- Email: [email protected]
Duke Surgical Education and Activities Laboratory and Comprehensive Education Institute
EDUCATION INSTITUTES
Duke Surgical Education and Activities Laboratory and Comprehensive Education Institute Marnelle Alexis, Ed.D., Bryan Clary, MD, Danny O Jacobs, MD, Aurora Pryor, MD Duke University Medical Center, Durham, North Carolina OVERVIEW OF THE INSTITUTE Purpose Duke University’s Department of Surgery responded to the need to enhance learner training when it created the Surgical Education and Activities Laboratory (SEAL) which forms the core of the Duke Comprehensive Education Institute (CEI). The mission of the Duke SEAL is to develop and validate a system for the optimal training in skills and techniques increasingly needed for the practice of modern, minimally invasive surgery. We train learners of all levels and across disciplines to optimize patient care and safety. The Duke SEAL uses virtual reality, computer-based learning, and other simulation techniques for training, patient safety improvement, certification of competence, increased operating room proficiency, applied research on surgical simulators, equipment, instruments or techniques, and education research on surgery. Among the educational research applications are investigations into skills acquisition, certification of competence, shortening the learning curve, and crisis management by multidisciplinary teams in the operating room, intensive care unit, or emergency room. Utilizing various techniques, we provide state-of-the-art instruction for many different types of learners. Learners who use SEAL benefit from round-the-clock access to minimally invasive laparoscopic surgical simulators; virtual reality laparoscopic surgical simulators, and endoscopy simulators for practicing flexible bronchoscopy as well as upper and lower gastrointestinal (GI) flexible endoscopy. Location SEAL is connected to the University computer network backbone providing extremely fast ethernet connectivity between applications and servers. There is a separate fiber line connecting the SimSuite network of 2 simulators and 8 pre/post test Correspondence: Inquiries to Marnelle Alexis, Ed.D., Duke University Medical Center, Duke South, Blue Zone, Room 3581, Durham, NC 27710; e-mail: marnelle.alexis@ duke.edu
338
workstations that allow remote control and monitoring. Three Clinical Patient Information Network (PIN) stations are strategically located in 2 areas of the SEAL to provide users with the ability to monitor clinical activities during their simulation training. There are 4 Windows XP workstations installed to provide customized training applications for fundamentals of laparoscopic surgery (FLS) modulation. The primary tasks of the SEAL are training, patient safety, and acquisition of new surgical techniques. These functions entail the development and certification of procedural competence. Validation of these techniques may minimize the use of animals in education and revolutionize surgical training. Duke University Medical School is located in Durham, North Carolina. The Duke SEAL suite is stationed in Duke South on the third floor, White Zone, in room 3570. The Surgical Education and Activities Laboratory is approximately 2000 square feet of state-of-the-art simulation, computing technology, and conference room space. Strengths The Duke Surgical Education and Activities Laboratory has much strength, which stems from Duke’s passion to educate and improve the quality of practicing physicians. The SEAL curriculum is 1 strong point. To effectively address the educational needs of the various learner groups, we have developed written curricula that are reviewed by expert faculty, program directors, and selected learners. Many of the established components of the SEAL curriculum from knot-tying and suturing to airway management and vascular anastomosis have been shaped by the ACS/APDS Surgical Skills Curriculum for Residents. Laboratory access and availability is another 1 of SEAL’s strengths. Because the laboratory is open 24 hours a day, learners are able to practice as much as they need to at the times that suit them best. Lastly, the SEAL contains cutting edge virtual reality and simulation equipment. With the use of Stryker Box Trainers, Immersion Lap VRs and Endoscopy simulators, METI Simulators as well as the SimSuite SimMan and Simantha, and Laerdal SimBaby, the Surgical Education and Activi-
Journal of Surgical Education • © 2010 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/$30.00 doi:10.1016/j.jsurg.2010.05.021
ties Laboratory is well-equipped to give its learners top-of-theline training.
