Education & Training
The Cognitive and Technical Skills Impact of the Congress of Neurological Surgeons Simulation Curriculum on Neurosurgical Trainees at the 2013 Neurological Society of India Meeting Samer G. Zammar1, Youssef J. Hamade2, Rami James N. Aoun2, Najib E. El Tecle1, Tarek Y. El Ahmadieh3, P. David Adelson4, Shekar N. Kurpad5, James S. Harrop6, Heather Hodge7, Ramesh C. Mishra8, Vedantam Rajshekhar9, Ali R. Rezai10, Suresh K. Sahkla11, Mithun G. Sattur12, Nathan R. Selden13, Ashwini D. Sharan6, Daniel K. Resnick14, Bernard R. Bendok2
OBJECTIVE: To assess the impact of a simulation-based educational curriculum of 4 modules on neurosurgical trainees at the Neurological Societies of India annual meeting, which was held in Mumbai, India, in December 2013.
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METHODS: We developed a microanastomosis, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), and durotomy repair and their corresponding objective assessment scales. Each module was divided into 3 components: 1) a before didactic cognitive knowledge and technical skills testing, 2) a didactic lecture, and 3) an after didactic cognitive knowledge and technical skills testing. We compared the trainees’ cognitive and technical scores from the before and after testing phases. Wilcoxon sum rank test was used to test statistical significance. The incorporation of a simulation-based educational program into neurosurgical education curriculum has faced a number of barriers. It is essential to develop and assess the success and feasibility of simulation-based modules on neurosurgical residents.
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on the microanastomosis, ACDF, PCF, and durotomy modules, respectively (P < 0.05). The practical hands-on scores increased from 45%, 45% to 60%, and 65% to 62%, 68%, 81%, and 70% on the microanastomosis, ACDF, PCF, and durotomy modules, respectively (P < 0.05). CONCLUSIONS: Our course suggests that a simulationbased neurosurgery curriculum has the potential to enhance resident knowledge and technical proficiency.
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INTRODUCTION
S
RESULTS: The knowledge test median scores increased from 60%, 69% to 72%, and 60% to 80%, 85%, 90%, and 75%
imulation has proven to be a cornerstone of education for various domains including aerospace, airline, and the military (27). In health care, through the use of cadaver dissection, simulation has been used for centuries as a physical model. As educational theories and understanding of teaching philosophies matured, the concept of modern simulation has also evolved. With the introduction of laparoscopic techniques, an education gap was noted when using only simulation models.
Key words ACDF - Durotomy - Education - Microanastomosis - PCF - Resident - Simulation - Spine - Vascular
Neurological Institute of Phoenix Children’s Hospital, Phoenix, AZ; 5Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI; 6Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA; 7Congress of Neurological Surgeons, Schaumburg, IL; 8Department of Neurosurgery, Neurosurgical Clinics, Kamayani Hospital, Agra, India; 9Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India; 10Department of Neurosurgery, The Ohio State University, Columbus, OH; 11 Department of Neurosurgery, Dr. Balabhai Nanavati Hospital and Saifee Hospital, Mumbai, Maharashtra, India; 12Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Bangalore, 560029, India; 13Department of Neurological Surgery, Oregon Health & Science University, Portland, OR; 14Department of Neurosurgery, University of Wisconsin, Madison, WI
Abbreviations and Acronyms ACDF: Anterior cervical discectomy and fusion CNS: Congress of Neurological Surgeons NOMAT: Northwestern Objective Microanastomosis Assessment Tool OSATS: Objective Structured Assessment of Technical Skill PCF: Posterior cervical fusion
To whom correspondence should be addressed: Bernard R. Bendok, M.D. [E-mail: [email protected]]
1
Available online: www.sciencedirect.com
2
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
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Department of Neurological Surgery, Northwestern Memorial Hospital, Chicago, IL; Department of Neurological surgery, Mayo Clinic Hospital, Phoenix, AZ; 3Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX; 4Barrow
WORLD NEUROSURGERY 83 [4]: 419-423, APRIL 2015
Citation: World Neurosurg. (2015) 83, 4:419-423. http://dx.doi.org/10.1016/j.wneu.2014.12.006 Supplementary digital content available online. Journal homepage: www.WORLDNEUROSURGERY.org
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Thus, present day simulation models are linked to the educational needs such as predefined curriculums. Experienced surgeons quickly identify the assets of learning new techniques in a simulated environment, proving this approach to be highly successful (10, 19, 22, 25). Incorporation of a simulation-based educational program into a neurosurgical education curriculum has faced a number of barriers including time constraints, funding limitations, technical limits of the current simulators, and the absence of validated objective assessment tools and curricula (13, 27). Recognizing the educational value of this modality. the Congress of Neurological Surgeons (CNS) has incorporated simulation approaches into their national and international educational curricula. Standard neurosurgical microsurgical and operative techniques are essential skills in which every neurosurgical resident should achieve competency. With changes in medical education, adequate access to these techniques can be challenging. To assess the potential impact of a simulation-based educational curriculum on neurosurgical residents, we introduced 4 simulation modules: microanastomosis, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), and durotomy repair and their corresponding objective assessment scales to the Neurological Societies of India annual meeting, which was held in Mumbai, India, in December 2013.
