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Empirical Investigations

Residents' Attitudes About the Introduction of a Surgical Skills Simulation Laboratory

Hagen, Susan S. MD; Ferguson, Kristi J. PhD; Sharp, William J. MD; Adam, Laura A. MD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2010 - Volume 5 - Issue 1 - p 28-32
doi: 10.1097/SIH.0b013e3181a3dfbe



Because of work hour limitations and the move toward competency-based training, surgical skills laboratories are being used to supplement the education of general surgery residents. In fact, the Accreditation Council for Graduate Medical Education requirements for Surgery Residency Programs now state that “Resources should include simulation and skills laboratories.”1 Although the Accreditation Council for Graduate Medical Education requirements neither specify the resources that should be available nor do they indicate whether residents should be required to use such resources, other groups such as the American College of Surgeons2 have developed recommendations for curriculum and skills in simulation centers.

Acquiring a psychomotor skill follows three stages: cognition (understanding the task), integration (the ability to apply the knowledge to skill and avoid inefficient movements), and automation (the ability to perform the task without thinking of each specific step).3,4 A surgical skills laboratory can methodically approach each of the necessary steps. The laboratories may also be helpful for teaching dexterity and manipulation of tools on inanimate objects or animals rather than humans. The skills obtained in a laboratory may improve precision and decrease time in the operating room, thereby reducing the cost of the operation and risks of prolonged anesthesia, although research documenting these benefits has yet to be conducted. Simulation laboratories are good for learning at a self-pace, practicing a repetitive skill, making errors in a safe learning environment, and they are available for practice at any time of day. Some authors believe that surgical simulation should be used in conjunction with traditional methods for optimal improvement in skill.4

Many programs have been able to measure improvement in skills in the operating room after practicing on bench model versus didactic training alone, including the ability to perform operations faster, with more precision and less error.5–7 Fried et al8 performed a thorough review of the literature and concluded that simulators benefit training surgeons in basic psychomotor skills, which translates into improved operating room performance.

Surgical skills laboratories have both been developed for basic skills and teaching modules for laparoscopy. Anastasias et al at the University of Toronto opened a surgical skills center that provided junior residents (post-graduate year [PGY]-1 and PGY-2) with basic surgical skills for 2 hours biweekly. They addressed issues such as tissue handling, wound closure, use of electrocautery, and chest tube insertion. The PGY-3 class was used as a historical control. The authors found no statistical difference in skills between those who participated in the course and those who did not.9 One limitation of the study is that there was no way to control whether the PGY-1 achieved competency earlier than the historical controls. Furthermore, the tasks taught were not complex, meaning that repetitive sessions may have less of an impact than a more complicated skill such as laparoscopy.

Although overall attitudes about the benefits of skills laboratories have been very positive,10,11 leaders in surgical education have affirmed that increased use of skills laboratories should always be considered as an adjunct to learning in the operating room rather than as a replacement.12 In summary, surgical skills laboratories help residents develop appropriate psychomotor skills in a safe environment before operating on a human. Because we prepared to implement a surgical skills laboratory at the University of Iowa Hospitals and Clinics, we sought the opinions or residents before initiating the curriculum, to help guide the curriculum and establish priorities.


After approval by the University's Institutional Review Board, we distributed a brief written survey (three pages) during a departmental conference to all surgery residents. Those who did not attend were followed up personally by a resident, who conducted the initial project to document residents' opinions about a skills laboratory and ensure their opinions were considered in the implementation of the laboratory. Written opinions of all University of Iowa Hospital and Clinics general surgery residents were obtained regarding (1) perceived preparedness of resident skill levels of both the individual resident and their colleagues in both open and laparoscopic techniques and (2) perceived usefulness of instituting a surgical skills laboratory to assist in open and laparoscopic techniques (Appendix, Supplemental Digital Content 1, for a copy of the questionnaire). The responses were grouped by intern (PGY-1), midlevel (PGY2–3), and senior (PGY4–5) because that fit with the way our residency teaching was organized.

Statistical Methods

To assess the reliability of the first questionnaire, we calculated alpha reliability coefficients for two sections of the first questionnaire that were expected to be internally consistent. The alpha reliability coefficient for the section regarding preparation at different levels of residency was 0.79, and for the section about benefits of skills laboratories, it was 0.83. We used analysis of variance to compare differences across residency groups.

A follow-up needs assessment (two pages) was distributed for PGY-1 and PGY-2 residents. The survey was distributed at a morning conference that required sign in. Residents who were not in attendance were asked to complete the survey by an administrative assistant ensuring 100% completion rate. The purpose of this survey was to address perceived importance of the skills laboratory and timing of sessions, as well as to determine residents' perceptions about whether the laboratory should be mandatory. The survey addressed residents' perceived skill in a variety of stations and preference of preferred sessions (See Appendix, Supplemental Digital Content 2, for a copy of the second survey).


