Surgical education is frustrating. I don't mean that it's hard to keep residents away from the popliteal artery during knee replacement (though sometimes they do seem rather determined to hit it). I’m talking about the fact that surgical education may have more in common with the guild system that enabled the professional formation of saddlemakers in medieval Italy than it does with, say, pilot training in the 21st century. Pure coincidence that there were 14 lesser guilds in classical Florence  and there are 14 surgical subspecialties ? I hope so.
Regardless, the quality of flight simulation vastly exceeds that of surgical simulation, and I’m not just talking about tools available to sharpen the skills of fighter pilots who want to land on pitching carrier decks at night, or even commercial pilots who fly 737s for Delta Airlines. A private pilot—a hobbyist, paying for simulator time with a credit card at a few bucks an hour—has better technology to help her improve his crosswind landings in a 40-year-old Cessna than does an orthopaedic resident at most university programs today who is trying to improve her surgical skills.
This is frustrating. Happily, in this month’s Clinical Orthopaedics and Related Research®, a research group from the University of Iowa, led by Donald D. Anderson PhD, demonstrated the efficacy of what they call a wire navigation simulator they developed, testing it in a mock operating room environment .
Wire navigation is a key surgical skill for orthopaedic trainees because it is used in so many diverse procedures (like hip fracture surgery, tension-band wiring, and many pediatric trauma applications), and because the skills required to manipulate a wire in three dimensions in advance of placing a cannulated screw may also generalize to other procedures that don’t use wires but do require three-dimensional aptitude, like arthroscopic surgery. Dr. Anderson’s team evaluated three approaches to surgical training: Simple pedagogy with didactic training, deliberate practice (didactics plus some relatively unsupervised training with the simulator, which gives helpful, specific feedback to its users), and proficiency training. The latter included all of the interventions from the two previous groups, plus supervised, hands-on skills testing in the simulator that required demonstration of proficiency with simpler tasks before moving on to more-advanced ones.
In a bit of perhaps unexpected good news, residents allocated to self-study in the simulator (deliberate practice) did as well those who underwent more-intensive proficiency training on some of the more-important endpoints, including achieving correct tip-apex distance for simulated hip fracture surgery .
What was most impressive to me about this study was the level of sophistication of the tool that they used: It gives me hope that the skills we now try to teach in high-stakes environments—like the hips of people’s mothers—might soon be disseminated in safer settings. It would be great to practice the surgical equivalent of tough crosswind landings without risking a crash in the operating room. Spend some time reading Dr. Anderson’s paper; I found it eye opening in terms of what now is possible in the realm of surgical simulation.
But there still are so many unmet needs; even if Dr. Anderson’s wire navigation simulator should prove to be the most-perfect wire navigation trainer humankind can devise, what about reaming glenoids? Cutting tibias during TKA (without cutting popliteal arteries)? Placing pedicle screws? It seems impractical to develop a simulator for all or even many of the most-common kinds of orthopaedic procedures we perform. That being so, what should surgical education in the 21st century look like?
Join me for the answer to this and other essential questions, as I go beyond the discoveries with Donald D. Anderson PhD, senior author of “Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?” in the Take 5 interview that follows.
Take 5 Interview with Donald D. Anderson PhD, senior author of “Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?”
Seth S. Leopold MD:Congratulations on publishing this exciting paper. I would love to get my hands on your simulator just to get the feel of it; I have a sense that even the great illustrations in this paper don’t do it justice. What would I learn by “playing” with it that isn’t evident from reading your study, and how can those features enable residents to develop wire-navigation skills more efficiently?
Donald D. Anderson PhD: Thank you for your kind words. It is certainly a goal of our team to get the simulator in your hands and in residency programs all over the United States. In the course of using the simulator, you would notice two main elements. The first is the tactile feedback drilling into the integrated Sawbones© (Pacific Research Company, Vashon Island, WA, USA) femur. A large part of orthopaedic surgery is using tools and feeling how they interact with bone. Although virtual reality simulators have plenty to offer, our belief is that having realistic tactile feedback is essential to learning. The second element that is particularly beneficial to learners (and potentially certifying bodies) is the ability to automatically and objectively score performance on the simulator. Residents want to know how they are doing. If they are struggling with a skill, they want an environment in which to practice that skill. This will allow residents to safely improve their skills, learning from mistakes long before entering the operating room.
