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Surgery_Schwartz. fundoplication • sentinal node biopsy and axillary lymph node dissection • open inguinal / femoral hernia repair • laparoscopic inguinal hernia repair • laparoscopic / open splenectomy • laparoscopic / open cholecystectomy • gastric resection and peptic ulcer disease • parathyroidectomy / thyroidectomyand cognitive performance could be assessed at the same time. 11 the simulation scenarios defined for this curriculum are listed in table 53 - 2. similar to the literature on basic skills training and assess - ment, procedural skills training and assessment has been shown to benefit learners when delivered via a structured curriculum. in addition, procedural skills training in a simulated environ - ment has been shown to transfer to the real - life clinical setting. in 2005, issenberg et al published a review of the features and uses of simulation training that lead to effective learning. 61 after reviewing 109 articles that specifically used simulation as an educational intervention and not for assessment alone, issenberg and colleagues noted that feedback, repetitive practice, and curricular intervention were among the top three features that lead to effective learning. of note, in this same article, it was noted that simulator validity was at the bottom of the list of features that lead to effective learning. in essence, trainees need protected time to engage in simulation - based learning exercises that have a high - level focus on deliberate and repetitive practice based on personalized feedback. this model is very similar to that used to train professional athletes. 62transfer of trainingthe determination that simulation - based education is effective requires assessment of training effect in either the clinical setting or one with a demonstrated relationship to a clinical setting. the latter might result from comparison to a validated “ gold standard ” training method. establishing a relationship between lab - based training and performance in the or requires validated measures of operative skills such as the widely used global assessment of operative laparoscopic skills ( goals ) method described by vassiliou. 63 the majority of studies of laparoscopic simulation training that examine transfer of skills to the clinical or make comparisons to control groups without highly structured and non - simulation based training. the results of these studies should eliminate any doubts that surgical learners, especially students and residents, can achieve training benefits from both proficiency - based and timeor repetitionor session number - based simulation practice. when the results of proficiency - based training are disse
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Surgery_Schwartz. ##cted out from the other models of training, consistently higher levels of clinical or 3animal or performance is observed with such training compared to without. 64 - 67 in one such review of skills transfer studies conducted between 2007 and 2013, dawe reported results for general surgery and gynecology procedures using different virtual reality and non - vr laparoscopic simulation platforms ( table 53 - 3 ). 48, 67 - 77 for the 12 randomized controlled trials with surgical residents as study subjects, all but one showed significantly better clinical performance for intervention groups compared to non – simulation - trained controls. the comprehensive reviews of skills transfer data under - score the wide disparities in study design characteristics, metrics, simulator types, and the difficulties in comparing effectiveness of different simulation interventions. the “ transfer effectiveness ratio ” ( ter ) has been forwarded as a means of expressing the relative magnitude of the training effect and may provide a basis for comparison of cost or time efficiency of different training methods. 78 to determine ter for a simulation training effort, one would calculate the difference in clinical effort ( time or some other measure such as number of cases ) between simulator - trained and alternative - trained groups to achieve a desired level of clinical performance, divided by training time received by the simulator - trained group. korndorffer raised concerns with studies of transfer of training when, irrespective of the improved results in lab performance with proficiency - based practice, residents studied by their group did not readily meet performance standards for more advanced skills set by expert surgeons in practice. 79 looking for opportunities to maximize the effectiveness of simulation training, stefanidis proposed training to “ automaticity ” by adding a secondary visuospatial task to practice with laparoscopic suturing, but only after proficiency levels were achieved with more standard laparoscopic suturing practice. 80 it was suggested that the added attentional challenge likely prompted the achievement of automaticity, the end result of which was much greater performance than was seen for proficiency - based practice alone. it is not clear, however, that simply adding to task difficulty improves training results if learner capabilities are not taken into account. in a separate study, stefanidis also reported that increased task difficulty during proficiency - based training causes measurable increases in cognitive workload and that when confronted with these challenges, novice learners did not perform better than those in proficiency - based training at a lower level of difficulty, suggesting a possible mismatch between task challenges and capacity to learn. 81
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Surgery_Schwartz. more work is required to characterize the proper balance of training difficulty and the capacity for learning in specific learners or learner groups. virtual realitythe use of virtual reality ( vr ) simulation as a way to deliver training experiences in surgery was proposed by satava in 1993. 82 within a few years, practical applications of this technology led to the first commercially available laparoscopic simulators and studies to determine their value. the earliest and most functional vr platform was mist - vr which permitted manipulation of abstract virtual objects using a realistic physical interface that transduced instrument motion into actions that could be observed in the virtual environment ( fig. 53 - 4 ). 83 even without a force feedback apparatus and haptic, or “ sense of touch, ” cues expected with instrument – instrument or instrument – object interactions, learners could experience the psychomotor challenges of videolaparoscopy and iteratively train until brunicardi _ ch53 _ p2163 - p2186. indd 216922 / 02 / 19 4 : 39 pm 2170specific considerationspart iitable 53 - 3randomized trials studying the effects of virtual reality training on surgical and ob - gyn resident operative performance vs. control trainees without virtual reality trainingauthor ( year ) participants ( n ) and simulatorprocedure assessedconclusionahlberg et al68 ( 2007 ) pgy 1 – 2 surgery residentsig ( 7 ) ; lap sim vr simulatorcg ( 6 ) no simulationlaparoscopic cholecystectomyig made fewer errors ( p = 0. 004 ), exposure ( p = 0. 040 ), clipping and tissue division ( p < 0. 008 ), and dissection ( p < 0. 031 ) compared with cgbanks et al69 ( 2007 ) pgy 1 gyn residentsig ( 10 ) ; limbs & things box trainercg ( 10 ) no simulationbilateral tubal ligationig scored higher than cg with all three evaluation tools : task - specific checklist ( p = 0. 002 ), osats ( p = 0. 003 ), pass - fail grade ( p = 0. 003 ) cosman et al70 ( 2007 ) junior surgical traineesig ( 5 ) ; lap sim vr simulatorcg ( 5 ) no simulationlaparoscopic cholecystectomy ( clip application and cystic artery
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Surgery_Schwartz. division ) ig had fewer errors ( p = 0. 05 ), better bimanual coordination ( p = 0. 05 ), higher global score ( p = 0. 04 ) than cggala et al71 ( 2013 ) gyn residentsig ( 48 ) ; fls box trainercg ( 54 ) no simulationpomeroy bilateral tubal ligationig had higher osats progression score than cg ( p = 0. 03 ) hogle et al72 ( 2009 ) pgy 1 surgery residentsig ( 6 ) ; lap sim vr simulatorcg ( 6 ) no simulationlaparoscopic cholecystectomyno significant difference between ig and cg in goalsdomain areas of depth perception, bimanual dexterity, efficiency, tissue handling, autonomylarsen et al73 ( 2009 ) firstand second - year ob - gyn registrarsig ( 13 ) ; lap sim vr simulatorcg ( 11 ) no simulationsalpingectomyig had higher score than cg in osa - ls scale ( p < 0. 001 ). ig completed procedure faster than cg ( p < 0. 001 ) sroka et al48 ( 2010 ) pgy 1 – 3 surgery residentsig ( 8 ) ; fls box trainercg ( 8 ) no simulationlaparoscopic cholecystectomy ( excision from liver bed ) ig had higher total goals score than cg ( p < 0. 001 ) and better goals domain scores for bimanual dexterity ( p = 0. 04 ), tissue handling ( p = 0. 04 ) van sickle et al74 ( 2008 ) pgy 3, 5 – 6 surgery residentsig ( 11 ) ; mist - vr simulatorcg no simulationnissen fundoplication ( placement of intracorporeal sutures ) ig completed task in less time ( p < 0. 003 ), committed fewer errors ( p < 0. 01 ), and had fewer needle manipulations ( p < 0. 05 ) than cgzendejas et al75 ( 2011 ) surgery residentsig ( 26 ) ; guildford mattu tep hernia task trainercg ( 24 ) no simulationtep inguinal hernia repairig faster on first procedure ( p < 0. 001 ) and had higher participation rates ( p < 0. 001 ). for subsequent repairs ig remained faster than cg.
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Surgery_Schwartz. goals score higher for ig ( p = 0. 001 ). complications and overnight stay less likely for first tep procedure in ig ( p < 0. 05 ). palter et al76 ( 2012 ) pgy 2 – 4 surgery residentsig ( 9 ) ; curriculum including simulation training on lapsim vr simulatorcg ( 9 ) no simulationright hemicolectomyig had higher osats score ( p = 0. 030 ) than cg. ig able to perform more operative steps than cg ( p = 0. 021 ) palter et al77 ( 2013 ) pgy 1 – 2 surgery residentsig ( 9 ) ; curriculum including simulation training on lapsim vr simulator and on fls box trainercg ( 9 ) no simulationcholecystectomyig had higher osats scores for first four procedures ( p = 0. 004, p = 0. 036, p = 0. 021, p = 0. 023 ) pgy = postgraduate year ; ig = intervention group ; cg = control group ; vr = virtual reality ; osats = objective structured assessment of technical skills ; goals = global operative assessment of laparoscopic skills ; osa - ls = objective structured assessment of laparoscopic salpingectomy ; tep = totally extraperitoneal. simulators : lapsim vr simulator ( surgical science, gothenburg, sweden ) ; laparoscopic stimulator and minimal access therapy unit ( mattu ) ( limbs and things, bristol, uk ) ; fundamentals of laparoscopic surgery ( fls ) training box simulator ( sages, los angeles, california, usa ) ; minimally invasive surgical trainer — virtual reality ( mist - vr ; mentice, gothenburg, sweden ). modified with permission from dawe sr, pena gn, windsor ja, et al. systematic review of skills transfer after surgical simulation - based training, br j surg. 2014 aug ; 101 ( 9 ) : 1063 - 1076. brunicardi _ ch53 _ p2163 - p2186. indd 217022 / 02 / 19 4 : 39 pm 2171skills and simulationchapter 53abfigure 53 - 4. the surgical interface for mist vr ( a ), consisting of rightand left - handed laparoscopic instruments on a gimbaled mount that transduces instrument motions into digital spatial data,
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Surgery_Schwartz. which determine the location and actions of instruments in the virtual space ( shown in b ) in the course of manipulating two - handed virtual objects. although basic renderings of geometric shapes, these virtual objects could be grasped, positioned, and treated with electrosurgery instruments, and they were shown to be an effective means to transfer skills to clinical surgery despite a relatively low level of fidelity to human tissues and absence of haptic feedback in the instrument interface. table 53 - 4studies comparing laparoscopic operative performance after training on virtual reality simulators vs. videoscopic box trainersauthor ( year ) study arms ( n ) subjectsproficiency - based training? conclusionshamilton et al92 ( 2002 ) vr ( 24 ) box trainer ( 25 ) firstand second - year surgical residentsnoimproved rater - blinded global assessments of laparoscopic cholecystectomy for vr but not box - trainer trained subjectsyoungblood et al93 ( 2005 ) vr ( 16 ) box trainer ( 17 ) no training ( 13 ) medical studentsnovr - trained students performed better than box trainer - trained on selected tasks in live porcine model. both trained groups outperformed nontrained. diesen et al94 ( 2011 ) vr ( 10 ) box trainer ( 8 ) internsmedical studentsnono difference in interval blinded video assessments of animal or task performancevr = virtual reality ; or = operating room. performance goals for precision, efficiency, and error avoidance were achieved. performance measurement was automated and included time, instrument motion, and electrosurgery use metrics, as well as a tally of the occurrence of predefined errors. all metrics were free of human observer bias. early studies of vr training using both proficiency - based and non – proficiency - based training methods showed it to be an effective means of improving laparoscopic skill both in the lab and in the operating room compared to non - vr trained controls. 68, 84 - 87 since the first studies of this type were performed almost 20 years ago, several comprehensive reviews of the growing body of literature on vr have continued to support the conclusion that skills acquired in vr transfer to the clinical setting ( table 53 - 3 ), not only for laparoscopy, but also for flexible endoscopy, sinuscopic surgery, and endovascular interventions. 66, 67, 88 - 91 largely due to small study sizes and some 4design limitations
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Surgery_Schwartz. , the quality of evidence of these studies is consistently described as below level i. based on available evidence, expanded use of vr for skills training could be justified, but few comparisons of training effectiveness have been made between physical laparoscopic video trainer ( “ box ” trainer ) and laparoscopic vr simulator - based training. crossover studies designed to determine if training in one environment improves performance in the other have not been especially helpful in defining the value of either. only a few studies have compared the effects of the two training methods on or performance ( table 53 - 4 ). although some advantage has been suggested, the prevailing view is that both can be used for highly effective laparoscopic practice. until better comparisons are made, use of proficiency - based training in the context of a larger curriculum appears to be the best way to achieve good training results irrespective of the training platform used. 5brunicardi _ ch53 _ p2163 - p2186. indd 217122 / 02 / 19 4 : 39 pm 2172specific considerationspart iivr simulator systems are significant capital investments for simulation centers that have competing procurement priori - ties. in a prospective randomized trial, orzech analyzed the cost impact of each type of training across canadian residency pro - grams and found that the transfer of training effect was greater for vr as compared to the box trainer group. however, box trainer use was found to be more cost effective except in larger residencies. 95 although the reasons for the latter finding require further analysis, the high acquisition costs of vr systems can be offset by an economy of scale benefit not realized with physical models where staffing for purposes of task setup and assess - ment and consumable items related to many tasks represent additive costs. flexible endoscopy vr simulator device sharing was shown to work effectively for a skills acquisition program across a network of texas institutions where procurement of numerous such simulators might not be practical. 96the role of haptics has been debated for laparoscopic vr simulators since the inclusion of sophisticated force feedback hardware adds substantially to the cost of surgical vr as well as to system computing demands. in simulated endoscopic and laparoscopic procedures, effective haptic cues are important contributors to the fidelity of the experience. for basic skills acquisition these features have not been shown to offer significant advantages over nonhaptic vr systems, although for more advanced skills haptic cues may permit greater precision of instrument use. 97
