- Email: [email protected]
Accreditation Council on Graduate Medical Education Technical Skills Competency Compliance: Urologic Surgical Skills
EDUCATION
Accreditation Council on Graduate Medical Education Technical Skills Competency Compliance: Urologic Surgical Skills Lara Hammond, MD, Janet Ketchum, CST, Bradley F Schwartz, DO, FACS In accordance with new mandates implemented by the Accreditation Council on Graduate Medical Education, reliance on operative case logs as demonstration of residents’ surgical competence will no longer be adequate. We describe the implementation of a comprehensive, year-round, mandatory skills laboratory curriculum as an integral component of our urology residency training program. STUDY DESIGN: We developed eight laboratory practicums using primarily nonhuman models: basic endoscopy, advanced endoscopy, ureteroscopy, percutaneous renal surgery, basic laparoscopy, advanced laparoscopy, urologic use of the gastrointestinal tract, and cadaveric pelvic dissection. RESULTS: Anonymous evaluations submitted by all training session participants indicate that acquisition of surgical skills is facilitated through participation in laboratory practicums. An incremental progression in proficiency was observed by all of the instructors and students who participated. There was a high degree of satisfaction with model fidelity and the value of technical experience gained. CONCLUSIONS: Our urologic surgery skills laboratory curriculum is an effective means of skills acquisition and maintenance for a wide variety of urologic techniques, including complex endourologic procedures. Patient care can safely be of secondary importance with respect to trainee experience in a low-stress environment that provides an opportunity for supervised repetitive performance of essential technical skills. We describe effective models, with high fidelity-to-cost ratio, that incorporate laboratory-based surgical skills training and evaluation into urology residency programs, with the aim of Accreditation Council on Graduate Medical Education competency guideline compliance. (J Am Coll Surg 2005;201:454–457. © 2005 by the American College of Surgeons) BACKGROUND:
Surgical education is in transition. Introduction of the Accreditation Council on Graduate Medical Education’s (ACGME) competency curriculum and evaluation plan requires residency programs to implement measurable teaching methods in technical skills training.1 Traditional use of operative case logs alone will likely not suffice as demonstration of surgical competence for future generations of surgeons.2 Additionally, operating-room expense and its high-stress environment, increased cost associated with training, and in-
creased complexity of surgical problems requiring expertise are calling into question the efficacy of traditional operating-room-based technical skills training for today’s surgical specialty residents.3–7 Our institution has an established Surgical Skills Training Center with comprehensive technical skills training programs for residents in orthopaedic, plastic, and general surgery, and offering an accredited fellowship training program in surgical education. The Southern Illinois University’s division of urology has recently developed a year-round curriculum of urologic skills training sessions effective in teaching urologic surgical techniques in a low-stress environment, where resident education can appropriately become the sole focus of activity, repetition of tasks is feasible, and documentation of participation and progress in terms of meeting the ACGME’s technical skill competency guidelines are possible. Use of perform-
Competing Interests Declared: None. Received March 9, 2005; Revised April 22, 2005; Accepted May 3, 2005. From the Division of Urology, Southern Illinois University School of Medicine, Springfield, IL. Correspondence address: Bradley F Schwartz, DO, FACS, Center for Laparoscopy and Endourology, Southern Illinois University School of Medicine, PO Box 19665, Springfield, IL 62794-9665.
© 2005 by the American College of Surgeons Published by Elsevier Inc.
454
ISSN 1072-7515/05/$30.00 doi:10.1016/j.jamcollsurg.2005.05.002
Vol. 201, No. 3, September 2005
Hammond et al
ance repetition in acquiring technical proficiency in professional fields as diverse as medicine, sports, aviation, and the arts is unquestioned.3–5,8–10 Indeed, practicing surgeons striving to acquire new technical skills to stay abreast of advances in their field usually begin with laboratory-based training courses. We present our originally designed, low-cost, high-fidelity model for an integrated surgical skills center curriculum for urologic technical skills training.
