximate the tissue. Primary skills assessed include holding and manipulation of the needle, following the curve of the needle, utilizing the full range of motion of the endowrist, and using graspers.Task 5: 3rd Arm CuttingThe trainee must switch control


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Surgery_Schwartz. and manipulation of the needle, following the curve of the needle, utilizing the full range of motion of the endowrist, and using graspers.Task 5: 3rd Arm CuttingThe trainee must switch control between different instruments to use the monopolar scissors to cut a simulated vein. Primary skills assessed include switching between and controlling multiple robot arms and cutting.Task 6: Puzzle Piece DissectionIn this task, the trainee must cut and remove a puzzle shape without incising the underlying tissue or cutting outside of the lines. Primary skills assessed include dissection, cutting, atraumatic tissue handling, sharp dissection, and blunt dissection.Task 7: Vessel Energy DissectionThe trainee must dissect through a fat layer to expose a vessel then coagulate the vessel at two points and finally cut the vessel between the two coagulated points. Primary skills assessed include accurate activation and use of energy sources, dissection of vessels and tissues, cutting and coagulation of


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Surgery_Schwartz. finally cut the vessel between the two coagulated points. Primary skills assessed include accurate activation and use of energy sources, dissection of vessels and tissues, cutting and coagulation of vessels, and multiple arm control.Table 53-7Principles of team-based health care• Shared goals: The team—including the patient and, where appropriate, family members or other support persons—works to establish shared goals that reflect patient and family priorities, and can be clearly articulated, understood, and supported by all team members.• Clear roles: There are clear expectations for each team member’s functions, responsibilities, and accountabilities, which optimize the team’s efficiency and often make it possible for the team to take advantage of division of labor, thereby accomplishing more than the sum of its parts.• Mutual trust: Team members earn each other’s trust, creating strong norms of reciprocity and greater opportunities for shared achievement.• Effective communication:


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Surgery_Schwartz. more than the sum of its parts.• Mutual trust: Team members earn each other’s trust, creating strong norms of reciprocity and greater opportunities for shared achievement.• Effective communication: The team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings.• Measurable processes and outcomes: The team agrees on and implements reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team’s goals. These are used to track and improve performance immediately and over time.Reproduced with permission from Mitchell P, Wynia M, Golden R, et al. Core Principles & Values of Effective Team-Based Health Care. Discussion Paper. Institute of Medicine, October 2012.a means of increasing the safety of healthcare. There are meth-ods to accomplish medical team training that do not involve simulation,


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Surgery_Schwartz. Care. Discussion Paper. Institute of Medicine, October 2012.a means of increasing the safety of healthcare. There are meth-ods to accomplish medical team training that do not involve simulation, but high-fidelity patient simulation has proven to be highly effective in increasing health care team competency, and systematic reviews have given evidence based endorsement of this approach.138Simulation training for communication and other teamwork-pertinent nontechnical skills requires learners to be embed-ded in realistic scenarios pertinent to a healthcare team’s 7actual clinical responsibilities where activities and interactions prompted by the simulated clinical circumstances can be prac-ticed and observed. The computer-driven high-fidelity manikin simulator serving as the “patient” at the center of these activities can be monitored and controlled to demonstrate realistic physi-ology consistent with the clinical condition needed for the scenario.139 Software-driven, physiologic


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Surgery_Schwartz. at the center of these activities can be monitored and controlled to demonstrate realistic physi-ology consistent with the clinical condition needed for the scenario.139 Software-driven, physiologic changes from the baseline state can occur in response to either manual commands or programmed adjustments to accurately depict, for example, new, ongoing and unexpected clinical developments with blood loss, sepsis, or myocardial ischemia. Basic interventions such as airway management, drug administration and wound care for moulaged body parts can also be performed. Hybrid simulations using both manikin and open abdominal or laparoscopic surgi-cal simulators have also been used to extend scenarios to an operating room setting, with all members of the surgical team engaged in their role-specific tasks.136,140,141 These events can be conducted in a dedicated simulation suite or in an actual clinical area where it would be termed in situ simulation.The postsimulation debriefing is an


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Surgery_Schwartz. tasks.136,140,141 These events can be conducted in a dedicated simulation suite or in an actual clinical area where it would be termed in situ simulation.The postsimulation debriefing is an essential compo-nent of simulation-based team training. This is where learning points are reinforced and progress towards desired knowledge, attitudes, and behavior can be developed.142,143 Participants are prompted to reflect on the events of the simulation and to openly discuss positive and negative aspects of the experience. The debriefing environment and discussion ought to be open, nonjudgmental, and directed at improvement in individual and overall team performance. A facilitator with strong content knowledge should ensure that the discussion includes identifica-tion of gaps between the observed and desired performance. An Brunicardi_Ch53_p2163-p2186.indd 217622/02/19 4:39 PM 2177SKILLS AND SIMULATIONCHAPTER 53effective facilitator is cognizant of the need to keep the debrief-ing


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Surgery_Schwartz. and desired performance. An Brunicardi_Ch53_p2163-p2186.indd 217622/02/19 4:39 PM 2177SKILLS AND SIMULATIONCHAPTER 53effective facilitator is cognizant of the need to keep the debrief-ing learner-centric and to keep discussion focused on oppor-tunities for improvement. Although debriefing is uniformly viewed as essential to health care team simulation effectiveness and structured debriefing models are frequently cited as highly effective, there is no consensus on which specific methods, including video review debriefings, represent best practices.144 Quality of implementation is consistently cited as the most important contributing factor to effectiveness of debriefing.The complexity of team-managed clinical events makes measurement of team performance challenging, but several assessment tools have been developed and used successfully in simulation settings. NOTECHS (Non-Technical Skills) and the NOTSS (Non-Technical Skills for Surgeons) instruments have been used to study


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Surgery_Schwartz. assessment tools have been developed and used successfully in simulation settings. NOTECHS (Non-Technical Skills) and the NOTSS (Non-Technical Skills for Surgeons) instruments have been used to study nontechnical abilities of individuals in surgi-cal teams.141,145-147 The principal focus of these rating scales is on the quality and effectiveness of situational awareness and com-munication. Instruments such as the Mayo High Performance Teamwork scale or the surgery-specific OTAS (Observational Team Assessment Scale) place focus on the team dynamics that extend beyond the single team member.148,149 These have been used to detect changes in team performance with training. Rosen suggested a framework for a best practices approach to team performance assessment in simulation that details specific appli-cations of measurement techniques in the simulation training environment.150Simulation training directed at nontechnical skills has been shown to improve clinical performance and improve


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Surgery_Schwartz. appli-cations of measurement techniques in the simulation training environment.150Simulation training directed at nontechnical skills has been shown to improve clinical performance and improve knowledge and attitudes about team functioning as measured in simulated surgical settings such as the trauma bay and the OR for interdis-ciplinary surgical teams and for surgical trainees.136,151-154 Two systematic reviews of simulation training to increase team skills in the operating room consistently bear out this result, but both also cited the small number of studies where simulation training effects were investigated in the clinical OR setting and lack of evidence of improved clinical outcomes with such training.155,156ERROR PREVENTIONError avoidance and prevention are the overarching goals of sur-gical care and the time-honored focus of surgical training.157 Fac-ulty who are responsible for training the next generation of highly qualified surgeons must facilitate the delicate balance