Figure 2. Anterior cervical discectomy and fusion setting.
retractor sets, and anterior cervical retractors were provided for the residents to perform an ACDF (Figure 2).
PCF Module Three simulator models from the CNScreated by Phacon (Leipzig, Germany) along with the drill, suction, nerve hooks, and cerebellar retractors were available for the PCF module. Using these instruments, the residents had to perform a posterior cervical laminectomy and foraminotomy (Figure 3).
Durotomy Repair Module METHODS Twenty neurosurgery residents from India participated in a structured simulation-based didactic and technical course. This consisted of simulation curriculums with a microanastomosis module, an ACDF module, a PCF module, and a spinal durotomy repair module.
Three simulator models (Pacific research Laboratories, Vashon Island, Washington, USA) along with the suture (4-0), needle holder, tubing, latex tubes, forceps, and intravenous bag were provided for the durotomy repair module. The neurosurgical trainees were asked to repair a spinal durotomy with these available tools (Figure 4).
Microanastomosis Module
Course Design
Four surgical microscopes were used for the microanastomosis session. One 3-mm silicone-based artificial vessel was provided for each resident. The vessel was placed on a wetted filter paper in a petri dish, which was fixed under the microscope (Figure 1). One scissor, 1 jeweler, 1 needle holder, and one 8-0 suture per trial were provided for each resident to perform an end-to-end anastomosis with interrupted stitches.
The overall course began with a 30-minute introductory lecture on simulation after which 4 rotations were created: microanastomosis, ACDF, PCF, and durotomy repair. Each session was scheduled for 2 hours. Four faculty members from the CNS proctored the residents during the sessions. The residents were given 15 minutes to complete a multiple choice test to assess their baseline knowledge on cerebral microanastomosis, ACDF, PCF, and durotomy repair (depending on which session they were in). Afterward, the residents were given 20 minutes to perform the specified task in each session. The residents’ performance was graded based on each module’s respective Objective Structured Assessment of Technical Skill (OSATS) scale (Supplementary Materials 1e4).
ACDF Module Six simulator models (Medtronic, Minneapolis, Minnesota, USA) were available for the ACDF module. A kerrison rongeur, a nerve hook “micro dissector,” an anterior cervical plate and screws, interbody cages and insertion tools, Kaspar distraction posts and
Figure 1. Microanastomosis setting.
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Figure 3. Pposterior cervical fusion setting.
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Figure 4. Durotomy repair setting.
Subsequently, a faculty member in each session gave a 30-minute didactic lecture or session focusing on cognitive knowledge and technical nuances of the respective skill. A video on microanastomosis was shown to illustrate technical nuances of the skill module. In the 3 other modules, a faculty member performed a live demonstration of the task that needs to be completed by the resident on a simulator. The residents then performed the technical skills with direct supervision of the faculty mentor, where they were graded with objective measurements. At the end of the sessions the students retook the 15-minute knowledge test. Wilcoxon sum rank test was used to test statistical significance for the change in performances before and after the didactic lecture.
RESULTS Performance on Before and After Didactic Knowledge Tests Cognitive knowledge related to the task improved for all modules among the tested residents (Figure 5). The median scores (range, 0e100) increased from 60 to 80 (P < 0.05) on the microanastomosis module, 69 to 85 on the ACDF module (P < 0.05), 72 to 90 on the PCF module (P < 0.05), and 60 to 75 on the durotomy repair module (P < 0.05).
Figure 5. The median cognitive test for the microanastomosis, anterior cervical discectomy and fusion, posterior cervical fusion, and durotomy repair modules.
WORLD NEUROSURGERY 83 [4]: 419-423, APRIL 2015
Figure 6. The median hands-on test for the microanastomosis, anterior cervical discectomy and fusion, posterior cervical fusion, and durotomy repair modules.
Performance on the Before and After Didactic Lecture Hands-On Simulation Assessment Scores The practical test median scores (score range, 0e100) increased from 45 to 62 (P < 0.05) in the microanastomosis module, 45 to 68 (P < 0.05) in ACDF module, 60 to 81 in the PCF module (P < 0.05), and 65 to 70 in the durotomy repair module (P < 0.05) (Figure 6).