still pebbles serving as renal and ureteral calculi, and the defect is then sutured closed. Ureteroscopy and stone manipulation techniques are then taught, allowing demonstration of a wide variety of endoscopic techniques, and introduction to a vast array of instrumentation, including many different styles of baskets, wires, stents, and sheaths. All equipment and supplies were donated or borrowed from the operating room. Percutaneous renal surgery is simulated on pig kidneys obtained and prepared as described previously. Each preimplanted kidney is placed inside an eviscerated chicken carcass (using standard supermarket chickens) to simulate the posterior tissue layers of the human. An open-ended ureteral catheter is inserted into the severed end of the ureter, and secured with silk ties. Fluoroscopic retrograde pyelography, through injection of contrast into the ureteral catheter, outlines the collecting system, enabling needle access into the desired calyx. Sequential dilation of the tract facilitates safety wire introduction followed by balloon dilation. Placement of the renal access sheath allows nephroscopy and stone manipulation. Additional training in percutaneous nephrolithotomy with the nephroscope, graspers, and various methods of stone fragmentation follow. Both rigid and flexible nephroscopy with the aid of fluoroscopy are practiced. Although the porcine kidney is smaller than the human kidney, the anatomy is remarkably similar. Thorough flexible and rigid calycoscopy and pelvioscopy is possible. All equipment and supplies were donated, with the exception of two standard supermarket chickens totaling $12. Basic laparoscopic skills are taught using commercially available devices simulating the abdominal compartment into which standard hospital laparoscopic equipment can be inserted to carry out skill-building object retrieval and transfer tasks in a repetitive manner. The laparoscopic trainers are part of our Surgical Skills Training Center’s permanent inventory; similar results can be obtained using large plastic containers available at retail outlets. Advanced laparoscopy includes performance of nephrectomy, nephroureterectomy, and partial nephrectomy in a live porcine animal model. Total laboratory service cost per animal is approximately $300. Cadaveric pelvic dissection features pelvic lymph node dissection, cystectomy, prostatectomy, urethral dissection, artificial urinary sphincter placement, and various sling procedures on fresh-frozen human cadaver parts. Cost per pelvic cadaver is approximately $150. Urologic use of the gastrointestinal tract includes urinary diversion techniques, such as ileal conduit and neobladder creation, performed on live, anesthetized pigs. Alterna-
4.
METHODS Our program consists of eight laboratory practicums using primarily nonhuman models. Six of the sessions require only low-cost retail items and readily available hospital equipment, supplemented with equipment loaned by professional instrument company representatives who, in our experience, are very accommodating toward educational endeavors. The curriculum offers gradated progression throughout the year and within individual sessions, to encompass the needs of residents of all training levels, and provide an opportunity for resident-to-resident teaching. A separate, customized, written syllabus containing learning objectives, procedure descriptions and discussion, diagrams, and references is provided before each practicum, and a concise, high-yield didactic session is held at the beginning of each laboratory. 1. The basic endoscopy training session features instruction in both rigid and flexible cystoscopic skills using inanimate models, such as pumpkins and green peppers. Wire and stent placement with simple object grasping and transfer (such as retrieving paperclips placed inside the vegetable cavity) are repetitively practiced under supervision to ensure correct technique. This practicum also offers an ideal opportunity to demonstrate basic handling and care of endoscopic equipment, thereby helping to prevent costly instrument damage by novices. Standard hospital equipment, donated stents and wires, and supermarket vegetables at a cost of less than $10 were used. 2. Advanced endoscopy focuses on transurethral surgery simulated by use of a porcine liver submerged in irrigant within a cored-out pumpkin. Electrocautery resection using standard transurethral instrumentation is carried out with surprising fidelity using this model. Borrowed and donated equipment leave the cost for this laboratory at $15 for three medium-sized pumpkins. 3. Ureteroscopic techniques are taught with use of porcine cadaver kidneys with intact ureters, donated by a local slaughterhouse. The pelvicalyceal system is incised to in-
5.
6.
7.
8.
ACGME Competency Compliance
455
456
Hammond et al
ACGME Competency Compliance
tively, these procedures can be performed on porcine cadaver organs for essentially no cost.