LEARNERS TARGETED Our Surgical Education and Activities Laboratory (SEAL) is designed to provide a comprehensive learning environment that can meet the needs of learners who are at different levels and represent various disciplines. We have already successfully trained attending physicians, surgical residents, fellows, medical students, and surgical physician assistants. In addition to surgery, we have learners from internal medicine, emergency medicine, and family practice. This year we continue to make advances and have increased our learner pool by adding undergraduate physician assistants, nurses, and industry staff to our roster of learners. Of special note, we have recently contracted with the North Carolina State Veterinary School (at North Carolina State University) to provide their second year veterinary residents with basic laparoscopic skills training in the SEAL. Description of Courses and How Often the Courses Are Offered In the Duke SEAL we have standard simulation courses and certifications such as the Fundamentals of Laparoscopic Surgery (FLS) or ACLS and we have also developed a host of unique courses and training modules to meet the needs of our varied learners. For OHNS residents we created the SIM-MAN Airway Simulation training module designed to effectively teach and assess tech-
FIGURE 1. Medical students practicing on Immersion Endoscopy simulators.
FIGURE 2. Surgical physician assistant practicing Peg Transfer on Stryker Endoscopy Box Trainer.
nical skills aspects related to OHNS emergent airway management and endoscopic techniques involved in bronchoscopic and flexible esophagoscopy. Trainees are oriented to the material and self practice until proficient performance levels are reached. The Fundamentals of Endoscopic Vessel Harvesting (FEVH) training module for our Surgical Physician Assistants is designed to effectively teach and assess technical skill aspects related to endoscopically harvesting the greater saphenous vein which can then be used as a conduit for coronary artery bypass grafting (CABG). Trainees are oriented to the materials and self practice until expert derived performance levels are reached. The Patient Safety In Multidisciplinary Team Coordination Training Course was designed to provide residents, nurses, and physician’s assistants from Duke with training in team coordination in order to improve patient safety and teamwork. Using TEAMSTEPS as a basis for the course, trainees complete a didactic component followed by simulation exercises and a debriefing. Intern Boot Camp is a 1-day course designed to assess the cognitive and manual skills acquisition of our general surgery first year interns and to standardize their level of preparedness for surgery. Learners are exposed to a didactic session consisting of related topics proctored by general surgery attending physicians and advanced residents. These topics include operating room basics, equipment, and patient care essentials. Learners then practice PEG transfer, camera driving, and knot-tying skills.
Journal of Surgical Education • Volume 67/Number 5 • September/October 2010
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ProMIS laparoscopy simulator, 2 AccuTouch Endoscopy Simulators to teach EGD, ERCP, colonoscopy, and flex bronchoscopy skills, 2 Lap VR Trainers to teach laparoscopic surgery skills, and the SIMSUITE SimMan, Simantha, and SimBaby Simulators to teach pediatric procedures, code scenarios, ATLS, and endovascular skills. Unique Teaching or Learning Methods Employed
FIGURE 3. Surgical resident performing work-up on Standardized Patient.
Our Standardized Patient program involves the use of standardized patients to increase learner education, training, and assessment of surgical knowledge and skills. The course enhances resident communication skills by providing structured evaluations of interactions with patients and it more directly measures performance in Accreditation Council for Graduate Medical Education (ACGME) core competencies to improve resident proficiency. Learners participate in a full day simulation experience using clinical cases, trained standardized patients, simulators in the SEAL, and real patients from the Duke Patient Advocacy Council Members committee. NSCU Veterinary Simulator Training was designed to give veterinary students useful skills to better their performance in animal surgery. This course consists of a didactic component in which the learners are introduced to simulation. Next the learners use the FLS Stryker Box trainers for pattern cutting and PEG transfer with suturing and endoloop being optional. The learners then gain camera driving skills on the METI simulator. Lastly the learners use the Lap VR for the basic skills of PEG transfer, pattern cutting, and camera driving, as well as the skills of running the bowel and lysis of adhesions.