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Surgery_Schwartz. , 98 however, surgical vr has advanced to the point where inventories of procedure types offered on specific commercially available systems are quite extensive and these will inevitably increase and encompass entire procedures. the realism of the user experience, including the haptic experience, may prove essential to effective learning of advanced surgical skills in a new generation of vr devices. the current generation of laparoscopic simulators are highly capable devices with a high degree of graphical realism, full haptic features, and numerous tasks available for training basic and procedural skills for general surgical, urologic, and gynecologic procedures ( fig. 53 - 5 ). despite encouraging progress made in vr simulation, two separate publications in 2007 and 2015 identified ongoing com - putational challenges in development of very high - fidelity simu - lations for surgery. 99, 100 these include the unique vr problems of modeling human tissues and the added demands of rendering the appropriate deformations when tissues are manipulated. one of the practical examples of this is that of guidewire behavior during vr as compared to real - life endovascular procedures, where variable elasticity characteristics of blood vessel walls were observed to result in real tissue or wire deformations that the vr software could not depict accurately. 101 also identified were disparities between levels of resourcing for surgical vr versus mainstream computer gaming, raising important ques - tions on how the full power of this technology can be realized to more fully simulate complex operations with a high degree of fidelity and realism. virtual reality for flexible endoscopythe use of virtual reality simulation to train for flexible endos - copy procedures is now well established and supported by consistent evidence of both skills transfer. sedlack compared colonoscopy skills between small groups of inexperienced vr - trained and nontrained gastroenterology fellows and found that vr training resulted in farther progression into the colon, better inspection skills, and a higher percentage of completed studies ( those that reached the cecum ). 102 this performance advantage extended out to 30 posttraining procedures. in the years since that report, four randomized controlled trials of vr training with blinding to training status during posttraining clinical colonos - copy have been conducted. 103 - 106 despite methodological issues with each of these trials ( no proficiency - based training, unsuper - vised vr practice on one, vaguely defined training characteris - tics of control groups ), all but one showed training benefits for figure 53 - 5. three
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Surgery_Schwartz. different current generation laparoscopic virtual reality simulators. a. lapvr vr simulator, cae healthcare, sarasota, fl. b. simbionix lap mentor vr simulator, littleton, co. c. lapsim vr simulator, surgical science ab, gothenburg, sweden. abcbrunicardi _ ch53 _ p2163 - p2186. indd 217222 / 02 / 19 4 : 39 pm 2173skills and simulationchapter 53abfigure 53 - 6. representation of patient - specific aortic vascular anatomy during simulation of endovascular aortic replacement ( evar ) for abdominal aortic aneurysm, with distal graft limbs in the ballerina ( a. crossed ) and standard ( b. uncrossed ) configurations. this example of patient - specific rehearsal requires preparation the virtual aorta from a dicom ( digital imaging and communications in medicine ) format file of patient computed tomography ( ct ) or ct angiogram imaging data. image is rendered on angio mentor vr simulator ( 3d systems, littleton, co ). ( reproduced with permission from pakeliani d, van herzeele i, lachat ml, et al : evar 2020 : training future aortic spe - cialists. emerging needs and the role of simulation. endovascular today 2017 march ; 16 ( 3 ) : 95 - 100. ) previously inexperienced vr - trained residents versus controls, especially in the earlier posttraining clinical cases based on either subjective determination of competency or measurement of procedure length. the study that did not show improved clini - cal performance compared to controls was a noninferiority com - parison to control subjects with undefined patient - based training where the two groups performed comparably well. randomized trials of vr training for upper endoscopy have shown signifi - cant performance advantages in both procedure length and sub - jective assessment of competency compared to both nontrained and patient - based training control groups. 107 - 109based on the highly standardized test environment that can be experienced in vr and concurrent validity to clinical endos - copy, the sages fes program utilizes vr flexible endoscopy simulation for certification of skills. systematic review of pub - lished literature on vr flexible endoscopy skills cite the need for better quality evidence in support of best training practices and improved patient outcomes
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Surgery_Schwartz. . 110 further study is required, especially in the area of proficiency - based vr flexible endos - copy training, which has been generally underutilized. virtual reality for endovascular interventionsvirtual reality simulation has been shown to be an effective alternative to training with animal or cadaver models for catheter - based vascular interventions. current simulations allow development of basic guidewire and catheter handling skills, as well as practice in use of fluoroscopy, angioplasty, and stenting techniques. procedural training for coronary, carotid, renal, neuro, peripheral vascular, and other interven - tions are feasible with measurement of learner performance in numerous areas such as procedure and fluoroscopy time, con - trast use, and intervention effectiveness. simulators display fluoroscopy images and allow for the selection and insertion of virtual catheter, balloon, and stent types, which are pertinent to the procedure being performed ( fig. 53 - 6 ). in small randomized trials, vr training has been shown to increase residents ’ periph - eral angioplasty skills with transfer of lab - acquired skills to the clinical or. 111, 112 after having previously shown that vr simu - lator assessment can effectively discriminate the level of clini - cal experience with carotid artery stenting among experienced interventionalists, van herzeele demonstrated that experienced interventionalists could also significantly increase carotid artery stenting skills following a 2 - day intensive course of didactic and vr training for this procedure. 113, 114 following training, decreased procedure and fluoroscopy time and decreased time for placement and retrieval of the embolic protection device were observed. although differing clinical outcomes were not seen in this small study, it was noted that internal carotid artery spasm frequency decreased after training. the incorporation of actual patient vascular anatomic information taken from computerized tomography data into a vascular interventional simulation as an aid to procedural plan - ning or technical procedure performance has been referred to as “ mission rehearsal ” or more commonly now, procedure specific rehearsal or procedure specific simulation. it has been described most extensively for carotid artery stenting procedures and high - lights how vr simulation can be directed toward the immedi - ate problems of clinical practice. cates ’ brief report of a single procedure was followed by small studies further demonstrat - ing the
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Surgery_Schwartz. feasibility and general impressions of the value of this method. 115 - 117 in a randomized comparison of trainees who per - formed either part - task rehearsal or rehearsal of the entire proce - dure, willaert reported that a similar performance benefit could be achieved, suggesting a potentially more time - efficient way to train, although the embolic protection device was in place slightly longer in the part - task - trained group. 118brunicardi _ ch53 _ p2163 - p2186. indd 217322 / 02 / 19 4 : 39 pm 2174specific considerationspart iiin a recent multinational european study, desender and colleagues randomized a series of 100 patients scheduled to undergo elective endovascular aneurysm repair ( evar ) for infrarenal aortic aneurysm to either have their procedure rehearsed with vr simulation preoperatively or to have the pro - cedure performed without rehearsal. 119 there were 26 % fewer minor errors, 76 % fewer major errors, and a 27 % fewer errors causing procedural delay in the vr rehearsal group. in addition, this group had significantly fewer angiograms performed to visualize proximal and distal graft landing zones. in a follow - up of this study, desender reported that patient - specific rehearsal before evar resulted in alteration of the operative plan for proximal landing zone ( 54 % ), distal landing zone ( 76 % ), stent graft main body size ( 16 % ), contralateral limb size ( 34 % ) or orientation ( 16 % ), and iliac extension size ( 28 % ). ninety - two percent of these changes were implemented during the actual evar case. 119patient - specific vr surgery simulationin addition to patient specific rehearsal for endovascular inter - ventions, vr simulations for or surgical procedures have begun to use patient imaging data to rehearse procedures preop - eratively. while many surgeons consciously and subconsciously mentally rehearse procedures before entering the operating room, this process does not allow for fully explicit informa - tion sharing between team members. moreover, even when the surgeon verbalizes a plan for other members of the or team after the mental rehearsal, it is not uncommon to unintentionally exclude important details that team members may value. the use of anatomically accurate vr simulations, based on patient - specific anatomy, may
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Surgery_Schwartz. allow for team - based rehearsals and reduce the risk of human error. in addition, vr - based rehearsals may also facilitate doctor - patient communication. 120patient - specific vr simulations have recently emerged for a variety of complex operations including pancreatectomies, hepatectomies, renal surgery, and hand surgery. 120 - 123 for one of the renal surgery simulations, patient - specific computed tomog - raphy ( ct ) data was captured and used to create 3d imaging for incorporation into the simulation. 122 the anatomical accuracy of various structures such as arteries, veins, ureters, and even tumors was reported to be high. another group compared the appearance of individual vascular structures while performing several patient - specific virtual hepatectomies simultaneously with real - life hepatectomies and also noted a high degree of accuracy. in addition, similar to the way ct angiograms are used in the or for surgical planning, this group was able to increase and decrease the transparency level of the patient spe - cific vr simulation and use it both as a real - time operative guide ( minimal transparency mode ) as well as an operative planning guide ( high transparency – vessel only view ). this enabled one system to be used seamlessly throughout the actual operation. 123according to reports, the time needed to create patient - specific vr simulations is relatively short. on average, it took approximate 2. 5 hours each for both the hepatectomy and pan - createctomy simulations. 120 in addition, compared to the use of 3d printed simulations, patient - specific vr simulations are readily reusable and do not consume as many resources. while these recent advances are quite promising, patient - specific vr simulators are a new technology, and thus additional studies are required to more fully understand the pros and cons of introduc - ing this technology into the patient care arena. as there contin - ues to be major improvements in patient - specific 3d rendering, including organ and tissue deformation in reaction to surgical manipulation, this increases the possibility of even more sophis - ticated and accurate vr simulations that can be used for pre - operative planning and rehearsing for complicated procedures. robotic surgery simulatorsafter the da vinci surgical system was first introduced in the united states in 1999, a number of simulation systems for teaching robotic surgery emerged. while there have been sev - eral versions of the da vinci system deployed worldwide, the basic
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Surgery_Schwartz. system components usually include dual hand controls, foot pedals, and a controllable 3d camera. 124 consistency in these system components allow for similar consistency in simu - lation design and delivery. currently, there are four different simulators geared towards imparting some level of competency in using the da vinci system : the sep - robot ( surgicalsim educational platform robot ; simsurgery, oslo, norway ) ; ross ( robotic surgery simulator - simulated surgical systems, san jose, ca ) ; dv - trainer ( mimic simulation, seattle, wa ), and the da vinci skills simulator ( intuitive surgical, santa clara, ca ). 124, 125 the sep - robot is a desktop - like system for training robotic skills in a vr graphical interface. the da vinci skills simulator, also called the “ backpack, ” is a hardware system that loads vr simulations into the actual da vinci console. 126 the ross and dv - trainer systems are stand - alone devices with surgical controls resembling those of the da vinci system. 124 these simulators largely focus on hand - eye coordination, tissue manipulation, suturing and knot tying. 127 the major benefit of vr simulators for training da vinci robotic skills is that they produce performance metrics including time, error measures, and motion analysis. 124 these simulators are increasingly being used for training novice surgeons in robotic skills for a variety of surgical specialties. when assessing simulator validity, researchers have noted that the use of robotic surgery simulators does translate to the clinical environment and the learning curve for initial console training for surgeons is significantly decreased. 124, 126 unfortunately, the available robotic surgery simulators still come with a high sticker price and varying agreement on the level of fidelity that is currently present in these technologies. 124 these deficiencies are likely due to the early stage of the robotic surgery approach, and it is likely that cheaper and more sophis - ticated systems will be available in the near future. 128fundamentals of robotic surgerythe fundamentals of robotic surgery ( frs ) is a robotic surgi - cal skills training and assessment program designed to provide a proficiency - based curriculum of basic technical skills to prepare surgeons for performing robotic surgery procedures across a wide range of specialties. the frs program was developed over a 2 - year period by subject matter experts from multiple surgi - cal societies, surgical educational societies, surgical boards, and other governing organizations through a series of four consensus conferences, which included over 80 international robotic sur -