The first survey yielded 100% response rate (n = 26). The respondents came from all years of residency (PGY1 = 5, PGY2 = 6, PGY3 = 5, PGY4 = 6, PGY5 = 4). For some of the analyses, residents were collapsed into groups (intern = PGY1, midlevel = PGY2–3, senior = PGY4–5).

In terms of their own preparation, interns and senior level residents were significantly more likely than midlevel residents to believe that their open operative skills were appropriate to their level of training (Table 1), whereas all three groups were neutral or slightly agreed that their laparoscopic skills were appropriate to their level of training. Interns disagreed with the statement that residents should be required to demonstrate mastery on either open or laparoscopic techniques before being allowed to operate on a patient, whereas senior residents were neutral about such requirements (analysis of variance comparing the means for the three groups was not significantly significant).

Table 1:
Attitudes Among Different Levels of Residents About Own Preparation and Benefits of Surgical Skills Simulators

When asked to assess the preparation of residents in general for open operative techniques, respondents indicated that interns were not as well prepared as either midlevel or senior residents, whereas midlevel residents were perceived as being less well prepared than senior residents. A similar result was demonstrated for perceptions about laparoscopic techniques (Table 2).

Table 2:
Attitudes Among All Respondents About the Preparation of Different Levels of Residents and About the Potential Benefits of Simulators for Different Levels of Residents (N = 26)

We then asked whether surgical skills simulators could help prepare different levels of residents for open or laparoscopic techniques. There was general agreement that surgical skills laboratories were beneficial for preparing interns and midlevel residents for open operative techniques but less support for preparing senior residents in this manner. For laparoscopic techniques, on the other hand, skills laboratories were perceived as beneficial for all three groups of residents. In addition, there was a trend for skills laboratories to be seen as more beneficial for teaching about laparoscopic techniques, although these differences were not statistically significant.

In terms of comments, 10 residents made favorable comments about skills laboratories (eg, “I think they would be great” or “I'm in favor of them”), whereas one resident commented that skills laboratories were better for basic skills instruction but noted that there is no substitute for learning on real patients in real life settings.

The second survey, distributed only to PGY-1 and PGY-2 residents also had 100% completion rate (n = 12). On a scale of 1 to 10, with 1 being not important and 10 being very important, residents scored a mean of 8.67 rating personal importance of the skills laboratory. Using the same scale, residents scored a mean of 8.83 regarding importance of the skills laboratory for the program in terms of recruiting and demonstrating value of teaching to the residents. Four of six PGY-1 residents and all of the PGY-2 residents (n = 6) felt the skills laboratory should be mandatory. Five residents in each class felt the skills laboratory time should be entirely protected (no pagers, unavailable for clinic, and operating room cases). One resident felt that participation in the operating room should be an exception to attendance in the skills laboratory.

Next residents were asked to rank established basic curriculum stations on a scale of 1 to 5 to establish comfort of performing the skill. The scale was described as: “1” indicates the resident would need someone to walk him/her through the skill, “3” means the skill could be performed unsupervised if push came to shove, and “5” the skill could be performed without assistance.

The mean calculation indicated that the PGY-1s were most comfortable with urinary catheterization (4.67) and the basics, two-handed tie, one-handed tie, and suturing (4.33). They were somewhat comfortable with passing and naming instruments (3.17), wound management (2.33), biopsy of tissue (2.17), chest tubes (2.00), casting (2.00), hernia repair (2.00), airway management (1.83), central line elective (1.67), central line code (1.50), and stapled gastrointestinal (GI) anastomosis (1.50). For all other skills, (vascular anastomosis, exploratory laparotomy, upper endoscopy, lower endoscopy, basic laparoscopy skills, hand sewn GI anastomosis, and skin Grafts) the mean was below 1.5 (Table 3).

Table 3:
Level of Comfort in Performing Surgical Skills by PGY1s and PGY2s

The mean score for the PGY-2s were as follows: urinary catheterization (5.00) and the basics, two-handed tie, one-handed tie, suturing (5.00), passing and naming instruments (4.33), placing a central line in an elective situation (4.33). They were somewhat comfortable with biopsy of tissue (3.83), chest tubes (3.67), placing a central line in a code (3.67), skin grafts (3.33), wound management (3.00), hernia repair (2.83), basic laparoscopy skills (2.83), airway management (2.67), stapled GI anastomosis (2.50), lower endoscopy (2.00), upper endoscopy (1.67), and hand-sewn GI anastomosis (1.67). For all other skills, (vascular anastomosis, exploratory laparotomy, casting) the mean was 1.5 or below.