DISCUSSION There is growing evidence showing the positive impact of simulation on resident training in numerous areas of health care (10, 25, 27). Resident duty hours, a proliferation of neurosurgical techniques, decentralization of care, and increasing societal expectations regarding quality of patient care have contributed to a sense of urgency to incorporate simulation into neurosurgical training curricula (3, 8). Advances in computer technology and 3 dimensional printing have also increased tantalizing opportunities to create high fidelity simulation paradigms. In a recent survey of neurosurgery program directors in the United States, simulation was judged to be an important training tool that could complement, but not replace, traditional operative training (13). Time and budgetary constraints, as well as lack of validated models, assessment scales, and curricula have slowed the incorporation of simulation into neurosurgical education (1, 5, 6, 8, 9, 13, 20). To address this issue, the CNS has established simulation-based educational modules aiming to facilitate training on essential techniques and skills in neurosurgery (8, 11, 15-17, 24, 26). The aim of these modules is to provide residents with the opportunity to reach a higher level of skill integrated with relevant clinical knowledge related to a specific neurosurgical technique (7). The components of the curriculum include objective assessment scales, which measure technical skill for hands-on modules, and cognitive examinations, which assess knowledge in the clinical and technical areas related to the techniques being simulated (12, 18). The role of objective assessment tools is to objectively quantify the resident’s skill to
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allow objective feedback and comparisons among skill levels. This may allow for cutoffs to be drawn regarding levels of skills that are desirable before human surgery. Likewise, the cognitive component helps integrate knowledge of the anatomy and the disease itself with the surgical technique and task at hand (8, 14, 19). For the purpose of this course, we adopted the CNS microanastomosis tool for the microanastomosis module, the CNS ACDF OSATS for the ACDF module, the CNS PCF OSATS for the PCF module, and the CNS CSF OSATS for the durotomy module. These scales are derived from the previously validated OSATS scale (12, 18). The OSATS scale has been tailored and adjusted to fit different surgical subspecialties (8, 10, 12, 14, 18). Similarly, the CNS microanastomosis tool was developed to assess microsurgical skills in anastomosis-related techniques using 11 different metrics such as respect of tissue, needle handling and bite uniformity, knot-tying efficiency, spacing of sutures, and evaluation of the end result. It is an abbreviated form of the Northwestern Objective Microanastomosis Assessment Tool (NOMAT) that has recently achieved face and construct validity in an internal study performed on 21 neurosurgery residents at Northwestern University (4). Face validity reflects the fidelity of the module in reproducing a realworld microsurgical setting and construct validity is defined as the ability of the module to differentiate between the microsurgical performances of trainees with different levels of experience. The NOMAT scale has also been used in previous national simulation courses (8). The CNS ACDF OSATS consists of 10 metrics that examine the ability of the resident to use the drill, perform discectomy and decompression of the neural elements, placement of distraction posts and interbody graft, and placement of anterior plate and screw in a surgically efficient manner. The CNS PCF OSATS involves 5 metrics that examine the ability of the resident to use the drill to remove the lamina and decompress neural elements to perform a successful posterior cervical foraminotomy. The CNS CSF OSATS consists of 7 metrics that assess the ability of the resident to repair a durotomy efficiently by emphasizing on the needle handling and care and bite uniformity, spacing of sutures, and knot tying (Supplementary Materials 1e4). In our course we combined a didactic lecture and a technical exercise for each of the 4 modules into a surgical curriculum. The main goal of the course was to assess the performance of neurosurgical residents on each task before and after the curriculum. Our results show that most participants significantly performed better on both the cognitive tests and practical skills after the didactic lectures in the microanastomosis, ACDF, PCF, and durotomy modules. Our findings are homogenous with the results of simulation-based curricula designed in other surgical specialties (2, 10, 14, 19, 21, 22, 25). Neurosurgery residents can
REFERENCES 1. Aoun SG, McClendon J Jr, Ganju A, Batjer HH, Bendok BR: The Association for Surgical Education’s roadmap for research on surgical simulation. World Neurosurg 78:4-5, 2012.
2. Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PE: Training in microsurgical skills: Does
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achieve acceptable levels of skill at these tasks with deliberate practice and repetition, which will likely enhance performance in the real operating room. It is also likely that learning curves can be further enhanced by attending or expert feedback. The importance of deliberate practice and expert feedback in simulation courses is crucial and has been extensively emphasized in the literature (8, 10, 21-23). Our group previously conducted a similar study on 7 candidates with no previous exposure to microanastomosis (8). The study showed that this educational module can enhance resident skills by demonstrating an average percentile NOMAT score increase from 46% to 56% (P ¼ 0.001) and an average cognitive test score increase from 56% to 85% (P ¼ 0.001) between the before and after didactic session (8). This course had natural time limitations as we only had 1 day at the Mumbai simulation course to test our modules. Ideally, deliberate practice yields best results if included in a timedistributed practice, as shown by Moulton et al. (21), who randomized 38 residents to receive either a 1-day training or a distributed weekly practice regimen training. Although both groups received the same total amount of practice (a total of 4 sessions), the study reported that the group that received timedistributed training performed significantly better in the final task when compared with the group that received a 1-day training (P < 0.05) (21). Data from our course suggest that modules with simulation-based technical exercises and an associated cognitive curriculum have the potential to enhance technical skill and related knowledge. Technological advances, such as 3-dimensional printing and holography, could further enhance these modules. Making the didactic component of these modules available online could further facilitate widespread applicability. Training technicians to oversee the exercises and or creating a video bank of technical nuances may further facilitate such modules.