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Surgery_Schwartz. of sur-gical care and the time-honored focus of surgical training.157 Fac-ulty who are responsible for training the next generation of highly qualified surgeons must facilitate the delicate balance between resident autonomy and patient safety. From a training perspective, gradual increases in patient responsibility, autonomous decision-making, and operative action provide a critical opportunity for independent hands-on performance, critical thinking, and action-based skill assessment. However, resident autonomy must be bal-anced with the goal of delivering high-quality, error-free patient care. A key component to achieving residency training goals includes exposure to techniques and strategies for avoiding errors. The relationship between errors and patient safety is well estab-lished in the literature and is also the cornerstone of the case review process for surgical morbidity and mortality conferences.158 Simulation technology allows trainees the opportunity to execute a variety of


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Surgery_Schwartz. literature and is also the cornerstone of the case review process for surgical morbidity and mortality conferences.158 Simulation technology allows trainees the opportunity to execute a variety of tasks and procedures while also experiencing the cognitive demands of surgery, including error correction and surgical planning decisions. Fig. 53-8 presents a framework for categorizing surgical errors that may take place on the cognitive-motor continuum.159Simulation-based curricular approaches to exposing and training surgical errors include (a) the use of error-enabled 8CognitiveError preventionWhat will prevent an error?Knows the anatomy: right technique; natural hx of disease; how to avoid an errorSelect the right operation; the right stitch; the right instrumentWhat should you be concerned about?Cognitive-motorError recognitionEstimate errorrisk for: technicalapproach andpatient selectionWhich of thesemay result in anerror?Error rescueWhat areyour optionsfor


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Surgery_Schwartz. should you be concerned about?Cognitive-motorError recognitionEstimate errorrisk for: technicalapproach andpatient selectionWhich of thesemay result in anerror?Error rescueWhat areyour optionsfor errorrescue?Describewhat youwould do ifError preventionPre-error makesadjustments totechnical approachbased on errorpreventionError recognitionNear miss recognitionfollowed by correctiveactionError rescuePost-error knows andexecutes options forerror correctionIdentify propertechnique;potential error:error riskKnows -surgicaloptionsExample: Plansahead of time toadjust tensionduring knot tyingbased on tissuetypeExample: Recognizesthat the first knot wasa little tight then makesan adjustment to getthe second knot justrightExample: First knotpulled throughRescue: Freshenstissue edge, placesa new stitchError loopFigure 53-8. A framework for understanding error prevention, error recognition, and error rescue/correction during both the cognitive phase as well as the cognitive-motor phase where


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Surgery_Schwartz. stitchError loopFigure 53-8. A framework for understanding error prevention, error recognition, and error rescue/correction during both the cognitive phase as well as the cognitive-motor phase where there is fluid integration and updating of motor and cognitive decisions. This fluid integration allows for an error loop, as each decision is based on the results of each motor action in a dynamic fashion where an error can take place with each decision or action. (Reproduced with permission from Pugh CM, Santacaterina S, DaRosa DA, et al: Intra-operative decision making: more than meets the eye, J Biomed Inform. 2011 Jun;44(3):486-496.)Brunicardi_Ch53_p2163-p2186.indd 217722/02/19 4:39 PM 2178SPECIFIC CONSIDERATIONSPART IIsimulations, where the learner can make any of a variety of errors during the course of the task; and (b) the use of forced-error simulations, where the learner experiences a specific, usually unexpected error and demonstrates error management as well as options for


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Surgery_Schwartz. during the course of the task; and (b) the use of forced-error simulations, where the learner experiences a specific, usually unexpected error and demonstrates error management as well as options for correction. Error management is a human factors process that includes making, detecting, and correcting errors.160,161 Several studies show that there is wide variation in the timing and type of operative decisions that residents make when interacting with an error-enabled simulation.112,162-164 Specific error training simulations have been developed using a cognitive task analysis approach to guide the design of error scenarios. Cognitive task analysis involves the use of structured interviews to explore how experts approach the error management process, including intraoperative decision-making and technical approaches.165,166 The error-enabled approach allows for a broad assessment of learning needs. The forced-error approach allows instructors to engage in specific error management


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Surgery_Schwartz. and technical approaches.165,166 The error-enabled approach allows for a broad assessment of learning needs. The forced-error approach allows instructors to engage in specific error management skills and metrics. Error-enabled and forced-error surgical simulation trainers have been used in a variety of research and training modules to allow observation and assessment of surgical residents as they independently perform operative procedures and practice the error management process.112,166,167Another approach to error training and assessment is the use of assessments that focus on errors. Current assessment tools for surgical skills include task-specific and global rating scales, final product analysis, and documentation of critical fail-ures.160,168 These existing tools for assessing surgical residents largely focus on manual techniques and procedure time and do not capture the cause of resident performance failures.169 Use of error-related theories in human factors allows for the


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Surgery_Schwartz. residents largely focus on manual techniques and procedure time and do not capture the cause of resident performance failures.169 Use of error-related theories in human factors allows for the devel-opment of error-centric skills assessments.161,170,171 One study used previously developed human error classifications, includ-ing omission versus commission and cognitive versus technical as a means of assessing surgical residents.162 Omission errors were defined as failure to perform a step entirely. Commis-sion errors represented failure to perform a step correctly. For example, failure to measure the hernia defect was categorized as an omission error, whereas measuring the hernia defect with an inaccurate method was categorized as a commission error. Errors in information, diagnosis, and strategy were categorized as cognitive, and errors in action, procedure, or mechanics were classified as technical. Use of assessment surveys with this type of differentiation allows for development of


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Surgery_Schwartz. were categorized as cognitive, and errors in action, procedure, or mechanics were classified as technical. Use of assessment surveys with this type of differentiation allows for development of error metrics in sur-gery and focused error training and feedback.172SIMULATION AND PATIENT OUTCOMESSurgical simulation training is intended to make patient care safe and free of avoidable errors and to maximize opportunities for good clinical outcomes. The Kirkpatrick four-level scale (Table 53-8) characterizes educational intervention effects, including those that might improve surgeon performance in clinical settings (Kirkpatrick level 3) or those that might actually improve patient outcomes (Kirkpatrick level 4).173 Despite the expanding use of simulation in proficiency-based practice models over at least 15 years, there are surprisingly few studies of simulation-based surgical training that can be described as Kirkpatrick level 4. On the other hand, there are numerous studies showing that


