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2010 THE AUTHORS; JOURNAL COMPILATION Laparoscopic and Robotic Urology

2010 BJU INTERNATIONAL

SIMULATION IN UROLOGY TRAINING ARORA ET AL.

BJUI

Framework for incorporating simulation into urology training

BJU INTERNATIONAL

Sonal Arora, Benjamin Lamb, Shabnam Undre, Roger Kneebone, Ara Darzi and Nick Sevdalis Department of Surgery and Cancer, Imperial College London, London, UK Accepted for publication 1 April 2010

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVES • 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 nontechnical 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.

INTRODUCTION 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 [1], the training of all clinicians has been increasingly called into account. Furthermore, although recent advances in minimally invasive surgery have yielded

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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.

situated within a fully-simulated operating rooms.

RESULTS • 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 decisionmaking 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 nontechnical skills in full crisis simulations

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 [2]. 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 [3]. There is an imperative need for novel approaches to

CONCLUSIONS • 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. KEYWORDS simulation, urology, virtual reality, clinical competence, teamwork, surgery

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-

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2010 THE AUTHORS

2 0 1 0 B J U I N T E R N A T I O N A L | 1 0 7 , 8 0 6 – 8 1 0 | doi:10.1111/j.1464-410X.2010.09563.x

SIMULATION IN UROLOGY TRAINING

based specialty, but also to train in the other attributes integral to being a safe urologist [4]. 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 [5]. These include situation awareness and decision-making, as well as stress management, communication and teamwork [5]. 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 [2]. 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 [3]. 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,

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underpinned by the notion of a systematic approach to training and assessment [7]. 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 animalbased 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