CONCLUSIONS The growing constraints on neurosurgical resident training in the form of work hour limitations and finances threaten to reduce the proficiency levels of graduating residents. Simulation can enhance neurosurgery resident training by serving as a complementary tool to traditional mentored operative training. It can also allow residents to achieve proficiency at specific surgical tasks that are typically not sufficiently encountered during residency (e.g., microanastomosis). Our data suggest that the CNS hybrid cognitive and hands-on simulation-based curricula of microanastomosis, ACDF, PCF, and durotomy repair have a positive impact on knowledge and technical skills of neurosurgical trainees. Further refinements are needed to make such curricula widely available for deliberate practice and skills assessment.
course-based learning deliver? Microsurgery 25: 481-485, 2005. 3. Batjer HH, Aoun SG, Rahme RJ, Bendok BR: Honoring our public responsibility: creating milestone and matrix-based training in an era of duty hour restrictions. Clin Neurosurg 59:70-74, 2012. 4. Bendok BR AS, El Ahmadieh TY, El Tecle NE, Batjer HH: A pilot study to assess microsurgical
skills and validate an objective assessment tool: the Northwestern Objective Microanastomosis Assessment Tool (NOMAT) [abstract]. Presented at: Congress of Neurological Surgeons Annual Meeting; San Francisco, California, October 1923, 2013. 5. Burchiel KJ: Simulation training in neurological surgery [commentary]. Neurosurgery 73(Suppl 1): 6-7, 2013.
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6. Dagi TF: The roles and future of simulation in neurosurgery [commentary]. Neurosurgery 73(Suppl 1):4-5, 2013. 7. Dreyfus SE, Dreyfus HL: A five-stage model of the mental activities involved in directed skill acquisition. University of California, Berkeley. DTIC Document, 1980. 8. El Ahmadieh TY, Aoun SG, El Tecle NE, Nanney AD 3rd, Daou MR, Harrop J, Batjer HH, Bendok BR: A didactic and hands-on module enhances resident microsurgical knowledge and technical skill. Neurosurgery 73(Suppl 1):51-56, 2013. 9. El Ahmadieh TY, El Tecle NE, Aoun SG, Yip BK, Ganju A, Bendok BR: How can simulation thrive as an educational tool? Just ask the residents. Neurosurgery 71:N18-19, 2012. 10. Fann JI, Calhoon JH, Carpenter AJ, Merrill WH, Brown JW, Poston RS, Kalani M, Murray GF, Hicks GL Jr, Feins RH: Simulation in coronary artery anastomosis early in cardiothoracic surgical residency training: the Boot Camp experience. J Thorac Cardiovasc Surg 139:1275-1281, 2010. 11. Fargen KM, Arthur AS, Bendok BR, Levy EI, Ringer A, Siddiqui AH, Veznedaroglu E, Mocco J: Experience with a simulator-based angiography course for neurosurgical residents: beyond a pilot program. Neurosurgery 73(Suppl 1):46-50, 2013. 12. Faulkner H, Regehr G, Martin J, Reznick R: Validation of an objective structured assessment of technical skill for surgical residents. J Assoc Am Med Coll 71:1363-1365, 1996. 13. Ganju A, Aoun SG, Daou MR, El Ahmadieh TY, Chang A, Wang L, Batjer HH, Bendok BR: The role of simulation in neurosurgical education: a survey of 99 United States neurosurgery program directors. World Neurosurg 80:e1-8, 2013. 14. Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS, Jarvi KA: The
educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 240: 374-381, 2004.
deliberate practice can achieve equivalency to senior surgery residents. J Thorac Cardiovasc Surg 145:1453-1458; discussion 1458-1459, 2013.
15. Harrop J, Lobel DA, Bendok B, Sharan A, Rezai AR: Developing a neurosurgical simulationbased educational curriculum: an overview. Neurosurgery 73(Suppl 1):25-29, 2013.
23. Price J, Naik V, Boodhwani M, Brandys T, Hendry P, Lam BK: A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: the role of deliberate practice. J Thorac Cardiovasc Surg 142:496-503, 2011.