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Surgery_Schwartz. at least 15 years, there are surprisingly few studies of simulation-based surgical training that can be described as Kirkpatrick level 4. On the other hand, there are numerous studies showing that clinician performance during the course of clinical care is improved after simulation training (Kirkpatrick level 3). As detection of changes in clinical Table 53-8Kirkpatrick level scale of educational outcomesKIRKPATRICK LEVELLEVEL DESCRIPTIONDESCRIPTION FOR SIMULATIONLevel 1ReactionDid the learner perceive value in using a simulator or participating in simulation training?Level 2LearningDid the learner’s knowledge, skill, or attitude improve as a result of the simulation training?Level 3Behavioral changeDid the knowledge, skills, and attitudes acquired during simulation transfer to the clinical environment?Level 4Institutional impactDid the simulation training program lead to improved patient outcomes?Data from Cox T, Seymour N, Stefanidis D: Moving the Needle: Simulation’s Impact on


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Surgery_Schwartz. environment?Level 4Institutional impactDid the simulation training program lead to improved patient outcomes?Data from Cox T, Seymour N, Stefanidis D: Moving the Needle: Simulation’s Impact on Patient Outcomes, Surg Clin North Am. 2015 Aug;95(4):827-838.outcomes can be quite challenging, it may be difficult to isolate simulation training effects from numerous other factors that can also affect patient outcomes. When looking specifically at a low-frequency complication event such as bile duct injury with laparoscopic cholecystectomy, the detection of a small, positive training effect is statistically improbable. However, the use of available Kirkpatrick level 3 data to support assumptions about training benefits is fully supportable given the preponderance of literature showing such benefit.The best current evidence for improved patient outcomes with simulation is that of technical and cognitive training for central venous catheter (CVC) insertion. In 2009, Barsuk et al monitored


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Surgery_Schwartz. best current evidence for improved patient outcomes with simulation is that of technical and cognitive training for central venous catheter (CVC) insertion. In 2009, Barsuk et al monitored catheter-related bloodstream infection incidence in an ICU setting over a 32-month period before and after institu-tion of proficiency-based simulation training. After simulation-trained medical residents began performing CVC insertion, an 85% reduction in these infections was observed (3.2 per 1000 catheter-days reduced to 0.50 infections per 1000 catheter-days).174 Subsequently, the same group reported that the finan-cial savings realized with these improved outcomes amounted to a 7:1 return of the investment for the training.175 In a similar sin-gle unit observational study, Burden et al reported a reduction in catheter-related bloodstream infection incidence from 6.47 per 1000 catheter days to 2.44 per 1000 catheter days after training intervention and comparable financial savings with shorter


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Surgery_Schwartz. reduction in catheter-related bloodstream infection incidence from 6.47 per 1000 catheter days to 2.44 per 1000 catheter days after training intervention and comparable financial savings with shorter ICU and hospital stays.176 Single cohort studies have inherent weak-nesses, but a somewhat smaller randomized trial of simulation training versus traditional apprenticeship model-trained controls also showed this reduced infection incidence (1.0 vs. 3.4 infec-tions per 1000 catheter-days, respectively).177Riley and colleagues conducted a study in three small community hospitals, administering TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) didactic team training to perinatal care teams at one hospital, TeamSTEPPS with an accompanying program of in situ simula-tions at a second, and no intervention at the third hospital, which Brunicardi_Ch53_p2163-p2186.indd 217822/02/19 4:39 PM 2179SKILLS AND SIMULATIONCHAPTER 53served as the study control.178,179


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Surgery_Schwartz. at a second, and no intervention at the third hospital, which Brunicardi_Ch53_p2163-p2186.indd 217822/02/19 4:39 PM 2179SKILLS AND SIMULATIONCHAPTER 53served as the study control.178,179 The simulation interventions were designed to involve triage, labor and delivery, and OR components of care. Perinatal outcomes were assessed using the Weighted Adverse Outcomes Score (WAOS). Simulation train-ing resulted in improved clinical results with a 37.4% decrease in WAOS observed in the simulation intervention group, while similar benefit was not observed in either the didactic-trained or control groups.TeamSTEPPS with supplemental simulation training was also studied by Capella and colleagues for team performance and patient outcomes in trauma care.180 Trauma resuscitations for successive 2-month periods separated by didactic and scenario-based simulation training to subjectively-defined proficiency levels (33 before training, 40 after training) were assessed in multiple teamwork domains


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Surgery_Schwartz. periods separated by didactic and scenario-based simulation training to subjectively-defined proficiency levels (33 before training, 40 after training) were assessed in multiple teamwork domains including overall performance using the TPOT (Trauma Team Performance Observation Tool). Significant improvements were observed post training in leader-ship, situational monitoring, mutual support, communication, and overall scoring. In addition, time to OR was also observed to decrease. Steinemann and colleagues reported on a larger number of trauma resuscitations, 141 before and 103 after in situ trauma bay patient simulation training with accompanying didactic instruction.181 Although significant improvements in patient outcomes were not observed in this study, resuscitation time did decrease following training.In a comprehensive review of literature examining simula-tion impact on patient outcomes, Zendejas identified 50 stud-ies purporting to show patient outcomes.182 For the majority of


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Surgery_Schwartz. training.In a comprehensive review of literature examining simula-tion impact on patient outcomes, Zendejas identified 50 stud-ies purporting to show patient outcomes.182 For the majority of these, the quality of clinical outcomes evidence was considered low, and appropriate validity data were reported for results in only a small number of published reports. In a subsequent review of 1328 articles resulting from an exhaustive literature search, Cox identified 12 individual articles that reported suf-ficient patient outcomes data to be considered Kirkpatrick level 4.183 Concerns regarding the relatively few studies of this nature are primarily methodological and relate to the prepon-derance of use of the observational preand posttraining study model with its inherent bias risk, rather than randomized con-trolled trials. These studies have also tended to be quite limited in size. In surgery, the general areas of surgeon performance that have lent themselves to study of educational


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Surgery_Schwartz. than randomized con-trolled trials. These studies have also tended to be quite limited in size. In surgery, the general areas of surgeon performance that have lent themselves to study of educational outcomes in the clinical setting after simulation training include technical abilities and observable behaviors during team-based activi-ties. The use of decreased operative time or technical errors as clinical outcomes after simulation training might suggest, but do not clearly establish, a patient safety or other efficacy benefit. However, these metrics have frequently been used to make the case for the potential for such benefits in skills transfer studies for procedures such as laparoscopic cholecystectomy and lapa-roscopic hernia repair.56,63 There is a clear need to obtain high quality evidence of how proficiency-based simulation training impacts surgical patient outcomes.In a recent study examining intern response to pediatric codes, simulation training was shown to significantly


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Surgery_Schwartz. evidence of how proficiency-based simulation training impacts surgical patient outcomes.In a recent study examining intern response to pediatric codes, simulation training was shown to significantly reduce the time to request help, to initiate bag-mask ventilation, and to ini-tiate chest compressions.184 Citing the rarity of pediatric codes, investigators measured this effect in in mock code situations using patient simulators. This use of a high-fidelity simulation environment as a surrogate for clinical events, that might oth-erwise be difficult to observe, may be the only practical model available for the study of provider performance outcomes with educational interventions.SIMULATION TRAINING FOR THE PRACTICING SURGEON AND MAINTENANCE OF SKILLGiven the current requirement for FLS and FES certification in residency, some authors have posed the important question of whether such certification should be applied more broadly to surgeons in practice.185 In a 2012 press release, both


