Alice in Simulation-Land: Surgical Simulation in Medical Education

Introduction

For decades, surgical education was modeled after Halsted who felt residents should live in the hospital and care for patients in a longitudinal manner to understand the natural history of disease with and without surgery (Polavarapu, Kulaylat, Sun, & Hamed, 2013). Unfortunately, this approach resulted in a workload which usually totaled 100-120 hours per week or more (Hutter, Kellogg, Ferguson, Abbott, & Warshaw, 2006). The Accreditation Council for Graduate Medical Education Residency Review Committee (ACGME RRC) determined that an 80-hour work week is more conducive to learning and a healthy lifestyle (Philibert, Friedmann, Williams, & ACGME Work Group on Resident Duty Hours, 2002). All surgical residents are now restricted to “duty hour” regulation renamed “clinical work hours” in 2017 (Table 1). Despite efforts to achieve improved life balance and patient safety, the 80-hour cap on resident work is estimated to decrease caseload by 28% in year one and 36% in year two of residency (Kamine, Gondek, & Kent, 2014). The influential paper “Why Johnny cannot operate” asked 114 residency program directors what operations graduating general surgery residents should be able to competently perform. The 121 procedures deemed essential by residency program directors were ranked by frequency performed and revealed an exponential decrease with nearly one-quarter of procedures never performed by graduating chief residents (Bell, 2009). Likewise, more than 20% of general surgery residents lack confidence in their surgical skills (Coleman, Esposito, Rozycki, & Feliciano, 2013). Trends toward integrated residencies compressing traditional general surgery (5-6 years) plus fellowships (1-3 years) into 6-year comprehensive programs has compounded the problem of potential gaps in resident experience and progression (Grant, Dixon, Glass, & Sakran, 2013). Many have observed that surgeons are less practice-ready and have achieved less graduated responsibility following completion of residency. Widespread concern for preparedness of general surgery residents to enter private practice or fellowship is shared by both fellowship directors and surgery residents (Matter et al., 2013).