16. Harrop J, Rezai AR, Hoh DJ, Ghobrial GM, Sharan A: Neurosurgical training with a novel cervical spine simulator: posterior foraminotomy and laminectomy. Neurosurgery 73(Suppl 1): 94-99, 2013. 17. Jabbour P, Chalouhi N: Simulation-based neurosurgical training for the presigmoid approach with a physical model. Neurosurgery 73(Suppl 1):81-84, 2013. 18. Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, Brown M: Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:273-278, 1997. 19. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD: The effect of bench model fidelity on endourological skills: a randomized controlled study. J Urol 167:1243-1247, 2002. 20. McCaslin AF, Aoun SG, Batjer HH, Bendok BR: Enhancing the utility of surgical simulation: from proficiency to automaticity. World Neurosurg 76: 482-484, 2011. 21. Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R: Teaching surgical skills: what kind of practice makes perfect? A randomized, controlled trial. Ann Surg 244:400-409, 2006.
24. Ray WZ, Ganju A, Harrop JS, Hoh DJ: Developing an anterior cervical diskectomy and fusion simulator for neurosurgical resident training. Neurosurgery 73(Suppl 1):100-106, 2013. 25. Satterwhite T, Son J, Carey J, Zeidler K, Bari S, Gurtner G, Chang J, Lee GK: Microsurgery education in residency training: validating an online curriculum. Ann Plastic Surg 68:410-414, 2012. 26. Schirmer CM, Elder JB, Roitberg B, Lobel DA: Virtual reality-based simulation training for ventriculostomy: an evidence-based approach. Neurosurgery 73(Suppl 1):66-73, 2013. 27. Singh H, Kalani M, Acosta-Torres S, El Ahmadieh TY, Loya J, Ganju A: History of simulation in medicine: from Resusci Annie to the Ann Myers Medical Center. Neurosurgery 73(Suppl 1): 9-14, 2013.
Citation: World Neurosurg. (2015) 83, 4:419-423. http://dx.doi.org/10.1016/j.wneu.2014.12.006 Journal homepage: www.WORLDNEUROSURGERY.org
22. Nesbitt JC, St Julien J, Absi TS, Ahmad RM, Grogan EL, Balaguer JM, Lambright ES, Deppen SA, Wu H, Putnam JB: Tissue-based coronary surgery simulation: medical student
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Call for Neurosurgery and the Arts World Neurosurgery is changing the cover art and filler art motif. This motif involves the display of art by neurosurgeons. Hence, we are seeking art, in any visual form, for this endeavor on an ongoing basis. Such art might naturally include photography, photographs of sculptures or paintings, prose or poetry, etc. We ask Neurosurgeons to submit high resolution images of such art. These images will be considered for future World Neurosurgery journal covers and for filler art. When submitting your images, please include a brief description. These can be submitted directly to [email protected].
WORLD NEUROSURGERY 83 [4]: 419-423, APRIL 2015
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The Cognitive and Technical Skills Impact of the Congress of Neurological Surgeons Simulation Curriculum on Neurosurgical Trainees at the 2013 Neurological Society of India Meeting Samer G. Zammar1, Youssef J. Hamade2, Rami James N. Aoun2, Najib E. El Tecle1, Tarek Y. El Ahmadieh3, P. David Adelson4, Shekar N. Kurpad5, James S. Harrop6, Heather Hodge7, Ramesh C. Mishra8, Vedantam Rajshekhar9, Ali R. Rezai10, Suresh K. Sahkla11, Mithun G. Sattur12, Nathan R. Selden13, Ashwini D. Sharan6, Daniel K. Resnick14, Bernard R. Bendok2
OBJECTIVE: To assess the impact of a simulation-based educational curriculum of 4 modules on neurosurgical trainees at the Neurological Societies of India annual meeting, which was held in Mumbai, India, in December 2013.
-
METHODS: We developed a microanastomosis, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), and durotomy repair and their corresponding objective assessment scales. Each module was divided into 3 components: 1) a before didactic cognitive knowledge and technical skills testing, 2) a didactic lecture, and 3) an after didactic cognitive knowledge and technical skills testing. We compared the trainees’ cognitive and technical scores from the before and after testing phases. Wilcoxon sum rank test was used to test statistical significance. The incorporation of a simulation-based educational program into neurosurgical education curriculum has faced a number of barriers. It is essential to develop and assess the success and feasibility of simulation-based modules on neurosurgical residents.
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on the microanastomosis, ACDF, PCF, and durotomy modules, respectively (P < 0.05). The practical hands-on scores increased from 45%, 45% to 60%, and 65% to 62%, 68%, 81%, and 70% on the microanastomosis, ACDF, PCF, and durotomy modules, respectively (P < 0.05). CONCLUSIONS: Our course suggests that a simulationbased neurosurgery curriculum has the potential to enhance resident knowledge and technical proficiency.