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Surgery_Schwartz. FES certification in residency, some authors have posed the important question of whether such certification should be applied more broadly to surgeons in practice.185 In a 2012 press release, both the ACS and SAGES made the recommendation that all surgeons per-forming laparoscopy obtain FLS certification. The potential to lower malpractice litigation risk under a self-insurance model was used as justification to certify 37 surgeons in FLS in the Harvard system in 2009.186 In a recent report, surgical oncolo-gists new to minimally invasive inguinal lymph node dissec-tion (MILND) were FLS tested prior to performance of their first clinical procedures, which were video-assessed using the GOALS scoring method.187 The FLS score was shown to corre-late with both GOALS results and operative time but not lymph node yield. However, evidence that a lab-based technical and cognitive skills test predicts observed operative technical skill in practicing surgeons is promising and warrants


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Surgery_Schwartz. time but not lymph node yield. However, evidence that a lab-based technical and cognitive skills test predicts observed operative technical skill in practicing surgeons is promising and warrants investigative follow-up.At the present time, the American Board of Surgery’s requirements for Maintenance of Certification (MOC) do not specifically include any certification of technical skills that might use surgical simulation.188 Nonetheless, simulation training and testing can be made available to surgeons in practice to provide an avenue for specific training. Although most investigations of VR use for laparoscopy have examined basic skills acquisition in the lab setting far in advance of any measured impact in the clinical OR, a recent innovative study of the use of a VR simulator for “warm-up” practice immediately before a procedure showed that this improved OR performance.189 As new surgical procedures and technologies are introduced to clinical practice, simulation training solutions


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Surgery_Schwartz. practice immediately before a procedure showed that this improved OR performance.189 As new surgical procedures and technologies are introduced to clinical practice, simulation training solutions could serve just as important a purpose to prepare for these as simulation training methods currently serve for laparoscopic surgery. In a recent publication relating to practicing surgeons, Sullivan et al. provide a framework for development of simulation-based certification models for both trainees and faculty surgeons.190FUTURE CONSIDERATIONSSimulation-based training and assessment is firmly established in surgical education, especially in graduate medical education where learners have been more extensively studied than any other simulation user group. The immediate future of simulation in surgery will likely see expanded use of proficiency-based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educa-tional outcomes as measured in


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Surgery_Schwartz. surgery will likely see expanded use of proficiency-based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educa-tional outcomes as measured in clinical settings.The question of what types of simulation-based assess-ments and training activities might be possible raises questions of where technological advances might open new opportunities.191 The advancement of virtual reality is inevitable, and much richer virtual experiences entering the mainstream in surgical educa-tion seems likely in the near future. Three-dimensional printing technology has been growing in its use and applications and has greatly facilitated the development of anatomically accurate bench top simulations for complex surgical procedures. Some of the materials allow for elegant instrument-based dissections, including the use of electrosurgery.192-1949Brunicardi_Ch53_p2163-p2186.indd 217922/02/19 4:39 PM 2180SPECIFIC CONSIDERATIONSPART IIAdvances in


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Surgery_Schwartz. allow for elegant instrument-based dissections, including the use of electrosurgery.192-1949Brunicardi_Ch53_p2163-p2186.indd 217922/02/19 4:39 PM 2180SPECIFIC CONSIDERATIONSPART IIAdvances in wearables, motion tracking, and sensor tech-nologies allow for a wide variety of hybrid and aug-mented experiences in simulation as well as extensive opportunities for the development of new performance metrics. One study using sensor technology for evaluating clinical breast examination skills noted key performance differences in expe-rienced physicians. Both the sensor data and sensor-guided video analysis allowed for skill quantifications that were previ-ously unknown but critical to performance excellence.195-196Opportunities for remote collaboration are now greatly improved with higher internet speeds, improvements in aug-mented reality technology, and ever-increasing camera reso-lution. VIPAR (Virtual Interactive Presence and Augmented Reality) allows for the visual field of a surgeon


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Surgery_Schwartz. speeds, improvements in aug-mented reality technology, and ever-increasing camera reso-lution. VIPAR (Virtual Interactive Presence and Augmented Reality) allows for the visual field of a surgeon to be converted to a simulation and projected in a remote location.197-198 As such, the system allows for intraoperative collaboration and telementoring.199Irrespective of what new simulation and engineering tech-nologies emerge, these technologies are here not just to stay but to grow as assessment and educational tools. This presents abundant opportunities for simulation leaders in surgery to improve the delivery of care by defining best practice in sim-ulation applications and keeping step with current and future changes in surgical practice.REFERENCESEntries highlighted in bright blue are key references. 1. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857. 2. To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine;


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Surgery_Schwartz. are key references. 1. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857. 2. To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine; 1999. 3. Satava RM. Historical review of surgical simulation—a personal perspective. World J Surg. 2008;32(2):141-148. 4. Martin JA, Regehr G, Reznick R, et al. Objective struc-tured assessment of technical skill (OSATS) for surgical residents. Br J Surg. 1997;84(2):273-278. 5. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative “bench station” examination. Am J Surg. 1997;173(3):226-230. 6. A prospective analysis of 1518 laparoscopic cholecystec-tomies. The Southern Surgeons Club. N Engl J Med. 1991; 324(16):1073-1078. 7. Rosser JC, Rosser LE, Savalgi RS. Skill acquisition and assessment for laparoscopic surgery. Arch Surg. 1997; 132(2):200-204. 8. Derossis AM, Bothwell J, Sigman HH, Fried GM. The effect of practice on performance in a


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Surgery_Schwartz. 2014;6(4):643-652. 30. American Board of Surgery; American College of Surgeons; Association of Program Directors in Surgery; Association for Surgical Education. Statement on surgical preresidency preparatory courses. Surgery. 2014;156(5):1059-1060. 31. Gomez PP, Willis RE, Schiffer BL, Gardner AK, Scott DJ. External validation and evaluation of an intermediate proficiency-based knot-tying and suturing curriculum. J Surg Educ. 2014;71(6):839-845. 32. Sanfey H, Ketchum J, Bartlett J, et al. Verification of proficiency in basic skills for postgraduate year 1 residents. Surgery. 2010;148(4):759-766; discussion 766-757.10Brunicardi_Ch53_p2163-p2186.indd 218022/02/19 4:39 PM 2181SKILLS AND SIMULATIONCHAPTER 53 33. Sanfey H, Dunnington G. Verification of proficiency: a prerequisite for clinical experience. Surg Clin North Am. 2010;90(3):559-567. 34. Satava RM, Gallagher AG. Next generation of procedural skills curriculum development: proficiency-based progression. J Health Spec.