Preparation time for laboratories 2, 3, and 4 ranged between 15 to 45 minutes, depending on the condition of the organs. RESULTS This surgical skills laboratory training curriculum was quite effective at simulating a wide variety of urologic procedures. The majority of these practicums were simple to set up, extremely low cost, and surprisingly high in fidelity, considering the use of “homemade” models constructed from readily available retail items. The sessions provided a rare chance for educators to concentrate on observation, instruction, evaluation, and documentation of trainee technique. Forms documenting satisfactory demonstration of operative technique, broken down into key tasks, by the end of each session were completed for each individual trainee by attending staff (Fig. 1). Anonymous evaluation forms submitted by all training session participants revealed a high degree of satisfaction with this model effectiveness in the application of urologic techniques. All participants rated the laboratory practicums as a valuable adjunct to intraoperative experience, worthwhile in furthering their comfort level with the equipment and techniques described and unique in providing an opportunity to practice technical skills repeatedly under faculty guidance without having the “case taken away from them.” It was also noted that these activities provided an opportunity to take extra time for greater familiarization with the wide variety of urologic instrumentation, and for comparison of different funds of knowledge, with several faculty members simultaneously presiding over practical training, which happens rarely in the operative setting. DISCUSSION We have now entered phase 2 of the ACGME’s timeline for implementation of their new Competencies in Resident’s Education. This 4-year phase spans July 2002 to June 2006, during which residency training programs are charged with devising systems to provide evidence of learning in the core competencies as defined by the ACGME’s Outcomes Assessment Project Advisory Group and a similar task force from the American Board of Surgery.1 Development of our structured urologic surgical skills training curriculum
J Am Coll Surg
provides a system to document resident technical competency in a formal, standardized construct. The experience in the training laboratory also provides important adjunctive training in resident surgical education in terms of reducing the learning curve for the acquisition of technical skills in a controlled environment that allows repetition of tasks or even portions of tasks, and a venue for hands-on training during which patient care can safely be removed as a consideration with respect to trainee experience.8–11 The ability to tailor the lesson to the needs of the individual student is an educational advantage not available in the operating-room setting.4 The low-stress environment of the skills laboratory also provides a unique opportunity for group technical training and rapport-building with multiple residents and attending staff in a collegial atmosphere.5 Many professions rely on the concept of using skill repetition in a nonthreatening environment to minimize performance error and maximize performance quality. Military and commercial aviation training programs use complex flight simulators to reproduce both routine and emergency contingencies on an ongoing basis to adequately prepare pilots for workplace competency. The cornerstone of training competitive athletes, musicians, and actors is exhaustive repetition in a practice setting under expert supervision to foster proficiency in performance of optimal technique.2–4 This curriculum represents a comprehensive program that provides compliance with ACGME guidelines for our residency program, and an enriching technical educational program with unique features not available to traditional training programs that rely solely on intraoperative experience for surgical skills education. In conclusion, surgical skills training centers represent the wave of the future for technical skills training in all surgical specialties as residency programs devise strategies to comply with new regulations for accreditation, and adjust to changing hospital inpatient populations and modern operating-room systems. Laboratory practicums provide a structured, standardized system of teaching and documenting competency in core urologic surgical techniques. They also allow a relaxed learning environment where education can be the focus of hands-on technical skill training, and the opportunity for supervised repetitive performance, of the utmost importance to the mastery of technical skill. Our originally designed
Vol. 201, No. 3, September 2005
Hammond et al
ACGME Competency Compliance
457
Figure 1. Example of evaluation instrument for the ureteroscopy laboratory module.
urologic surgical skills laboratory curriculum is the first of its kind to our knowledge, and might serve well as a template for other urology programs planning to incorporate laboratory-based training and evaluation of technical skills into their residency training programs. REFERENCES 1. Dunnington GL, Williams RG. Addressing the new competencies for residents’ surgical training. Acad Med 2003;78: 14–21. 2. Miller DC, Montie JE, Faerber GJ. Evaluating the Accreditation Council on Graduate Medical Education core clinical competencies: techniques and feasibility in a urology training program. J Urol 2003;170:1312⫺1317. 3. Edison MI, Horgan S, Helton WS. Using small-group workshops to improve surgical residents’ technical skills. Acad Med 2001;76:557–558. 4. Haluck RS, Krummel TM. Computers and virtual reality for
5. 6. 7.
8. 9. 10. 11.
surgical education in the 21st century. Arch Surg 2001;135:786–792. Gawande AA. Creating the educated surgeon in the 21st century. Am J Surg 2001;181:551–556. Anastakis DJ, Wanzel KR, Brown MH, et al. Evaluating the effectiveness of a 2-year curriculum in a surgical skills center. Am J Surg 2003;185:378–385. Wanzel KR, Matsumoto ED, Hamstra SJ, Anastakis DJ. Teaching technical skills: training on a simple, inexpensive, and portable model. Plast Reconstr Surg 2002;109: 258–263. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD. A novel approach to endourological training: training at the Surgical Skills Center. J Urol 2001;166:1261–1266. Powers TW, Murayama KM, Toyama M, et al. Housestaff performance is improved by participation in a laparoscopic skills curriculum. Am J Surg 2002;184:626–630. Coleman RL, Muller CY. Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial. Am J Obstet Gynecol 2002;186:836–842. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance. Ann Surg 2002;236:458–464.
