Exclusive Preview: Interview with Dr Douglas Smink about Surgical Simulation

In the September issue of 'Surgeons News', Mark Baillie speaks to Dr Douglas Smink, key speaker at October’s Faculty of Surgical Trainers Annual Meeting, about his work and why he believes simulation for assessment is inevitable

Based at Boston’s Brigham and Women’s Hospital, the STRATUS Simulation Centre is a 6000sqft world-class facility that serves the entire 800-bed hospital. The facility is used by clinical staff of every grade and specialty, but more and more it’s being used by consultants learning new techniques.

It’s not surprising the centre is in demand as its facilities range from hi-tech virtual reality surgical simulators to low-fidelity task trainers which can focus on laparoscopy, endoscopy and open surgical skills. There are simulators to teach transoesophageal echo, standardised patients for OSCE-type exams and a mock operating room for interdisciplinary team training.

"STRATUS is quite a resource for our institution," remarks Dr Douglas Smink, the centre’s Associate Medical Director. “We are a large hospital with over 1000 trainees. Over the five years I’ve been involved, usage of the centre has grown by 20% each year. We’re getting close to capacity and the challenges now are space and faculty within the centre who work with the groups who use it.”

For such a popular facility serving a large hospital, the STRATUS core faculty is surprisingly small; there’s Dr Smink plus a medical director, a director for education and research, and a surgical skills nurse. This leaves much of what happens at the facility up to the groups who use it. As Dr Smink puts it, “We help them plan what they want to teach – make sure that it’s going to be high quality – and then we leave the teaching and clinical expertise to them; that’s where they shine.”

One of Dr Smink’s particular areas of interest also happens to be one of the biggest challenges in the use of simulation: “I am sure that at some point in my career I will have to prove my skills on a simulator – it may not be technical – it may be teamwork, but as we move forward we are going to see more assessment of competency – that only makes sense.”

Ultimately, he believes this type of assessment will be tied to credentialing and certification and cites the precedent in the US where anaesthetists must prove their skills in a simulated environment every 10 years. But surgery is not at that stage yet, Dr Smink says, “The simulators aren’t good enough yet to assess a practising surgeon and the data to show the level of competency needed are not available yet. Until we address those issues it will be hard to convince the authorities that this is the way to go.

"Assessing competency is one of the hardest things we do with a simulator – simulators are used for a lot of different reasons; this is one of the things I will talk about during my lecture at the Faculty of Surgical Trainers meeting. Simulators are mainly used for teaching, but their use for assessing competency requires a higher level of use; I think we in the medical profession don’t use simulation to assess competency as well or as much as we’d like to."

Having said that, there is a clear indication of the direction of travel; he cites the Fundamentals of Laparoscopic Surgery progamme in the US, the scheme that allows trainees to receive board certification based, in part, on the demonstration of basic laparoscopic skills.

Some of the challenges around using simulation to demonstrate competency can be attributed to its integration with training programmes in the US. Although some use of simulation is a requirement of all training programmes, there is no specific guidance on exactly how it should be incorporated, and – as Dr Smink points out – there are variations in curricula around the country.

In support of this and to move towards greater standardisation there are a number of groups, headed by the American College of Surgeons, who have come together to create specific simulation curricula. One such is the Association for Program Directors in Surgery (of which Dr Smink is a member) who have created a simulation curriculum in three phases: for basic skills; procedural skills; and team-based communication skills.

A second challenge for simulation concerns the evidence to demonstrate retention of skills after simulator training. This, Dr Smink concedes, remains an area of much-needed research and debate continues around the best ways to use simulators. Dr Smink believes the evidence is in favour of using simulators in short sessions over a longer time: “It’s one of the reasons we try to match the topic covered in simulation with what trainees are doing at that point in their rotation. If you can teach a skill that will then be used in a clinical environment during the next few months, then the likelihood that it will be retained is so much higher.”

One of Dr Smink’s reasons for speaking at the FST conference in October stems from his keen interest in RCSEd’s non-technical skills for surgeons (NOTSS) project: "I am a huge convert to the importance of NOTSS following attendance at an RCSEd Masterclass on the topic. When you show that nomenclature to surgeons, they know that it makes sense, but they’ve never seen it so clearly articulated before. Now our challenge is to teach it."

Dr Smink sees so much potential for simulation in this area that one of the original members of the NOTSS working group, Dr Steven Yule, is now Director of Education and Research at the STRATUS unit.

Does Dr Smink believe simulation will ever replace learning from patients? "Simulation is never the same as it is in the real world; you can teach people to tie knots and to suture in simulation but in the real world tissues feel different. So simulation can bring trainees to a much higher level of skill but it’s only in a real setting that you know for sure that someone can do it."

Although he’s clear that there’s nothing to equal learning skills in a real clinical setting, Dr Smink is a reasoned advocate for what simulation can offer by way of support to learning in the real world: “On a given day, we can make sure that trainees receive the right amount of training on the condition or procedure that we want them to be trained on. But in a real setting, a lot depends on what type of condition a patient presents with. It’s about trying to make learning in the real world more efficient and safer.”

One gets an impression that a few final pieces of evidence need to fall into place before simulation can make a major breakthrough in the practice of surgery: “We know simulation is beneficial but we perhaps need more evidence for its educational value and how it will result in better patient outcomes. It’s an obligation of those of us who do simulation to show those things because once you have that data it will be impossible for people to not do it.”

His quest may be nearing completion, but for the moment at least Dr Smink seems happy to continue exploring and gathering evidence in the simulated world.

Dr Douglas Smink will give the keynote lecture at the Faculty of Surgical Trainers Annual Meeting ‘Playing for Real – Simulation in Surgical Training’, 24 October 2013, Birmingham. For further information click here or phone +44 (0)131 668 9237.