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Surgery_Schwartz. trial of virtual reality simulator training: transfer to live patients. Am J Surg. 2007;194(2):205-211. 106. Haycock A, Koch AD, Familiari P, et al. Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training. Gastrointest Endosc. 2010;71(2):298-307. 107. Ferlitsch A, Schoefl R, Puespoek A, et al. Effect of virtual endoscopy simulator training on performance of upper gastrointestinal endoscopy in patients: a randomized controlled trial. Endoscopy. 2010;42(12):1049-1056. 108. Ende A, Zopf Y, Konturek P, et al. Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial. Gastrointest Endosc. 2012;75(2):254-260. 109. Shirai Y, Yoshida T, Shiraishi R, et al. Prospective randomized study on the use of a computer-based endoscopic simulator for training in esophagogastroduodenoscopy. J Gastroenterol Hepatol. 2008;23(7 pt 1):1046-1050.Brunicardi_Ch53_p2163-p2186.indd 218222/02/19 4:39


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Surgery_Schwartz. the use of a computer-based endoscopic simulator for training in esophagogastroduodenoscopy. J Gastroenterol Hepatol. 2008;23(7 pt 1):1046-1050.Brunicardi_Ch53_p2163-p2186.indd 218222/02/19 4:39 PM 2183SKILLS AND SIMULATIONCHAPTER 53 110. Walsh CM, Sherlock ME, Ling SC, Carnahan H. Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy. Cochrane Database Syst Rev. 2012(6):CD008237. 111. Chaer RA, Derubertis BG, Lin SC, et al. Simulation improves resident performance in catheter-based intervention: results of a randomized, controlled study. Ann Surg. 2006;244(3):343-352. 112. Hseino H, Nugent E, Lee MJ, et al. Skills transfer after proficiency-based simulation training in superficial femoral artery angioplasty. Simul Healthc. 2012;7(5):274-281. 113. Van Herzeele I, Aggarwal R, Choong A, et al. Virtual reality simulation objectively differentiates level of carotid stent experience in experienced interventionalists. J Vasc Surg.


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Surgery_Schwartz. Herzeele I, Aggarwal R, Choong A, et al. Virtual reality simulation objectively differentiates level of carotid stent experience in experienced interventionalists. J Vasc Surg. 2007;46(5):855-863. 114. Van Herzeele I, Aggarwal R, Neequaye S, et al. Experienced endovascular interventionalists objectively improve their skills by attending carotid artery stent training courses. Eur J Vasc Endovasc Surg. 2008;35(5):541-550. 115. Cates CU, Patel AD, Nicholson WJ. Use of virtual reality simulation for mission rehearsal for carotid stenting. JAMA. 2007;297(3):265-266. 116. Hislop SJ, Hedrick JH, Singh MJ, et al. Simulation case rehearsals for carotid artery stenting. Eur J Vasc Endovasc Surg. 2009;38(6):750-754. 117. Willaert W, Aggarwal R, Bicknell C, et al. Patient-specific simulation in carotid artery stenting. J Vasc Surg. 2010; 52(6):1700-1705. 118. Willaert W, Aggarwal R, Harvey K, et al. Efficient implementation of patient-specific simulated rehearsal for the carotid artery stenting


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Surgery_Schwartz. artery stenting. J Vasc Surg. 2010; 52(6):1700-1705. 118. Willaert W, Aggarwal R, Harvey K, et al. Efficient implementation of patient-specific simulated rehearsal for the carotid artery stenting procedure: part-task rehearsal. Eur J Vasc Endovasc Surg. 2011;42(2):158-166. 119. Desender L, Van Herzeele I, Lachat M, et al. A multicentre trial of patient specific rehearsal prior to EVAR: impact on procedural planning and team performance. Eur J Vasc Endovasc Surg. 2017;53(3):354-361. 120. Endo K, Sata N, Ishiguro Y, et al. A patient-specific surgical simulator using preoperative imaging data: an interactive simulator using a three-dimensional tactile mouse. J Comp Surg. 2014;1(10). 121. Eschweiler J, Stromps JP, Fischer M, et al. Development of a biomechanical model of the wrist joint for patient-specific model guided surgical therapy planning: Part 1. Proc Inst Mech Eng H. 2016;230(4):310-325. 122. Makiyama K, Yamanaka H, Ueno D, et al. Validation of a patient-specific simulator for


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Surgery_Schwartz. patient-specific model guided surgical therapy planning: Part 1. Proc Inst Mech Eng H. 2016;230(4):310-325. 122. Makiyama K, Yamanaka H, Ueno D, et al. Validation of a patient-specific simulator for laparoscopic renal surgery. Int J Urol. 2015;22(6):572-576. 123. Oshiro Y, Yano H, Mitani J, et al. Novel 3-dimensional virtual hepatectomy simulation combined with real-time deformation. World J Gastroenterol. 2015;21(34):9982-9992. 124. Liu M, Curet M. A review of training research and virtual reality simulators for the da Vinci surgical system. Teach Learn Med. 2015;27(1):12-26. 125. Bric J, Connolly M, Kastenmeier A, Goldblatt M, Gould JC. Proficiency training on a virtual reality robotic surgical skills curriculum. Surg Endosc. 2014;28(12):3343-3348. 126. Lyons C, Goldfarb D, Jones SL, et al. Which skills really matter? Proving face, content, and construct validity for a commercial robotic simulator. Surg Endosc. 2013;27(6):2020-2030. 127. Abboudi H, Khan MS, Aboumarzouk O, et al.


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Surgery_Schwartz. et al. Which skills really matter? Proving face, content, and construct validity for a commercial robotic simulator. Surg Endosc. 2013;27(6):2020-2030. 127. Abboudi H, Khan MS, Aboumarzouk O, et al. Current status of validation for robotic surgery simulators—a systematic review. BJU Int. 2013;111(2):194-205. 128. Moglia A, Ferrari V, Morelli L, et al. A systematic review of virtual reality simulators for robot-assisted surgery. Eur Urol. 2016;69(6):1065-1080. 129. Smith R, Patel V, Satava R. Fundamentals of robotic surgery: a course of basic robotic surgery skills based upon a 14-society consensus template of outcomes measures and curriculum development. Int J Med Robot. 2014;10(3):379-384. 130. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320(7237):781-785. 131. Helmreich RL, Davies JM. Anaesthetic simulation and lessons to be learned from aviation. Can J Anaesth. 1997;44(9):907-912. 132. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment:


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Surgery_Schwartz. RL, Davies JM. Anaesthetic simulation and lessons to be learned from aviation. Can J Anaesth. 1997;44(9):907-912. 132. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988;69(3):387-394. 133. Gaba DM. Improving anesthesiologists’ performance by simulating reality. Anesthesiology. 1992;76(4):491-494. 134. Boet S, Bould MD, Fung L, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Anaesth. 2014;61(6):571-582. 135. Fung L, Boet S, Bould MD, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: a systematic review. J Interprof Care. 2015;29(5):433-444. 136. Paige JT, Kozmenko V, Yang T, et al. High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Surgery. 2009;145(2):138-146. 137. Mitchell P, Wynia M, Golden R, et