Accreditation Council on Graduate Medical Education Technical Skills Competency Compliance: Urologic Surgical Skills Lara Hammond, MD, Janet Ketchum, CST, Bradley F Schwartz, DO, FACS In accordance with new mandates implemented by the Accreditation Council on Graduate Medical Education, reliance on operative case logs as demonstration of residents’ surgical competence will no longer be adequate. We describe the implementation of a comprehensive, year-round, mandatory skills laboratory curriculum as an integral component of our urology residency training program. STUDY DESIGN: We developed eight laboratory practicums using primarily nonhuman models: basic endoscopy, advanced endoscopy, ureteroscopy, percutaneous renal surgery, basic laparoscopy, advanced laparoscopy, urologic use of the gastrointestinal tract, and cadaveric pelvic dissection. RESULTS: Anonymous evaluations submitted by all training session participants indicate that acquisition of surgical skills is facilitated through participation in laboratory practicums. An incremental progression in proficiency was observed by all of the instructors and students who participated. There was a high degree of satisfaction with model fidelity and the value of technical experience gained. CONCLUSIONS: Our urologic surgery skills laboratory curriculum is an effective means of skills acquisition and maintenance for a wide variety of urologic techniques, including complex endourologic procedures. Patient care can safely be of secondary importance with respect to trainee experience in a low-stress environment that provides an opportunity for supervised repetitive performance of essential technical skills. We describe effective models, with high fidelity-to-cost ratio, that incorporate laboratory-based surgical skills training and evaluation into urology residency programs, with the aim of Accreditation Council on Graduate Medical Education competency guideline compliance. (J Am Coll Surg 2005;201:454–457. © 2005 by the American College of Surgeons) BACKGROUND:
Surgical education is in transition. Introduction of the Accreditation Council on Graduate Medical Education’s (ACGME) competency curriculum and evaluation plan requires residency programs to implement measurable teaching methods in technical skills training.1 Traditional use of operative case logs alone will likely not suffice as demonstration of surgical competence for future generations of surgeons.2 Additionally, operating-room expense and its high-stress environment, increased cost associated with training, and in-
creased complexity of surgical problems requiring expertise are calling into question the efficacy of traditional operating-room-based technical skills training for today’s surgical specialty residents.3–7 Our institution has an established Surgical Skills Training Center with comprehensive technical skills training programs for residents in orthopaedic, plastic, and general surgery, and offering an accredited fellowship training program in surgical education. The Southern Illinois University’s division of urology has recently developed a year-round curriculum of urologic skills training sessions effective in teaching urologic surgical techniques in a low-stress environment, where resident education can appropriately become the sole focus of activity, repetition of tasks is feasible, and documentation of participation and progress in terms of meeting the ACGME’s technical skill competency guidelines are possible. Use of perform-
Competing Interests Declared: None. Received March 9, 2005; Revised April 22, 2005; Accepted May 3, 2005. From the Division of Urology, Southern Illinois University School of Medicine, Springfield, IL. Correspondence address: Bradley F Schwartz, DO, FACS, Center for Laparoscopy and Endourology, Southern Illinois University School of Medicine, PO Box 19665, Springfield, IL 62794-9665.
© 2005 by the American College of Surgeons Published by Elsevier Inc.
454
ISSN 1072-7515/05/$30.00 doi:10.1016/j.jamcollsurg.2005.05.002
Vol. 201, No. 3, September 2005
Hammond et al
ance repetition in acquiring technical proficiency in professional fields as diverse as medicine, sports, aviation, and the arts is unquestioned.3–5,8–10 Indeed, practicing surgeons striving to acquire new technical skills to stay abreast of advances in their field usually begin with laboratory-based training courses. We present our originally designed, low-cost, high-fidelity model for an integrated surgical skills center curriculum for urologic technical skills training.
