Sim one, do one, teach one: Considerations in designing training curricula for surgical simulation

Background. Although there is value in the use of simulation for the acquisition of fundamental surgical skills through goal-directed practice in a safe environment, there is little evidence guiding educators on how to best implement simulation within surgical skills curricula. This thesis reviews the application of the expert-performance model in surgery and the role of simulation in surgical skills acquisition. The focus is on implementation of deliberate practice, highlighting the principles of proficiency-based training, part-task training and overtraining. In a randomized controlled trial, we investigated the impact of part-task training by examining whether practicing a basic laparoscopic simulator task (peg transfer, PT) facilitates learning of a more complex skill (intracorporeal suture, ICS). We examined overtraining by comparing ICS learning and PT retention in subjects that had standard PT training (passing proficiency) to subjects who overtrained on PT (expert proficiency). Methods. Surgically naive subjects were randomized to one of three PT training groups: control, standard training, and overtraining. All participants then trained in ICS. The learning curves for ICS were analyzed by estimating the learning plateau and rate using nonlinear regression. Skill retention was assessed by retesting participants one month after training. Results. Part-task training: ICS learning plateau rose with increasing PT training and there was a trend toward higher initial ICS scores and faster learning rates with increasing PT training. Overtraining: At retention, there were no differences in PT scores. Overtrained participants saved time in learning ICS compared to controls, but PT overtraining took longer than the time saved on ICS training. Conclusion. In surgically naive subjects, part-task training with peg transfer alone was associated with slight improvements in the learning curve for intracorporeal suturing. However, overtraining with peg transfer did not improve skill retention and peg training alone was not an efficient strategy for learning intracorporeal suturing.