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Surgery_Schwartz. Kozmenko V, Yang T, et al. High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care. Surgery. 2009;145(2):138-146. 137. Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine. 2012. Available at: https://www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values.pdf. Accessed August 27, 2018. 138. Eddy K, Jordan Z, Stephenson M. Health professionals’ experience of teamwork education in acute hospital settings: a systematic review of qualitative literature. JBI Database System Rev Implement Rep. 2016;14(4):96-137. 139. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Qual Saf Health Care. 2004;13 Suppl 1:i11-18. 140. Paige JT, Kozmenko V, Yang T, et al. Attitudinal changes resulting from repetitive training of operating room personnel using of high-fidelity simulation at the point of


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Surgery_Schwartz. 2004;13 Suppl 1:i11-18. 140. Paige JT, Kozmenko V, Yang T, et al. Attitudinal changes resulting from repetitive training of operating room personnel using of high-fidelity simulation at the point of care. Am Surg. 2009;75(7):584-590; discussion 590-581. 141. Powers KA, Rehrig ST, Irias N, et al. Simulated laparoscopic operating room crisis: An approach to enhance the surgical team performance. Surg Endosc. 2008;22(4):885-900. 142. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007;2(2):115-125. 143. Paige JT, Arora S, Fernandez G, Seymour N. Debriefing 101: training faculty to promote learning in simulation-based training. Am J Surg. 2015;209(1):126-131. 144. Levett-Jones T, Lapkin S. The effectiveness of debriefing in simulation-based learning for health professionals: a systematic review. JBI Libr Syst Rev. 2012;10(51): 3295-3337. 145. Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary crisis simulations: the way forward for


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Surgery_Schwartz. for health professionals: a systematic review. JBI Libr Syst Rev. 2012;10(51): 3295-3337. 145. Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary crisis simulations: the way forward for training surgical teams. World J Surg. 2007;31(9):1843-1853. 146. Yule S, Flin R, Maran N, et al. Surgeons’ non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system. World J Surg. 2008;32(4): 548-556. 147. Yule S, Parker SH, Wilkinson J, et al. Coaching non-technical skills improves surgical residents’ performance in a simulated operating room. J Surg Educ. 2015;72(6):1124-1130. 148. Malec JF, Torsher LC, Dunn WF, et al. The mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills. Simul Healthc. 2007;2(1):4-10. 149. Healey AN, Undre S, Vincent CA. Developing observational measures of performance in surgical teams. Qual Saf Health Care. 2004;13(suppl 1):i33-40. 150. Rosen MA, Salas E, Wilson KA,


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Surgery_Schwartz. AN, Undre S, Vincent CA. Developing observational measures of performance in surgical teams. Qual Saf Health Care. 2004;13(suppl 1):i33-40. 150. Rosen MA, Salas E, Wilson KA, et al. Measuring team performance in simulation-based training: adopting best practices for healthcare. Simul Healthc. 2008;3(1):33-41.Brunicardi_Ch53_p2163-p2186.indd 218322/02/19 4:39 PM 2184SPECIFIC CONSIDERATIONSPART II 151. Knudson MM, Khaw L, Bullard MK, et al. Trauma training in simulation: translating skills from SIM time to real time. J Trauma. 2008;64(2):255-263; discussion 263-254. 152. Hamilton NA, Kieninger AN, Woodhouse J, et al. Video review using a reliable evaluation metric improves team function in high-fidelity simulated trauma resuscitation. J Surg Educ. 2012;69(3):428-431. 153. Gettman MT, Pereira CW, Lipsky K, et al. Use of high fidelity operating room simulation to assess and teach communication, teamwork and laparoscopic skills: initial experience. J Urol.


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Surgery_Schwartz. MT, Pereira CW, Lipsky K, et al. Use of high fidelity operating room simulation to assess and teach communication, teamwork and laparoscopic skills: initial experience. J Urol. 2009;181(3):1289-1296. 154. Dedy NJ, Bonrath EM, Zevin B, Grantcharov TP. Teaching nontechnical skills in surgical residency: a systematic review of current approaches and outcomes. Surgery. 2013;154(5): 1000-1008. 155. Tan SB, Pena G, Altree M, Maddern GJ. Multidisciplinary team simulation for the operating theatre: a review of the literature. ANZ J Surg. 2014;84(7-8):515-522. 156. Cumin D, Boyd MJ, Webster CS, Weller JM. A systematic review of simulation for multidisciplinary team training in operating rooms. Simul Healthc. 2013;8(3):171-179. 157. Darosa DA, Pugh CM. Error training: missing link in surgical education. Surgery. 2012;151(2):139-145. 158. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434-1442. 159. Schmidt


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Surgery_Schwartz. Surgery. 2012;151(2):139-145. 158. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434-1442. 159. Schmidt RA, Lee TD. Motor Learning and Performance: From Principles to Application. 5th ed. Champaign, IL: Human Kinetics; 2014. 160. Kontogiannis T. User strategies in recovering from errors in man-machine systems. Safety Science. 1999;32(1):49-68. 161. Rasmussen J. Human errors: A taxonomy for describing human malfunction in industrial installations. J Occup Accident. 1982;4(2-4):311-333. 162. D’Angelo AL, Law KE, Cohen ER, et al. The use of error analysis to assess resident performance. Surgery. 2015;158(5):1408-1414. 163. Pugh CM, DaRosa DA, Santacaterina S, Clark RE. Faculty evaluation of simulation-based modules for assessment of intraoperative decision making. Surgery. 2011;149(4):534-542. 164. Tang B, Hanna GB, Cuschieri A. Analysis of errors enacted by surgical trainees during skills training


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Surgery_Schwartz. modules for assessment of intraoperative decision making. Surgery. 2011;149(4):534-542. 164. Tang B, Hanna GB, Cuschieri A. Analysis of errors enacted by surgical trainees during skills training courses. Surgery. 2005;138(1):14-20. 165. Clark RE, Pugh CM, Yates KA, et al. The use of cognitive task analysis to improve instructional descriptions of procedures. J Surg Res. 2012;173(1):e37-42. 166. Law KE, Ray RD, D’Angelo AD, et al. Exploring senior residents’ intraoperative error management strategies: a potential measure of performance improvement. J Surg Educ. 2016;73(6):e64-e70. 167. Pugh CM, Santacaterina S, DaRosa DA, Clark RE. Intra-operative decision making: more than meets the eye. J Biomed Inform. 2011;44(3):486-496. 168. Schmitz CC, DaRosa D, Sullivan ME, et al. Development and verification of a taxonomy of assessment metrics for surgical technical skills. Acad Med. 2014;89(1):153-161. 169. Falcone JL, Hamad GG. The American Board of Surgery Certifying Examination: a


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Surgery_Schwartz. and verification of a taxonomy of assessment metrics for surgical technical skills. Acad Med. 2014;89(1):153-161. 169. Falcone JL, Hamad GG. The American Board of Surgery Certifying Examination: a retrospective study of the decreasing pass rates and performance for first-time examinees. J Surg Educ. 2012;69(2):231-235. 170. Reason JT. Human Error. Cambridge, England: Cambridge University Press; 1990. 171. Hooper BJ, O’Hare DP. Exploring human error in military aviation flight safety events using post-incident classification systems. Aviat Space Environ Med. 2013;84(8):803-813. 172. Wiegmann DA. Analysis of error management strategies during cardiac surgery: theoretical and practical implications. Paper presented at: Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2010. 173. Yardley S, Dornan T. Kirkpatrick’s levels and education “evidence.” Med Educ. 2012;46(1):97-106. 174. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based


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Surgery_Schwartz. 2010. 173. Yardley S, Dornan T. Kirkpatrick’s levels and education “evidence.” Med Educ. 2012;46(1):97-106. 174. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169(15):1420-1423. 175. Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010;5(2):98-102. 176. Burden AR, Torjman MC, Dy GE, et al. Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle? J Clin Anesth. 2012;24(7):555-560. 177. Khouli H, Jahnes K, Shapiro J, et al. Performance of medical residents in sterile techniques during central vein catheterization: randomized trial of efficacy of simulation-based training. Chest. 2011;139(1):80-87. 178. Riley W, Davis S, Miller K, et al.


