Guidance on the role of simulation in formal training by the British Orthopaedic Association

Kapil Sugand and Hiro Tanaka

A proposed position has been compiled on the role of simulation in formal training at any stage between medical school to consultancy. The BOA recognises the importance of maintaining a high-quality standard of training and is in the process of becoming the first orthopaedic body to officially release a White Paper on the topic. Proctorship/ apprenticeship still remains the gold standard for training, demonstrating competency and building confidence; but simulation acts as a favourable adjunct to enhance patient safety, which is of utmost priority.

Description of current challenges

The quality of national training has been affected by numerous generational changes as outlined in Table 1.

Definition of simulation

Many definitions of surgical simulation exist. The Society of Simulation in Healthcare defines it as follows:

“A technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions” (Society of Simulation in Healthcare, 2013) [7].

A contextualised version includes recreating clinical scenarios in a safe and monitored environment in order for the participant to learn, develop and hone both technical and non-technical clinical skills without compromising patient safety. As the participant is able to practise a skillset in order to demonstrate competence and confidence to the assessor considered an expert in the field, the assessor, who is is able to evaluate the performance before offering constructive and personalised feedback at regular intervals. The purpose of simulation is self-directed goal-orientated rehearsal. Hence, it ought to be incorporated into regular routine not only to demonstrate continued maturity but to also avoid skills decay. Take heed of 'out of sight, out of mind'.

Possible solutions

1. Learning from other specialist organisations

Simulation is both recognised and has become mandated within the curriculum as championed by the General Medical Council8 and other international medical bodies.

Additionally, both the body of work and National Standards Framework are recognised from national organisations such as the Association for Simulated Practice in Healthcare (ASPiH), the Society for Simulation in Healthcare (SSH), Health Education England (HEE) and the Joint Committee on Intercollegiate Examinations (JCIE) as well as the current peer-reviewed literature globally.

2. Working within the BOA

There is an evolving practice of the development, validation and administration of simulation solutions within T&O training through its direct involvement with its diverse membership from medical students through to Consultants. The BOA is also actively collaborating with British Orthopaedic Trainees Association (BOTA) and British Orthopaedic Medical Student Association (BOMSA) in searching for innovative modalities to enhance educational impact. There is also a dedicated section within the Annual BOA Congress highlighting advancements of simulation practice through rigorous research methodologies.

3. Establishing a healthy working relationship with industry partners

Working relationships with industry partners will be forged in order to introduce simulation solutions to its diverse and versatile membership. Opportunities to showcase simulation modalities will be conducted at the annual BOA and BOTA Congresses, discussed at the Simulation section of the Congress through free papers and posters highlighting research on validation of both software and hardware solutions. The BOA will support the showcasing of commercial simulation products and introduce the vendors to its clients. Clients will consist of Training Programme Directors, Deanery Representatives, Consultant Trainers as well as Trainees. The notion of ‘try before you buy’ concept will be supported while encouraging vendors to offer trial periods to institutions prior to making a sizeable investment into its purchase or hire licensing.

4. Lexicon

The definitions outlined in the Health Education Dictionary compiled by the Society for Simulation in Healthcare (Table 2) is acknowledged. This list is not exhaustive and the entire lexicon can be found on their website (www.ssih.org/dictionary) for further information and definitions.

Other recognised terms are acknowledged in Table 3.

5. Modes of simulation

The following are simulation techniques that are recognised and can be principally categorised as in Table 4.

i. Analogue modalities

Historically, most T&O trainees have experienced some form of simulation; the commonest modality being low-fidelity drybones. This technique is usually for learning procedural steps, obtaining appropriate range of measurements and familiarising with new surgical equipment. Analogue alternatives include drybones with simulated soft tissue envelopes including muscles, tendon, ligaments and neurovascular bundles. Box trainers were able to simulate arthroscopic procedures to improve skills as well as manual dexterity including triangulation, economy of movement and pace. Distributed interactive simulation is a combination of analogue modalities that increases the extent of both fidelity, immersion and interaction (Figure 1). Such clinical scenarios may consist of a series of simulation tasks, in various clinical areas and involve multidisciplinary colleagues, thereby reflecting technical and nontechnical skills.

Figure 1: Distributed interactive simulation scenario consisting of phantom limbs, cardiac monitors, theatre lights and actual theatre draping.

ii. Digital modalities

With ever-evolving educational technology, digital simulation solutions have also been commercialised. However, a major limitation to its access is costing. T&O has traditionally been slow to turn to simulation technology compared to other surgical specialities. Options consist of online virtual clinical scenarios that may assess cognitive task analysis for a technical procedure as well as surgical decision-making (Figure 2). Hardware technology has led to the development of simulators using augmented or virtual reality software to simulate operations. With a stake from blue chip companies, holography (Figure 3) in surgery has also become an option to delineate operative steps and visualising abstract concepts in anatomy and physiology. These digital solutions also allows for telepresence where learning can take place in an immersive and interactive virtual setting, regardless of geography and resources for hardware.

