BACKGROUND
Present apprenticeship model for surgical training is ‘see one, do one, teach one’ which is neither safe nor ethical and inconsistent model for qualifying skilled surgeons. It is also likely to be challenged because of increased public scrutiny on patient safety. Various scientific evidences also do not justify performing maiden experiment directly on patients. Training medical postgraduates in surgery without simulator is neither ethical nor safe in today's context of Ethics, Evidences and surgical Excellence. Unskilled surgeons present the single biggest risk to patients in the operating room. A report by the Institute of Medicine in 2002 indicated that up to 44,000 people die from medical errors in the U.S. every year. The report also indicated that training of health professionals was not adequate and assessment was insufficient for ongoing proficiency.
USE OF SIMULATOR FOR TRAINING
The concept of use of simulators is evolved from aviation industry wherein the pilot takes mandatory training before actually taking the air craft. Simulation is the replication and modelling of real-life situations. The simulator provides real and virtual world to deliver optimum learning and feedback. The surgeon's performance is tracked and analyzed in real-time against validated metrics for that particular task. On completion, the surgeon gets immediate, comprehensive and accurate feedback on their performance. Simulator generates performance records for individuals and groups which can be recorded for later review by users and a class administrator. These records are available as straightforward Excel and Word files. Simulator is also available as a networked system, to offer integrated class management and administration. The training on simulator increases patient safety by facilitating surgical proficiency and can be practiced again and again, until the set threshold performance is achieved. Certification and training is standardized as per instructor led or self-directed that can also give objective feedback. Continuous tracking of performance highlights areas that need improvement so that further practice is focused on increasing effectiveness and reducing errors. This can also accelerate the pace of adoption 2of new procedures and devices, helps in rehearsal of patient-specific uncommon or complicated operation and establishing adaptation to critical procedural tasks. Thus, simulators meet adult learning needs in the form of structured, replicable learning experience based on prior experience and resources. Surgeons learn with set tasks that are surgically-relevant, understand and accept the gaps in their knowledge and deficiency in surgical skill.
CURRICULUM REFORMS
Education in surgery needs reformation and mandatory changes for re-certification of surgical performance and outcome every year by each doctor. There is increased acceptance to set standards for surgical performance and proficiency. Professional organization like Association of Surgeons and Boards of Certification are involved in developing standard curricula and new metrics for validating and assessing surgical skill to process for re-certification every year. National Surgical Quality Improvement and Division of Research and Optimal Patient Care (DROPC) has recommended use of electronic medical records and documenting outcomes as a key component of accreditation.
Surgical education now recognizes the need for background training in practice sessions, on models or by simulation devices before operating on a live patient. The goal is to ensure that surgical residents have encountered simulations of the critical situations they will face in real life and have learned a safe way to approach each patient. The curriculum allows all residents to manage specific simulated case scenarios addressing essential content areas without the variability associated with clinical rotations. In addition, residents are able to learn, test various options, make errors, and engage in the self-assessment process without the concerns associated with real patients. The Fundamentals of Surgery Curriculum addresses all six core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). Medical knowledge and patient care are the competencies of primary emphasis.
In India, EthiSkills course is available at Mumbai, New Delhi and Chennai. The curriculum has been standardized to include all common Ob/Gyn procedures that focus mainly on hands on skills building and covers principles of conventional (open) and minimal access (endoscopic) surgical procedures. This can be made mandatory for all medical post graduate students before giving degree by the authorities. Each surgical procedure has a clinical case detail, investigations, key learning points, aims and objectives of continuous quality improvements points, simple and complex exercises on simulators. Core competencies and expected performance are well defined. The curriculum has been devised to build a learner's confidence within the safety of a virtual environment, provides the same learning opportunities for all residents, emphasizes critical thinking skills, supplements current educational programs, is available 24/7 through any computer with internet access and provides tools for program directors to track performance and outcome records of resident. With changing times, there is a 3need not only to recommend but also make mandatory for enforcing surgical re-certification and credentialing process. Same way Level-II & Level-III Laparoscopic Surgery & Hysteroscopic surgery Modules can be designed to fulfill the need of accreditation process under the FOGSI –ICOG or MCI recommendations.
CONCLUSION
Use of simulators for post graduate surgical training is safe and ethical to achieve surgical excellence for the next generation of medical professionals. There is a need to reform the curriculum with emphasis on the use of simulators and periodic re-certification to ensure surgical proficiency.