American Academy of Orthopaedic Surgeon and the American Association of Orthopaedic Surgeon (AAOS), Arthroscopy Association of North America (AANA) and the Orthopaedic Trauma Association, OTA are moving forward on simulation-based training.
American Academy of Orthopaedic Surgeon and the American Association of Orthopaedic Surgeon (AAOS), Arthroscopy Association of North America (AANA) and the Orthopaedic Trauma Association, OTA are moving forward on simulation-based training.

The first Orthopaedic Summit (MEdSim 4, 2013 Pedowitz) guaranteed a top down, bottom up approach to developing simulation based training needed for orthopaedic surgeons.  From the Board to medical school all agreed that new approaches for surgical skills training were needed and they would work together to see that simulation based training and new simulation devices were developed to provide the best possible training for orthopaedic surgeons and residents.

Since the first meeting the organizations have been involved in updating current simulators and developing new ones. The second Summit was held in November with approximately 120 participants representing the various boards and organizations with guest speakers from different specialties providing different approaches that their specialties had used to develop simulations/simulators and curricula.

Robert A. Pedowitz, MD, PhD, who co chaired both summits, said “Simulation-based training can have a positive impact on both graduate medical education for residents and continuing medical education for all of us in practice.”

“Creating a simulation-based training curriculum requires breaking down a procedure into individual tasks and setting proficiency standards that the trainee must meet. It requires development of unique measurement tools to provide continuous feedback to the trainee as a task is mastered.”

“We have an opportunity, through these new projects, to create training programs that help prepare residents for their initial surgical experiences,” Each project is beginning with curriculum design as the keystone for simulator development.

Attendees at the first Summit recommended that surgical skills training for residents be mandated as a required part of residency training. Since then, both the American Board of Orthopaedic Surgery (ABOS) and the Resident Review Committee (RRC) in orthopaedic surgery have implemented this mandate with identical requirements.

J.L. Marsh, MD, in his presentation updated attendees on the ABOS and RRC requirements for surgical skills training.  He is chair of the residency review committee.  He said the new requirements encompass a high degree of technical skills and are based on expert performance not just native talent.  They are based on simulated events which require deliberate practice.

During the Q and A after his presentation a discussion took place where one of the attendees questioned the criteria for selection of residents and wondered if perhaps the emphasis on selecting those with high test scores was a true indication of  surgical competency or just their ability to score well on tests. A lively discussion ensued and all agreed that it was something that needed to be examined.

Robert Sweet, MD, a urologic surgeon from the University of Minnesota, discussed his simulation center, Sim Portal and where urology is in context of other specialties in using simulation. During his residency, he did a two year American Foundation of Urologic Diseases Health Policy Fellowship under the mentorship of Dr. Richard Satava (MEdSim 3, 2013, Interview)  Sweet focused on development and validation of simulation tools during his presentation. The community leader credits Satava for his ability to set up the University of Minnesota’s Sim Portal and his background in simulation and curricula development.

As founding director of the Center for Research in Education and Simulation Technologies (CREST) his focus is developing and designing solutions to medical education needs through the use of simulation technologies.  Dr. Sweet believes that simulation is the heart of the future of healthcare.

He feels simulations need to be based on defined education goals, detailed assessment and established criteria levels.  Simulation provides a safe environment to recover from errors and learn from mistakes, while enhancing psychomotor skills and technique without injuring a patient. Sweet encourage attendees who are setting up simulation centers to engage their faculties from the beginning. That way, they experience by-in and feel they are part of the program.  When asked about fidelity of simulators he said it must be sufficient to meet educational objectives.

Mark Nousiainen MD, from Sunnybrook in Toronto, gave an update from the first summit and said simulation was very important to them because cadavers are far more expensive in Canada than in the US as people do not donate their bodies.  They have a small teacher-student ratio and their residents are subjected to a great deal of deliberate practice with frequent evaluations.  They advance when they demonstrate proficiency so the curriculum is not time based. .Because residents know they are going to have a mid-module evaluation by a panel of experts it makes them more responsible for their education.

The first Summit called for the development of new simulation devices expressly designed for PGY-1 and PGY-2 residents. Two devices are currently being investigated—one focused on teaching basic arthroscopy skills and the other focused on basic fracture fixation, using hip fracture as the initial diagnosis.

AANA, in partnership with the AAOS, is leading development of the basic arthroscopy simulator. The AANA/AAOS project team is defining the content delivery options that integrate with the simulator; content development will follow. As the development process proceeds, the project team will seek a corporate partner to help invent the simulator.

