RICHARD M. SATAVA, MD
With the origins of objective assessment of psychomotor skills for surgical residents by leaders like Richard Reznick et al [1] and Gerald Fried et al [2] in the 1990s, the foundation of the revolution in teaching surgical procedures was introduced. Initially, and to a greater extent still today, the assessment is of basic tasks and simple procedures; the more complicated full surgical procedures await further advances in the technology of simulators as well as assessment tools. Nevertheless, enormous progress has been made in quantifying performance, and validation has been successful not only for the laboratory, but Seymour et al [3] and others have also validated that virtual reality training in the laboratory translates into improved performance in the operating theater.
As with all scientific research, when the scientific evidence supports a new approach, the next step is incorporation into practice. Because of the validation, there is now a requirement for simulation-based training with objective assessment to be part of the skills training of surgeons. The Accreditation Council on Graduate Medical Education (ACGME), the Residency Review Committee (RRC), the Association of Program Directors in Surgery (APDS), the American College of Surgeons (ACS), and American Board of Surgery (ABS) have worked hard to reach consensus, establish, and adopt the 6 areas of competency that all residents must achieve (Table 1). Although certain areas of skills training are well validated, some areas like communication skills and professionalism are still being developed.
Now that the areas for competency have been agreed upon, the difficult task begins of developing the curricula that will support the training and assessment of these skills. One of the major benefits of the development of curricula is that this forms the beginning of the standardization of skills training. Once again, the ACS, ABS, and APDS have united to develop the skills curricula. As of September 2008, the required curriculum for the first 20 basic skills and simple procedures has been released (Table 2). This has completed Phase 1 of curriculum development; Phases 2 and 3 will be developed over the next 2 years (Table 3). All surgical residency training programs are now required to have these fundamental skills-training curricula with assessment of the outcomes; what has not been mandated is the manner in which the training and assessment will occur. This provides the training program directors some latitude for presenting the training. However, this also leaves a gap in achieving a uniform curriculum on a national basis (see below).
In preparation for the establishment of curricula, the ACS has developed a certification process for a skills-training center. These ACS Accredited Education Institutes (ACS-AEI) will form the nucleus of cooperation in bringing a standardization to the training and assessment process. The initial steps have been to develop the criterion for an ACS-AEI, an application process, a survey instrument, the teams of surveyors to evaluate the applicant training centers, an evaluation methodology, and the certification award process. This has all been accomplished between 2005 and today. Surveys have been conducted, and now 18 ACS-AEI centers have been certified.
In May 2007, the first meeting of the ACS-AEI centers occurred to establish the Consortium of ACS-AEI. The goals are to establish shared, uniform resources (databases, learning management software, networking, etc), to evaluate the ACS-APDS curricula with the intent of adopting a common implementation of the curricula, to develop uniform outcomes for the curricula, and to develop a research agenda to further the scientific pursuit of education, training, and assessment (Table 4). This will allow the ACS-AEIs to become regional resources for disseminating information throughout the region, to provide a resource to “train the trainers” for other institutions in their region, and to provide resident (student and surgeons) training for those institutions that do not have their own training centers and still need to meet the ACGME and RRC requirements.
The types of training and assessment that the centers will address must be comprehensive and include students, residents, and practicing surgeons. The purposes include initial assessment of fundamental abilities (aptitude), basic skills and established procedures, new procedures (for both students and established surgeons, maintenance of certification (MoC), retraining (or re-entry training) of skills after absence from performing surgery, and when necessary, remediation (Table 5).
The new directions for the ACS-AEI will be in (1) forming networks of centers to integrate and collaborate; (2) establishing a research agenda in application and validation of new training and assessment methods; (3) performing multi-center trials of new procedures and techniques (such as NOTES); (4) developing/evaluation of new simulators and curricula with their appropriate outcomes and assessment tools; and (5) distributing (over the Internet) all of the above information.
The challenge is enormous, but the opportunities are even more exciting than ever. We are in a complete revolution in surgical education. If history serves us well, such a revolution occurs only once every hundred years, as evidenced by the fact that the last revolution began in 1908 with the Flexner Report. Whatever is established during these next 10 years is likely to endure for the next century.
The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official, or as reflecting the views of the Departments of the Army, Navy, or Air Force, the Defense Advanced Research Projects Agency, or the Department of Defense.
Correspondence: Richard M. Satava, MD, FACS, Department of Surgery, University of Washington Medical Center, 1959 Pacific St NE, Seattle, Washington, 98195, USA. Telephone: 206 616 2250, Fax: 206 616 9138, E-mail: rsatava@u.washington.edu
Richard Satava, MD, FACS, is Professor of Surgery at the University of Washington Medical Center, and Senior Science Advisor at the US Army Medical Research and Materiel Command in Ft. Detrick, MD. He has served on the White House Office of Science and Technology Policy (OSTP) Committee on Health, Food and Safety. He is currently a member of the Emerging Technologies and Resident Education, and Informatics committees of the American College of Surgeons (ACS), is past president of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), past president of the Society of Laparoendoscopic Surgeons (SLS), and is on the Board of Governors of the National Board of Medical Examiners (NBME) as well as on a number of surgical societies. He has more than 200 publications and book chapters in diverse areas of advanced surgical technology.
References
1. Martin JA, Regehr G, Reznick R, et al. Objective Structured Assessment of Technical Skill (OSATS) for surgical residents. Br J Surg. 1997;84:273-278.
2. Derossis AM, Antoniuk M, Fried GM. Evaluation of laparoscopic skills: a 2-year follow-up during residency training. Can J Surg. 1999;42(4):293-296.
3. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236:458-463.