SPECIAL FEATURES Equipment The Surgical Education and Activities Laboratory currently features 5 Stryker Endoscopy Box Trainers to teach laparoscopic surgery skills, 2 METI Simulators to teach laparoscopic skills, a
340
The curriculum of the SEAL is integrated with the overall resident curriculum. The SEAL supplements the didactic curriculum content and prepares the residents for clinical skills required on the ward and in the operating room or emergency department. A web-based version of the didactic content complements lectures and incorporates objectives and a post test. Topics for minimally invasive surgery didactics are included in the lecture series and online curriculum in addition to the skills addressed in the laboratory. This assures a fundamental knowledge base for all learners. SEAL has carefully designed a unique curriculum that will allow for the long term follow-up of learners, especially general surgery residents. The structure of courses within the curriculum are both incremental and progressive, building upon knowledge and skills learned in prior courses and at varying resident levels from interns to chief years. We have implemented a form of learner’s progress that informs both the learner and evaluator where an individual learner is at a given point in time. Through the use of paper and electronic records learners may store and review copies of results of laboratory experiences including simulation assessment print outs. We have also established a checklist that tells the learner and evaluator at what level they should be—this allows close monitoring of actual progress against targets, allowing evaluators to identify potential problems of learners at interim times rather than at final completion when it would be too late to take corrective action. Whereas most course modules will not lead to a nationally recognized qualification, there is at least 1 verification of proficiency that is obtained via long term learning which also serves as a prerequisite to progressing to the next level, and that is the successful completion and passing of the cognitive and manual skills portion of Fundamentals of Laparoscopic Surgery (FLS). The SEAL is of great value to individuals and groups within and external to Duke as we provide enhanced skills-based and cognitive training to learners of all expertise and across multiple disciplines, and as we contribute to the science of the use of simulation as educational tools. Figs 1-3.
Journal of Surgical Education • Volume 67/Number 5 • September/October 2010
Duke Surgical Education and Activities Laboratory and Comprehensive Education Institute Marnelle Alexis, Ed.D., Bryan Clary, MD, Danny O Jacobs, MD, Aurora Pryor, MD Duke University Medical Center, Durham, North Carolina OVERVIEW OF THE INSTITUTE Purpose Duke University’s Department of Surgery responded to the need to enhance learner training when it created the Surgical Education and Activities Laboratory (SEAL) which forms the core of the Duke Comprehensive Education Institute (CEI). The mission of the Duke SEAL is to develop and validate a system for the optimal training in skills and techniques increasingly needed for the practice of modern, minimally invasive surgery. We train learners of all levels and across disciplines to optimize patient care and safety. The Duke SEAL uses virtual reality, computer-based learning, and other simulation techniques for training, patient safety improvement, certification of competence, increased operating room proficiency, applied research on surgical simulators, equipment, instruments or techniques, and education research on surgery. Among the educational research applications are investigations into skills acquisition, certification of competence, shortening the learning curve, and crisis management by multidisciplinary teams in the operating room, intensive care unit, or emergency room. Utilizing various techniques, we provide state-of-the-art instruction for many different types of learners. Learners who use SEAL benefit from round-the-clock access to minimally invasive laparoscopic surgical simulators; virtual reality laparoscopic surgical simulators, and endoscopy simulators for practicing flexible bronchoscopy as well as upper and lower gastrointestinal (GI) flexible endoscopy. Location SEAL is connected to the University computer network backbone providing extremely fast ethernet connectivity between applications and servers. There is a separate fiber line connecting the SimSuite network of 2 simulators and 8 pre/post test Correspondence: Inquiries to Marnelle Alexis, Ed.D., Duke University Medical Center, Duke South, Blue Zone, Room 3581, Durham, NC 27710; e-mail: marnelle.alexis@ duke.edu
338
