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Editorial: The need to devise a better means of training

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There is increasing concern that current UK trainees at the end of their training are less experienced than their previous counterparts and continue to require more education, skills and support when they assume their consultant posts in the form of mentoring.

It is generally accepted that the numbers of hours required to become an ‘expert’ is 10 000–30 000 and currently in the UK our trainees experience =6000 h of training. Much of this is due to the impact of the European Working Time Directive (EWTD) and the government ‘New Deal’ initiative on junior doctors contracts introduced in 2003. The UK conundrum shared with many other healthcare systems is how to provide effective training within the demands of service commitment and the EWTD. Skills training has therefore been seen as the mechanism to resolve the situation, encompassing the acquisition of both technical and non-technical skills. The challenge therefore is to devise innovative ways of training within the limit of fewer hours and training, not service, must become the priority for trainees and for those surgeons, departments and hospitals that train them.

Contemporary urology training is moving out of clinical practice and simulation is increasingly used to provide a safe and supportive learning environment for learning and maintaining skills. However, this needs the following criteria:

• An agreed curriculum

• Agreed set of standards

• A validated form of assessment

• The availability of local and national skills centres

• Educators and trainers

The problem is that traditionally the UK has few training centres, together with a lack of trained manpower and funding. However, controversy still remains over the efficacy of simulation for training and those who are able to fund such projects comment on the paucity of available data in relation to the predictability of future outcomes and patient safety.

Projects such as the Simulation and Technology enhanced Learning Initiative (STeLI) initiative documented in this paper are important contributors to the evidence base. The programme aims to establish the feasibility and acceptability of a centralised, simulation-based system incorporating both skills and non-technical skills aspects of training. The latter involving crisis resource management using the SimMan model to teach team-working, decision-making, and communication skills in various settings between senior and junior trainees. Not surprisingly senior trainees scored significantly better on virtual reality simulators, bench-top box trainers and the European wet-lab training facility, as well as in human patient simulation training in crisis resource management (CRM) using SimMan, than junior trainees. The interesting point raised in this paper is that the trainees’ behaviour shows the value of inclusion of the CRM training and the interplay between technical and non-technical skills. Non-technical skills have often been sidelined in courses focusing on technical skills acquisition and this paper highlights the importance and added-value of incorporating such a skill set into future course content and curricula.

Thus, there is no doubt that some surgical skills can be learned in the laboratory and although this will never be a substitute for operative experience, the first steps of training can be accelerated with potential reduction of risk to patients. Increasingly data from sources such as the STeLI project underline a better appreciation of the importance of the training in non-technical skills, which equip surgeons in working under stress and more importantly working as a team player. However, the ultimate test for simulation is whether the model and content is able to reduce surgical errors, improve patient safety and reduce operative time and costs. To try and answer these questions BAUS in conjunction with the Specialist Advisory Committee (SAC) in Urology have recognised that the technology is there but there is a need to identify trainers keen to train, with the nomination of a national lead for simulation to develop a national strategy to deliver a viable programme aligned to the curriculum to try and answer the important question: ‘Does simulation enhance real-life performance of a surgical technique?’.

Adrian D. Joyce
St James’ University Hospital, Leeds LS9 7TF, UK

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Learning curve vs discovery curve: Training urological surgeons, what can we learn from sport?

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Improving training in the United Kingdom may benefit from a more analytical assessment of natural abilities, individual learning curves and understanding and providing the necessary training methods to let trainees reach their potential. It used to be said that surgeons learnt from their mistakes, but surely this philosophy and approach is unacceptable in the 21st Century. To learn from a mistake when it could have been avoided in the first place, with the correct guidance, could be considered negligence. Of course to err is human and none of us are superhuman. However, what we must try to avoid is the “self-discovery” curve in surgery.

Vickers paper assessing fellowships to learn radical prostatectomy showed that a fellowship could shorten your learning curve. I have been on several fellowships abroad and what they had in common was of course numbers. Centres do not get a reputation or expertise by doing one case a year. However they also had in common a structured approach to training fellows that started with observation in theatre, then bedside assisting and finally doing defined steps of the procedure.

The combination of structured training and suitable experience is key to good surgical development. The individual who takes up golf and teaches himself or herself is unlikely to become a scratch golfer and may develop ugly habits that hold them back from reaching their potential. This can be seen in surgery. To complete the golfing analogy (and apologies to non-golfers): once a golfer has a reasonable swing and knows what he/she is doing, the single thing that will define how good he/she gets is how often they play.

Modern professional sportsmen are assessed for their technique using technology and we are starting to see this level of scrutiny in robotic training. Anyone who has used the Mimic technology in the Da Vinci robotic training, will recognise that it looks at several aspects of surgical technique, including economies of movement. In my own experience as an early trainee in open or endoscopic surgery I was rarely told how to hold an instrument properly or indeed about ergonomics and economies of movement. The focus was usually on the operative field, where to cut etc.

In professional sports much thought and investment has gone into creating the optimum environment to initially assess individuals for natural ability, then supporting and nurturing their talent, strengthening them both mentally and physically so that their “investment” is enabled to perform in the toughest situations as well as having longevity. Should we not aspire to do the same for our surgical trainees?

Justin Collins is a Consultant Urologist at Ashford and St Peters NHS Foundation Trust, UK and is a regular trainer on the faculty at IRCAD, Strasbourg, France. @4urology

 

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Article of the week: Reality check: simulators are effective training tools for robotic surgery

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Current status of validation for robotic surgery simulators – a systematic review

Hamid Abboudi, Mohammed S. Khan, Omar Aboumarzouk*, Khurshid A. Guru†, Ben Challacombe, Prokar Dasgupta and Kamran Ahmed

MRC Centre for Transplantation, King’s College London, King’s Health Partners, Department of Urology, Guy’s Hospital, London, *Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK, and †Department of Urology, Roswell Park Center for Robotic Surgery, Roswell Park Cancer Institute, Buffalo, New York, USA

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To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE®, EMBASE® and PsycINFO® databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; ‘expert’ and ‘novice’. Experts ranged in experience from 21–2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer®, ProMIS®, SimSurgery Educational Platform® (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial.Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

 

 

 

 

 

 

 

 

 

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Editorial: VR simulators can improve patient safety

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You wouldn’t expect the pilot of the aeroplane in which you fly to the EAU or AUA meeting to be a novice who was training on the aeroplane that you were being transported in! Similarly, patients undergoing robot-assisted surgery do not expect to be the “guinea pigs” upon which trainee surgeons move up the learning curve of surgical experience. Sometimes, however, they are.

Surgical simulators offer the means for surgeons to gain experience before moving to operating on actual patients. However, the publication from Guy’s and St Thomas’s illustrates how little research has been done yet to confirm that outcomes are improved by such a move.

Patient safety is a “buzz word” at present, especially after the report of Robert Francis QC on the Mid-Staffordshire NHS Trust disaster. It seems probable that virtual reality (VR) simulators can improve safety, not only by improving technical skills, but also by enhancing non-technical “human factor” responses.

Much work needs to be done to provide the VR training facilities and ensure access to them for all urology trainees. Once they are in place studies will be needed to confirm their value. In a world where doctors and Trusts are facing a tidal wave of litigation there seems little doubt that this is the way ahead.

Roger Kirby
The Prostate Centre, London W1G 8GT

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