Using Simulation as a Teaching Tool

Using Simulation as a Teaching Tool American Association of Thoracic Surgery Developing the Academic Surgeon April 28, 2012 Edward D. Verrier, MD MerendinoProfessor of Cardiovascular Surgery University of Washington Surgical Director Joint Council on Thoracic Surgery Education

Simulation in Cardiothoracic Surgery Acknowledgments Nahush A. Mokadam, MD University of Washington James Fann, MD Stanford University Richard Satava, MD University of Washington

Background and Rationale TEACHING AND RESIDENT TRAINING Environment: Patient safety / outcomes Operating room efficiency Teamwork emphasis Work hours limitations Service still required Changes in general surgery training: Less open, more endoscopic Little vascular Changes in CT surgery practice Caseload Patients older, more co-morbidities Procedures more complex

Background and Rationale TEACHING AND RESIDENT TRAINING New skills and techniques Catheter based skills: TAVI, TEVAR Learner: Google generation: facts available, cognitive skills lacking Educator: Mixed priorities ACGME Competency initiative 6 basic ACGME competencies Assessment Technical skills Accountability Airline standards

Background TEACHING AND RESIDENT TRAINING Simulation has not been traditionally part of cardiac surgical training Several centers have informal or semi-formal curricula Due to the short training period (2-3) years, focus has been on clinical experience rather than simulation

SIMULATION IN CARDIOTHORACIC SURGERY SPECIAL CONSIDERATIONS Multiple sub-procedures / tasks to cardiac surgery Tasks that are not easily correctable Tasks that have serious consequences Tasks that may be visualized by only one surgeon Tasks that require educated assistance Different / unique anatomy in some cases Tools / instruments that require practice

Simulation as a Teaching Tool Basic Surgical Skills (knot tying, bronchoscopy) Pre-operative Planning (advanced imaging) Preparation for the Operating Room (warm-up) Crisis Management for Rare Events (CPB) Virtual Patients Cognitive skills Introduction of New Skills (catheter based skills) Team Training (communication, professionalism) Deliberate Practice (with mentor) Formative feedback (BID process) Assessment (criterion based)

Joint Council on Thoracic Surgery Education Established in 2008 AATS, ABTS, STS, TSFRE Simulation Committee

Simulation Manual 90 page manual Variety of simulators in cardiac and thoracic surgery Bulky to use and implement

Wet Labs Untapped resource In-Kind Grants from Industry Full set-up and clean-up Food-safe Environment Twice Yearly Schedule Aortic and Mitral Valves

Aortic Valve Surgery Wet-Lab - Curriculum Background reading and review: Cardiac Surgery in the Adult, Chapter 32, Pathophysiology of Aortic Valve Disease. Available online at: http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/3/2008/825 Multimedia Manual of Cardiothoracic Surgery, Supra-annular Aortic Valve Replacement. Available online at: http://mmcts.ctsnetjournals.org/cgi/content/full/2005/1129/mmcts.2004.000646 Atlas of Cardiac Surgical Techniques, Chapter 9, Aortic Valve Replacement. Attached PDF Atlas of Cardiac Surgical Techniques, Chapter 10, Aortic Root Enlargement Techniques. Attached PDF Goals and Objectives Wet Lab: To understand aortic valve anatomy To understand aortic valve pathophysiology To demonstrate surgical techniques for aortic valve replacement To review surgical techniques for aortic root enlargement Please read the materials before the wet lab, as they will serve to enhance your hands-on experience.

AHRQ Cardiac Surgery Training Grant 1R18HS020451-01 Collaboration of 8 institutions 2 groups of 16 first year cardiothoracic residents - Total 32 residents

AHRQ - Cardiac Surgery Training Grant Overview Simulator Based training for first year cardiothoracic residents in 6 different cardiac surgery modules, each over 7 weeks, for 2 years Formal simulator based training is 1/2 day per week for each resident

Specific Aims Learn the component tasks of a given module using a rigorous simulatorbased curriculum. Evaluate component task-based training of complex surgical procedures. Evaluate the effectiveness of deliberate practice of technical skills as a means of reliably achieving expertise. Teach the process of briefing and debriefing for evaluating performance. Analyze the data. Produce a curriculum for simulator based training. Make readily available to the entire surgical community the results of this project.