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Surgery_Schwartz. residents in sterile techniques during central vein catheterization: randomized trial of efficacy of simulation-based training. Chest. 2011;139(1):80-87. 178. Riley W, Davis S, Miller K, et al. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf. 2011;37(8):357-364. 179. Agency for Healthcare Research and Quality. TeamSTEPPS Guide to Action: Creating a Safety Net for your Healthcare Organization. Available at: https://www.onlineregistrationcenter .com/company_images/347/TeamSTEPPS_GuideToAction .pdf. Accessed August 27, 2018. 180. Capella J, Smith S, Philp A, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ. 2010;67(6):439-443. 181. Steinemann S, Berg B, Skinner A, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ. 2011;68(6):472-477. 182. Zendejas B, Brydges R, Wang AT, Cook DA. Patient outcomes


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Surgery_Schwartz. A, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ. 2011;68(6):472-477. 182. Zendejas B, Brydges R, Wang AT, Cook DA. Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med. 2013;28(8):1078-1089. 183. Cox T, Seymour N, Stefanidis D. Moving the needle: simulation’s impact on patient outcomes. Surg Clin North Am. 2015;95(4):827-838. 184. Ross JC, Trainor JL, Eppich WJ, Adler MD. Impact of simulation training on time to initiation of cardiopulmonary resuscitation for first-year pediatrics residents. J Grad Med Educ. 2013;5(4):613-619. 185. Hafford ML, Van Sickle KR, Willis RE, et al. Ensuring competency: are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel? Surg Endosc. 2013;27(1): 118-126. 186. Derevianko AY, Schwaitzberg SD, Tsuda S, et al. Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery


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Surgery_Schwartz. surgeons and operating room personnel? Surg Endosc. 2013;27(1): 118-126. 186. Derevianko AY, Schwaitzberg SD, Tsuda S, et al. Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery training and testing: a benchmark for patient safety. Surg Endosc. 2010;24(3):616-623. 187. Zendejas B, Jakub JW, Terando AM, et al. Laparoscopic skill assessment of practicing surgeons prior to enrollment in a surgical trial of a new laparoscopic procedure. Surg Endosc. 2017;31(8):3313-3319. 188. Buyske J. Forks in the road: the assessment of surgeons from the American Board of Surgery perspective. Surg Clin North Am. 2016;96(1):139-146. 189. Calatayud D, Arora S, Aggarwal R, et al. Warm-up in a virtual reality environment improves performance in the operating room. Ann Surg. 2010;251(6):1181-1185. 190. Sullivan SA, Anderson BM, Pugh CM. Development of technical skills: education, simulation, and maintenance of certification. J Craniofac Surg.


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Surgery_Schwartz. operating room. Ann Surg. 2010;251(6):1181-1185. 190. Sullivan SA, Anderson BM, Pugh CM. Development of technical skills: education, simulation, and maintenance of certification. J Craniofac Surg. 2015;26(8):2270-2274.Brunicardi_Ch53_p2163-p2186.indd 218422/02/19 4:39 PM 2185SKILLS AND SIMULATIONCHAPTER 53 191. Badash I, Burtt K, Solorzano CA, Carey JN. Innovations in surgery simulation: a review of past, current and future techniques. Ann Transl Med. 2016 Dec;4(23):453. 192. Gause CD, Hsiung G, Schwab B, et al. Advances in pediatric surgical education: a critical appraisal of two consecutive minimally invasive pediatric surgery training courses. J Laparoendosc Adv Surg Tech A. 2016;26(8):663-670. 193. Cheung CL, Looi T, Lendvay TS, Drake JM, Farhat WA. Use of 3-dimensional printing technology and silicone modeling in surgical simulation: development and face validation in pediatric laparoscopic pyeloplasty. J Surg Educ. 2014;71(5):762-767. 194. Chan HH, Siewerdsen JH, Vescan A,


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Surgery_Schwartz. technology and silicone modeling in surgical simulation: development and face validation in pediatric laparoscopic pyeloplasty. J Surg Educ. 2014;71(5):762-767. 194. Chan HH, Siewerdsen JH, Vescan A, et al. 3D rapid prototyping for otolaryngology-head and neck surgery: applications in image-guidance, surgical simulation and patient-specific modeling. PLoS One. 2015;10(9):e0136370. 195. Laufer S, Cohen ER, Kwan C, et al. Sensor technology in assessments of clinical skill. N Engl J Med. 2015 Feb 19;372(8):784-786. 196. Laufer S, D’Angelo AD, Kwan C, et al. Rescuing the Clinical Breast Examination: Advances in Classifying Technique and Assessing Physician Competency. Ann Surg. 2016 Sep 21. 197. Shenai MB, Dillavou M, Shum C, et al. Virtual interactive presence and augmented reality (VIPAR) for remote surgical assistance. Neurosurgery. 2011;68(1 suppl):200-207; discussion 207. 198. Shenai MB, Tubbs RS, Guthrie BL, Cohen-Gadol AA. Virtual interactive presence for real-time, long-distance


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Surgery_Schwartz. for remote surgical assistance. Neurosurgery. 2011;68(1 suppl):200-207; discussion 207. 198. Shenai MB, Tubbs RS, Guthrie BL, Cohen-Gadol AA. Virtual interactive presence for real-time, long-distance surgical collaboration during complex microsurgical procedures. J Neurosurg. 2014;121(2):277-284. 199. Ponce BA, Jennings JK, Clay TB, et al. Telementoring: use of augmented reality in orthopaedic education: AAOS exhibit selection. J Bone Joint Surg Am. 2014;96(10):e84.Brunicardi_Ch53_p2163-p2186.indd 218522/02/19 4:39 PM


