A New Mandate for SimulationA New Mandate for Simulation--

Based Orthopaedic Surgery Skills Based Orthopaedic Surgery Skills

Training in the United States: Training in the United States:

Moving From Concept to Moving From Concept to

ImplementationImplementation

Robert A. Pedowitz, MD, PhDRobert A. Pedowitz, MD, PhD

Professor of Orthopaedic SurgeryProfessor of Orthopaedic Surgery

David Geffen School of Medicine at UCLADavid Geffen School of Medicine at UCLA

DisclosureDisclosure

�� Consulting: Stryker, DJ OrthoConsulting: Stryker, DJ Ortho

�� Chair, Simulation Task Force (AAOS) Chair, Simulation Task Force (AAOS)

�� Chair, Fundamentals of Arthroscopic Chair, Fundamentals of Arthroscopic

Surgery Training (Surgery Training (FASTFAST) Program ) Program

(AANA(AANA--AAOSAAOS--ABOS) ABOS)

�� CoCo--Chair, Motor Skills Curriculum Chair, Motor Skills Curriculum

Task Force (ABOSTask Force (ABOS--AAOS)AAOS)

How Do We Acquire Surgical Skills?How Do We Acquire Surgical Skills?

�� ObservationObservation

�� Practice (on patients)Practice (on patients)

�� CompetencyCompetency

�� ProficiencyProficiency

�� Expertise (Master level skills)Expertise (Master level skills)

�� New surgical techniquesNew surgical techniques

�� Continuing medical educationContinuing medical education

How did we get here?How did we get here?

Been the same way, for a Been the same way, for a longlong timetime

The Apprenticeship ModelThe Apprenticeship Model

� Train a next generation of practitioners

� Apprentice (protégé): Builds career

� The Master: Educates while working

� The apprentice learns trade or

profession, in exchange for continued

labor for an agreed period AFTER

achieving measurable competencies

Flexner Report (1910):Flexner Report (1910):

The apprenticeship model The apprenticeship model

was preserved, especially for was preserved, especially for

surgical trainingsurgical training

The Apprenticeship ModelThe Apprenticeship Model

�Master: Educates while working

�Apprentice: Builds career

BuildsCharacter

2007: ACGME Core 2007: ACGME Core CompetenciesCompetencies

� Patient Care

� Medical Knowledge

� Practice Based Learning and Improvement

� Systems Based Practice

� Professionalism

� Interpersonal Skills and Communication

What about surgical skills?What about surgical skills?

Vague definition of Vague definition of

““competencycompetency”” for for

procedural specialtiesprocedural specialties

The Evolving The Evolving

Role of Simulation Role of Simulation

in Medicinein Medicine

MedicalEducation

ComputersGaming

SimulationAssessment(Proficiency)

PatientSafetyOUR

APPROACHWILL

CHANGE

We can (and should) We can (and should)

learn from other learn from other

disciplinesdisciplines

AviationAviation

AviationAviation

��High RiskHigh Risk

��ExpensiveExpensive

SurgerySurgery

��High RiskHigh Risk

��ExpensiveExpensive

This is coreculture in

flight safety

Surgery will follow the aviation Surgery will follow the aviation

industry because:industry because:

� Both are high risk and complex

� The public will demand it

� Technologies make it feasible

� Cost is dropping

What is Simulation?What is Simulation?

The imitation of a The imitation of a

realreal--world process world process

or system over time.or system over time.

What is Simulation?What is Simulation?

NotNot limited to virtual limited to virtual

reality, computerreality, computer--

based simulationbased simulation..

We already We already useuse simulation in orthosimulation in ortho

�� Bone and joint modelsBone and joint models

�� Knot tying boardsKnot tying boards

�� Cadaver surgeryCadaver surgery

�� CaseCase--based programsbased programs

�� Orthopaedic learning centerOrthopaedic learning center

�� Virtual reality knee arthroscopyVirtual reality knee arthroscopy

But not used systematically

Not used to assess proficiency

These are low cost & easy to use

Which Is

Better?

