Surgical skills training and the role of skills centres

In 1964, astronaut Virgil ‘Gus’ Grissom underwent 20 normal and 46 aborted launches, 51 simulated booster failures and 211 systems malfunctions to train for what amounted to a 4.5 h space flight. It took surgery almost another 30 years to begin to recognize that comprehensive skills training like this is essential for complex tasks to be performed safely and reliably. We can no longer rely upon the haphazard ‘apprenticeship’ model of training in surgery; apart from being educationally and ethically unsound, this traditional approach is medico-legally unacceptable. In 1993 the Calman Report [1] promoted the need for standardization in the teaching of basic surgical skills. The Royal College of Surgeons of England subsequently played a key role in introducing formalized teaching of basic surgical skills and has helped to introduce programmes into many countries, including Australia. Basic surgical skills training is now an established part of basic surgical training in the UK and Australia.

The undisciplined introduction of laparoscopic techniques during the early 1990s led Cuschieri [2] to comment about the ‘uncontrolled expansion of surgical endoscopic practice which amounted to the biggest un-audited free-for-all in the history of surgery’[3]. Indeed the euphemism of the surgical ‘learning curve’ largely stemmed from this laparoscopic experience. It needs to be recognized that the surgical ‘learning curve’ represents preventable injuries to patients that are a direct consequence of surgical incompetence. Skills training has a primary role in minimizing this ‘learning curve’ and allowing for the proper provision of credentials for surgeons to undertake new and innovative procedures. The use of simulators for surgical training has obvious advantages; procedures can be practised repeatedly and increasingly complex failures can be introduced, all without endangering a live patient. Second, skills training has a role in maintaining ‘recency’, a concept common in aviation but often tacitly ignored in surgery. The concept is straightforward; recent practice improves performance of a particular task. This has been shown well in numerous surgical series; surgical outcome is consistently better for surgeons who regularly undertake a particular operative procedure than for others who may only occasionally undertake the same procedure. Current ‘Continuing Professional Development’ re-accreditation of surgeons requires no re-assessment of skills, yet this is precisely what the job of surgery entails. It is akin to re-accrediting pilots using every measure except the ability to fly an aeroplane.

Skills centre-based training can be used not only to teach a skill but also as a means of assessment, both of technical competence and of decision-making skills. As yet there are few performance standards defined, but groups such as the Center for Advanced Technology in Surgery at Stanford have joined with others to form the SurgSim group. Its primary mission is to evaluate new simulators proposed for surgical education, to establish construct validity and examine the ‘learning curve’ with repeated use.

Urological surgery is well suited to practical skills training outside the operating room, using simulators. Endourological procedures lend themselves particularly well to simulation, using either low-fidelity models such as porcine kidney and ureter for training in ureterorenoscopy, or using high-fidelity devices such as the UROMentor™ (Simbionix, Tel Aviv, Israel; http:www.simbionix.com). This is a commercially available virtual reality multimedia simulator and intelligent tutoring system for training in a variety of endourological procedures. Recently, a renal percutaneous needle access module has been developed by the same company (the PERC Mentor™) which accurately simulates fluoroscopic access for percutaneous nephrolithotomy. Limbs and Things (http:www.limbsandthings.com) market a prostatic model which has similar electrical and cutting characteristics to the human prostate, and allows trainees to learn the fundamentals of TURP using a standard resectoscope and electrosurgical diathermy in a safe, controlled environment. The model lacks bleeding, but this aspect is being developed in simulators that use computer-based virtual reality. Such virtual reality simulations are most readily applied to image-based procedures such as endoscopy, laparoscopy and interventional radiology, each of which has immediate relevance to much of the practice of urological surgery.

The development of skills training in surgery has lead to the establishment of skills laboratories and dedicated multidisciplinary training facilities such as CTEC (The Centre for Medical and Surgical Skills in Perth, Western Australia; http:www.ctec.uwa.edu.au). This is a state-of-the-art training facility incorporating a fully equipped medical and surgical workshop, a virtual hospital (operating theatre, emergency department, intensive care and a four-bed ward) along with a high-fidelity simulated anaesthesia mannequin. The centre caters for practical skills-based training across all health disciplines at all career levels. This cross disciplinary interplay allows for development of what the aviation industry refers to as ‘Crew Resource Management’ skills. Attempts to enhance skills performance can otherwise be criticised for over-emphasis upon ‘singular, uni-dimensional constructs’, i.e. the purely mechanical tasks being performed by the surgeon [4]. Purely operative technical skill is a double-edged weapon. As Babcock observed in 1928 ‘brilliantly performed operations may be unnecessary, unwisely selected, or untimed for the particular condition’[5]. Surgical skills require the integration of decision making and mechanical processes, as well as effective teamwork to achieve successful outcomes.

Skills centres will play an increasing role in the future of medical and surgical education. They are becoming an essential arena for the training and maintenance of surgical skills at basic (undergraduate), intermediate (Registrar) and advanced (Consultant) levels. The rapid introduction of new technologies combined with the modern concepts of training, as well as ethical and medicolegal pressures, will demand that ‘learning curves’ are consigned to skills laboratories, away from live patients. It also seems likely that skills centres will take on an expanding role in providing the credentials of surgeons and maintaining skills standards. However, the real impetus for expanding the role of skills centres will arise once measurable benefits to patients are demonstrated.