In terms of ranking the importance of various skills for simulator sessions, PGY1s rated the following as their top five skills: basic lap skills, chest tubes, central line elective, airway management, and exploratory laparotomy (Table 4). Next were central line code, hand-sewn GI anastomosis, upper endoscopy, hernia repair, lower endoscopy, and casting. Ties and sutures, and urinary catheterization were not ranked by any PGY1s. Results for the PGY2s were similar, except they included hand-sewn GI anastomosis and hernia repair in their top five. No PGY-2s ranked the basics (such as two-handed tie, one-handed tie, suturing), urinary catheterization, or skin grafts as an important skills station.

Table 4:
Rank Order of Important Surgical Skills to Learn Through Simulation By PGY1s and PGY2s


Stronger support for skills laboratories for interns may reflect the fact that interns have less operating room experience and, therefore, may be more likely to benefit from practicing skills under supervision.

Greater support for using simulation in general could indicate a belief that such skills are more easily taught in a simulation environment. Surgical skills laboratories are recognized as an essential part of general surgery training, yet there are many barriers to implementing an effective skills laboratory, such as cost and adequate personnel for organization and instruction. One such barrier may be concern on the part of residents that time spent in a skills laboratory might replace time spent in the operating room. Both PGY-1 and PGY-2 residents felt the skills laboratory was important to their personal professional development and to the program. Surprisingly, almost all PGY-1 and PGY-2 residents felt the skills laboratory should be mandatory and protected. Opinions are mixed in terms of requiring proficiency in the laboratory before residents are allowed to operate on patients.

After the results of this initial survey, our department decided to base our skills laboratory on the American College of Surgeons and the Association of Program Directors (ACS-APDS) National Curriculum developed by a national panel of experts in the field of surgery. The first phase of three includes basic surgical skills designed with first and second year residents in mind. The decision to use the APDS curriculum was made because the curriculum had been developed by a panel of experts, the breadth of the curriculum was appropriate for junior residents, it was readily available, and without associated cost.

This assessment also demonstrated that the needs of PGY-1 and PGY-2 residents are different. Even though they may be participating in the same curriculum, the PGY-2 residents have greater comfort in performing skills than PGY-1 residents (3.55 vs. 1.92). The PGY-1s only ranked three stations above a “3” (urinary catheterization, the basics such as tying and suturing, and naming and passing instruments), whereas the PGY-2s ranked eight stations above a “3,” (urinary catheterization, the basics, two-handed tie, one-handed tie, suturing, biopsy of tissue, passing and naming instruments, placing a central line in an elective situation, chest tubes, and skin grafts). Neither group was comfortable performing exploratory laparotomy, vascular anastomosis, upper endoscopy, and hand sewn GI anastomosis with maximal assistance. In terms of priority of the skills sessions, both groups had the highest mean rank order for basic laparoscopic skills. With the exception of wound management, the PGY-1 and PGY-2 residents identified the same top 10 skills stations, but the rank order varied. These results indicate that the skills laboratories should be separate for the different residency classes. Another benefit of separation of the classes is a higher instructor to resident ratio, providing more individual attention from an expert in the field.

Although we had a 100% response rate for our study, a limitation of the study is that the sample size is relatively small and respondents are all from a single institution. As residency programs implement surgical skills laboratories, understanding local opinions about the potential benefits may help to design the laboratories for maximal educational benefit. The results of this survey helped shape the order of the skills laboratory curriculum. By conducting these surveys before implementing our skills laboratory, we learned that using simulation to teach certain skills was not valued by residents. We believed this was because the survey was conducted midyear, after many of them had learned the skills through other means. So we instituted a semiintensive skills laboratory during orientation to address some of these basic skills, such as urinary catheterization, basic suturing, and knot tying. The remainder of the skills labs are held once a month for PGY-1 and PGY-2 residents.

The PGY-1 and PGY-2 level instruction is facilitated by one or more faculty members based on the ACS-APDS National Curriculum. All residents participate in an animal skills laboratory held twice a year designed to improve laparoscopic techniques. The PGY-1, PGY-2, and PGY-3 residents work on basic laparoscopic skills such as appendectomies and cholecystectomies, whereas the senior residents do more advanced cases such as Nissen fundiplication. In addition, the senior residents participate in another animal based skills laboratory focusing on advanced laparoscopic techniques and trauma management.

Response among residents has been favorable, as time spent in the laboratory supplements rather than replaces time spent in the operating room. In summary, targeting resources to the learners who are most likely to benefit, to the skills most appropriately taught or reinforced in a skills laboratory, and sequencing them in a way that learners find useful will ensure that resources are used most effectively.


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Training; Education; Surgical Education Residency and Internship; Technical Skills

Supplemental Digital Content

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