Motor skills training in orthopaedic surgery: a paradigm shift toward a simulation-based educational curriculum.

For centuries, surgery has been taught using an apprenticeship model. As Atesok et al explain in their timely and thoughtful review in this issue of the Journal of the American Academy of Orthopaedic Surgeons, surgical skills training will change dramatically in the coming years, toward more objective, proficiency-based approaches. This transformation will improve patient safety and educational efficiency. Structured curriculum, surgical simulation, and objective assessment of technical proficiency will be critical parts of this change. In their up-to-date and comprehensive book, Gallagher and O’Sullivan provide an excellent overview of the background and rationale for this paradigm shift, which has been largely pioneered in nonorthopaedic procedural specialties. It is a very good reference for those interested in the principles of simulation training and objective assessment of proficiency. To become an orthopaedic surgeon, residents must learn vast amounts of medical knowledge, and they must acquire surgical skills to practice in an increasingly complex and technically demanding field. Using a common comparison to the airline industry, it is not enough that pilots understand the way airplanes work. When we step on board, we expect that the pilot can actually fly the plane, every time. Why is it not the same for surgery? There are probably many explanations, but a short answer is best. Surgical training is simply a few decades behind the aviation industry. We believe this is about to change. New educational expectations, advanced simulation technologies, and heightened concerns about patient safety create an intersection of forces that will lead to rapid changes in surgical skills education, moving away from total reliance on the apprenticeship model. Some of these changes will be met with skepticism, and each adjustment of the system demands careful and deliberate validation. However, resistance to change will not maintain the current approach. New simulation technology and improved educational and assessment techniques will make it possible for residents and practicing orthopaedic surgeons to acquire surgical skills in a safe environment, where errors are not only acceptable but embraced as part of the learning process. The American Academy of Orthopaedic Surgeons (AAOS) Council on Education (COE) convened a simulation summit on November 4, 2011, which we had the pleasure of co-chairing. In assembling the roster for the summit, we were guided by the advice of Richard Satava, MD, a pioneer in general surgery simulation training. Dr. Satava recommended that it was critical to bring together the expert surgical educators, content-delivery organizations, and certifying bodies to define common needs and objectives. The Simulation Summit was attended by representatives of the AAOS, various orthopaedic speRobert A. Pedowitz, MD, PhD