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INTRODUCTION
S
RESULTS: The knowledge test median scores increased from 60%, 69% to 72%, and 60% to 80%, 85%, 90%, and 75%
imulation has proven to be a cornerstone of education for various domains including aerospace, airline, and the military (27). In health care, through the use of cadaver dissection, simulation has been used for centuries as a physical model. As educational theories and understanding of teaching philosophies matured, the concept of modern simulation has also evolved. With the introduction of laparoscopic techniques, an education gap was noted when using only simulation models.
Key words ACDF - Durotomy - Education - Microanastomosis - PCF - Resident - Simulation - Spine - Vascular
Neurological Institute of Phoenix Children’s Hospital, Phoenix, AZ; 5Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI; 6Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA; 7Congress of Neurological Surgeons, Schaumburg, IL; 8Department of Neurosurgery, Neurosurgical Clinics, Kamayani Hospital, Agra, India; 9Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India; 10Department of Neurosurgery, The Ohio State University, Columbus, OH; 11 Department of Neurosurgery, Dr. Balabhai Nanavati Hospital and Saifee Hospital, Mumbai, Maharashtra, India; 12Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Bangalore, 560029, India; 13Department of Neurological Surgery, Oregon Health & Science University, Portland, OR; 14Department of Neurosurgery, University of Wisconsin, Madison, WI
Abbreviations and Acronyms ACDF: Anterior cervical discectomy and fusion CNS: Congress of Neurological Surgeons NOMAT: Northwestern Objective Microanastomosis Assessment Tool OSATS: Objective Structured Assessment of Technical Skill PCF: Posterior cervical fusion
To whom correspondence should be addressed: Bernard R. Bendok, M.D. [E-mail: [email protected]]
1
Available online: www.sciencedirect.com
2
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
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Department of Neurological Surgery, Northwestern Memorial Hospital, Chicago, IL; Department of Neurological surgery, Mayo Clinic Hospital, Phoenix, AZ; 3Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX; 4Barrow
WORLD NEUROSURGERY 83 [4]: 419-423, APRIL 2015
Citation: World Neurosurg. (2015) 83, 4:419-423. http://dx.doi.org/10.1016/j.wneu.2014.12.006 Supplementary digital content available online. Journal homepage: www.WORLDNEUROSURGERY.org
www.WORLDNEUROSURGERY.org
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EDUCATION & TRAINING
Thus, present day simulation models are linked to the educational needs such as predefined curriculums. Experienced surgeons quickly identify the assets of learning new techniques in a simulated environment, proving this approach to be highly successful (10, 19, 22, 25). Incorporation of a simulation-based educational program into a neurosurgical education curriculum has faced a number of barriers including time constraints, funding limitations, technical limits of the current simulators, and the absence of validated objective assessment tools and curricula (13, 27). Recognizing the educational value of this modality. the Congress of Neurological Surgeons (CNS) has incorporated simulation approaches into their national and international educational curricula. Standard neurosurgical microsurgical and operative techniques are essential skills in which every neurosurgical resident should achieve competency. With changes in medical education, adequate access to these techniques can be challenging. To assess the potential impact of a simulation-based educational curriculum on neurosurgical residents, we introduced 4 simulation modules: microanastomosis, anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), and durotomy repair and their corresponding objective assessment scales to the Neurological Societies of India annual meeting, which was held in Mumbai, India, in December 2013.
Figure 2. Anterior cervical discectomy and fusion setting.
retractor sets, and anterior cervical retractors were provided for the residents to perform an ACDF (Figure 2).
PCF Module Three simulator models from the CNScreated by Phacon (Leipzig, Germany) along with the drill, suction, nerve hooks, and cerebellar retractors were available for the PCF module. Using these instruments, the residents had to perform a posterior cervical laminectomy and foraminotomy (Figure 3).
Durotomy Repair Module METHODS Twenty neurosurgery residents from India participated in a structured simulation-based didactic and technical course. This consisted of simulation curriculums with a microanastomosis module, an ACDF module, a PCF module, and a spinal durotomy repair module.
Three simulator models (Pacific research Laboratories, Vashon Island, Washington, USA) along with the suture (4-0), needle holder, tubing, latex tubes, forceps, and intravenous bag were provided for the durotomy repair module. The neurosurgical trainees were asked to repair a spinal durotomy with these available tools (Figure 4).
Microanastomosis Module
Course Design
Four surgical microscopes were used for the microanastomosis session. One 3-mm silicone-based artificial vessel was provided for each resident. The vessel was placed on a wetted filter paper in a petri dish, which was fixed under the microscope (Figure 1). One scissor, 1 jeweler, 1 needle holder, and one 8-0 suture per trial were provided for each resident to perform an end-to-end anastomosis with interrupted stitches.
