Sonal Arora, Department of Surgery and Cancer, 10th Floor, QEQM Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK. e-mail: firstname.lastname@example.org
Study Type – Therapy (case series)
Level of Evidence 4
What’s known on the subject? and What does the study add?
Simulation-based training can provide urology trainees with the opportunity to develop their technical and non-technical skills in a safe and structured environment. Despite its promised benefits, incorporation of simulation into current curricula remains minimal.
This paper provides a comprehensive review of the current status of simulation for both technical and non-technical skills training as it pertains to urology. It provides a novel framework with contextualised examples of how simulation could be incorporated into a stage-specific curriculum for trainees through to experienced urologists, thus aiding its integration into current training programmes.
• Changes to working hours, new technologies and increased accountability have rendered the need for alternative training environments for urologists.
• Simulation offers a promising arena for learning to take place in a safe, realistic setting.
• Despite its benefits, the incorporation of simulation into urological training programmes remains minimal.
• The current status and future directions of simulation for training in technical and non-technical skills are reviewed as they pertain to urology.
• A framework is presented for how simulation-based training could be incorporated into the entire urological curriculum.
MATERIALS AND METHODS
• The literature on simulation in technical and non-technical skills training is reviewed, with a specific focus upon urology.
• To fully integrate simulation into a training curriculum, its possibilities for addressing all the competencies required by a urologist must be realized.
• At an early stage of training, simulation has been used to develop basic technical skills and cognitive skills, such as decision-making and communication.
• At an intermediate stage, the studies focus upon more advanced technical skills learnt with virtual reality simulators.
• Non-technical skills training would include leadership and could be delivered with in situ models.
• At the final stage, experienced trainees can practise technical and non-technical skills in full crisis simulations situated within a fully-simulated operating rooms.
• Simulation can provide training in the technical and non-technical skills required to be a competent urologist.
• The framework presented may guide how best to incorporate simulation into training curricula.
• Future work should determine whether acquired skills transfer to clinical practice and improve patient care.
The past decade has seen a dramatic change in healthcare delivery and training for urologists. Subsequent to the publication of the Institute of Medicine’s report, ‘To err is human’ and other studies showing that 10% of hospitalized patients suffer an adverse event , the training of all clinicians has been increasingly called into account. Furthermore, although recent advances in minimally invasive surgery have yielded important benefits to patients, paradoxically, they have posed a significant challenge to surgeons who must master the counter intuitive instruments and the loss of tactile feedback . Although these techniques have steep learning curves and require significant time to learn, trainees have fewer and fewer opportunities (e.g. as a result of reduced training time through the European Working Time Directive, etc,) to develop and hone such skills via regular clinical practice . There is an imperative need for novel approaches to surgical training outside of the operating room (OR).
Simulation-based training offers an alternative training environment that is particularly well suited to urology: many index procedures, such as resection of bladder tumours and prostates, are carried out endoscopically and therefore can be taught effectively using virtual reality (VR). Simulation can be used not only to develop the psychomotor skills crucial to any craft-based specialty, but also to train in the other attributes integral to being a safe urologist . These go beyond just technical skills. For example, urologists do not work alone in the OR, nor do they face crisis scenarios without their team, and therefore training to be an effective team-member is also needed. This is achieved through more complex simulation training, focussing upon non-technical skills. These ‘non-technical skills’ comprise cognitive and behavioural skills that complement a surgeon’s manual dexterity . These include situation awareness and decision-making, as well as stress management, communication and teamwork . Simulation-based training in non-technical skills is thus the next frontier in urological training and relevant reports have begun to emerge in the literature. Regardless of type of skill, simulation offers urologists the opportunity to practise in a safe, controlled environment that maximizes learning, at the same time as minimizing the chances of errors in patient care [6,7]. Most importantly, this type of training is cost effective and the skills acquired in simulation are transferable to the clinical setting .
Despite these benefits and the BAUS guidelines advocating simulation-based laparoscopic training, the integration of simulation technologies into surgical training remains minimal [3,8]. One reason for this is that for simulation to be incorporated into any training curriculum, it must be shown to be efficacious in meeting the learning objectives required to be a competent urologist. A lack of understanding of what type of simulation is effective for what stage of training, coupled with a misperception that it is always expensive, resource intensive and requires dedicated centres (which most trainees have little access to), may also explain the poor uptake of simulation into urological training .
A strategic overview of the ‘type’ of simulation suitable for learning technical and non-technical skills across the entire curriculum is necessary to fully incorporate simulation into a urological training programme. It is also possible, within such a framework, to identify key competencies within a curriculum using simulation, as well as how they can be addressed. This model can provide a standardized programme of training, commencing in a classroom or a skills laboratory and progressing into the OR, underpinned by the notion of a systematic approach to training and assessment .
The present review aims to provide a critical overview the current status of simulation for both technical and non-technical skills training as they pertain to urologists. It aims to do so in the context of a framework that provides examples of how simulation could be incorporated into a curriculum for trainees through to experienced urologists. Finally, some considerations regarding the future use of simulation in urological training are presented.