still pebbles serving as renal and ureteral calculi, and the defect is then sutured closed. Ureteroscopy and stone manipulation techniques are then taught, allowing demonstration of a wide variety of endoscopic techniques, and introduction to a vast array of instrumentation, including many different styles of baskets, wires, stents, and sheaths. All equipment and supplies were donated or borrowed from the operating room. Percutaneous renal surgery is simulated on pig kidneys obtained and prepared as described previously. Each preimplanted kidney is placed inside an eviscerated chicken carcass (using standard supermarket chickens) to simulate the posterior tissue layers of the human. An open-ended ureteral catheter is inserted into the severed end of the ureter, and secured with silk ties. Fluoroscopic retrograde pyelography, through injection of contrast into the ureteral catheter, outlines the collecting system, enabling needle access into the desired calyx. Sequential dilation of the tract facilitates safety wire introduction followed by balloon dilation. Placement of the renal access sheath allows nephroscopy and stone manipulation. Additional training in percutaneous nephrolithotomy with the nephroscope, graspers, and various methods of stone fragmentation follow. Both rigid and flexible nephroscopy with the aid of fluoroscopy are practiced. Although the porcine kidney is smaller than the human kidney, the anatomy is remarkably similar. Thorough flexible and rigid calycoscopy and pelvioscopy is possible. All equipment and supplies were donated, with the exception of two standard supermarket chickens totaling $12. Basic laparoscopic skills are taught using commercially available devices simulating the abdominal compartment into which standard hospital laparoscopic equipment can be inserted to carry out skill-building object retrieval and transfer tasks in a repetitive manner. The laparoscopic trainers are part of our Surgical Skills Training Center’s permanent inventory; similar results can be obtained using large plastic containers available at retail outlets. Advanced laparoscopy includes performance of nephrectomy, nephroureterectomy, and partial nephrectomy in a live porcine animal model. Total laboratory service cost per animal is approximately $300. Cadaveric pelvic dissection features pelvic lymph node dissection, cystectomy, prostatectomy, urethral dissection, artificial urinary sphincter placement, and various sling procedures on fresh-frozen human cadaver parts. Cost per pelvic cadaver is approximately $150. Urologic use of the gastrointestinal tract includes urinary diversion techniques, such as ileal conduit and neobladder creation, performed on live, anesthetized pigs. Alterna-
4.
METHODS Our program consists of eight laboratory practicums using primarily nonhuman models. Six of the sessions require only low-cost retail items and readily available hospital equipment, supplemented with equipment loaned by professional instrument company representatives who, in our experience, are very accommodating toward educational endeavors. The curriculum offers gradated progression throughout the year and within individual sessions, to encompass the needs of residents of all training levels, and provide an opportunity for resident-to-resident teaching. A separate, customized, written syllabus containing learning objectives, procedure descriptions and discussion, diagrams, and references is provided before each practicum, and a concise, high-yield didactic session is held at the beginning of each laboratory. 1. The basic endoscopy training session features instruction in both rigid and flexible cystoscopic skills using inanimate models, such as pumpkins and green peppers. Wire and stent placement with simple object grasping and transfer (such as retrieving paperclips placed inside the vegetable cavity) are repetitively practiced under supervision to ensure correct technique. This practicum also offers an ideal opportunity to demonstrate basic handling and care of endoscopic equipment, thereby helping to prevent costly instrument damage by novices. Standard hospital equipment, donated stents and wires, and supermarket vegetables at a cost of less than $10 were used. 2. Advanced endoscopy focuses on transurethral surgery simulated by use of a porcine liver submerged in irrigant within a cored-out pumpkin. Electrocautery resection using standard transurethral instrumentation is carried out with surprising fidelity using this model. Borrowed and donated equipment leave the cost for this laboratory at $15 for three medium-sized pumpkins. 3. Ureteroscopic techniques are taught with use of porcine cadaver kidneys with intact ureters, donated by a local slaughterhouse. The pelvicalyceal system is incised to in-
5.
6.
7.
8.
ACGME Competency Compliance
455
456
Hammond et al
ACGME Competency Compliance
tively, these procedures can be performed on porcine cadaver organs for essentially no cost.