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Surgery_Schwartz. gery experts, behavioral psychologists, medical educators, stat - isticians, and psychometricians. 129 the multidisciplinary team of experts agreed upon the critical skills and tasks to be included in a comprehensive basic curriculum, and a task deconstruction was performed to identify the tasks, subtasks, and errors that needed to be measured. a modified delphi methodology was then used to create a matrix of specific robotic surgery tasks, common errors, desired outcomes, and quantitative metrics to 6brunicardi _ ch53 _ p2163 - p2186. indd 217422 / 02 / 19 4 : 39 pm 2175skills and simulationchapter 53table 53 - 5the four online modules for the fundamentals of robotic surgery curriculummodule 1introduction to surgical robotic systems, includes an overview of minimally invasive surgery, advantages of robotic assisted surgery, components of robotic systems, and system functionalitymodule 2didactic instructions for robotic surgery systems, provides an overview of robotic surgery systems, as well as detailed information regarding the pre -, intra -, and postoperative phasesmodule 3psychomotor skills curriculum, consists of background and general principles of the psychomotor tasks, an introduction to the physical model on which the tasks are performed, and general scoring guidelines for all the tasks, followed by detailed descriptions of each task, including the targeted primary and secondary skills and metricsmodule 4team training and communication skills, includes background on the degradation of situation awareness and the teamstepps process followed by detailed content covering communication, situational awareness, mutual support, leadership, the preoperative phase, robotic docking, intraoperative phase, postoperative phase, and a review of five scenariossupport those outcomes. finally, a second round classic delphi anonymous rating was used to ensure concurrence, prioritize the task rankings, and eliminate low - scoring tasks. all trainees must first complete an online curriculum consisting of four modules. each of the four online modules is followed by a short quiz, requiring a minimum of 70 % cor - rect to proceed in the training ( table 53 - 5 ). the curriculum also includes a cumulative, cognitive test following completion of all modules. abfigure 53 - 7. a. the simulated abdominal cavity for training in the fundamentals of robotic surgery. b. the 18 - cm removable dome model
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Surgery_Schwartz. featuring well - defined areas for executing each of the seven psychomotor exercises outlined in table 53 - 6. ( used with permission from the institute for surgical excellence. ) following online course completion, trainees must com - plete seven psychomotor exercises using a surgical robot, a simulated abdomen, and an 18 - cm, removable dome model ( fig. 53 - 7 ). the psychomotor exercises consist of the following tasks : docking / instrument insertion, ring tower transfer, knot tying, railroad track, 3rd arm cutting, puzzle piece dissection, and ves - sel energy dissection ( table 53 - 6 ). nontechnical skillsfor surgeons, the term “ nontechnical skills ” refers to the cog - nitive knowledge and teamwork - related abilities that must be integrated with psychomotor skills and abilities. there are no sharp demarcations between these areas of skill, but different simulation methods are suitable for training each, and all should be addressed. high - fidelity patient simulation and team skillsrecognition of the role of human factors in the occurrence of preventable errors has spawned various efforts to train behav - iors conducive to high - performing teams. crew resource man - agement ( crm ) training utilizing simulation has been credited with increased safety in aviation. 130, 131 lessons learned from crm have been adapted to medical training with simulators focusing on medical team performance in complex clinical situ - ations. this development came about in the 1990s driven pri - marily by anesthesiologists responsible for establishing the first high - fidelity simulation environments. 132, 133 these were devel - oped for simulation of crisis - level events where management could be practiced under realistic but safe conditions. 134 - 136 such training could be scaled to involve a single learner to focus on clinical management up to an entire care team able to practice team processes. development of a program for such training requires an understanding of the principles underlying team effectiveness and the specific characteristics of an expert team. in a 2012 discussion paper on team - based health care emerging from the best practices innovation collaborative of the institute of medicine ( iom ) roundtable on value & science - driven health care, such principles were clearly laid out following a careful analysis of effective medical teams across the country ( table 53 - 7 ). 137 this document provides an excellent review of characteristics and values that surgical teams can aspire to. the necessity to
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Surgery_Schwartz. train these skills has been widely accepted as brunicardi _ ch53 _ p2163 - p2186. indd 217522 / 02 / 19 4 : 39 pm 2176specific considerationspart iitable 53 - 6the seven psychomotor dome tasks for the fundamentals of robotic surgery curriculumtask 1 : docking / instrument insertionthe first psychomotor exercise provides training and assessment of proper docking and instrument insertion using the simulated abdomen. task 2 : ring tower transferthe trainee removes a ring from the right middle tower and places it on the lower left tower. primary skills assessed include hand, eye, and instrument coordination, camera navigation, and use of the camera pedal. task 3 : knot tyingthe trainee ties a surgeon ’ s knot to approximate two eyelets such that they touch each other. primary skills assessed include appropriate handling of suture material and tying secure knots. task 4 : railroad trackthe trainee must perform horizontal mattress suturing through a series of target points to approximate the tissue. primary skills assessed include holding and manipulation of the needle, following the curve of the needle, utilizing the full range of motion of the endowrist, and using graspers. task 5 : 3rd arm cuttingthe trainee must switch control between different instruments to use the monopolar scissors to cut a simulated vein. primary skills assessed include switching between and controlling multiple robot arms and cutting. task 6 : puzzle piece dissectionin this task, the trainee must cut and remove a puzzle shape without incising the underlying tissue or cutting outside of the lines. primary skills assessed include dissection, cutting, atraumatic tissue handling, sharp dissection, and blunt dissection. task 7 : vessel energy dissectionthe trainee must dissect through a fat layer to expose a vessel then coagulate the vessel at two points and finally cut the vessel between the two coagulated points. primary skills assessed include accurate activation and use of energy sources, dissection of vessels and tissues, cutting and coagulation of vessels, and multiple arm control. table 53 - 7principles of team - based health care • shared goals : the team — including the patient and, where appropriate, family members or other support persons — works to establish shared goals that reflect patient and family priorities, and can be clearly articulated, understood, and supported by all team members. • clear roles : there are clear expectations for each team member ’ s functions, responsibilities
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Surgery_Schwartz. , and accountabilities, which optimize the team ’ s efficiency and often make it possible for the team to take advantage of division of labor, thereby accomplishing more than the sum of its parts. • mutual trust : team members earn each other ’ s trust, creating strong norms of reciprocity and greater opportunities for shared achievement. • effective communication : the team prioritizes and continuously refines its communication skills. it has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings. • measurable processes and outcomes : the team agrees on and implements reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team ’ s goals. these are used to track and improve performance immediately and over time. reproduced with permission from mitchell p, wynia m, golden r, et al. core principles & values of effective team - based health care. discussion paper. institute of medicine, october 2012. a means of increasing the safety of healthcare. there are meth - ods to accomplish medical team training that do not involve simulation, but high - fidelity patient simulation has proven to be highly effective in increasing health care team competency, and systematic reviews have given evidence based endorsement of this approach. 138simulation training for communication and other teamwork - pertinent nontechnical skills requires learners to be embed - ded in realistic scenarios pertinent to a healthcare team ’ s 7actual clinical responsibilities where activities and interactions prompted by the simulated clinical circumstances can be prac - ticed and observed. the computer - driven high - fidelity manikin simulator serving as the “ patient ” at the center of these activities can be monitored and controlled to demonstrate realistic physi - ology consistent with the clinical condition needed for the scenario. 139 software - driven, physiologic changes from the baseline state can occur in response to either manual commands or programmed adjustments to accurately depict, for example, new, ongoing and unexpected clinical developments with blood loss, sepsis, or myocardial ischemia. basic interventions such as airway management, drug administration and wound care for moulaged body parts can also be performed. hybrid simulations using both manikin and open abdominal or laparoscopic surgi - cal simulators have also been used to extend scenarios to an operating room setting, with all members of the surgical team engaged in their role - specific tasks. 136, 140
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Surgery_Schwartz. , 141 these events can be conducted in a dedicated simulation suite or in an actual clinical area where it would be termed in situ simulation. the postsimulation debriefing is an essential compo - nent of simulation - based team training. this is where learning points are reinforced and progress towards desired knowledge, attitudes, and behavior can be developed. 142, 143 participants are prompted to reflect on the events of the simulation and to openly discuss positive and negative aspects of the experience. the debriefing environment and discussion ought to be open, nonjudgmental, and directed at improvement in individual and overall team performance. a facilitator with strong content knowledge should ensure that the discussion includes identifica - tion of gaps between the observed and desired performance. an brunicardi _ ch53 _ p2163 - p2186. indd 217622 / 02 / 19 4 : 39 pm 2177skills and simulationchapter 53effective facilitator is cognizant of the need to keep the debrief - ing learner - centric and to keep discussion focused on oppor - tunities for improvement. although debriefing is uniformly viewed as essential to health care team simulation effectiveness and structured debriefing models are frequently cited as highly effective, there is no consensus on which specific methods, including video review debriefings, represent best practices. 144 quality of implementation is consistently cited as the most important contributing factor to effectiveness of debriefing. the complexity of team - managed clinical events makes measurement of team performance challenging, but several assessment tools have been developed and used successfully in simulation settings. notechs ( non - technical skills ) and the notss ( non - technical skills for surgeons ) instruments have been used to study nontechnical abilities of individuals in surgi - cal teams. 141, 145 - 147 the principal focus of these rating scales is on the quality and effectiveness of situational awareness and com - munication. instruments such as the mayo high performance teamwork scale or the surgery - specific otas ( observational team assessment scale ) place focus on the team dynamics that extend beyond the single team member. 148, 149 these have been used to detect changes in team performance with training. rosen suggested a framework for a best practices approach to team performance assessment in simulation that details specific appli - cations of measurement techniques in the simulation training environment. 150simulation
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Surgery_Schwartz. training directed at nontechnical skills has been shown to improve clinical performance and improve knowledge and attitudes about team functioning as measured in simulated surgical settings such as the trauma bay and the or for interdis - ciplinary surgical teams and for surgical trainees. 136, 151 - 154 two systematic reviews of simulation training to increase team skills in the operating room consistently bear out this result, but both also cited the small number of studies where simulation training effects were investigated in the clinical or setting and lack of evidence of improved clinical outcomes with such training. 155, 156error preventionerror avoidance and prevention are the overarching goals of sur - gical care and the time - honored focus of surgical training. 157 fac - ulty who are responsible for training the next generation of highly qualified surgeons must facilitate the delicate balance between resident autonomy and patient safety. from a training perspective, gradual increases in patient responsibility, autonomous decision - making, and operative action provide a critical opportunity for independent hands - on performance, critical thinking, and action - based skill assessment. however, resident autonomy must be bal - anced with the goal of delivering high - quality, error - free patient care. a key component to achieving residency training goals includes exposure to techniques and strategies for avoiding errors. the relationship between errors and patient safety is well estab - lished in the literature and is also the cornerstone of the case review process for surgical morbidity and mortality conferences. 158 simulation technology allows trainees the opportunity to execute a variety of tasks and procedures while also experiencing the cognitive demands of surgery, including error correction and surgical planning decisions. fig. 53 - 8 presents a framework for categorizing surgical errors that may take place on the cognitive - motor continuum. 159simulation - based curricular approaches to exposing and training surgical errors include ( a ) the use of error - enabled 8cognitiveerror preventionwhat will prevent an error? knows the anatomy : right technique ; natural hx of disease ; how to avoid an errorselect the right operation ; the right stitch ; the right instrumentwhat should you be concerned about? cognitive - motorerror recognitionestimate errorrisk for : technicalapproach andpatient selectionwhich of thesemay result in anerror? error rescuewhat areyour optionsfor errorrescue? describewhat youwould do iferror preventionpre - error makesadjustments totechnical approachbased on errorpre
