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EDITORIALS: Roger Kneebone and Rajesh Aggarwal Surgical training using simulation BMJ 2009; 338: b1001 [Full text]

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‘Is there a substitute for experience in surgical training?’

Rohit S. Malliwal   (7 July 2009)

‘Is there a substitute for experience in surgical training?’ 7 July 2009
Rohit S. Malliwal, Clinical Medical Student Barts and The London School of Medicine and Dentistry, Turner Street, Whitechapel, London E1 2AD Send response to journal: Re: ‘Is there a substitute for experience in surgical training?’	Traditional surgical training has been based on the pedagogy of an apprenticeship since the 16th Century and to this day little has changed. Juniors have always observed and assisted their seniors in performing procedures and, when confident, they would themselves attempt the procedure under close supervision. Familiarity and proficiency were gained by practicing on patients repeatedly for years; under close supervision and counsel of your senior. However, traditional surgical training is set to change with reduced training opportunities for juniors due to factors such as the European working time directive (EWTD), which has subsequently reduced working hours, coupled with the realisation and acceptance that it is morally unacceptable for novices to learn new skills on patients (1, 2). So is there a substitute for the experience of observing and assisting on countless operations, or in the least, an adjunct which may help ameliorate the reduction in working hours and experience? A simple solution would be to extend training time to enable juniors to achieve the hours required for competence. However, this flies in the face of the Calman report which instigated the adoption of the EWTD, streamlining of training and reduction in training time (1). Some groups have advocated an increase in the use of human cadaveric based models and anaesthetised animal simulations, which have been shown to be highly effective at allowing juniors to reach a reasonable level of proficiency ; which also goes onto translate into operative procedural ability (1, 2). However, there is another option being touted as the ‘next best thing’. There are numerous studies that have shown that virtual reality simulation may well hold the key to training future surgeons. Indeed, Kneebone and Aggarwal (2009) (7) give a excellent analysis into the study by Larsen et al. (2009) (6) demonstrating that junior registrars trained to intermediate proficiency on a laparoscopic simulator can perform a surgical procedure for the first time to a higher standard than novice surgeons without prior exposure to simulation (1). This demonstrates that simulation based training may be able to accelerate a surgeons learning curve and proficiency for a particular operation (6) Nevertheless, this training adjunct does have its limitations. The article reflects that surgical experience encompasses more than just physical manipulative skill. However, during their training; surgeons are exposed to abnormal and distorted anatomy, surgical complications and above all the unknown (7) Coupled to this; the pressure of performing an operation, particularly when tired and in the context of an operative multidisciplinary team and with a large caseload, lead to the conclusion that simulators are not the panacea to this impasse (7). In reality, perhaps there is no substitute for the experience gained by doing and redoing a procedure multiple times, facing the uncertainties of anatomical variation and surgical complications. Surely operative experience is and should remain the ‘gold standard’ (1). References 1) Bernstein M, Knifed E, Ethical challenges of in-the-field training: a surgical perspective. Learn Inq 2007 1:169-174. Springer Science+Business Media. 2) Kelty C, Duffy J, Cooper G. Out-of-hours work in cardiothoracic surgery: implications of the New Deal and Calman for training. Postgrad Med J. 1999;75:351–352. 3) Chikwe J, de Souza AC, Pepper JR. No time to train the surgeons. BMJ. 2004;328:418–419. 4) Anastakis DJ, Regehr G, Reznick RK, Cusimano M, Murnaghan J, Brown M, Hutchison C., Assessment of technical skills transfer from the bench training model to the human model. Am J Surg. 1999 Feb;177(2):167-70. 5) Datta V, Bann S, Beard J, Mandalia M, Darzi A., Comparison of bench test evaluations of surgical skill with live operating performance assessments. J Am Coll Surg. 2004 Oct;199(4):603-6. 6) Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, Schroeder TV, Ottesen BS., Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ. 2009 May 14;338:b1802. 7) Kneebone R., Aggarwal R., Surgical Training using simlation. (2009) BMJ 338:b1001. Competing interests: None declared