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Surgery_Schwartz. Web-Based Education and Implications of Social MediaLillian S. Kao and Michael E. Zenilman 54chapterINTRODUCTIONSurgical education has changed significantly over the past two decades. Disruptive forces such as work hour restrictions and the advent of laparoscopy have forced educators to rethink how and where to teach residents. Technologies, including the inter-net and web-based applications, have further enabled educators to redesign surgical education (Fig. 54-1). The internet has become an integral tool not just in surgical education but also in Americans’ lives by changing the way that people communicate with each other, access information, and conduct their daily lives. Today, almost 9 in 10 American adults use the internet. Furthermore, the internet has revolutionized education by allowing for expanded reach, asynchronous learning whereby students and instructors do not have to be on the same time schedule, and multimedia materials.Like internet usage, social media has seen a


Surgery_Schwartz

Surgery_Schwartz. allowing for expanded reach, asynchronous learning whereby students and instructors do not have to be on the same time schedule, and multimedia materials.Like internet usage, social media has seen a rise in adop-tion over the past decade. Social media is a term that encom-passes multiple computer-mediated platforms that are used for creating and sharing information, ideas, and other content. Social media facilitates communication and interactions across virtual networks. Commonly used platforms include Facebook, Twitter, Snapchat, and Instagram. Social media can be used for multiple purposes including social and professional network-ing; however, this chapter will focus on its uses in surgical education.WEB-BASED EDUCATIONWeb-based educational resources include lectures and webi-nars, simulators, assessment tools, and interactive mentoring and coaching. Furthermore, entire web-based curricula have been developed that can link to online resources such as journal articles, interactive


Surgery_Schwartz

Surgery_Schwartz. assessment tools, and interactive mentoring and coaching. Furthermore, entire web-based curricula have been developed that can link to online resources such as journal articles, interactive anatomy modules, and videos of operations. There are multiple advantages to web-based education. For sur-gical trainees, web-based educational materials allow access regardless of time of day or night, provide interactive tools for learning (i.e., anatomy), and videos for viewing operations and procedures. Furthermore, for practicing surgeons, web-based educational resources include forums for sharing challenging cases and procuring advice, activities for obtaining continuing 12education, and rapid access to information about new technolo-gies and research. However, there may also be disadvantages in terms of costs and technical problems.Multiple studies have evaluated learning outcomes after implementation of web-based educational interventions. In sur-gical education, these interventions may be


Surgery_Schwartz

Surgery_Schwartz. terms of costs and technical problems.Multiple studies have evaluated learning outcomes after implementation of web-based educational interventions. In sur-gical education, these interventions may be used to teach patient care and decision-making via online case studies, convey knowledge using online didactic materials, or introduce surgical skills. However, studies evaluating these interventions tend to be nonrandomized, small, and single center. A 2008 systematic review and meta-analysis by Cook et al evaluated the effect of internet-based learning across healthcare in general. The review suggested that internet-based learning is better than no interven-tion but has similar effectiveness as traditional educational methods. A more recent 2015 systematic review by Jayakumar et al focused on web-based education in surgery. They reported a positive effect, but the majority of studies included in the review lacked a control. Based on the current literature, the internet should be


Surgery_Schwartz

Surgery_Schwartz. on web-based education in surgery. They reported a positive effect, but the majority of studies included in the review lacked a control. Based on the current literature, the internet should be considered one tool among many that can facilitate learning. However, further studies are necessary to identify the key elements that improve effectiveness. Web-based educational materials should be developed keeping adult learning theories and principles in mind.Web-based surgical curricula have been developed both at an institutional and at a national level. A widely-used curricu-lum is the Surgical Council on Resident Education (SCORE) curriculum, which is available via an online portal. Developed in 2006, SCORE is based on the six core competencies required of a graduating resident: patient care, medical knowledge, professionalism, communication, practice-based learning, and systems-based practice. SCORE is the result of an ongoing col-laborative effort of the American Board of Surgery,


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Surgery_Schwartz. care, medical knowledge, professionalism, communication, practice-based learning, and systems-based practice. SCORE is the result of an ongoing col-laborative effort of the American Board of Surgery, American College of Surgeons, American Surgical Association, Asso-ciation of Program Directors in Surgery, Association for Surgical Education, Residency Review Committee for Surgery of the Accreditation Council of Graduate Medical Education, and Society of American Gastrointestinal and Endoscopic Surgeons. The SCORE curriculum provides content for topics to be covered during a 5-year general surgery residency and is adding fellowship-level content as well. The SCORE Portal modules for each topic include learning objectives, discussion 3Introduction2187Web-Based Education2187Social Media–Based Education2188What is Social Media? / 2188Journal Clubs / 2190Live-Tweeting Conferences / 2190Interactive Forums and Communities / 2190Public Education / 2192Pitfalls in Web and Social Media–Based


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Surgery_Schwartz. Education2188What is Social Media? / 2188Journal Clubs / 2190Live-Tweeting Conferences / 2190Interactive Forums and Communities / 2190Public Education / 2192Pitfalls in Web and Social Media–Based Education2192Implications and Future Directions2194Brunicardi_Ch54_p2187-p2196.indd 218713/02/19 2:37 PM 2188Disruptive forces1995200020052010ImpactSurgical educationEnabling technologiesFigure 54-1. The relationship between disruptive forces, enabling technologies, and surgical education. (Reproduced with permission from Pugh CM, Watson A, Bell RH, Jr, et al. Surgical education in the internet era. J Surg Res. 2009 Oct;156(2):177-182.)Key Points1 The internet has become an integral tool not just in surgical education but also in Americans’ lives by changing the way that people communicate with each other, access informa-tion, and conduct their daily lives.2 The internet has revolutionized surgical education by allow-ing for expanded reach—asynchronous learning whereby students and


Surgery_Schwartz

Surgery_Schwartz. with each other, access informa-tion, and conduct their daily lives.2 The internet has revolutionized surgical education by allow-ing for expanded reach—asynchronous learning whereby students and instructors do not have to be on the same time schedule—and multimedia materials such as interactive les-sons and videos.3 Despite the appeal of web-based education, systematic reviews and meta-analyses have failed to identify high-quality studies demonstrating that it is superior to standard educational methods in improving learning outcomes.4 Web-based and virtual reality simulators can be used both to teach technical skills and to assess performance. Virtual reality simulators have been effective in training surgeons on technical skills that translate to operating room performance.5 Online and social media–based journal clubs can overcome barriers associated with traditional journal clubs such as lack of a convenient time and no local clinical or methodological experts. However, they may


Surgery_Schwartz

Surgery_Schwartz. social media–based journal clubs can overcome barriers associated with traditional journal clubs such as lack of a convenient time and no local clinical or methodological experts. However, they may require more time and commit-ment from the leaders, and they may not be as effective as traditional, in-person, faculty-moderated journal clubs.6 Social media rapidly and exponentially increases the spread of information.7 Multiple pitfalls exist with regards to web and social media–based education, including but not limited to: (a) need for more widespread adoption and use, (b) lack of accuracy and regulatory oversight over educational content, (c) issues regarding patient confidentiality and privacy, (d) nondisclo-sure of conflicts of interest, and (e) paucity of evidence for effectiveness of these materials for improving knowledge, attitudes, skills, and outcomes.8 Social media has become a necessary component of surgical practice.questions, text resources and videos, and self-assessment