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Surgery_Schwartz. ##ventionerror recognitionnear miss recognitionfollowed by correctiveactionerror rescuepost - error knows andexecutes options forerror correctionidentify propertechnique ; potential error : error riskknows - surgicaloptionsexample : plansahead of time toadjust tensionduring knot tyingbased on tissuetypeexample : recognizesthat the first knot wasa little tight then makesan adjustment to getthe second knot justrightexample : first knotpulled throughrescue : freshenstissue edge, placesa new stitcherror loopfigure 53 - 8. a framework for understanding error prevention, error recognition, and error rescue / correction during both the cognitive phase as well as the cognitive - motor phase where there is fluid integration and updating of motor and cognitive decisions. this fluid integration allows for an error loop, as each decision is based on the results of each motor action in a dynamic fashion where an error can take place with each decision or action. ( reproduced with permission from pugh cm, santacaterina s, darosa da, et al : intra - operative decision making : more than meets the eye, j biomed inform. 2011 jun ; 44 ( 3 ) : 486 - 496. ) brunicardi _ ch53 _ p2163 - p2186. indd 217722 / 02 / 19 4 : 39 pm 2178specific considerationspart iisimulations, where the learner can make any of a variety of errors during the course of the task ; and ( b ) the use of forced - error simulations, where the learner experiences a specific, usually unexpected error and demonstrates error management as well as options for correction. error management is a human factors process that includes making, detecting, and correcting errors. 160, 161 several studies show that there is wide variation in the timing and type of operative decisions that residents make when interacting with an error - enabled simulation. 112, 162 - 164 specific error training simulations have been developed using a cognitive task analysis approach to guide the design of error scenarios. cognitive task analysis involves the use of structured interviews to explore how experts approach the error management process, including intraoperative decision - making and technical approaches. 165, 166 the error - enabled approach allows for a broad assessment of learning needs. the forced - error approach allows instructors to engage in specific error management skills and
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Surgery_Schwartz. metrics. error - enabled and forced - error surgical simulation trainers have been used in a variety of research and training modules to allow observation and assessment of surgical residents as they independently perform operative procedures and practice the error management process. 112, 166, 167another approach to error training and assessment is the use of assessments that focus on errors. current assessment tools for surgical skills include task - specific and global rating scales, final product analysis, and documentation of critical fail - ures. 160, 168 these existing tools for assessing surgical residents largely focus on manual techniques and procedure time and do not capture the cause of resident performance failures. 169 use of error - related theories in human factors allows for the devel - opment of error - centric skills assessments. 161, 170, 171 one study used previously developed human error classifications, includ - ing omission versus commission and cognitive versus technical as a means of assessing surgical residents. 162 omission errors were defined as failure to perform a step entirely. commis - sion errors represented failure to perform a step correctly. for example, failure to measure the hernia defect was categorized as an omission error, whereas measuring the hernia defect with an inaccurate method was categorized as a commission error. errors in information, diagnosis, and strategy were categorized as cognitive, and errors in action, procedure, or mechanics were classified as technical. use of assessment surveys with this type of differentiation allows for development of error metrics in sur - gery and focused error training and feedback. 172simulation and patient outcomessurgical simulation training is intended to make patient care safe and free of avoidable errors and to maximize opportunities for good clinical outcomes. the kirkpatrick four - level scale ( table 53 - 8 ) characterizes educational intervention effects, including those that might improve surgeon performance in clinical settings ( kirkpatrick level 3 ) or those that might actually improve patient outcomes ( kirkpatrick level 4 ). 173 despite the expanding use of simulation in proficiency - based practice models over at least 15 years, there are surprisingly few studies of simulation - based surgical training that can be described as kirkpatrick level 4. on the other hand, there are numerous studies showing that clinician performance during the course of clinical care is improved after simulation training ( kirkpatrick level 3 ). as detection of changes in clinical table 53 - 8kirkpatrick level scale of educational outcomeskirkpatrick levellevel descriptiondescription for simulationlev
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Surgery_Schwartz. ##el 1reactiondid the learner perceive value in using a simulator or participating in simulation training? level 2learningdid the learner ’ s knowledge, skill, or attitude improve as a result of the simulation training? level 3behavioral changedid the knowledge, skills, and attitudes acquired during simulation transfer to the clinical environment? level 4institutional impactdid the simulation training program lead to improved patient outcomes? data from cox t, seymour n, stefanidis d : moving the needle : simulation ’ s impact on patient outcomes, surg clin north am. 2015 aug ; 95 ( 4 ) : 827 - 838. outcomes can be quite challenging, it may be difficult to isolate simulation training effects from numerous other factors that can also affect patient outcomes. when looking specifically at a low - frequency complication event such as bile duct injury with laparoscopic cholecystectomy, the detection of a small, positive training effect is statistically improbable. however, the use of available kirkpatrick level 3 data to support assumptions about training benefits is fully supportable given the preponderance of literature showing such benefit. the best current evidence for improved patient outcomes with simulation is that of technical and cognitive training for central venous catheter ( cvc ) insertion. in 2009, barsuk et al monitored catheter - related bloodstream infection incidence in an icu setting over a 32 - month period before and after institu - tion of proficiency - based simulation training. after simulation - trained medical residents began performing cvc insertion, an 85 % reduction in these infections was observed ( 3. 2 per 1000 catheter - days reduced to 0. 50 infections per 1000 catheter - days ). 174 subsequently, the same group reported that the finan - cial savings realized with these improved outcomes amounted to a 7 : 1 return of the investment for the training. 175 in a similar sin - gle unit observational study, burden et al reported a reduction in catheter - related bloodstream infection incidence from 6. 47 per 1000 catheter days to 2. 44 per 1000 catheter days after training intervention and comparable financial savings with shorter icu and hospital stays. 176 single cohort studies have inherent weak - nesses, but a somewhat smaller randomized trial of simulation training versus traditional apprenticeship model - trained controls also showed this reduced infection incidence ( 1. 0
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Surgery_Schwartz. vs. 3. 4 infec - tions per 1000 catheter - days, respectively ). 177riley and colleagues conducted a study in three small community hospitals, administering teamstepps ( team strategies and tools to enhance performance and patient safety ) didactic team training to perinatal care teams at one hospital, teamstepps with an accompanying program of in situ simula - tions at a second, and no intervention at the third hospital, which brunicardi _ ch53 _ p2163 - p2186. indd 217822 / 02 / 19 4 : 39 pm 2179skills and simulationchapter 53served as the study control. 178, 179 the simulation interventions were designed to involve triage, labor and delivery, and or components of care. perinatal outcomes were assessed using the weighted adverse outcomes score ( waos ). simulation train - ing resulted in improved clinical results with a 37. 4 % decrease in waos observed in the simulation intervention group, while similar benefit was not observed in either the didactic - trained or control groups. teamstepps with supplemental simulation training was also studied by capella and colleagues for team performance and patient outcomes in trauma care. 180 trauma resuscitations for successive 2 - month periods separated by didactic and scenario - based simulation training to subjectively - defined proficiency levels ( 33 before training, 40 after training ) were assessed in multiple teamwork domains including overall performance using the tpot ( trauma team performance observation tool ). significant improvements were observed post training in leader - ship, situational monitoring, mutual support, communication, and overall scoring. in addition, time to or was also observed to decrease. steinemann and colleagues reported on a larger number of trauma resuscitations, 141 before and 103 after in situ trauma bay patient simulation training with accompanying didactic instruction. 181 although significant improvements in patient outcomes were not observed in this study, resuscitation time did decrease following training. in a comprehensive review of literature examining simula - tion impact on patient outcomes, zendejas identified 50 stud - ies purporting to show patient outcomes. 182 for the majority of these, the quality of clinical outcomes evidence was considered low, and appropriate validity data were reported for results in only a small number of published reports. in a subsequent review of 1328 articles resulting from an exhaustive literature search, cox identified 12 individual articles that reported suf - ficie
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Surgery_Schwartz. ##nt patient outcomes data to be considered kirkpatrick level 4. 183 concerns regarding the relatively few studies of this nature are primarily methodological and relate to the prepon - derance of use of the observational preand posttraining study model with its inherent bias risk, rather than randomized con - trolled trials. these studies have also tended to be quite limited in size. in surgery, the general areas of surgeon performance that have lent themselves to study of educational outcomes in the clinical setting after simulation training include technical abilities and observable behaviors during team - based activi - ties. the use of decreased operative time or technical errors as clinical outcomes after simulation training might suggest, but do not clearly establish, a patient safety or other efficacy benefit. however, these metrics have frequently been used to make the case for the potential for such benefits in skills transfer studies for procedures such as laparoscopic cholecystectomy and lapa - roscopic hernia repair. 56, 63 there is a clear need to obtain high quality evidence of how proficiency - based simulation training impacts surgical patient outcomes. in a recent study examining intern response to pediatric codes, simulation training was shown to significantly reduce the time to request help, to initiate bag - mask ventilation, and to ini - tiate chest compressions. 184 citing the rarity of pediatric codes, investigators measured this effect in in mock code situations using patient simulators. this use of a high - fidelity simulation environment as a surrogate for clinical events, that might oth - erwise be difficult to observe, may be the only practical model available for the study of provider performance outcomes with educational interventions. simulation training for the practicing surgeon and maintenance of skillgiven the current requirement for fls and fes certification in residency, some authors have posed the important question of whether such certification should be applied more broadly to surgeons in practice. 185 in a 2012 press release, both the acs and sages made the recommendation that all surgeons per - forming laparoscopy obtain fls certification. the potential to lower malpractice litigation risk under a self - insurance model was used as justification to certify 37 surgeons in fls in the harvard system in 2009. 186 in a recent report, surgical oncolo - gists new to minimally invasive inguinal lymph node dissec - tion ( milnd ) were fls tested prior to performance of their first clinical procedures, which were video