SIMULATION IN THE EARLY STAGES OF TRAINING
The early stages of training are those at the start of a urological training programme typically within the first few postgraduate years. For example, in the UK, this stage refers to what has been termed the early phase of the Intercollegiate Surgical Curriculum (ISCP) Project, equating to a junior resident position in the USA.
Junior urological trainees are typically expected to become competent in technical skills such cysto-urethroscopy, urethral and suprapubic catheterization, circumcision and scrotal surgery. The learning of such basic techniques can reliably take place in surgical skills workshops using synthetic and animal-based tissues in a stepwise manner (Fig. 1). For example, one study showed that urologists who develop skills such as endoscopic suturing on a pelvic trainer, and then progress to a porcine model, reported no complications and a conversion rate of <2% in their real-life laparoscopic procedures . It is emphasized that starting with an animal model would be a waste of time and money because the basic laparoscopic skill must first be developed. VR simulators such as the Uro MentorTM (Simbionix USA Corp., URO Mentor, Simbionix Ltd, Lod, Israel) have also been validated and used for this stage and are better suited to achieve these skills. For example, Watterson et al.  found that using the validated Uro Mentor resulted in quicker training of basic ureteroscopic tasks for 20 trainees without previous expertise. Assessment tools currently available include motion analysis using tools such as the Imperial College Surgical Assessment Device  and global rating scales such as Observational Structured Assessment of Technical skills [11,12]. This has been validated for use in urology , with studies now showing that it can be used to reliably assess performance in procedures such as cystoscopy and ureteroscopy .
The curriculum for junior urological trainees also provides a first platform for the introduction of the concept and components of non-technical skills training, such as teamwork, situation awareness and decision-making. In other safety-critical industries such as aviation, flight deck simulation is used by junior pilots to practice non-technical skills . In urology, given that such skills have historically not been at the core of surgical training, classroom-based, didactic delivery of training is an appropriate starting point. Pen-and-paper simulations can also be effectively used in such cases. As an example, one study used simulated case scenarios to investigate how urologists make treatment decisions about patients with prostate cancer . These scenarios are more cost effective than full-scale simulations, but still informative in terms of surgeons’ thinking and decision-making processes, which are often hard to verbalize and communicate. Role plays using simulated patients are also an effective form of simulation to practise and learn communication skills at this stage.
Assessment of these skills for formative and summative purposes could be carried out not only using rating scales, but also within clinical practice as workplace-based assessment. In the UK, the ISCP has already introduced several workplace-based assessments that look at technical skills; these could be complemented by the introduction of a specific non-technical skills assessment. For example, in anaesthesia, tools for reliable and valid non-technical skills assessment have already been developed and trialed, and similar tools can be translated to urology .
INCORPORATING SIMULATION AT THE INTERMEDIATE STAGE OF TRAINING
This typically forms the middle phase of a urological training programme or residency. In the UK, intermediate trainees are expected to develop skills in general and emergency urology that are acquired in the early phase, with the aim of progressing to independent practice. At this stage of training, the use of computer-based VR could be incorporated into curricula because it allows the safe practice of higher-risk minimally invasive techniques required for competency (Fig. 1). VR simulators have been shown to be effective in training for index procedures such as laparoscopic nephrectomy, laparoscopic radical prostactectomy and, more, recently robot-assisted laparoscopic prostatectomy and cystectomy [15,16]. For example, TURP simulators have been developed and validated . In another study, Sethi et al.  used a simulated Da Vinci robot to perform robot-assisted laparoscopic prostatectomy and showed good face and content validity.
Non-technical skills training using simulation for intermediate trainees would focus more on leadership and interdisciplinary communication in preparation for the adoption of a more senior role in the operating team. This can be delivered in full-team scenarios situated within a fully-simulated OR using procedures and problems that the trainee should adequately handle. However, even trainees at this stage do not have to rely upon a simulated OR (typically only found within a simulation centre) to develop these skills. Clinical staff, actors or embedded educational personnel could be used to recreate team-based scenarios using ‘in situ simulation’, which could take place in a side room in a ward or within an OR present within every hospital.
Most recently, ‘distributed simulation’ represents an innovative approach that can be used to widen access to high-fidelity immersive simulation. It consists of a portable simulation environment that can be set up anywhere by anyone, and can deliver contextualized team training at a fraction of the cost of simulated ORs .
Assessment of these team-based skills is feasible via validated scales such as the Observational Teamwork Assessment for Surgery, comprising a psychometrically robust tool, which captures comprehensively a range of behaviours in real and simulated ORs. The tool has been shown to be reliable and valid for use in urological procedures, both laparoscopic and open .
