Invited Commentary

Abstract

It has long been known that surgical simulation is beneficial in the education of trainees. Laparoscopic simulation can predict intraoperative surgical performance in general surgery residents [1Steigerwald S.N. Park J. Hardy K.M. Gillman L.M. Vergis A.S. Does laparoscopic simulation predict intraoperative performance? A comparison between the Fundamentals of Laparoscopic Surgery and LapVR evaluation metrics.Am J Surg. 2015; 209: 34-39Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. In addition, structured boot camps for postgraduate year one (PGY-1) residents correlate with improved higher American Board of Surgery In-Training Examination scores and residents’ performance in validated measurements of technical skills [2Fernandez G.L. Page D.W. Coe N.P. et al.Boot cAMP: educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship.J Surg Educ. 2012; 69: 242-248Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar]. The same is true for simulation in cardiothoracic surgical education. Feins and associates [3Feins R.H. Burkhart H.M. Conte J.V. et al.Simulation-based training in cardiac surgery.Ann Thorac Surg. 2017; 103: 312-321Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar] demonstrated that first year residents completing cardiac surgery training modules, simulating such procedures as initiation and management of cardiopulmonary bypass, aortic valve surgery, and coronary artery bypass grafting, improved their performance in component tasks with simulation-based training. The data in support of simulation training in surgical education led the Accreditation Council for Graduate Medical Education in 2008 to mandate that all surgery residencies build a cogent simulation program into their curriculum. For cardiothoracic surgery trainees beginning residency on or after July 1, 2017, 20 hours of simulation are required [4Review Committee for Thoracic Surgery. Case Requirements for Residents Beginning on or After July 1, 2017. Available at http://www.acgme.org/Portals/0/PFAssets/ProgramResources/CaseRequirementsForResidentsBeginningJuly2017.pdf?ver=2017-03-30-141914-970. Accessed March 4, 2018.Google Scholar]. Mandating simulation training for our trainees is admirable, but at what cost? Literally speaking, at what cost? Surgical simulation, whether it is high or medium fidelity, is expensive. Using a high-fidelity simulator to train surgery residents in endoscopy, Raque and colleagues [5Raque J. Goble A. Jones V.M. Waldman L.E. Sutton E. The relationship of endoscopic proficiency to educational expense for virtual reality simulator training amongst surgical trainees.Am Surg. 2015; 81: 747-752PubMed Google Scholar] found an average cost per resident of $715 over 6 years. Building a simulation program modeled on the American College of Surgeons/Association of Program Directors in Surgery Skills Curriculum can cost more than $22,000 [6Pentiak P.A. Schuch-Miller D. Streetman R.T. et al.Barriers to adoption of the surgical resident skills curriculum of the American College of Surgeons/Association of Program Directors in Surgery.Surgery. 2013; 154: 23-28Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. In this issue of The Annals of Thoracic Surgery, Ramirez and colleagues [7Ramirez A.G. Nuradin N. Byiringiro F. et al.Creation, implementation, and assessment of a general thoracic surgery simulation course in Rwanda.Ann Thorac Surg. 2018; 105: 1842-1850Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] present a general thoracic surgery simulation course, developed at an American academic program, that was specifically to be implemented in a low-resource university setting in Rwanda. The authors’ curriculum consisted of basic open thoracic surgical procedures, ranging from positioning and posterolateral thoracotomy to performing a lung decortication. The simulation components were inexpensive (including tools such as a teaching skeleton and a football), did not require electricity, were easily built, and used standard operating room equipment. In addition, the exercises were paired with an online resource (http://thoracicsurgeryeducation.com) that provided guidance on model assembly and supplemented on-site instruction. For a minimal cost, the authors were able to demonstrate the successful implementation of a low-fidelity simulation curriculum for thoracic surgery trainees in a low-resource setting, leading to improved participant confidence and knowledge attainment. This study by Ramirez and colleagues [7Ramirez A.G. Nuradin N. Byiringiro F. et al.Creation, implementation, and assessment of a general thoracic surgery simulation course in Rwanda.Ann Thorac Surg. 2018; 105: 1842-1850Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar], which was intended for global health and the benefit of training programs in low-resource nations, may be translatable to low-resource residency programs in this country. First year cardiothoracic surgery residents, whether they are PGY-1 residents in an integrative program or PGY-6 residents in an independent program, have less and less exposure to thoracic surgery before starting their training. Low-fidelity simulation, as described by Ramirez and associates [7Ramirez A.G. Nuradin N. Byiringiro F. et al.Creation, implementation, and assessment of a general thoracic surgery simulation course in Rwanda.Ann Thorac Surg. 2018; 105: 1842-1850Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar], could provide a curriculum of modest “suspension of disbelief” that would be introductory to the specialty. Combining with other lean cost strategies, such as the use of low-fidelity vascular models and task shifting faculty time from traditional curriculum didactics to simulation, may help make the required simulation training in residencies affordable [8Helder M.R. Rowse P.G. Ruparel R.K. et al.Basic cardiac surgery skills on sale for $22.50: an aortic anastomosis simulation curriculum.Ann Thorac Surg. 2016; 101 (discussion 322): 316-322Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 9Calhoon J.H. Baisden C. Holler B. et al.Thoracic surgical resident education: a costly endeavor.Ann Thorac Surg. 2014; 98 (discussion 2014–5): 2012-2014Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. The low-cost model described by Ramirez and colleagues [7Ramirez A.G. Nuradin N. Byiringiro F. et al.Creation, implementation, and assessment of a general thoracic surgery simulation course in Rwanda.Ann Thorac Surg. 2018; 105: 1842-1850Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] may prove beneficial not only to learners already in residency programs, but also to prospective students who are seeking an introduction to our specialty. Surgical skills courses increase medical students’ interest in thoracic surgery [10Tesche L.J. Feins R.H. Dedmon M.M. et al.Simulation experience enhances medical students’ interest in cardiothoracic surgery.Ann Thorac Surg. 2010; 90 (discussion 1973–4): 1967-1973Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. One can see modestly resourced surgery interest groups in US medical schools adopting this curriculum to the benefit of their members. The cost of educating trainees can be incredible, but the value of surgical simulation to learners is accepted. In addition, the requirements of the Accreditation Council for Graduate Medical Education for a developed simulation curriculum in accredited residency programs necessitate that those programs find ways to mitigate the cost barrier. Perhaps program directors and other education leaders can take insight from the strategies of surgical volunteerism and global health and translate those lessons of cost efficiency to their own resource-challenged learning environments. Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in RwandaThe Annals of Thoracic SurgeryVol. 105Issue 6PreviewThe primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty. Full-Text PDF