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Surgery_Schwartz. - assessed using the goals scoring method. 187 the fls score was shown to corre - late with both goals results and operative time but not lymph node yield. however, evidence that a lab - based technical and cognitive skills test predicts observed operative technical skill in practicing surgeons is promising and warrants investigative follow - up. at the present time, the american board of surgery ’ s requirements for maintenance of certification ( moc ) do not specifically include any certification of technical skills that might use surgical simulation. 188 nonetheless, simulation training and testing can be made available to surgeons in practice to provide an avenue for specific training. although most investigations of vr use for laparoscopy have examined basic skills acquisition in the lab setting far in advance of any measured impact in the clinical or, a recent innovative study of the use of a vr simulator for “ warm - up ” practice immediately before a procedure showed that this improved or performance. 189 as new surgical procedures and technologies are introduced to clinical practice, simulation training solutions could serve just as important a purpose to prepare for these as simulation training methods currently serve for laparoscopic surgery. in a recent publication relating to practicing surgeons, sullivan et al. provide a framework for development of simulation - based certification models for both trainees and faculty surgeons. 190future considerationssimulation - based training and assessment is firmly established in surgical education, especially in graduate medical education where learners have been more extensively studied than any other simulation user group. the immediate future of simulation in surgery will likely see expanded use of proficiency - based training given the consistent demonstrations of effectiveness in improving surgeon skills and improved educa - tional outcomes as measured in clinical settings. the question of what types of simulation - based assess - ments and training activities might be possible raises questions of where technological advances might open new opportunities. 191 the advancement of virtual reality is inevitable, and much richer virtual experiences entering the mainstream in surgical educa - tion seems likely in the near future. three - dimensional printing technology has been growing in its use and applications and has greatly facilitated the development of anatomically accurate bench top simulations for complex surgical procedures. some of the materials allow for elegant instrument - based dissections, including the use of electrosurgery. 192 - 1949brunicardi _ ch53 _ p2163 - p2186. indd 217922 / 02 / 19 4 : 39 pm 2180specific considerationspart iiadvances in wearable
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Surgery_Schwartz. ##s, motion tracking, and sensor tech - nologies allow for a wide variety of hybrid and aug - mented experiences in simulation as well as extensive opportunities for the development of new performance metrics. one study using sensor technology for evaluating clinical breast examination skills noted key performance differences in expe - rienced physicians. both the sensor data and sensor - guided video analysis allowed for skill quantifications that were previ - ously unknown but critical to performance excellence. 195 - 196opportunities for remote collaboration are now greatly improved with higher internet speeds, improvements in aug - mented reality technology, and ever - increasing camera reso - lution. vipar ( virtual interactive presence and augmented reality ) allows for the visual field of a surgeon to be converted to a simulation and projected in a remote location. 197 - 198 as such, the system allows for intraoperative collaboration and telementoring. 199irrespective of what new simulation and engineering tech - nologies emerge, these technologies are here not just to stay but to grow as assessment and educational tools. this presents abundant opportunities for simulation leaders in surgery to improve the delivery of care by defining best practice in sim - ulation applications and keeping step with current and future changes in surgical practice. referencesentries highlighted in bright blue are key references. 1. leape ll. error in medicine. jama. 1994 ; 272 ( 23 ) : 1851 - 1857. 2. to err is human : building a safer health system. washington, dc : national academy press, institute of medicine ; 1999. 3. satava rm. historical review of surgical simulation — a personal perspective. world j surg. 2008 ; 32 ( 2 ) : 141 - 148. 4. martin ja, regehr g, reznick r, et al. objective struc - tured assessment of technical skill ( osats ) for surgical residents. br j surg. 1997 ; 84 ( 2 ) : 273 - 278. 5. reznick r, regehr g, macrae h, martin j, mcculloch w. testing technical skill via an innovative “ bench station ” examination. am j surg. 1997 ; 173 ( 3 ) : 226 - 230. 6. a prospective analysis of 1518 laparoscopic cholecystec - tomies. the southern surgeons club. n engl j med. 1991 ; 324 ( 16 ) : 1073 - 1078
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Surgery_Schwartz. . 7. rosser jc, rosser le, savalgi rs. skill acquisition and assessment for laparoscopic surgery. arch surg. 1997 ; 132 ( 2 ) : 200 - 204. 8. derossis am, bothwell j, sigman hh, fried gm. the effect of practice on performance in a laparoscopic simulator. surg endosc. 1998 ; 12 ( 9 ) : 1117 - 1120. 9. gallagher ag, ritter em, champion h, et al. virtual reality simulation for the operating room : proficiency - based training as a paradigm shift in surgical skills training. ann surg. 2005 ; 241 ( 2 ) : 364 - 372. 10. sachdeva ak. establishment of american college of surgeons - accredited education institutes : the dawn of a new era in surgical education and training. j surg educ. 2010 ; 67 ( 4 ) : 249 - 250. 11. scott dj, dunnington gl. the new acs / apds skills curriculum : moving the learning curve out of the operating room. j gastrointest surg. 2008 ; 12 ( 2 ) : 213 - 221. 12. korndorffer jr, arora s, sevdalis n, et al. the american college of surgeons / association of program directors in surgery national skills curriculum : adoption rate, challenges and strategies for effective implementation into surgical residency programs. surgery. 2013 ; 154 ( 1 ) : 13 - 20. 13. bell rh. surgical council on resident education : a new organization devoted to graduate surgical education. j am coll surg. 2007 ; 204 ( 3 ) : 341 - 346. 14. carraccio cl, benson bj, nixon lj, derstine pl. from the educational bench to the clinical bedside : translating the dreyfus developmental model to the learning of clinical skills. acad med. 2008 ; 83 ( 8 ) : 761 - 767. 15. ericsson ka. deliberate practice and acquisition of expert performance : a general overview. acad emerg med. 2008 ; 15 ( 11 ) : 988 - 994. 16. ericsson ka, krampe rt, tesch - romer c. the role of deliberate practice in the acquisition of expert performance. psychol rev. 1993 ; 100 ( 3 ) : 363 - 406. 17. bridges m, diamond dl. the financial impact of teaching
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Surgery_Schwartz. surgical residents in the operating room. am j surg. 1999 ; 177 ( 1 ) : 28 - 32. 18. gould jc. building a laparoscopic surgical skills training laboratory : resources and support. jsls. 2006 ; 10 ( 3 ) : 293 - 296. 19. britt ld, richardson jd. residency review committee for surgery : an update. arch surg. 2007 ; 142 ( 6 ) : 573 - 575. 20. acgme program requirements for graduate medical education in general surgery. revised common program requirements effective : july 1, 2018. available at : https : / / www. acgme. org / portals / 0 / pfassets / programrequirements / 440generalsurgery2018. pdf? ver = 2017 - 10 - 03 - 110315 - 270. accessed august 27, 2018. 21. american board of surgery. flexible endoscopy curriculum for general surgery residents. 2014. available at : https : / / www. absurgery. org / xfer / abs - fec. pdf. accessed august 27, 2018. 22. haluck rs, satava rm, fried g, et al. establishing a simulation center for surgical skills : what to do and how to do it. surg endosc. 2007 ; 21 ( 7 ) : 1223 - 1232. 23. friedell ml. starting a simulation and skills laboratory : what do i need and what do i want? j surg educ. 2010 ; 67 ( 2 ) : 112 - 121. 24. meier ah. running a surgical education center : from small to large. surg clin north am. 2010 ; 90 ( 3 ) : 491 - 504. 25. brunt lm, halpin vj, klingensmith me, et al. accelerated skills preparation and assessment for senior medical students entering surgical internship. j am coll surg. 2008 ; 206 ( 5 ) : 897 - 904 ; discussion 904 - 897. 26. fernandez gl, page dw, coe np, et al. boot camp : educational outcomes after 4 successive years of preparatory simulation - based training at onset of internship. j surg educ. 2012 ; 69 ( 2 ) : 242 - 248. 27. krajewski a, filippa d, staff i, singh r, kirton oc. implementation of
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Surgery_Schwartz. an intern boot camp curriculum to address clinical competencies under the new accreditation council for graduate medical education supervision requirements and duty hour restrictions. jama surg. 2013 ; 148 ( 8 ) : 727 - 732. 28. cohen er, barsuk jh, moazed f, et al. making july safer : simulation - based mastery learning during intern boot camp. acad med. 2013 ; 88 ( 2 ) : 233 - 239. 29. blackmore c, austin j, lopushinsky sr, donnon t. effects of postgraduate medical education “ boot camps ” on clinical skills, knowledge, and confidence : a meta - analysis. j grad med educ. 2014 ; 6 ( 4 ) : 643 - 652. 30. american board of surgery ; american college of surgeons ; association of program directors in surgery ; association for surgical education. statement on surgical preresidency preparatory courses. surgery. 2014 ; 156 ( 5 ) : 1059 - 1060. 31. gomez pp, willis re, schiffer bl, gardner ak, scott dj. external validation and evaluation of an intermediate proficiency - based knot - tying and suturing curriculum. j surg educ. 2014 ; 71 ( 6 ) : 839 - 845. 32. sanfey h, ketchum j, bartlett j, et al. verification of proficiency in basic skills for postgraduate year 1 residents. surgery. 2010 ; 148 ( 4 ) : 759 - 766 ; discussion 766 - 757. 10brunicardi _ ch53 _ p2163 - p2186. indd 218022 / 02 / 19 4 : 39 pm 2181skills and simulationchapter 53 33. sanfey h, dunnington g. verification of proficiency : a prerequisite for clinical experience. surg clin north am. 2010 ; 90 ( 3 ) : 559 - 567. 34. satava rm, gallagher ag. next generation of procedural skills curriculum development : proficiency - based progression. j health spec. 2015 ; 3 : 198 - 205. 35. nemeth zh, lazar el, paglinco sr, et al. experience of general surgery residents in the creation of small bowel and colon anastomoses. j surg educ. 2016 ; 73 ( 5 ) : 844 - 850. 36. jensen ar, wright as, mcintyre lk, et al
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Surgery_Schwartz. . laboratory - based instruction for skin closure and bowel anastomosis for surgical residents. arch surg. 2008 ; 143 ( 9 ) : 852 - 858 ; discussion 858 - 859. 37. olson tp, becker yt, mcdonald r, gould j. a simulation - based curriculum can be used to teach open intestinal anastomosis. j surg res. 2012 ; 172 ( 1 ) : 53 - 58. 38. egle jp, malladi sv, gopinath n, mittal vk. simulation training improves resident performance in hand - sewn vascular and bowel anastomoses. j surg educ. 2015 ; 72 ( 2 ) : 291 - 296. 39. palter vn, grantcharov t, harvey a, macrae hm. ex vivo technical skills training transfers to the operating room and enhances cognitive learning : a randomized controlled trial. ann surg. 2011 ; 253 ( 5 ) : 886 - 889. 40. melvin ws, johnson ja, ellison ec. laparoscopic skills enhancement. am j surg. 1996 ; 172 ( 4 ) : 377 - 379. 41. rosser jc, rosser le, savalgi rs. objective evaluation of a laparoscopic surgical skill program for residents and senior surgeons. arch surg. 1998 ; 133 ( 6 ) : 657 - 661. 42. derossis am, fried gm, abrahamowicz m, et al. development of a model for training and evaluation of laparoscopic skills. am j surg. 1998 ; 175 ( 6 ) : 482 - 487. 43. fried gm, derossis am, bothwell j, sigman hh. comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. surg endosc. 1999 ; 13 ( 11 ) : 1077 - 1081 ; discussion 1082. 44. stefanidis d, hope ww, korndorffer jr, markley s, scott dj. initial laparoscopic basic skills training shortens the learning curve of laparoscopic suturing and is cost - effective. j am coll surg. 2010 ; 210 ( 4 ) : 436 - 440. 45. peters jh, fried gm, swanstrom ll, et al. development and validation of a comprehensive program of education and assessment of the basic fundamentals
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Surgery_Schwartz. 1089. 183. cox t, seymour n, stefanidis d. moving the needle : simulation ’ s impact on patient outcomes. surg clin north am. 2015 ; 95 ( 4 ) : 827 - 838. 184. ross jc, trainor jl, eppich wj, adler md. impact of simulation training on time to initiation of cardiopulmonary resuscitation for first - year pediatrics residents. j grad med educ. 2013 ; 5 ( 4 ) : 613 - 619. 185. hafford ml, van sickle kr, willis re, et al. ensuring competency : are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel? surg endosc. 2013 ; 27 ( 1 ) : 118 - 126. 186. derevianko ay, schwaitzberg sd, tsuda s, et al. malpractice carrier underwrites fundamentals of laparoscopic surgery training and testing : a benchmark for patient safety. surg endosc. 2010 ; 24 ( 3 ) : 616 - 623. 187. zendejas b, jakub jw, terando am, et al. laparoscopic skill assessment of practicing surgeons prior to enrollment in a surgical trial of a new laparoscopic procedure. surg endosc. 2017 ; 31 ( 8 ) : 3313 - 3319. 188. buyske j. forks in the road : the assessment of surgeons from the american board of surgery perspective. surg clin north am. 2016 ; 96 ( 1 ) : 139 - 146. 189. calatayud d, arora s, aggarwal r, et al. warm - up in a virtual reality environment improves performance in the operating room. ann surg. 2010 ; 251 ( 6 ) : 1181 - 1185. 190. sullivan sa, anderson bm, pugh cm. development of technical skills : education, simulation, and maintenance of certification. j craniofac surg. 2015 ; 26 ( 8 ) : 2270 - 2274. brunicardi _ ch53 _ p2163 - p2186. indd 218422 / 02 / 19 4 : 39 pm 2185skills and simulationchapter 53 191. badash i, burtt k, solorzano ca, carey
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Surgery_Schwartz. jn. innovations in surgery simulation : a review of past, current and future techniques. ann transl med. 2016 dec ; 4 ( 23 ) : 453. 192. gause cd, hsiung g, schwab b, et al. advances in pediatric surgical education : a critical appraisal of two consecutive minimally invasive pediatric surgery training courses. j laparoendosc adv surg tech a. 2016 ; 26 ( 8 ) : 663 - 670. 193. cheung cl, looi t, lendvay ts, drake jm, farhat wa. use of 3 - dimensional printing technology and silicone modeling in surgical simulation : development and face validation in pediatric laparoscopic pyeloplasty. j surg educ. 2014 ; 71 ( 5 ) : 762 - 767. 194. chan hh, siewerdsen jh, vescan a, et al. 3d rapid prototyping for otolaryngology - head and neck surgery : applications in image - guidance, surgical simulation and patient - specific modeling. plos one. 2015 ; 10 ( 9 ) : e0136370. 195. laufer s, cohen er, kwan c, et al. sensor technology in assessments of clinical skill. n engl j med. 2015 feb 19 ; 372 ( 8 ) : 784 - 786. 196. laufer s, d ’ angelo ad, kwan c, et al. rescuing the clinical breast examination : advances in classifying technique and assessing physician competency. ann surg. 2016 sep 21. 197. shenai mb, dillavou m, shum c, et al. virtual interactive presence and augmented reality ( vipar ) for remote surgical assistance. neurosurgery. 2011 ; 68 ( 1 suppl ) : 200 - 207 ; discussion 207. 198. shenai mb, tubbs rs, guthrie bl, cohen - gadol aa. virtual interactive presence for real - time, long - distance surgical collaboration during complex microsurgical procedures. j neurosurg. 2014 ; 121 ( 2 ) : 277 - 284. 199. ponce ba, jennings jk, clay tb, et al. telementoring : use of augmented reality in orthopaedic education : aaos exhibit selection. j bone joint surg am. 2014 ; 96 ( 10 ) : e84. brunicard