SIMULATION FOR EXPERIENCED TRAINEES
This is the final stage of urological training and runs into independent practice as a consultant/attending urologist. At this level, urologists are expected to be fully competent to manage not only the routine urological procedure, but also to cope with unexpected problems . Simulation-based modules developed for surgical crisis management skills are therefore particularly suitable for this stage. Here, complex tasks are simulated and assessed, such as uncontrolled haemorrhage or on-table cardiac arrest. Events such as uncontrolled bleeding from a TURP or even a transurethral resection syndrome can be simulated using a range of VR simulators or synthetic models. Undre et al.  provided a model for such crisis simulation training and found it to be feasible for both training and feedback.
Such crises typically involve not just the surgeon, but the entire team, and therefore the boundaries between technical and non-technical performance become blurred.
Here, simulation for experienced trainees would focus on full-scale crisis management. Attention should be paid to develop scenarios that require the integration of both technical and non-technical skills to successfully manage a crisis. Drawing again from experience in the aviation industry, this should be practised in simulated ORs without the risk of endangering the patient. For example, Gettman et al.  successfully used high-fidelity simulation in a simulated OR to teach and assess teamwork, communication and laparoscopic skills with urologists who were taught to manage crisis scenarios such as carbon dioxide embolism leading to patient death.
CHALLENGES AND FUTURE DIRECTIONS IN SIMULATION-BASED TRAINING
As reviewed above, simulation can be incorporated into the entire urological curriculum to provide both technical and non-technical skills training. The framework presented suggests how this could best be carried out in a manner appropriate to the competencies required of the trainee for his/her stage of training (Fig. 1). It is important to note that this does not only apply to the ISCP in the UK. For example, early evidence suggests that simulation-based modules can help meet the requirements for Accreditation Council for Graduate Medical Education in the USA .
Although such a framework is an initial step towards well defined simulation-based training programmes in urology, significant challenges remain and render simulation with a potential yet to be fully realized. First, whereas technical skills training has made significant progress in the past 10 years, non-technical training is still lagging behind. Unlike the other safety-critical industries, the human-factor aspects of care delivery remain under-researched and often misunderstood in surgery. Although pilots practise on simulators routinely throughout their professional careers and military personnel rehearse missions in scenario simulations, non-technical skills of urology trainees are neither made explicit, nor are they systematically taught and assessed .
One reason for this lack of focus on the behavioural aspects of surgical training may be a result of the misconception of simulation as a training tool. ‘Simulation’ refers to the wider context within which operative skills are learned and consolidated, whereas ‘simulators’ refer to physical models or computer system (i.e. hardware and software). Simulation-based training therefore involves much more than purchasing of VR models: it involves a robust training curriculum; reliable and valid assessment tools; and expert, trained faculty. The key challenge for the future is to provide enough of these elements to recreate an authentic experience, without creating unmanageable levels of difficulty or cost.
Using the framework presented in this review, and in the light of the aforementioned complexities coupled with the expanding evidence base, we believe that there are several requirements for the successful implementation of simulation as outlined below.
TIME AND CONTEXTUALIZED ENVIRONMENT
Trainees should have dedicated time to practise on simulators and take part in simulated scenarios. Depending on their level, trained actors can assist in the training, or other members of a surgical team can be present to ensure that the simulation is adequately modelled after the clinical environment.
COMMITMENT AND ‘BUY-IN’ FROM TRAINERS
Consultant level surgeons should be able to take on a training role by attending train-the-trainer courses and having sufficient time available amongst their clinical duties. Models for providing faculty incentives should be investigated.
APPROPRIATE USE OF TECHNOLOGY
A range of simulators of different levels of fidelity and realism are commercially available. Simulation-based training does not necessarily require the availability of very expensive technology. At lower levels of training, the mastery of a basic skill is probably achieved without excessive cost. At higher levels, where behavioural skills are required, fidelity is not solely a function of the simulator: a simple box trainer can be draped and taken into a real OR, where a full team will ensure that the simulation exercise ‘feels’ realistic for the urologist.
APPRECIATION OF LEARNING TOOLS
Training can only be achieved when the learner has an expectation of what is being taught, and how it is to be achieved. Psychometrically robust tools should be used with care for formative assessment and feedback, and subsequently for summative assessment. Importantly, a curriculum should guide the trainee and trainer, with explicitly defined learning outcomes and criteria to ascertain whether they have been achieved.
An evidence base needs to be further developed with respect to the effectiveness and validity of simulators and simulation. Specifically, studies need to be conducted to determine the transfer of skills to the OR and the cost-effectiveness of this type of training.
As laparoscopy in urology continues to increase, the challenge is to establish and maintain a system for training the psychomotor and non-technical skills required to be a competent urologist. Simulation holds the potential to improve the learning environment for the surgeon and trainee alike. A systematic framework can guide the best use of simulation, paving the way for its successful integration into a training curriculum.
This work was supported by the Association of Surgical Education CESERT grant and the National Institute for Health Research through the Imperial Centre for Patient Safety and Service Quality
CONFLICT OF INTEREST
There was no involvement of the funders in study design, data collection, data analysis, manuscript preparation or publication decisions