Simulation-based training as a continuous means of vascular surgical education—a roadmap

A soccer player does not train solely by watching and playing matches, just as a pianist does not practice and develop his skills simply by attending and giving concerts. How may it therefore seem adequate for a surgeon to develop their skills exclusively in the operating room while treating real patients?

The established method to train as a vascular surgeon was, for the longest time, the accumulation of theoretical knowledge by studying relevant literature and clinical cases, while also developing operative skills by observation and performance of surgical procedures on patients. After years of education, the trainees are finally tested according to their in-depth knowledge and understanding of the specialty field and their individual operative caseload. Surgical skills were and are mainly acquired by observation and a learning-by-doing approach in the operating room. Although simulation and practice of specific skills and indeed entire surgeries has long been in development [1], it is only during the past two decades that simulation-based training (SBT) has truly begun to establish a foothold in the curriculums of open vascular surgery education [2].

Often-cited reasons for the need for SBT are limited workhours reduced by legislation, and thus reduced caseload and exposure: Additionally, a change in therapeutic approaches, with an ever-growing number of endovascular treatments often resulting in a reduction of open vascular surgery, and finally a waning acceptance in the general public and most importantly among patients themselves of a learning-by-doing approach with education and training being performed on patients have been observed [2‐4]. The strategy of training inexperienced surgeons by operating on real patients, albeit under strict supervision, to further develop their skillset raises ethical questions [5].

Regarding safety issues in the practice of medicine and surgery in particular, medical professionals have very often found inspiration in other fields, such as the aviation industry. Measures such as redundancy and checklists have been adopted in many areas. The topic of SBT is no different. The training of pilots requires many hours of experience and countless repetition of exactly timed procedures in a very much standardized surrounding. The aviation industry pioneered and has long established this method of learning, providing a safe environment for trainees to acquire, test, and hone their capabilities.

SBT in vascular surgery was reported to be effective for teaching new and improve existing skills, as well as for increasing the levels of confidence for performing specific procedures [6, 7]. There are several factors that influence the quality and efficacy of training and thereby produce a flatter or steeper learning curve for participants [6]. It is, however, important to note that any type of training is useful [8]. It has been shown that faculty instruction greatly improves the learning curve of residents in complex simulations [9]. Furthermore, the effect of SBT, at least when performed in rather short, compact courses, will reach a plateau of skills improvement. The level of improvement mainly depends on the complexity of the practiced task and the educational level of the trainee. While simple bench models showed little to no significant progress in the skills of more senior trainees, more complex models do show improvement in skills even in senior doctors [4, 6]. To what extent exactly the progress in SBT translates into real-life operative skills is little known, as research is scarce [1].

A commonly used assessment tool for surgical performance is the objective structured assessment of technical skill (OSATS) [10]. OSATS allows the evaluation of a trainee in seven categories by a five-point system in each category.

Monitoring a trainee’s progress is an important part of any educational program. Very effective is constructive feedback by experienced trainers, possibly improving the learning curve and experience of the individual learner as well as the quality of the educator and their teaching methods.

Developing a program for SBT is a complex project which requires more than simply procuring simulation material for practice. Bismuth et al. [4] give an exemplary list of topics to consider when aiming to establish a training center for vascular surgery:

In our approach to establish a center for SBT in vascular surgery at the Graz Medical University, we planned similar to the points listed above. After considering several options for simulators and curriculum, discussions with the relevant decision-makers regarding set-up and financial aspects were initiated.

Publications have shown the positive effects of SBT on trainees and the high demand for such programs among young surgeons. Participation in such courses within the KAGes is generally encouraged by the employer, but also the Austrian Medical Board and the state government, as these qualify as continuing medical education (CME). As the attendance of such courses is financed internally by specially allocated funds for every department within the KAGes, the courses for KAGes employees are free of charge to the attending trainees. In contrast to other medical specialties in the case of vascular surgery, undergoing SBT is not a mandatory part of the curriculum for residents. A lack of participants seems improbable though. With reduced total numbers of open vascular surgical procedures and limited working hours for surgeons and trainees, the benefit of SBT to increase exposure and improve skills appears self-evident.

The intent, time, and capacity to learn and therefore attend courses and skills training seems obvious. Additional incentive is provided for junior and senior doctors by awarding credits for the Austrian CME program to participants.

Implementing and further developing SBT for open vascular surgery will improve the quality of education for junior surgeons. As an additional means to practice and gain experience and confidence in their technical abilities, this training facility will help to compensate for lower numbers of operations performed and less time spent in the operating room in a way that is safe for patients and reassuring for residents. Furthermore, the selective inclusion of interns and medical students into the program will support staff recruitment by encouraging graduates to consider a career in vascular surgery.

Practice makes perfect, and while simulation cannot substitute for real-life surgery, it can be a valuable tool to learn and maintain basic skills in vascular surgery. Thus, we hope to establish SBT for vascular surgery as a fixed program in the KAGes simulation center in Graz.