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Surgery_Schwartz. ##i _ ch53 _ p2163 - p2186. indd 218522 / 02 / 19 4 : 39 pm brunicardi _ ch53 _ p2163 - p2186. indd 218622 / 02 / 19 4 : 39 pmthis page intentionally left blank web - based education and implications of social medialillian s. kao and michael e. zenilman 54chapterintroductionsurgical education has changed significantly over the past two decades. disruptive forces such as work hour restrictions and the advent of laparoscopy have forced educators to rethink how and where to teach residents. technologies, including the inter - net and web - based applications, have further enabled educators to redesign surgical education ( fig. 54 - 1 ). the internet has become an integral tool not just in surgical education but also in americans ’ lives by changing the way that people communicate with each other, access information, and conduct their daily lives. today, almost 9 in 10 american adults use the internet. furthermore, the internet has revolutionized education by allowing for expanded reach, asynchronous learning whereby students and instructors do not have to be on the same time schedule, and multimedia materials. like internet usage, social media has seen a rise in adop - tion over the past decade. social media is a term that encom - passes multiple computer - mediated platforms that are used for creating and sharing information, ideas, and other content. social media facilitates communication and interactions across virtual networks. commonly used platforms include facebook, twitter, snapchat, and instagram. social media can be used for multiple purposes including social and professional network - ing ; however, this chapter will focus on its uses in surgical education. web - based educationweb - based educational resources include lectures and webi - nars, simulators, assessment tools, and interactive mentoring and coaching. furthermore, entire web - based curricula have been developed that can link to online resources such as journal articles, interactive anatomy modules, and videos of operations. there are multiple advantages to web - based education. for sur - gical trainees, web - based educational materials allow access regardless of time of day or night, provide interactive tools for learning ( i. e., anatomy ), and videos for viewing operations and procedures. furthermore, for practicing surgeons, web - based educational resources include forums for sharing challenging cases and procuring advice, activities for
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Surgery_Schwartz. obtaining continuing 12education, and rapid access to information about new technolo - gies and research. however, there may also be disadvantages in terms of costs and technical problems. multiple studies have evaluated learning outcomes after implementation of web - based educational interventions. in sur - gical education, these interventions may be used to teach patient care and decision - making via online case studies, convey knowledge using online didactic materials, or introduce surgical skills. however, studies evaluating these interventions tend to be nonrandomized, small, and single center. a 2008 systematic review and meta - analysis by cook et al evaluated the effect of internet - based learning across healthcare in general. the review suggested that internet - based learning is better than no interven - tion but has similar effectiveness as traditional educational methods. a more recent 2015 systematic review by jayakumar et al focused on web - based education in surgery. they reported a positive effect, but the majority of studies included in the review lacked a control. based on the current literature, the internet should be considered one tool among many that can facilitate learning. however, further studies are necessary to identify the key elements that improve effectiveness. web - based educational materials should be developed keeping adult learning theories and principles in mind. web - based surgical curricula have been developed both at an institutional and at a national level. a widely - used curricu - lum is the surgical council on resident education ( score ) curriculum, which is available via an online portal. developed in 2006, score is based on the six core competencies required of a graduating resident : patient care, medical knowledge, professionalism, communication, practice - based learning, and systems - based practice. score is the result of an ongoing col - laborative effort of the american board of surgery, american college of surgeons, american surgical association, asso - ciation of program directors in surgery, association for surgical education, residency review committee for surgery of the accreditation council of graduate medical education, and society of american gastrointestinal and endoscopic surgeons. the score curriculum provides content for topics to be covered during a 5 - year general surgery residency and is adding fellowship - level content as well. the score portal modules for each topic include learning objectives, discussion 3introduction2187web - based education2187social media – based education2188what is social media? / 2188journal clubs / 2190live -
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Surgery_Schwartz. tweeting conferences / 2190interactive forums and communities / 2190public education / 2192pitfalls in web and social media – based education2192implications and future directions2194brunicardi _ ch54 _ p2187 - p2196. indd 218713 / 02 / 19 2 : 37 pm 2188disruptive forces1995200020052010impactsurgical educationenabling technologiesfigure 54 - 1. the relationship between disruptive forces, enabling technologies, and surgical education. ( reproduced with permission from pugh cm, watson a, bell rh, jr, et al. surgical education in the internet era. j surg res. 2009 oct ; 156 ( 2 ) : 177 - 182. ) key points1 the internet has become an integral tool not just in surgical education but also in americans ’ lives by changing the way that people communicate with each other, access informa - tion, and conduct their daily lives. 2 the internet has revolutionized surgical education by allow - ing for expanded reach — asynchronous learning whereby students and instructors do not have to be on the same time schedule — and multimedia materials such as interactive les - sons and videos. 3 despite the appeal of web - based education, systematic reviews and meta - analyses have failed to identify high - quality studies demonstrating that it is superior to standard educational methods in improving learning outcomes. 4 web - based and virtual reality simulators can be used both to teach technical skills and to assess performance. virtual reality simulators have been effective in training surgeons on technical skills that translate to operating room performance. 5 online and social media – based journal clubs can overcome barriers associated with traditional journal clubs such as lack of a convenient time and no local clinical or methodological experts. however, they may require more time and commit - ment from the leaders, and they may not be as effective as traditional, in - person, faculty - moderated journal clubs. 6 social media rapidly and exponentially increases the spread of information. 7 multiple pitfalls exist with regards to web and social media – based education, including but not limited to : ( a ) need for more widespread adoption and use, ( b ) lack of accuracy and regulatory oversight over educational content, ( c ) issues regarding patient confidentiality and privacy, ( d ) nondisclo - sure of conflicts of interest, and ( e ) pau
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Surgery_Schwartz. ##city of evidence for effectiveness of these materials for improving knowledge, attitudes, skills, and outcomes. 8 social media has become a necessary component of surgical practice. questions, text resources and videos, and self - assessment quizzes. although improvements in quality examination per - formance among residencies that subscribe to score are prom - ising, no studies have definitely demonstrated that score use improves resident knowledge, skills, or clinical performance. web - based education can also be used for assessing and teaching surgical skills. in 2013, birkmeyer et al performed a study that correlated surgical skills in bariatric surgery, based on blinded reviews of videotaped operations, to clini - cal outcomes. the ability to discriminate surgeons with good and poor technical skills using video - based assessments has signifi - cant implications for training surgeons and for evaluating their performance. with regards to training, multiple web - based and virtual reality simulators have been developed that allow resi - dents to practice tasks and skills repetitively at their own pace and on their own time. these simulators can quantify efficiency of motion and time to complete a task as well as provide 4real - time feedback. these metrics have been demonstrated to have construct validity ( in that they measure what they are sup - posed to be measuring ) and criterion validity ( in that they cor - relate with operative performance ). for example, randomized trials have demonstrated that surgical simulation training corre - lates with decreased operative time and improves subjectively rated performance on technical skills in the live setting. web - based assessments have also been used in combination with physical simulators to provide similar metrics. with regards to surgeons in practice, there has been increased enthusiasm for the use of video - based coaching to complement intraoperative teaching. in particular, postopera - tive review of videotaped procedures allows surgeons to receive individualized feedback about opportunities for improvement without the time constraints or pressures of the operating room. randomized trials of surgical coaching in simulated settings suggests benefits over traditional simulator training, and larger trials in a live setting are ongoing. although most coaching occurs face - to - face, there are opportunities to use web - based coaching. as an example, telementoring has been used to proc - tor surgeons in the operating room, even across the globe. barriers to web - based education include the up - front costs for development and the need for technical expertise. as already noted, web
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Surgery_Schwartz. - based education for teaching knowledge may not be more effective than traditional methods. on the other hand, simulation and video - based coaching hold significant prom - ise in improving training in and assessment of surgical skills. however, widespread implementation of video - based coaching will require a culture shift for surgeons to accept assistance and resources such as time, availability of coaches, and finances. ongoing studies will provide data regarding the effectiveness of these educational strategies. social media – based educationwhat is social media? social media is a term describing websites and web - based applications that enable users to share ideas, information, and brunicardi _ ch54 _ p2187 - p2196. indd 218813 / 02 / 19 2 : 37 pm 2189web - based education and implications of social mediachapter 54 @ twitteruser1 @ twitteruser2a @ twitteruser1 @ twitteruser2bfigure 54 - 2. social media usage can be ( a ) unidirectional or ( b ) bidirectional. user names on twitter are denoted by “ @ ”. a. @ twitteruser2 is following @ twitteruser1. she is receiving all of his messages in her twitter feed. however, @ twitteruser1 does not follow her back and therefore does not receive her messages in return. b. @ twitteruser1 and @ twitteruser2 follow each other. therefore, they each receive each other ’ s messages in their twitter feeds. content through virtual networking. although social media is often used to interact with friends and family, social media can also be used for educational and professional purposes. examples include twitter - based journal clubs, facebook - based discussion forums, and professional networking sites such as linkedin or researchgate. social media platforms can serve different purposes including social networking, microblogging, blogging, photo sharing, video sharing, and crowdsourcing. commonly used social media platforms in surgery include facebook, twitter, and youtube. facebook is the most popular social networking site ; it can be accessed via desktops, laptops, and mobile phones. it allows users to exchange information, photos, and videos with specified contacts or “ friends ” with whom there is a two - way relationship. twitter is another popu - lar social media platform. it is a microblogging site that, like facebook, allows exchange of messages and photos but limits messages or tweets to 140 characters or less. twitter users may
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Surgery_Schwartz. have one or two - way relationships with other users. followers of a user receive all of that person ’ s tweets in their twitter feed. youtube is a social media platform that allows users to share videos. social media usage in surgery may be unidirectional or bidirectional ( fig. 54 - 2 ). for example, journals such as the new england journal of medicine may have a large number of followers but may be following very few users back. given that the number of journal articles published daily has risen expo - nentially, particularly with the advent of open access journals, keeping up with the surgical literature can be overwhelming. following journals on social media is one strategy for staying updated. although conventional media outlets such as newspa - pers and news channels may draw attention to practice - changing studies, social media is another platform by which such infor - mation can be promoted and disseminated by journals. many surgical journals have an online and social media presence, and many have social media editors who curate the posted materials. popular social media platforms for journals include facebook and twitter. both platforms allow journals to post text, figures, and links to abstracts or journal articles. both platforms allow others to share information or comment on articles. however, twitter restricts text to 140 characters. a recent innovation that may counteract the limited number of allowed characters is the visual abstract, which is a concise pictorial representation of an article ’ s key points ( fig. 54 - 3 ). recently, a prospective, case - control crossover study was performed whereby tweets about articles from annals of surgery were either accompanied by a visual abstract or tweeted with text alone. accompaniment of a tweet with a visual abstract resulted in a threefold increase in article visits. thus, the majority of journal followers may merely receive the information about new publications ( uni - directional flow of information ). however, users may also choose to respond to posts with comments ( bidirectional flow of information ). surgicaltreatment asurgicaltreatment boutcomescomplications15 % 11 % mortalityauthor a et al. journal. date. journal logo8 % 4 % comparison of surgical treatment a versussurgical treatment bpatients with disease xfigure 54 - 3. a visual abstract is a graphical summary of the main results of a journal article. brunicardi _ ch54 _ p2187 - p2196