Preparation time for laboratories 2, 3, and 4 ranged between 15 to 45 minutes, depending on the condition of the organs. RESULTS This surgical skills laboratory training curriculum was quite effective at simulating a wide variety of urologic procedures. The majority of these practicums were simple to set up, extremely low cost, and surprisingly high in fidelity, considering the use of “homemade” models constructed from readily available retail items. The sessions provided a rare chance for educators to concentrate on observation, instruction, evaluation, and documentation of trainee technique. Forms documenting satisfactory demonstration of operative technique, broken down into key tasks, by the end of each session were completed for each individual trainee by attending staff (Fig. 1). Anonymous evaluation forms submitted by all training session participants revealed a high degree of satisfaction with this model effectiveness in the application of urologic techniques. All participants rated the laboratory practicums as a valuable adjunct to intraoperative experience, worthwhile in furthering their comfort level with the equipment and techniques described and unique in providing an opportunity to practice technical skills repeatedly under faculty guidance without having the “case taken away from them.” It was also noted that these activities provided an opportunity to take extra time for greater familiarization with the wide variety of urologic instrumentation, and for comparison of different funds of knowledge, with several faculty members simultaneously presiding over practical training, which happens rarely in the operative setting. DISCUSSION We have now entered phase 2 of the ACGME’s timeline for implementation of their new Competencies in Resident’s Education. This 4-year phase spans July 2002 to June 2006, during which residency training programs are charged with devising systems to provide evidence of learning in the core competencies as defined by the ACGME’s Outcomes Assessment Project Advisory Group and a similar task force from the American Board of Surgery.1 Development of our structured urologic surgical skills training curriculum
J Am Coll Surg
provides a system to document resident technical competency in a formal, standardized construct. The experience in the training laboratory also provides important adjunctive training in resident surgical education in terms of reducing the learning curve for the acquisition of technical skills in a controlled environment that allows repetition of tasks or even portions of tasks, and a venue for hands-on training during which patient care can safely be removed as a consideration with respect to trainee experience.8–11 The ability to tailor the lesson to the needs of the individual student is an educational advantage not available in the operating-room setting.4 The low-stress environment of the skills laboratory also provides a unique opportunity for group technical training and rapport-building with multiple residents and attending staff in a collegial atmosphere.5 Many professions rely on the concept of using skill repetition in a nonthreatening environment to minimize performance error and maximize performance quality. Military and commercial aviation training programs use complex flight simulators to reproduce both routine and emergency contingencies on an ongoing basis to adequately prepare pilots for workplace competency. The cornerstone of training competitive athletes, musicians, and actors is exhaustive repetition in a practice setting under expert supervision to foster proficiency in performance of optimal technique.2–4 This curriculum represents a comprehensive program that provides compliance with ACGME guidelines for our residency program, and an enriching technical educational program with unique features not available to traditional training programs that rely solely on intraoperative experience for surgical skills education. In conclusion, surgical skills training centers represent the wave of the future for technical skills training in all surgical specialties as residency programs devise strategies to comply with new regulations for accreditation, and adjust to changing hospital inpatient populations and modern operating-room systems. Laboratory practicums provide a structured, standardized system of teaching and documenting competency in core urologic surgical techniques. They also allow a relaxed learning environment where education can be the focus of hands-on technical skill training, and the opportunity for supervised repetitive performance, of the utmost importance to the mastery of technical skill. Our originally designed
Vol. 201, No. 3, September 2005
Hammond et al
ACGME Competency Compliance
457
Figure 1. Example of evaluation instrument for the ureteroscopy laboratory module.
urologic surgical skills laboratory curriculum is the first of its kind to our knowledge, and might serve well as a template for other urology programs planning to incorporate laboratory-based training and evaluation of technical skills into their residency training programs. REFERENCES 1. Dunnington GL, Williams RG. Addressing the new competencies for residents’ surgical training. Acad Med 2003;78: 14–21. 2. Miller DC, Montie JE, Faerber GJ. Evaluating the Accreditation Council on Graduate Medical Education core clinical competencies: techniques and feasibility in a urology training program. J Urol 2003;170:1312⫺1317. 3. Edison MI, Horgan S, Helton WS. Using small-group workshops to improve surgical residents’ technical skills. Acad Med 2001;76:557–558. 4. Haluck RS, Krummel TM. Computers and virtual reality for
5. 6. 7.
8. 9. 10. 11.
surgical education in the 21st century. Arch Surg 2001;135:786–792. Gawande AA. Creating the educated surgeon in the 21st century. Am J Surg 2001;181:551–556. Anastakis DJ, Wanzel KR, Brown MH, et al. Evaluating the effectiveness of a 2-year curriculum in a surgical skills center. Am J Surg 2003;185:378–385. Wanzel KR, Matsumoto ED, Hamstra SJ, Anastakis DJ. Teaching technical skills: training on a simple, inexpensive, and portable model. Plast Reconstr Surg 2002;109: 258–263. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD. A novel approach to endourological training: training at the Surgical Skills Center. J Urol 2001;166:1261–1266. Powers TW, Murayama KM, Toyama M, et al. Housestaff performance is improved by participation in a laparoscopic skills curriculum. Am J Surg 2002;184:626–630. Coleman RL, Muller CY. Effects of a laboratory-based skills curriculum on laparoscopic proficiency: a randomized trial. Am J Obstet Gynecol 2002;186:836–842. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance. Ann Surg 2002;236:458–464.