A new simulator focusing on basic fracture fixation training is being developed by an AAOS/OTA partnership, under the direction of Marcus F. Sciadini, MD.

“Our goal is to create an affordable simulation trainer for residents, with the capability for expansion to include multiple fracture fixation procedures,” explained Dr. Sciadini. “Each procedure would be supported by a curriculum requiring the learner to meet certain proficiency requirements. The ideal trainer would incorporate authentic visual images that mimic the fluoroscopic imaging data obtained during routine orthopaedic procedures as well as realistic tactile feedback via a handheld haptic device.”

The project team’s mandate includes designing a curriculum to integrate with the simulator so as to maximize the benefits to residents. The AAOS/OTA Project Team is currently seeking a corporate partner for the project.

The Summit also called for development of a basic surgical skills training curriculum for orthopaedic residents with emphasis on the use of simulation prior to operating room experience. The ABOS has convened a project team to plan and organize such a curriculum, under the leadership of J. L.Marsh, MD, and Robert Pedowitz, MD. Representatives from the ABOS, the AAOS, and the American Orthopaedic Association Council of Orthopaedic Residency Directors (CORD) program are also part of the project team, which is creating a standardized set of modules for all residency programs to use in implementing the required curriculum changes.

Simple, low-cost simulations and new simulation technologies under development will be instrumental in implementing basic skills training, noted Dr. Marsh. “We have already agreed on a module template and a curriculum of 17 modules as surgical skills training exercises for orthopaedic PGY-1s,”

Robert A. Pedowitz, MD, PhD gave an update on the FAST program which will teach arthroscopic skills progressively via a curriculum-based, hands-on, cost-effective education program.. “Beginning with the basics, students will learn arthroscopic skills sequentially, before they are taught the full surgical procedure.”

The FAST program has the following specific goals to:

  • Teach arthroscopy skills in a step-wise mannerTrain across cognitive, psychomotor, and affective domains;Allow students to learn and practice at their own pace (advance via proficiency);
  • Create a flexible platform to be used for advanced arthroscopy skills training;
  • Integrate with existing educational programs;
  • Develop opportunities for online CME and, possibly, Maintenance of Certification (MOC)programs;
  • Leverage existing educational content, expertise, and organizational resources;
  • Develop simple metrics to monitor learning progress and confirm proficiency;
  • Integrate FAST with virtual reality trainers and competency testers; and
  • Place the deliverables into the hands of the end-users in a cost-effective manner
To help achieve these goals, Dr. Pedowitz believes that training programs should take advantage of alternatives to expensive, high-definition virtual reality systems for teaching and assessing basic orthopaedic skills. For example, he noted, a Swedish company offers a fluoroscopy training system that, when combined with a USB connector and commercial-grade haptic arm, could serve as an inexpensive simulator for practicing placing pins. When combined with two haptic arms, the device could be used as an in-home arthroscopy trainer..

“To have a set of teaching tools that enables residents to practice arthroscopy skills at home, with more expensive simulation devices available at the residency program and hospital levels, and ultimately, state-of-the-art and highly sophisticated virtual reality equipment at regional centers where testing is my vision for orthopaedic education and training” said Pedowitz..

Charged with developing an educational curriculum designed for PGY-1 and PGY-2 residents, the AAOS/Orthopaedic Trauma Association (OTA) simulation project team chose hip fractures as their starting point.

“We have established the concept of a progressive curriculum that begins with very basic procedures—but has the potential to incorporate increasingly complex cases applicable for upper-level residents or even fellows,” said Marcus F. Sciadini, MD.

The project team has identified femoral neck fractures, iliosacral screw positioning, anterior column screw placement, retrograde and antegrade femoral nailing, and interlocking and blocking screw placement as the core group of procedures for simulation training.

“The nice thing about these simulation models is that they provide quantifiable performance goals in terms of time, pin accuracy, and even radiation exposure equivalency, without actually having to experience it,” said Sciadini. “Radiation safety and fluoroscopy exposure are important; orthopaedists frequently use fluoroscopy, particularly in trauma.”

Dr. Sciadini noted that, 90% of physicians underestimate the risk associated with pediatric radiographs and computed tomography, and that orthopedists have limited understanding of radiation physics. As a result, the project team is hoping to incorporate the concept of decreasing radiation exposure into its education curriculum.

“Although in the preliminary stages,  being able to incorporate fluoroscopy training into the simulation realm is very exciting,” said  Sciadini. “it lends itself to using the simulator in a very effective educational mode.”

While the orthopaedic community might have seen themselves “as lagging behind general surgery in the use of simulation” as one speaker said, they are making great strides to rectify the problem and are already contemplating topics for their next Summit.