KEY CONCEPT:

Fidelity must be

sufficient

to achieve our

educational objectives

Low cost can be

very effective

Atesok, et al: Surgical simulation Atesok, et al: Surgical simulation

in orthopaedic skills training, in orthopaedic skills training,

JAAOS 2012JAAOS 2012

The current The current evidenceevidence

in orthopaedic skills in orthopaedic skills

training is limitedtraining is limited

Hypothesis:Hypothesis:

Simulation-based training

will facilitate the learning

curve and enhance patient

safety in orthopaedic surgery

Recent Changes in Recent Changes in

Orthopaedic Training Orthopaedic Training

in the United Statesin the United States

AAOS Orthopaedic Surgery Simulation AAOS Orthopaedic Surgery Simulation

Summit 11/4/2011: Meeting ObjectivesSummit 11/4/2011: Meeting Objectives

�� Establish a dialogue between orthopaedic Establish a dialogue between orthopaedic organizationsorganizations

�� Develop a roadmap for simulation training Develop a roadmap for simulation training in orthopaedic resident educationin orthopaedic resident education

�� Identify orthopaedic curriculum changes Identify orthopaedic curriculum changes that might be necessarythat might be necessary

�� Discuss opportunities for use of simulation Discuss opportunities for use of simulation by American Board of Orthopaedic Surgery by American Board of Orthopaedic Surgery

LeadLead--up to the up to the

Simulation Summit:Simulation Summit:

What are the likely What are the likely

barriers to change?barriers to change?

Current and Future Use of Surgical Skills Current and Future Use of Surgical Skills

Training Laboratories in Orthopaedic Training Laboratories in Orthopaedic

Resident Education: A National SurveyResident Education: A National Survey

Karam, Pedowitz, Natividad, Murray, MarshKaram, Pedowitz, Natividad, Murray, Marsh

J Bone Joint Surg Am. 2013;95:e4(1J Bone Joint Surg Am. 2013;95:e4(1--8)8)

Survey Responses from 86 / 185 residency directors (46%)687 / 4549 orthopaedic residents (15%)

Results of a 2011 National Orthopaedic Results of a 2011 National Orthopaedic

Program Director and Resident SurveyProgram Director and Resident Survey

��Only 50% with skills lab & programOnly 50% with skills lab & program

��Interest in a standardized orthopaedic Interest in a standardized orthopaedic skills curriculumskills curriculum

��Little knowledge of the department Little knowledge of the department budget for skills training or the cost budget for skills training or the cost of running a skills labof running a skills lab

��Cost is perceived as a challengeCost is perceived as a challenge

Hours per week of dedicated time

Access to motor skills lab

Frequency Valid Percent CI Lower Upper

Completely Agree 40 47% 11% 36% 58%

Somewhat agree 28 33% 10% 23% 43%

Neutral 11 13% 7% 6% 20%

Somewhat Disagree 3 4% 4% 0% 7%

Completely Disagree 3 4% 4% 0% 7%

Total 85 100%

Frequency Valid Percent CI Lower Upper

Completely Agree 10 12% 7% 5% 19%

Somewhat agree 18 21% 9% 13% 30%

Neutral 27 32% 10% 22% 42%

Somewhat Disagree 17 20% 9% 12% 29%

Completely Disagree 12 14% 7% 7% 22%

Total 84 100%

a) Future surgical skills simulation should become a required part of residency training.

b) Future surgical skills simulation should become a part of board certification and re-certification for orthopaedic surgeons in practice.

80%

80%

Perceived Barriers

Willingness to Pay for Surgical SimulatorsWillingness to Pay for Surgical Simulators

Orthopaedic Surgery Simulation Orthopaedic Surgery Simulation

Summit: November 4, 2011Summit: November 4, 2011

�� 28 Attendees: COE, AANA, ABOS, RRC, 28 Attendees: COE, AANA, ABOS, RRC,

AOSSM, ASES, ASSH, OTA, AOSSM, ASES, ASSH, OTA,

AOA/CORD, AOFAS, VR project teamAOA/CORD, AOFAS, VR project team

�� 3 guest speakers3 guest speakers

�� Sponsored by AAOS COESponsored by AAOS COE

�� Strong representation: ABOS & RRCStrong representation: ABOS & RRC

�� CoCo--Chairs Chairs –– Rob Pedowitz & Larry Marsh Rob Pedowitz & Larry Marsh

Simulation Summit: November 4, 2011Simulation Summit: November 4, 2011

��Consensus: Surgical Simulation Consensus: Surgical Simulation

��Should be part of residency education Should be part of residency education

and for proficiency assessmentand for proficiency assessment

��Methodology should be curriculumMethodology should be curriculum--

basedbased

��Develop with RRC & ABOS guidance Develop with RRC & ABOS guidance

(Mandate (Mandate �� ImplementationImplementation))

�� In 2012, the ABOS & Orthopaedic In 2012, the ABOS & Orthopaedic

RRC mandated structured motor RRC mandated structured motor

skills training for the PGY1 yearskills training for the PGY1 year

��Required implementation: 7/1/2013Required implementation: 7/1/2013

��Dedicated space & time, structured Dedicated space & time, structured

curriculum, metricscurriculum, metrics

�� Integration: Longitudinal trainingIntegration: Longitudinal training

PGY-1 Changes (Effective 7/1/13)

� Total time a resident is assigned to any one non-orthopaedic service must not exceed two months.