The overall course began with a 30-minute introductory lecture on simulation after which 4 rotations were created: microanastomosis, ACDF, PCF, and durotomy repair. Each session was scheduled for 2 hours. Four faculty members from the CNS proctored the residents during the sessions. The residents were given 15 minutes to complete a multiple choice test to assess their baseline knowledge on cerebral microanastomosis, ACDF, PCF, and durotomy repair (depending on which session they were in). Afterward, the residents were given 20 minutes to perform the specified task in each session. The residents’ performance was graded based on each module’s respective Objective Structured Assessment of Technical Skill (OSATS) scale (Supplementary Materials 1e4).
ACDF Module Six simulator models (Medtronic, Minneapolis, Minnesota, USA) were available for the ACDF module. A kerrison rongeur, a nerve hook “micro dissector,” an anterior cervical plate and screws, interbody cages and insertion tools, Kaspar distraction posts and
Figure 1. Microanastomosis setting.
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Figure 3. Pposterior cervical fusion setting.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.12.006
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Figure 4. Durotomy repair setting.
Subsequently, a faculty member in each session gave a 30-minute didactic lecture or session focusing on cognitive knowledge and technical nuances of the respective skill. A video on microanastomosis was shown to illustrate technical nuances of the skill module. In the 3 other modules, a faculty member performed a live demonstration of the task that needs to be completed by the resident on a simulator. The residents then performed the technical skills with direct supervision of the faculty mentor, where they were graded with objective measurements. At the end of the sessions the students retook the 15-minute knowledge test. Wilcoxon sum rank test was used to test statistical significance for the change in performances before and after the didactic lecture.
RESULTS Performance on Before and After Didactic Knowledge Tests Cognitive knowledge related to the task improved for all modules among the tested residents (Figure 5). The median scores (range, 0e100) increased from 60 to 80 (P < 0.05) on the microanastomosis module, 69 to 85 on the ACDF module (P < 0.05), 72 to 90 on the PCF module (P < 0.05), and 60 to 75 on the durotomy repair module (P < 0.05).
Figure 5. The median cognitive test for the microanastomosis, anterior cervical discectomy and fusion, posterior cervical fusion, and durotomy repair modules.
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Figure 6. The median hands-on test for the microanastomosis, anterior cervical discectomy and fusion, posterior cervical fusion, and durotomy repair modules.
Performance on the Before and After Didactic Lecture Hands-On Simulation Assessment Scores The practical test median scores (score range, 0e100) increased from 45 to 62 (P < 0.05) in the microanastomosis module, 45 to 68 (P < 0.05) in ACDF module, 60 to 81 in the PCF module (P < 0.05), and 65 to 70 in the durotomy repair module (P < 0.05) (Figure 6).
DISCUSSION There is growing evidence showing the positive impact of simulation on resident training in numerous areas of health care (10, 25, 27). Resident duty hours, a proliferation of neurosurgical techniques, decentralization of care, and increasing societal expectations regarding quality of patient care have contributed to a sense of urgency to incorporate simulation into neurosurgical training curricula (3, 8). Advances in computer technology and 3 dimensional printing have also increased tantalizing opportunities to create high fidelity simulation paradigms. In a recent survey of neurosurgery program directors in the United States, simulation was judged to be an important training tool that could complement, but not replace, traditional operative training (13). Time and budgetary constraints, as well as lack of validated models, assessment scales, and curricula have slowed the incorporation of simulation into neurosurgical education (1, 5, 6, 8, 9, 13, 20). To address this issue, the CNS has established simulation-based educational modules aiming to facilitate training on essential techniques and skills in neurosurgery (8, 11, 15-17, 24, 26). The aim of these modules is to provide residents with the opportunity to reach a higher level of skill integrated with relevant clinical knowledge related to a specific neurosurgical technique (7). The components of the curriculum include objective assessment scales, which measure technical skill for hands-on modules, and cognitive examinations, which assess knowledge in the clinical and technical areas related to the techniques being simulated (12, 18). The role of objective assessment tools is to objectively quantify the resident’s skill to