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Surgery_Schwartz. . indd 218913 / 02 / 19 2 : 37 pm 2190specific considerationspart iijournal clubsjournals may promote bidirectional flow of information by hosting social media – based journal clubs. from an educational standpoint, journal clubs have traditionally served not only as an adjunct to lectures but also as a forum to teach about critical appraisal of the literature. furthermore, when facilitated by faculty with clinical expertise on the subject being discussed, surgical trainees can bet - ter evaluate how to incorporate the evidence into practice. how - ever, barriers to traditional journal clubs may include poor participation, lack of a convenient time, or absence of local exper - tise in either the clinical topic or research methodology. social media – based journal clubs can help to overcome these barriers by allowing for asynchronous discussion and expert moderators. online journal clubs can be carried out in real time, but they also allow respondents to comment hours or even days later to a conversation. multiple specialties, including surgery, have developed social media – based journal clubs. tips for suc - cessfully launching an online journal club can be garnered from the expanding experience with them ( table 54 - 1 ). social media – based journal clubs in surgery have been conducted via facebook, twitter, or a combination of the two platforms. they have also taken the form of a blog. although commonly associated with personal journals or diaries, blogs can also be found on professional websites that are updated frequently by a person or group ( i. e., by a journal or surgical society ). conversations from journal club discussions can also be compiled and summarized into a transcript either manually or using web - based applications such as storify. these transcripts can be posted on the journal website or shared. furthermore, 5atable 54 - 1ten tips for setting up an online journal club tip 1create an online home page that serves as a launching pad for your journal club discussions 2develop and register a hashtag on twitter 3incorporate not only twitter but other collaborative platforms as part of your online journal club 4ensure that the time of the journal club is convenient for your target audience 5help prepare participants by aggregating other online resources relevant to the article 6consider inviting the authors of the featured article or other experts in the field 7suggest journal club participants consider using specific twitter management applications during the tweet chat 8eng
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Surgery_Schwartz. ##age the participants to cultivate and incentivize more discussion 9connect to the online community by following and engaging with other relevant social media accounts10link back to the original paper by inserting a comment on pubmed commonsdata from chan tm, thoma b, radecki r, et al. ten steps for setting up an online journal club, j contin educ health prof. 2015 spring ; 35 ( 2 ) : 148 - 154. summaries from either in - person or online journal clubs can be added to the pubmed citation via pubmed commons. preliminary data suggests that online journal clubs increase discussion about articles, views of the abstract, and downloads ( fig. 54 - 4 ). for example, the international gen - eral surgery journal club held four moderated discussions of journal articles on twitter between march and june 2014. the reviewed articles covered topics relating to bariatric surgery ( march ), venous thromboembolism in trauma ( april ), diverticu - litis ( may ), and contralateral prophylactic mastectomy for breast cancer ( june ). although the authors and invited experts only moderated discussions for 3 days, twitter activity increased in the days preceding and following these discussions. further - more, daily views of the article and downloads increased cor - respondingly. thus, online journal clubs are a potential strategy for increasing surgeon education about seminal articles. while social media – based journal clubs hold much appeal, there is a paucity of data regarding their effectiveness in teach - ing participants about critical appraisal skills. a multicenter randomized trial compared journal clubs moderated by a faculty member to online discussions. surgical resi - dents in both arms utilized modules developed by the evidence based reviews in surgery steering committee ; these modules include the relevant guide to critical appraisal and a method - ological and clinical review. residents randomized to the mod - erated group scored higher on a validated test evaluating critical appraisal skills. further study is required to assess the effective - ness of social media – based journal clubs in disseminating new knowledge as well as in teaching critical appraisal. live - tweeting conferencestraditionally, surgeons have attended regional and national conferences to network, learn new information relevant to their practice, and exchange ideas. however, with the advent of social media, surgeons no longer have to physically attend a conference to perform all those activities
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Surgery_Schwartz. . live - tweeting is a term used to describe the posting of comments on twitter about an event while it is ongoing. multiple surgical and nonsurgical societies have adopted twitter to expand the reach of their conferences. by denoting tweets as emanating from a specific conference with a unique hashtag, the reach and number of impressions can actually be measured ( fig. 54 - 5 ). the reach refers to the number of unique recipients of messages from a specific group of twitterers ( or people posting on twitter ). impressions refers to each time a message was delivered to a recipient ; a recipient may receive the same message more than once. neither reach nor impressions measure whether the recipient read the tweet. as an example of how reach and impressions can be used to provide metrics for social media, the healthcare hashtag project allows registered conference hashtags to track the latest tweets, the most prolific twitterers of conference - related tweets, the most commonly mentioned twitterers, and the number of impressions ( fig. 54 - 6 ) ( https : / / www. symplur. com / healthcare - hashtags / ). as noted in the figure, social media rapidly and exponentially increases the spread of information. transcripts of conference - related tweets can also be assembled to allow a conversation thread to be organized into a cohesive discussion. interactive forums and communitiesinteractive forums and communities are another method by which both the internet and social media can be used for 5b6brunicardi _ ch54 _ p2187 - p2196. indd 219013 / 02 / 19 2 : 37 pm 2191web - based education and implications of social mediachapter 54atimedaily html views & pdf downloads of featured article during each of 4 monthly igsjc twitter journal clubstweets025050075010001250tweet activity on # igsjc10. mar24. mar7. apr21. apr5. may19. may2. junb0100number of html views pdf downloads200300400100dates of journal club + / – 5 daysmarch 3 - 5june 4 - 50255075html viewpdf downloadfigure 54 - 4. impact of a social media – based journal club on twitter activity, hypertext markup language ( html ) views, and
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Surgery_Schwartz. portable document format ( pdf ) downloads. a. activity during a twitter - based journal club such as the international general surgery journal club ( igsjc ) can be tracked by denoting the journal club related tweets with a hashtag ( # igsjc ). twitter activity increased during each of four journal clubs. b. daily html views and pdf downloads of featured articles also increased around the time period of the four twitter journal clubs. ( unpublished data from sarah bryczowski and michael e. zenilman. ) @ twitteruser14 followers ( 3 unique, 1 shared ) reach : 7 unique usersimpressions : 8 impressionseach user receivedtweet from @ twitteruser1 : 1 impression eachreceivedtweet fromboth users : 2impressionseach user receivedtweet from @ twitteruser2 : 1 impression each @ twitteruser24 followers ( 3 unique, 1 shared ) figure 54 - 5. difference between reach and impressions in twitter. if there are two twitter users and each has three unique followers and one shared follower, then there are seven unique recipients of their combined tweets. their total reach is seven unique users. if both users tweet the same message, then one user will have received the message twice. however, each time the message was delivered counts as an impression ; thus, the followers will have a total of eight impressions. brunicardi _ ch54 _ p2187 - p2196. indd 219113 / 02 / 19 2 : 37 pm 2192specific considerationspart iiimpressionstweetsparticipantsavg tweets / houravg tweets / participant4272298443, 601the numbers @ user1 123 @ user2 65 @ user3 62 @ user4 46 @ user5 42 @ user6 32 @ user7 21 @ user8 19 @ user9 17 @ user10 16top 10 by mentions @ user3 27 @ user11 25 @ user7 23 @ user4 23 @ user12 19 @ user13 13 @ user14 12 @ user15 11 @ user2 10 @ user1 9top 10 by tweets @ user13 103, 937 @ user24 80, 956 @ user4 42, 976 @ user3 40, 911 @ user6 28, 966 @ user41 22, 534 @ user52 14, 56
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Surgery_Schwartz. ##6 @ user72 13, 514 @ user35 11, 965 @ user68 9862top 10 by impressionsthe # surgery conference 54 - 6. example of conference analytics from healthcare hashtags ( https : / / www. symplur. com / healthcare - hashtags / ). sur - gery conferences can tag tweets by using a prespecified hashtag ( i. e., # surgeryconference ) to denote conference - related messages. these can then be tracked. a mention occurs when a user includes another user ’ s name in the tweet. note in the example that even if there are only a few users tweeting about a conference, the number of impressions can be large if several of those users have a large number of followers. for example, @ user13 only tweeted 13 times but had 103, 937 impressions. educational purposes. they are examples of crowdsourcing whereby information is gathered by enlisting the assistance of a large number of participants. crowdsourcing often involves the general public or a loosely defined group of individuals as opposed to outsourcing, which tasks a project to a specific company or group. for example, wikipedia is an example of crowdsourcing. in surgery, an example of crowdsourcing are the web - based communities formed by the american college of surgeons. members can belong to one or more communities which are based on specialty ( i. e., general surgery or endocrine surgery ), geography ( i. e., florida chapter ), level of education ( i. e., medical students or senior surgeons ), special interest ( i. e., surgeon writers ), or issue ( i. e., quality improvement and advo - cacy ). members can post and respond to discussion threads that cover a wide range of topics including advice for challenging cases, surgical history, and political issues. an example of a social media – based interactive forum is the international hernia collaboration ( ihc ) which is housed on facebook. participants include not only surgeons but also healthcare providers and industry representatives interested in improving outcomes after hernia surgery. membership in the ihc is limited to those who have been vetted and approved. the forum allows members to ask for advice on difficult cases, debate controversial topics, post step - by - step instructions on procedures or management strategies, and disseminate informa - tion rapidly to a wide
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Surgery_Schwartz. audience. collaborative forums such as the ihc allow for real - time, interactive, case - based, continuing education. public educationthe educational opportunities provided by the internet and social media are not limited to healthcare providers. the inter - net and social media are also being increasingly used to educate patients and their families. there are multiple media through which health education is spread, including, but not limited to, online or social media discussion forums run by patients, patient support groups, healthcare providers, or healthcare orga - nizations ; blogs or newsrooms ; or electronic and mobile health patient portals. social media allows patients rapid access to information regardless of time or location. however, as noted in the following section, the accuracy of social media – based educational materials cannot be guaranteed, and patients should utilize caution in relying on the information to make important healthcare decisions. pitfalls in web and social media – based educationdespite the many advantages of web and social media – based education, significant potential pitfalls still remain. first, widespread adoption and utilization is a challenge. although internet and mobile phone usage is prevalent, effec - tiveness of web - based educational materials is dependent upon trainees ’ and surgeons ’ uptake of the technology and available resources. despite increasing availability of the internet and mobile technology, not all surgeons use it for educational pur - poses. for example, a systematic review and meta - analysis by guraya et al found that three out of four medical students use social networking sites, but only one out of five uses them for educational purposes. furthermore, lack of utilization can impact educational effectiveness. in the previously mentioned multicenter trial comparing a moderated journal club to an online version, low participation in the internet journal club was postulated to be a significant factor in the poorer perfor - mance on a critical appraisal test. more attention to instruc - tional design may improve uptake and effectiveness. a systematic review and meta - analysis by cook et al determined that features such as interactivity, practice exercises, repeti - tion, and feedback are associated with improved learning out - comes. the authors also noted that the evidence base upon which to design internet - based learning programs is limited by poor study methodology, failure to use conceptual frame - works, and lack of adherence to reporting standards. thus, while the aforementioned features should be considered in designing future web and social media – based educational pro - grams, further evidence - based guidance is