�� Six months of orthopaedic surgery Six months of orthopaedic surgery

rotations rotations designed to foster proficiency in basic

surgical skills, the general care of orthopaedic patients both as inpatients and in the outpatient clinics, the management of orthopaedic patients in the emergency department, and the cultivation of an orthopaedic knowledge base.

�� Formal instruction in basic surgical Formal instruction in basic surgical skills, which may be provided skills, which may be provided longitudinally or as a dedicated longitudinally or as a dedicated rotation during either the orthopaedic rotation during either the orthopaedic or nonor non--orthopaedic surgical rotationsorthopaedic surgical rotations

� Basic surgical skills training must be designed to integrate with skills training in subsequent post graduate years and should prepare the PGY-1 resident to participate in orthopaedic surgery cases.

� The basic surgical skills curriculum must include:

� (i) Goals and objectives and assessment metrics

� (ii) Skills used in the initial management of injured patients, including splinting, casting, application of traction devices, and other types of immobilization

� (iii) Basic operative skills, including soft tissue management, suturing, bone management, arthroscopy, fluoroscopy, and use of basic orthopaedic equipment.

Motor Skills Curriculum Motor Skills Curriculum

Development Process:Development Process:

Still a challenge!Still a challenge!

WeWe’’ve Used An Inefficient ve Used An Inefficient

Development ProcessDevelopment Process

Virtual Reality ArthroscopyHigh Fidelity, Expensive,

Moderately Complex Procedure

Validation Studies (Almost) Done

Will it be affordable?

Will it meet our needs?

Lots of dollars

Lots and lots of hours

A Different ApproachA Different Approach

• Refine a simulation strategy

• Pick (or develop) the simulation “gizmos”

Consider performance

metrics

Select an audience

Define the needs

Develop a CurriculumGet what you want

Saves time & money

Development of Simulation MethodsDevelopment of Simulation Methods

Deriving Deriving FromFrom the Curriculumthe Curriculum

Teaching Strategies MetricsTeaching Strategies Metrics

BasicBasic Arthroscopy SkillsArthroscopy Skills

�� Equipment tutorialEquipment tutorial

�� Image trackingImage tracking

�� Image stabilityImage stability

�� OrientationOrientation

�� TriangulationTriangulation

�� Track & probeTrack & probe

�� Moving targetMoving target

�� Switch handsSwitch hands

�� Shaver controlShaver control

�� Scope toolsScope tools

�� Multiple variablesMultiple variables

�� Managing stressManaging stress

Development of Simulation MethodsDevelopment of Simulation Methods

Deriving Deriving FromFrom the Curriculumthe Curriculum

Teaching Strategies Teaching Strategies

Motor Skills VirtualMotor Skills Virtual

Laboratory RealityLaboratory Reality

Standardized Standardized

curriculum curriculum

templatetemplate

ABOS / AAOS / AANA Orthopaedic ABOS / AAOS / AANA Orthopaedic

Motor Skills Curriculum Template Motor Skills Curriculum Template

(Modified from the ACS/APDS, ASSET, and (Modified from the ACS/APDS, ASSET, and

FAST Program Curriculum Templates, 2012)FAST Program Curriculum Templates, 2012)

Step 1: Problem Identification & Needs Assessment

Step 2: Goals and Objectives

Step 3: Syllabus Development

Step 4: Learner Evaluation and Feedback

Step 5: Periodic Curriculum Review, Module Evaluation, Metric Validation and Refinement

Step 3: Syllabus DevelopmentStep 3: Syllabus DevelopmentA. Assumptions (prerequisite knowledge and motor skills)

B. Suggested readings

C. Description of laboratory module

D. Description of techniques and procedure

E. Common errors and prevention strategies

F. Demonstrate expert performance / video

G. Recommendations for motor skills practice

H. Supplies and station setup

I. Suggested duration for completion of module

J. Estimated budget for this module

Ongoing Orthopaedic Ongoing Orthopaedic

Simulation InitiativesSimulation Initiatives

�� FASTFAST Program (AANAProgram (AANA--AAOSAAOS--ABOS) ABOS)

