PRSonally Speaking

Friday, October 4, 2013

Models and simulators used to practice surgical skills in plastic surgery
by Arturo Prado, MD
One of the most important objectives of plastic surgery residents is to practice skills in a safe environment before going into the operating room.

As surgical judgment relies on cognitive and professional skills, it can be better supervised in a simulated operating scenario, enabling trainees to receive feedback about their technical and nontechnical performance.

There are different types of simulators used in plastic surgery:
1. Bench models that are cheap, portable, reusable and have minimal risks with best use in training of basic skills for novice plastic surgeons and that can only measure discrete skills.

2. Live animals that permits practice of hemostasis and models of operations (microsurgery, vascular, nerves, flaps, muscular transpositions, blood flow, etc.) and can measure advanced procedural knowledge and dissection skills.

3. Cadavers, they are the only true anatomy simulator and where we can practice entire operations, with best use for continuing medical education.

4. Human performance simulators that permit three-dimension simulation, data capture, interactivity, team training, crisis management, feed back.

5. Virtual reality surgical simulators with minimal setup time, data capture, three dimension not well simulated (laparoscopic skills laboratory, endoscopic and transcutaneous procedural skills, robotics).
These models follow the Fitts-Posner three stage theory of motor skill acquisition and that has a:
1. Cognitive stage in which the trainee intellectualizes the task, with a performance that is erratic in its distinct steps; the best example is with tying a knot, in which the learner must understand the mechanics of the skill, how to hold the tie, how to place the throws, and how to move the hands.

2. Integrative stage in which with practice and feedback, knowledge is translated into appropriate motor behavior; the learner is still thinking about how to move the hands and hold the tie but is able to execute the task more fluidly and with fewer interruptions.

3. Autonomous stage in which practice gradually results in smooth performance; the learner no longer needs to think about how to execute this particular task and can concentrate on other aspects of the procedure.
With these tools we can address the increasingly limited opportunities for technical training and assessment that are offered to residents and fellows, not only during training but also throughout their careers.

It is no longer necessary to educate in a system that relies on chance opportunities for learning new skills.

Simulation allows for risk-free training in technical skills. For the first time, a proficiency-based curriculum can make the actual level of skill rather than a predetermined period of time the primary factor in plastic surgery resident progression up the training ladder, ensuring that patients are cared with expertise in the procedures they perform.

Although simulations alone cannot improve the quality of health care, they do significantly advance clinical education, especially when combined with enriched curricular and educational environments such as virtual operating rooms and lead to enhance clinical reasoning and professionalism.
Arturo Prado is an associate professor of plastic and general surgery at the University of Chile School of Medicine.