workstations that allow remote control and monitoring. Three Clinical Patient Information Network (PIN) stations are strategically located in 2 areas of the SEAL to provide users with the ability to monitor clinical activities during their simulation training. There are 4 Windows XP workstations installed to provide customized training applications for fundamentals of laparoscopic surgery (FLS) modulation. The primary tasks of the SEAL are training, patient safety, and acquisition of new surgical techniques. These functions entail the development and certification of procedural competence. Validation of these techniques may minimize the use of animals in education and revolutionize surgical training. Duke University Medical School is located in Durham, North Carolina. The Duke SEAL suite is stationed in Duke South on the third floor, White Zone, in room 3570. The Surgical Education and Activities Laboratory is approximately 2000 square feet of state-of-the-art simulation, computing technology, and conference room space. Strengths The Duke Surgical Education and Activities Laboratory has much strength, which stems from Duke’s passion to educate and improve the quality of practicing physicians. The SEAL curriculum is 1 strong point. To effectively address the educational needs of the various learner groups, we have developed written curricula that are reviewed by expert faculty, program directors, and selected learners. Many of the established components of the SEAL curriculum from knot-tying and suturing to airway management and vascular anastomosis have been shaped by the ACS/APDS Surgical Skills Curriculum for Residents. Laboratory access and availability is another 1 of SEAL’s strengths. Because the laboratory is open 24 hours a day, learners are able to practice as much as they need to at the times that suit them best. Lastly, the SEAL contains cutting edge virtual reality and simulation equipment. With the use of Stryker Box Trainers, Immersion Lap VRs and Endoscopy simulators, METI Simulators as well as the SimSuite SimMan and Simantha, and Laerdal SimBaby, the Surgical Education and Activi-
Journal of Surgical Education • © 2010 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/$30.00 doi:10.1016/j.jsurg.2010.05.021
ties Laboratory is well-equipped to give its learners top-of-theline training.
LEARNERS TARGETED Our Surgical Education and Activities Laboratory (SEAL) is designed to provide a comprehensive learning environment that can meet the needs of learners who are at different levels and represent various disciplines. We have already successfully trained attending physicians, surgical residents, fellows, medical students, and surgical physician assistants. In addition to surgery, we have learners from internal medicine, emergency medicine, and family practice. This year we continue to make advances and have increased our learner pool by adding undergraduate physician assistants, nurses, and industry staff to our roster of learners. Of special note, we have recently contracted with the North Carolina State Veterinary School (at North Carolina State University) to provide their second year veterinary residents with basic laparoscopic skills training in the SEAL. Description of Courses and How Often the Courses Are Offered In the Duke SEAL we have standard simulation courses and certifications such as the Fundamentals of Laparoscopic Surgery (FLS) or ACLS and we have also developed a host of unique courses and training modules to meet the needs of our varied learners. For OHNS residents we created the SIM-MAN Airway Simulation training module designed to effectively teach and assess tech-
FIGURE 1. Medical students practicing on Immersion Endoscopy simulators.
FIGURE 2. Surgical physician assistant practicing Peg Transfer on Stryker Endoscopy Box Trainer.
nical skills aspects related to OHNS emergent airway management and endoscopic techniques involved in bronchoscopic and flexible esophagoscopy. Trainees are oriented to the material and self practice until proficient performance levels are reached. The Fundamentals of Endoscopic Vessel Harvesting (FEVH) training module for our Surgical Physician Assistants is designed to effectively teach and assess technical skill aspects related to endoscopically harvesting the greater saphenous vein which can then be used as a conduit for coronary artery bypass grafting (CABG). Trainees are oriented to the materials and self practice until expert derived performance levels are reached. The Patient Safety In Multidisciplinary Team Coordination Training Course was designed to provide residents, nurses, and physician’s assistants from Duke with training in team coordination in order to improve patient safety and teamwork. Using TEAMSTEPS as a basis for the course, trainees complete a didactic component followed by simulation exercises and a debriefing. Intern Boot Camp is a 1-day course designed to assess the cognitive and manual skills acquisition of our general surgery first year interns and to standardize their level of preparedness for surgery. Learners are exposed to a didactic session consisting of related topics proctored by general surgery attending physicians and advanced residents. These topics include operating room basics, equipment, and patient care essentials. Learners then practice PEG transfer, camera driving, and knot-tying skills.
