Application of surgical skill simulation training and assessment in orthopaedic trauma.

Importance of simulation The surgical restoration of a severely fractured extremity is a complex procedure requiring skills that a surgeon trainee must acquire during their education. Traditional surgical education has consisted of a mixture of didactic lessons with periodic clinical and surgical apprenticeship-based experience. These experiences, although beneficial, are not uniform and do little to assure technical competence. The apprenticeship model is challenged not only by a lack of opportunities to expose trainees to the necessary variety of procedures,1 and the expense of such training,2,3 but also by the need to ensure patient safety while exposing trainees to new experiences.4 There is strong evidence that the current training approach may not be optimally safe. In a review of surgical errors, 63.5% of cases involved technical error and 29% included an error in judgment.5 Both of these types of errors can be ascribed to a lack of experience. These and similar findings have led to the call for greater transparency in the training and assessment of surgical residents. The American Board of Surgery has mandated that, rather than just documenting the surgeries a resident participated in, proficiency in basic laparoscopic skills must be documented prior to allowing graduates to be tested for certification.6 Surgical simulation can help address shortcomings in the traditional apprenticeship training model by providing residents with opportunities to (1) practice important procedures that they may not otherwise encounter and (2) practice procedures efficiently until competency is achieved, (3) without exposing live patients to undue risk. Simulation can provide immediate and detailed feed-back that can improve learning efficiency. With newly imposed restrictions on resident work hours, financial pressures, and increased public scrutiny, simulationbased technical training and assessment tools are receiving renewed attention. Before a surgical simulator construct can be used to assess competency, however, the scientific validity of the simulator and of the performance assessment must be established.7 A well-designed and rigorously validated simulator can provide quantitative, repeatable assessment of specific surgical skills and can predict performance in the operating room. The benefits of training using surgical simulation are already being realized in general surgery, particularly for laparoscopic surgery. Medical students and residents trained on simulators demonstrate improved performance in actual surgeries. For example, in one study, training on a laparoscopic simulator was shown to lead to reliably fewer errors during actual surgery on an anesthetized animal.8 In another study, residents were trained to a certified level in the laparoscopic simulator and then performed their first actual surgery with fewer errors and caused fewer injuries than did a control group of non-simulation-trained residents.9