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Surgery_Schwartz. needed. second, the quality of information available online and via social media may not be accurate or reliable. multiple reports have been published regarding the inaccuracies of web - based educational materials. surgeons and surgical trainees should carefully evaluate the source of educational material, search for conflicts of interest that may result in biased information, assess how recently the information was updated, and cross - check references. the lay public may have more difficulty in identifying trustworthy surgical educational materials on the internet. healthcare providers should guide patients to reputable websites and to encourage discussion regarding the accuracy of the content. third, useful dialog and advice about difficult cases must be balanced with ethical considerations surrounding patient con - fidentiality and privacy. appropriate safeguards must be taken 7brunicardi _ ch54 _ p2187 - p2196. indd 219213 / 02 / 19 2 : 37 pm 2193web - based education and implications of social mediachapter 54table 54 - 2the american college of physicians ethics, professionalism and human rights committee ; the american college of physicians council of associates ; and the federation of state medical boards special committee on ethics and professionalism published a position paper on online medical professionalismposition 1use of online media can bring significant educational benefits to patients and physicians, but it may also pose ethical challenges. maintaining trust in the profession and in patient – physician relationships requires that physicians consistently apply ethical principles for preserving the relationship, confidentiality, privacy, and respect for persons to online settings and communications. position 2the boundaries between professional and social spheres can blur online. physicians should keep the two spheres separate and comport themselves professionally in both. position 3email or other electronic communications should only be used by physicians in an established patient – physician relationship and with patient consent. documentation about patient care communications should be included in the patient ’ s medical record. position 4physicians should consider periodically “ self - auditing ” to assess the accuracy of information available about them on physician - ranking websites and other sources online. position 5the reach of the internet and online communications is far and often permanent. physicians, trainees, and medical students should be aware that online postings may have future implications for their professional lives. data from farnan jm1, snyder sulmasy l, worster bk, et al : online medical professionalism : patient and public relationships : policy statement from the american college of physicians and the federation of state medical boards, ann
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Surgery_Schwartz. intern med. 2013 apr 16 ; 158 ( 8 ) : 620 - 627. to ensure that patients cannot be identified based on provided information, that patients have consented to have their informa - tion posted anonymously, and that all case - related comments are appropriate and professional. while common sense should be utilized in posting about patient cases, only a few organizations have published guidelines for how to safeguard against potential pitfalls. in 2013, the american college of physicians ethics, professionalism, and human rights committee ; the american college of physicians council of associates ; and the federa - tion of state medical boards special committee on ethics and professionalism published a position statement about online medical education ( table 54 - 2 ). the paper stated that “ maintain - ing trust in the profession and in patient – physician relationships requires that physicians consistently apply ethical principles for preserving the relationship, confidentiality, privacy, and respect for persons to online settings and communications. ” fourth, conflicts of interest must be clearly stated. jour - nals require authors to declare relevant conflicts of interest, but multiple studies suggest that these often go unreported. simi - larly, conflicts of interest should be disclosed on social media. however, such disclosures may be more difficult on social media due to the limited number of allowable characters ( i. e., 140 characters for twitter ) or to the way information is propa - gated. for example, a surgeon may disclose an industry relation - ship on an original tweet, but the disclosure may not appear in subsequent comments of a discussion thread. surgeons post - ing on social media must make it their ethical and professional obligation to disclose their conflicts of interest. furthermore, users of social media content must be aware of the potential for bias introduced by undisclosed conflicts of interest and per - form due diligence in assessing the reliability of the source. lastly, regulatory bodies and professional organizations should publish standardized guidelines for disclosing on social media or develop mechanisms by which disclosure can be publicly accessed ( such as the open payments database ). fifth, professionalism must always be maintained. sur - geons posting content on the web or on social media must be aware that information will be widely disseminated and avail - able for posterity ; messages posted on social media cannot be fully retracted. as already mentioned, surgeons must strive to maintain patient privacy, ensure accuracy of information, and disclose conflicts of interest. furthermore, surgeons must be aware of unint
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Surgery_Schwartz. ##entional interpretations of messages ( i. e., as discriminatory or unprofessional ). multiple studies of health - care providers ’ social media sites have identified potentially and clearly unprofessional content ; these studies have included medical students, residents, and practicing surgeons. despite the prevalence of unprofessional content, few surgical residency programs have formal institutional social media policies. fur - thermore, the american college of physicians and federation of state medical boards position statement only addresses a few of the issues surrounding web - based activities including for patient and physician education ( table 54 - 3 ). table 54 - 3online medical professionalism and educationpositions on professionalism in online patient and physician education • the internet can be a powerful tool for education. • physicians should guide patients to high quality online resources that are accurate and objective. these sites should have peer - reviewed content or have verifiable mechanisms for quality control of information. • online resources for learning can be used by patients and physicians. • the internet and social networking can be used to improve public health. physicians engaged in online communities should ensure the security of the networks and restriction of participation to verified users. clinical scenarios should not contain any personal identifying information, and patient consent should be obtained before sharing the vignette. • discussion of frustrations online undermines trust and professionalism and should be avoided. data from farnan jm1, snyder sulmasy l, worster bk, et al : online medical professionalism : patient and public relationships : policy statement from the american college of physicians and the federation of state medical boards, ann intern med. 2013 apr 16 ; 158 ( 8 ) : 620 - 627. brunicardi _ ch54 _ p2187 - p2196. indd 219313 / 02 / 19 2 : 37 pm 2194specific considerationspart iilastly, studies evaluating the effectiveness of web - based education have had varied results. a recent systematic review by taveira - gomes et al assessed 251 articles using computer - based learning methodologies in medical education ; the num - ber of articles on this topic has increased over time. the most commonly used metrics for evaluating the effectiveness of these methodologies were assessments of knowledge, attitudes, and skills. the majority of studies reported positive effects on these outcomes, although the more rigorous studies ( i. e., randomized trials ) were less likely
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Surgery_Schwartz. to find a positive effect. online activ - ity ( i. e., number of posts or views ) was tracked in a few stud - ies, but results were conflicting regarding whether increased engagement correlated with improved performance. this review suggests that high - quality studies are needed of web - based edu - cational interventions and that these studies need to include measures of clinical performance and outcomes. implications and future directionsthe society of university surgeons ’ social and legislative committee issued a position statement entitled : “ social media is a necessary component of surgery practice. ” given the rapid pace with which technology is advancing and the familiar - ity of the current generation ( generation z ) with the inter - net, surgeons have no choice but to harness the power of the internet and social media or risk being left behind. many jour - nals are phasing out print versions, and several journals are already online only. furthermore, textbooks may also become a relic from the past as publishers move towards developing digi - tal versions that include interactive graphics, audio, and video. as surgical education continues to evolve, future directions may include broader indications for utilization of weband social media - based resources. for example, video - based coaching with face - to - face discussions have been used postoperatively to sup - plement intraoperative teaching. however, preoperative crowd - sourcing in planning a challenging case or intraoperative video telementoring are other applications of video - based coaching. future research efforts should focus on identifying the most effective formats and components of web and social media – based educational interventions, using rigorous methods to compare educational methods, and measuring clinical out - comes. moreover, standardized guidelines should be instituted in order to safeguard against ethical and professional misconduct. bibliographybirkmeyer jd, finks jf, o ’ reilly a, oerline m, et al ; michigan bariatric surgery collaborative. surgical skill and complica - tion rates after bariatric surgery. n engl j med. 2013 ; 369 ( 15 ) : 1434 - 1442. this study correlated blinding reviewer ratings of videotaped laparoscopic gastric bypass procedures to clinical outcomes. greater skill was associated with lower rates of com - plications, reoperations, readmissions, and emergency depart - ment visits. bresnahan er, huynh dtk, jacob b. social media and education in hernia repair
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Surgery_Schwartz. . in : hope ww, cobb ws, adrales gl, eds. textbook of hernia. cham : springer international publishing ; 2017 : 373 - 379. this book chapter describes the international hernia collaboration, which is a facebook - based community of practicing surgeons, trainees, and industry representatives. the goals of the collaboration include exchange of ideas and advice regarding patient care, discussion and debate of controversial topics in hernia management, and dissemination of information to a global audience. chan tm, thoma b, radecki r, et al. ten steps for setting up an online journal club. j contin educ health prof. 2015 ; 35 ( 2 ) : 148 - 154. written by a multidisciplinary group of authors, this article provides 10 helpful hints for setting up an online journal club, using examples from existing journal clubs. cook da, levinson aj, garside s, dupras dm, erwin pj, montori vm. instructional design variations in internet - based learn - ing for health professions education : a systematic review and meta - analysis. acad med. 2010 ; 85 ( 5 ) : 909 - 922. this systematic review and meta - analysis of 51 studies, including 30 random - ized trials, identified several key features of internet - based learning interventions that were associated with improved learning outcomes : interactivity, practice exercises, repeti - tion, and feedback. however, the evidence base upon which to design internet - based learning programs is limited by poor study designs, failure to use conceptual frameworks, and lack of adherence to reporting standards. cook da, levinson aj, garside s, dupras dm, erwin pj, montori vm. internet - based learning in the health professions : a meta - analysis. jama. 2008 ; 300 ( 10 ) : 1181 - 1196. this meta - analysis of 201 studies reported that internet - based instruction had a positive effect on educational outcomes as compared to no intervention, but that there was similar effectiveness between internet - based instruction and traditional educational methods. farnan jm, synder sulmasy l, worster bk, chaudhry hj, rhyne ja, arora vm ; american college of physicians ethics, profes - sionalism and human rights committee ; american college of physicians council of associates ; federation of state medical boards special committee on
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Surgery_Schwartz. ethics and professionalism. online medical professionalism : patient and public rela - tionships : policy statement from the american college of physicians and the federation of state medical boards. ann intern med. 2013 ; 158 ( 8 ) : 620 - 627. this position statement pro - vides recommendations on issues relating to professional use of the internet and social media including but not limited to : use of social media for nonclinical purposes, patient confidentiality in online discussions, and use of web - based patient education resources. guraya sy. the usage of social networking sites by medical stu - dents for educational purposes : a meta - analysis and systematic review. n am j med sci. 2016 ; 8 ( 7 ) : 268 - 278. this review of 10 articles published between 2004 and 2014 suggested that although 75 % of medical students use social networking sites, only 20 % use them for academic or educational purposes. fur - thermore, none of these studies evaluated whether use of social media improved academic performance. ibrahim am, lillemoe kd, klingensmith me, dimick je. visual abstracts to disseminate research on social media : a prospective, case - control crossover study. ann surg. 2017 ; 266 ( 6 ) : e46 - e48. this prospective, case - control crossover study compared the impact of tweets alone versus tweets accompanied by a visual abstract on article visits ; there was a threefold increase when visual abstracts accompanied the tweets. jayakumar n, brunckhorts o, dasgupta p, khan ms, ahmed k. e - learning in surgical education : a systematic review. j surg educ. 2015 ; 72 ( 6 ) : 1145 - 1157. this systematic review of 38 studies suggested that while the majority of studies evaluating electronic learning in surgical education demonstrate a positive effect, most lack a proper control. mcleod rs, macrae hm, mckenzie me, victor jc, brasel kj ; evidence based reviews in surgery steering committee. a moderated journal club is more effective than an internet journal club in teaching critical appraisal skills : results of a multicenter randomized controlled trial. j am coll surg. 8brunicardi _ ch54 _ p2187 - p2196. indd 219413 / 02 / 19 2 : 37 pm 2195web - based education and implications of social mediachapter 54
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Surgery_Schwartz. ##2010 ; 211 ( 6 ) : 769 - 776. this multicenter randomized trial reported that surgical residents who participated in a journal club moderated by a faculty member scored higher on a vali - dated test of critical appraisal than those who participated in an online journal club. pugh cm, watson a, bell rh jr, et al. surgical education in the internet era. j surg res. 2009 ; 156 ( 2 ) : 177 - 182. this article describes the factors that led to a change in surgical education over the last two decades. taveira - gomes t, ferreira p, taveira - gomes i, severo m, ferreira ma. what are we looking for in computer - based learning inter - ventions in medical education? a systematic review. j med internet res. 2016 ; 18 ( 8 ) : e204. this systematic review assessed recent studies on computer - based learning ( cbl ) for types of software platforms and interventions and adherence to current recommendations for cbl research. brunicardi _ ch54 _ p2187 - p2196. indd 219513 / 02 / 19 2 : 37 pm
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