AHRQ -Cardiac Surgery Training Grant Module Breakdown 4 weeks of simulator training on component parts 3 weeks training of entire procedure using Ramphal Cardiac Simulator

CPB Syllabus Week 1: Fundamentals of CPB Week 2: Fundamentals of CPB Aortic Cannulation Week 3: Fundamentals of CPB Aortic Cannulation Venous Cannulation Week 4: Fundamentals of CPB Aortic Cannulation Venous Cannulation Cardioplegia Weeks 5, 6, 7: Full CPB on Ramphal Simulator

Structure of Instruction Briefing Performance of Task Debriefing Assessment

Week 1: Fundamentals

Cardiopulmonary Bypass

50 Steps Checklist

Troubleshooting

Week 2: Aortic Cannulation

Aortic Cannulation Pressurized porcine aorta in a box Red fluid Recitation of 50 Steps

Aortic Cannulation

Assessment

Week 3: Venous Cannulation

Venous Cannulation Pressurized porcine heart in a box Red fluid Recitation of 50 Steps Demonstration of Aortic cannulation

Venous Cannulation

Week 4: Static CPB

Pressurized porcine heart Red Fluid Recapitulation of all steps of CPB, including cognitive and technical aspects Static CPB

Weeks 5-7: RamphalSimulator

RamphalSimulator Full Operating Room Simulation Recapitulation of Weeks 1-4 Ability to apply troubleshooting

Ramphal Simulator

Beating Heart

Recreating the OR

Upcoming Modules Coronary artery bypass Aortic valve replacement Disaster scenarios Aortic dissection Air embolism Sudden deterioration in cardiac function

Observations Nonthreatening environment No one ever taught me that before. Steady improvement in surgical skills Development of automaticity Faculty development

Simulation as a Teaching Tool Basic Surgical Skills (knot tying, bronchoscopy) Pre-operative Planning (advanced imaging) Preparation for the Operating Room (warm-up) Crisis Management for Rare Events (CPB) Virtual Patients Cognitive skills Introduction of New Skills (catheter based skills) Team Training (communication, professionalism) Deliberate Practice (with mentor) Formative feedback (BID process) Assessment (criterion based)

OSATS Methodology Objective Structured Assessment of Technical Skills Richard Reznick, Univ of Toronto - 1998

Quantified objective assessment Blue Dragon passive recording device Correlation of motion analysis with qualitative assessment- OSATS Courtesy Blake Hannaford, University of Washington, Seattle Courtesy Richard Reznick, Toronto, CANADA

Novice Objective Assessment Intermediate Expert Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000

SIMULATION IN CARDIAC SURGERY METRICS for Simulation 1. Time for task completion 2. Quality of task 3. Economy of motion-tracking 4. Situational assessment 5. Logical sequence 6. Knowledge of anatomy 7. Crisis management

SIMULATION IN CARDIAC SURGERY OPERATIVE TEACHING ASSESSMENT 1. Feasibility 2. Reliability 3. Validity a. Predictive: predict future performance b. Content: intent to measure vs. actual content c. Concurrent: correlate with gold standard d. Construct: measure what we purport to measure e. Face: task or examination resembles real life

Future Directions Prerequisite Curriculum Training and Advancement Board RRC requirement / Certification Maintenance of Certification

Traditional Paradigm Change Halstedian - See one, do one, teach one Determined by patient flow Conventional fixed didactic lectures Subjective personal evaluation Specific time and place Next Generation Simulation Do many, mentored always Each student every variation at own pace Interactive, updated (web based) lecture Standardized, objective, criterion based evaluation Continuous at point of clinical care

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Questions and Discussion Thank you!