Dr. Leopold:I was glad to see that the less-intensive educational intervention (deliberate practice) did rather well in your study. I’ve noticed the same thing when I give residents hands-on time with arthroplasty navigation systems in the lab. These systems tend to provide enough feedback for learners to self-educate, at least to some degree. Assuming you agree, how might we take best advantage of this apparent feature of contemporary navigation tools in the venue of surgical education, both of residents and perhaps even of fully trained surgeons?
Dr. Anderson: This was definitely a bit of a surprise to our team. We initially thought that practicing specific components of the skill would lead to a better, more-robust mastery of the skill. We still debate whether or not this is the case, and it could well be that later, in the face of distractions or unanticipated difficulties, the more-robust skill may win the day. However, the deliberate practice undeniably led to positive results by our current metrics of performance. As we expand to training on other areas of wire navigation for applications such as placing an iliosacral screw or wires for fixing pediatric elbow fractures, we will continue to explore what training methods improve resident performance most efficiently. However, this does underscore the fact that given an environment for practice with automated feedback, residents can learn key skills and transfer them to higher-level applications. Therefore, providing residents with a dedicated time and space for practice is key to having higher performing residents.
Dr. Leopold:Doesn’t the great number and variety of orthopaedic procedures work against simulation as the “way of the future” of orthopaedic education? If we cannot simulate even all of the most-common procedures in our specialty, which are so different from one another, how can we bring orthopaedic psychomotor education into the modern era?
Dr. Anderson: This really gets to the heart of a debate we have all the time, which is, do we teach surgeons general skills or are we teaching them to perform specific tasks? It is hard to say which characterization is more accurate, but I think it is likely a bit of both. For instance, we believe wire navigation is a fundamental skill that can be applied to a variety of surgical procedures. Learning the basics of navigating a wire under fluoroscopic guidance on a hip simulator may well translate to improved performance when placing a wire in the elbow. I don’t believe that we need a simulator for every procedure that orthopaedic surgeons perform. More likely, a suite of three to five more general simulators (wire navigation, arthroscopy, and fracture reduction, for example) should offer residents the fundamental skills they need before entering the operating room to refine them in a broader range of procedures.
Dr. Leopold:Given the pressures to contain costs, it’s important to think who the stakeholders are here; that is, who will benefit from all this technology, and how we might convince them it’s worth the cost. Look into your crystal ball. In 5 years, how many orthopaedic simulators will a training program need to do the job right, how much will that cost, and—importantly—who is going to pick up the tab for all this expensive technology?
Dr. Anderson: There are several stakeholders who benefit from this line of research. First and foremost is the patient. Simulation training has the potential to reduce errors in the operating room, leading to better surgical outcomes. A second beneficiary is the residency training program. Allowing a resident to make and learn from mistakes outside of the operating room will focus learning in the operating room. I’m not much of a prognosticator, but I will say that folks may be a bit surprised by the affordability of orthopaedic simulators in 5 years—perhaps more on the order of tens of thousands of dollars rather than hundreds of thousands (the going rate for some higher-end simulators today). I believe that as the costs of these simulators come down, programs will recognize that being spared the costs of cadaveric specimens and imaging time (two expensive elements of training at our institution) may more than offset the purchase price of the simulators.
Dr. Leopold:Ages ago, I looked at relationships between confidence, competence, and gender in the acquisition of a simple psychomotor skill. We found that before instruction, confidence was inversely related to competence, and this troublesome finding was worse in men than women. In a profession like ours that includes many more men than women—and given that nearly all men seem to self-assess as being better-than-average drivers, and better-than-average kissers, despite the law of averages—how important is it to evaluate things like gender and age in more-realistic surgical tasks like those you’re studying? How could findings on that topic that be used in surgical education, if at all?
Dr. Anderson: Gender and age effects are two interesting areas in which I believe this research has the potential to expand our understanding. Although we haven’t yet looked at the relationship between gender, confidence, and performance, an objective surgical simulator may be a way of demonstrating that there is, in fact, no difference between the skill of male and female medical students, orthopaedic residents, or surgeons. This could be a way to dispel unintended biases in the orthopaedic community. In looking at age, an objective evaluation of performance based on a simulator could be a way for surgeons to continue to demonstrate their competence as they get into the later stages of their career.