Figure 2: Interaction with the virtual patient; here the participant is gathering information from the primary survey.

Figure 3: Holographic images from a lecture in orthopaedic trauma.. The lecturers are featured behind the Pepper’s Ghost foil as if they were next to the holographic images. This positioning also allows for interaction with the dynamic animations to make the learning experience more immersive and interactive.

iii. Hybrid models

There is also scope for introducing hybrid modalities in order to demonstrate training effect, skills decay and the validation of simulation models. An example would be comparing the educational impact of digital simulation against analogue modalities including reading the operation technique (OpTech), and then having trainees' performance assessed when performing the same procedure on a patient under supervision.

iv. Learning theory

Many theories on adult learning have been posed. However, the unifying hypothesis is for simulation to curb the learning curve. There is also evidence suggesting that the first attempt on a simulator ought to be invalid to account for the learning curve of the familiarisation of hardware or software rather than the performance of the simulation task. Cognitive load of learning a new skill can be reduced by isolating and breaking the tasks into manageable chunks. Cognitive task analysis will allow the learner to understand the streams of decision-making required in order to master a new skillset. Furthermore, the popular adage of ‘seeing one, learning one and doing one’ has now been replaced with teaching and doing many with persistent practice. Simulation is only effective if utilised consistently in order to attain a training effect. Infrequent or disrupted utilisation of simulation will lead to skills decay after a ‘wash out’ period. The Dreyfus model outlines stages of competency and proficiency until a master level is achieved [9].

6. Invited validation of national courses (CPD)

The BOA is aware of an increasing number of courses run by institutions that offer simulation training, whether that be for learning and acquiring new technical skills, demonstrating competency to be signed off for Intercollegiate Surgical Curriculum Programme (ISCP) core requirements, or preparing for the specialist exams. Both the vetting and validation processes of any course will be supported with a mission to advance T&O training, skillsets and education by offering CPD points upon application. Any such courses will also be featured in an online rolodex once built.

7. Increasing revenue streams

The BOA is a registered charity and relies on various avenues of income. The additional income will go towards supporting our mission, research and advocacy of our membership with respect to education and training. This proposal, yet to be vetted, aims to introduce further streams of income as follows:

1. Application for CPD points for a course.

2. Introductory commissions between vendors to clients.

3. Encouraging more vendors to attend BOA and BOTA Congresses.

4. Ticket sales from potential Congress dedicated to simulation products –estimated to be held in 2025.

Limitations

This is a preliminary proposal. It has yet to take into account the expert opinions of its representatives and membership. However, this will be an evolving process and our plans have been outlined in the ‘future work’ section. This proposed White Paper has yet to be vetted by EdCar and the BOA as a whole.

Future work

This report will be an evolving body of work that will continuously develop with time and research. Subsequent proposed phases consist of the following:

1. Conducting a national consensus through subspeciality bodies of the BOA to determine the principal objectives and guidance on effective training and the role of simulation. Participants will consist of Consultant trainers as well as Trainee Representatives from undergraduate medicine, Foundation Doctors, Core Trainees and Specialist Trainees. The new evidence will better inform future guidance on simulation-based practice with more consistency in hope of evidence-based standardisation to cater for personalised needs.

2. Expanding categories for the BOA Simulation Award.

3. Collaborating with international orthopaedic professional bodies to increase opportunities for research fellowships.

4. Increasing the number of educational content offerings, including videos on index procedures, screencasts and training videos.

5. Collaborating with industrial partners to validate simulation training programmes.

6. Compiling training toolkits to institutions so that there is a basic level of simulation offered to T&O trainees nationwide which can be incorporated into ISCP work based assessments locally.

7. To foster working relationships with other institutions related and unrelated to orthopaedics for an inter-disciplinary influence to our work. Proposed organisations include the Royal Society of Arts, Science Council, Institute of Science and Technology, Institute of Clinical Research, Institute of Engineering and Technology, AO, SICOT and Royal Society of Public Health, as well as universities.

About BOA Education and Careers Committee (EdCar)

The BOA is the recognised national professional body for all subspecialities under the principal surgical field of trauma and orthopaedics. The EdCar Committee consists of a host of Consultants, Associate Specialists, and Trainee Representatives with a combined experience of simulation methods, training both undergraduates and postgraduates and, stemming from a versatile range of subspecialities.

References

References can be found online at www.boa.ac.uk/publications/JTO.

Kapil Sugand is a Peripheral Nerve & Musculoskeletal Surgery Fellow at the Royal National Orthopaedic Hospital. He is a member of the BOA Education and Careers Committee.

Hiro Tanaka is a Consultant Foot & Ankle Surgeon, Aneurin Bevan Local Health Board. He is the BOA Honorary Secretary, a member of the BOA Education and Careers Committee and co-directs the BOA Future Leaders Programme.