Journal of Surgical Education • Volume 67/Number 5 • September/October 2010
339
ProMIS laparoscopy simulator, 2 AccuTouch Endoscopy Simulators to teach EGD, ERCP, colonoscopy, and flex bronchoscopy skills, 2 Lap VR Trainers to teach laparoscopic surgery skills, and the SIMSUITE SimMan, Simantha, and SimBaby Simulators to teach pediatric procedures, code scenarios, ATLS, and endovascular skills. Unique Teaching or Learning Methods Employed
FIGURE 3. Surgical resident performing work-up on Standardized Patient.
Our Standardized Patient program involves the use of standardized patients to increase learner education, training, and assessment of surgical knowledge and skills. The course enhances resident communication skills by providing structured evaluations of interactions with patients and it more directly measures performance in Accreditation Council for Graduate Medical Education (ACGME) core competencies to improve resident proficiency. Learners participate in a full day simulation experience using clinical cases, trained standardized patients, simulators in the SEAL, and real patients from the Duke Patient Advocacy Council Members committee. NSCU Veterinary Simulator Training was designed to give veterinary students useful skills to better their performance in animal surgery. This course consists of a didactic component in which the learners are introduced to simulation. Next the learners use the FLS Stryker Box trainers for pattern cutting and PEG transfer with suturing and endoloop being optional. The learners then gain camera driving skills on the METI simulator. Lastly the learners use the Lap VR for the basic skills of PEG transfer, pattern cutting, and camera driving, as well as the skills of running the bowel and lysis of adhesions.
SPECIAL FEATURES Equipment The Surgical Education and Activities Laboratory currently features 5 Stryker Endoscopy Box Trainers to teach laparoscopic surgery skills, 2 METI Simulators to teach laparoscopic skills, a
340
The curriculum of the SEAL is integrated with the overall resident curriculum. The SEAL supplements the didactic curriculum content and prepares the residents for clinical skills required on the ward and in the operating room or emergency department. A web-based version of the didactic content complements lectures and incorporates objectives and a post test. Topics for minimally invasive surgery didactics are included in the lecture series and online curriculum in addition to the skills addressed in the laboratory. This assures a fundamental knowledge base for all learners. SEAL has carefully designed a unique curriculum that will allow for the long term follow-up of learners, especially general surgery residents. The structure of courses within the curriculum are both incremental and progressive, building upon knowledge and skills learned in prior courses and at varying resident levels from interns to chief years. We have implemented a form of learner’s progress that informs both the learner and evaluator where an individual learner is at a given point in time. Through the use of paper and electronic records learners may store and review copies of results of laboratory experiences including simulation assessment print outs. We have also established a checklist that tells the learner and evaluator at what level they should be—this allows close monitoring of actual progress against targets, allowing evaluators to identify potential problems of learners at interim times rather than at final completion when it would be too late to take corrective action. Whereas most course modules will not lead to a nationally recognized qualification, there is at least 1 verification of proficiency that is obtained via long term learning which also serves as a prerequisite to progressing to the next level, and that is the successful completion and passing of the cognitive and manual skills portion of Fundamentals of Laparoscopic Surgery (FLS). The SEAL is of great value to individuals and groups within and external to Duke as we provide enhanced skills-based and cognitive training to learners of all expertise and across multiple disciplines, and as we contribute to the science of the use of simulation as educational tools. Figs 1-3.
Journal of Surgical Education • Volume 67/Number 5 • September/October 2010