�� Copernicus Project (AANA)Copernicus Project (AANA)

�� Fluoro / Radiation Safety (AAOSFluoro / Radiation Safety (AAOS--OTA) OTA)

�� Basic Motor Skills (ABOSBasic Motor Skills (ABOS--AAOS) AAOS)

Fundamentals of Fundamentals of

Arthroscopic Surgery Arthroscopic Surgery

Training ProgramTraining Program

((FAST FAST Program)Program)

(AANA(AANA--AAOSAAOS--ABOS)ABOS)

BasicBasic Arthroscopy SkillsArthroscopy Skills

�� Equipment tutorialEquipment tutorial

�� Image trackingImage tracking

�� Image stabilityImage stability

�� OrientationOrientation

�� TriangulationTriangulation

�� Track & probeTrack & probe

�� Moving targetMoving target

�� Switch handsSwitch hands

�� Shaver controlShaver control

�� Scope toolsScope tools

�� Multiple variablesMultiple variables

FASTFAST Program ModulesProgram Modules

1. Basic Principles of Arthroscopy

2. Basic Triangulation Skills

3. Basic Interventional Arthroscopy

4. Biomaterials & Anchor Insertion

5. Arthroscopic Knot Tying

6. Suture Passage

Learning to tie arthroscopic knots

Is there a better way?

Is This More Is This More EffectiveEffective??

AANA Copernicus ProjectAANA Copernicus Project

�� Concept: ProficiencyConcept: Proficiency--based progressionbased progression

�� Moderate skill level: Scope BankartModerate skill level: Scope Bankart

�� Development Steps:Development Steps:

��Task deconstructionTask deconstruction

��Metric definition and validationMetric definition and validation

��Course reCourse re--design (OLC, Rosemont)design (OLC, Rosemont)

��Prospective educational assessmentProspective educational assessment

AAOSAAOS--OTA OTA

Fluoroscopy ProjectFluoroscopy Project

��Safety issue: Radiation exposureSafety issue: Radiation exposure

��Surgical procedure: FluoroscopySurgical procedure: Fluoroscopy--

guided hip fracture fixationguided hip fracture fixation

��Virtual reality and hapticsVirtual reality and haptics

ABOS ABOS

Basic Basic

Motor Motor

Skills Skills

ModulesModules

� J. Lawrence Marsh, MD (Chair, ABOS)

� James E. Carpenter, MD (ABOS)

� Shepard R. Hurwitz, MD (ABOS)

� Michelle A. James, MD (ABOS)

� Joel T. Jeffries, MD (AOA/CORD)

� David F. Martin, MD (ABOS)

� Peter M. Murray, MD (ABOS)

� Bradford O. Parsons, MD (AAOS)

� Robert A. Pedowitz, MD, Ph.D. (Co-Chair, AAOS)

� Brian C. Toolan, MD (AAOS)

� Ann E. Van Heest, MD (AOA/CORD)

� M. Daniel Wongworawat, MD (AAOS)

1. Sterile Technique and Operating Room Set-Up

2. Knot Tying & Suturing

3. Basic Microsurgical Suturing

4. Soft Tissue Handling Techniques

5. Casting and Splinting

6. Traction

7. Compartment Syndrome

8. Bone Handling Techniques - Osteotomy

9. Fluoroscopic Knowledge and Skills

ABOS Basic Motor Skills Modules

10. K-Wire Techniques

11. Techniques Basic to Internal Fracture Fixation

12. Principles and Techniques of Fracture Reduction

13. External Fixation

14. Basic Arthroscopy Skills

15. Basic Arthroplasty Skills

16. Joint Aspiration and Injection

17. Patient Safety, Team Training, Consent

ABOS Basic Motor Skills Modules

Conclusion:Conclusion:Moving From Concept Moving From Concept

to Implementationto Implementation

Surgery Surgery willwill follow follow

the aviation example:the aviation example:

� Both are high risk and expensive

� Public will demand it

� Technologies make it feasible

� Simulation will be cost-effective

� U.S. Orthopaedic Surgery:

Making some progress

SurgicalEducation

ComputersGaming

SimulationAssessment(Proficiency)

PatientSafety

Follow The PrinciplesFollow The Principles

��Curriculum:Curriculum: Comes first

��Metrics:Metrics: Validation critical for high stake assessment

��Efficiency:Efficiency: Simulation must

be useful and cost-effective