PROFICIENCY BASED TRAINING
RICHARD M. SATAVA, MD
A revolution is occurring in surgical education, driven by the introduction of surgical simulators for the training and assessment (and eventually the certification) of surgical technical skills. The revolution is a combination of devices (simulators), processes (curriculum-based training), validation (objective assessment), and policy (criterion-based benchmarks) to usher in proficiency based training. This results in a fundamental shift in the way surgeons will be trained in the future.
Two factors initiated this revolution. First came the introduction of surgical simulators as a technical tool that can replace real objects (patients, animal surrogates, or inanimate objects) by computer images. The simulators are simultaneously a training and an assessment device, for the signals from the handles that change the video image of the simulation are also tracked by the computer and measure performance. As the decade of simulators has progressed, the visual realism has improved and haptics (touch) has been added to some models. Second came the process of objective assessment, as initially demonstrated by Reznick (Objective Structured Assessment of Technical Skills – OSATS) and Fried (McGill Inanimate System for Training and Evaluation of Laparoscopic Skills – MISTELS). This methodology applies a rigorous design to the training of fundamental surgical technical skills and then stringently evaluates performance by specific metrics. The result has been that technical skills can be quantitatively measured, and the individual student’s performance can be objectively and accurately assessed.
Once simulation started, in the 1980s and 1990s, acceptance was slow. It was necessary for 2 other factors to be introduced before the surgical community was willing to accept simulation as a legitimate tool for surgical training. The first step occurred as rigorous validation studies were conducted that proved unequivocally that training on simulators improved performance in the operating room. Numerous studies are now available on many different simulators, both computer based and mannequin based, to support the important contribution of simulators to training. Some of the earliest results (Reznick and Fried) presaged similar results in computer-based simulators. The second factor was understanding that simulators were not meaningful without the context of a total curriculum. A simulator is simply one “tool” in the surgical educator’s toolbox in training a resident. A curriculum that begins with anatomy, steps of the procedure, and error identification leads up to the skills performance on the simulator, and then is followed by the objective assessment, outcomes analysis, and feedback to the student for improvement of performance. The simulator must be embedded within such a comprehensive teaching curriculum.
Simulation for surgical skills is now firmly entrenched in the mindset of surgical education, but it is necessary to move implementation into training programs. Yet another step will be required—the establishment of levels of proficiency (for each simulator) by experienced (expert) surgeons. When the experienced surgeon performs on the simulator, the results can be considered the “criterion” that the student must achieve before being allowed to perform surgery or a specific procedure on a patient. This “proficiency-based” training will have 2 profound influences. First, students will continue to train until they have achieved proficiency—not in the operating room on a patient, but in the laboratory by objective performance metrics to ensure the highest quality of error-free surgery before ever operating on a patient. Second, the student will train for however long is needed to achieve proficiency—whether it be 5 trials on the simulator or 25 trials. Thus, the training of a surgeon may no longer be for a fixed time period or number of procedures, rather the student will train until proficient. This may well change how training programs are organized—some students will take 3 years to 4 years, while others may take 6 years to 7 years. What will be certain is that residents will not graduate until they have competency proven objectively and unequivocally.
The time has come to move beyond the Halsted model of surgical training and into a new era— proficiency-based training.
Address reprint requests to: Richard M. Satava, MD, Professor of Surgery, University of Washington Medical Center, Room BB 430, Seattle, WA 98195, USA. Telephone: 206 616 2250, E-mail: firstname.lastname@example.org
Richard M. Satava, MD, is a Professor of Surgery at the University of Washington School of Medicine, a Special Assistant in Advanced Technologies at the US Army Medical Research and Material Command in Ft. Detrick, Maryland and will soon return as a program manager at the Defense Advanced Research Projects Agency. He has served on the White House Office of Science and Technology Policy Committee on Health, Food, and Safety is a Past President of the Society of Laparoendoscopic Surgeons.
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