The Successful Development and Implementation of a Novel, Biliary Surgical Simulation Pathway Training Curriculum

Joseph M Buchholz, BS, Charles M Vollmer, MD, Kiyoyuki W Miyasaka, MD, Denise LaMarra, MS, Noel N Williams, MB, BCh, MCh, FRCSI, FRCS, Jon B Morris, MD, Rajesh Aggarwal, MD, PhD, MA, FRCS. Perelman School of Medicine at the University of Pennsylvania.

INTRODUCTION
Traditionally, the function of simulation in surgical education is to provide instruction in procedural tasks and technical skills. Recently, the importance of instruction in nontechnical areas, such as communication and teamwork, was realized and these elements need to be integrated into surgical simulation training programs. On rotation, the surgical resident requires proficiency in both technical and nontechnical skills in order to prevent adverse events through the entire patient care pathway: pre-op, intra-op, and post-op. We designed and implemented a PGY-1 surgical simulation training curriculum targeting these skills throughout an elective surgical procedure pathway focused on biliary disease.

METHODS
The implementation of a biliary surgical simulation curriculum was done in such a manner that summative pathway sessions were completed at the start and conclusion of the training module. These sessions provide proficiency assessments of resident performance across the entire biliary care pathway before and after simulation training. Each resident completed a pre-op, intra-op, and post-op scenario, sequentially, during each pathway session. The pre-op and post-op scenarios required the resident to interact with a standardized patient (SP) presenting either with choledocholithiasis (pre-op) or normal post-op course after a laparoscopic cholecystectomy (post-op). The intra-op session was held in a simulated operating room where the resident completed a laparoscopic cholecystectomy. The OR was complete with a confederate scrub tech, a confederate anesthesiologist, and a porcine liver/gallbladder model. This training session required the resident to follow the same patient through the entire pathway of care. Faculty assessments, resident self-assessments, and SP assessments of resident performance were collected for every pathway scenario. All performance evaluation tools used were standardized operative or clinical assessment forms approved by the American Board of Surgery. With summative pathway sessions at the front and back-end of the training module, the rest of the module was comprised of formative sessions with a biliary disease focus. These formative sessions were made up of hands-on sessions, didactic lectures, and standardized patient encounters. Surgical residents were removed from hospital service for the entirety of the simulation-training curriculum allowing them to focus all efforts on learning activities.

RESULTS
Preliminary data has been collected for the first five surgical interns to undergo this novel simulation training method. Faculty ratings indicated that resident performance improved in every single category evaluated during the pathway. Mean overall improvements for each scenario were (before training to after training): Pre-op 3.4 to 4.6 (out of 5); Intra-op 1.5 to 4.0 (out of 5); Post-op 6.2 to 7.6 (out of 9). The resident self-assessments also showed improvements: Pre-op 3.0 to 4.0; Intra-op 1.0 to 2.6; Post-op 5.6 to 7.4.

CONCLUSION
It is imperative that surgical residents undergo simulation training directly linked to their hospital responsibilities so as to provide immediate performance improvement and reduce errors in the clinical environment. This pathway simulation training curriculum for biliary disease has successfully accomplished this and shows an improvement in intern performance across the entire pre-op, intra-op, and post-op surgical care pathway. These results support the continued use of this novel and innovative simulation educational concept.