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allow objective feedback and comparisons among skill levels. This may allow for cutoffs to be drawn regarding levels of skills that are desirable before human surgery. Likewise, the cognitive component helps integrate knowledge of the anatomy and the disease itself with the surgical technique and task at hand (8, 14, 19). For the purpose of this course, we adopted the CNS microanastomosis tool for the microanastomosis module, the CNS ACDF OSATS for the ACDF module, the CNS PCF OSATS for the PCF module, and the CNS CSF OSATS for the durotomy module. These scales are derived from the previously validated OSATS scale (12, 18). The OSATS scale has been tailored and adjusted to fit different surgical subspecialties (8, 10, 12, 14, 18). Similarly, the CNS microanastomosis tool was developed to assess microsurgical skills in anastomosis-related techniques using 11 different metrics such as respect of tissue, needle handling and bite uniformity, knot-tying efficiency, spacing of sutures, and evaluation of the end result. It is an abbreviated form of the Northwestern Objective Microanastomosis Assessment Tool (NOMAT) that has recently achieved face and construct validity in an internal study performed on 21 neurosurgery residents at Northwestern University (4). Face validity reflects the fidelity of the module in reproducing a realworld microsurgical setting and construct validity is defined as the ability of the module to differentiate between the microsurgical performances of trainees with different levels of experience. The NOMAT scale has also been used in previous national simulation courses (8). The CNS ACDF OSATS consists of 10 metrics that examine the ability of the resident to use the drill, perform discectomy and decompression of the neural elements, placement of distraction posts and interbody graft, and placement of anterior plate and screw in a surgically efficient manner. The CNS PCF OSATS involves 5 metrics that examine the ability of the resident to use the drill to remove the lamina and decompress neural elements to perform a successful posterior cervical foraminotomy. The CNS CSF OSATS consists of 7 metrics that assess the ability of the resident to repair a durotomy efficiently by emphasizing on the needle handling and care and bite uniformity, spacing of sutures, and knot tying (Supplementary Materials 1e4). In our course we combined a didactic lecture and a technical exercise for each of the 4 modules into a surgical curriculum. The main goal of the course was to assess the performance of neurosurgical residents on each task before and after the curriculum. Our results show that most participants significantly performed better on both the cognitive tests and practical skills after the didactic lectures in the microanastomosis, ACDF, PCF, and durotomy modules. Our findings are homogenous with the results of simulation-based curricula designed in other surgical specialties (2, 10, 14, 19, 21, 22, 25). Neurosurgery residents can
REFERENCES 1. Aoun SG, McClendon J Jr, Ganju A, Batjer HH, Bendok BR: The Association for Surgical Education’s roadmap for research on surgical simulation. World Neurosurg 78:4-5, 2012.
2. Atkins JL, Kalu PU, Lannon DA, Green CJ, Butler PE: Training in microsurgical skills: Does
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achieve acceptable levels of skill at these tasks with deliberate practice and repetition, which will likely enhance performance in the real operating room. It is also likely that learning curves can be further enhanced by attending or expert feedback. The importance of deliberate practice and expert feedback in simulation courses is crucial and has been extensively emphasized in the literature (8, 10, 21-23). Our group previously conducted a similar study on 7 candidates with no previous exposure to microanastomosis (8). The study showed that this educational module can enhance resident skills by demonstrating an average percentile NOMAT score increase from 46% to 56% (P ¼ 0.001) and an average cognitive test score increase from 56% to 85% (P ¼ 0.001) between the before and after didactic session (8). This course had natural time limitations as we only had 1 day at the Mumbai simulation course to test our modules. Ideally, deliberate practice yields best results if included in a timedistributed practice, as shown by Moulton et al. (21), who randomized 38 residents to receive either a 1-day training or a distributed weekly practice regimen training. Although both groups received the same total amount of practice (a total of 4 sessions), the study reported that the group that received timedistributed training performed significantly better in the final task when compared with the group that received a 1-day training (P < 0.05) (21). Data from our course suggest that modules with simulation-based technical exercises and an associated cognitive curriculum have the potential to enhance technical skill and related knowledge. Technological advances, such as 3-dimensional printing and holography, could further enhance these modules. Making the didactic component of these modules available online could further facilitate widespread applicability. Training technicians to oversee the exercises and or creating a video bank of technical nuances may further facilitate such modules.
CONCLUSIONS The growing constraints on neurosurgical resident training in the form of work hour limitations and finances threaten to reduce the proficiency levels of graduating residents. Simulation can enhance neurosurgery resident training by serving as a complementary tool to traditional mentored operative training. It can also allow residents to achieve proficiency at specific surgical tasks that are typically not sufficiently encountered during residency (e.g., microanastomosis). Our data suggest that the CNS hybrid cognitive and hands-on simulation-based curricula of microanastomosis, ACDF, PCF, and durotomy repair have a positive impact on knowledge and technical skills of neurosurgical trainees. Further refinements are needed to make such curricula widely available for deliberate practice and skills assessment.
course-based learning deliver? Microsurgery 25: 481-485, 2005. 3. Batjer HH, Aoun SG, Rahme RJ, Bendok BR: Honoring our public responsibility: creating milestone and matrix-based training in an era of duty hour restrictions. Clin Neurosurg 59:70-74, 2012. 4. Bendok BR AS, El Ahmadieh TY, El Tecle NE, Batjer HH: A pilot study to assess microsurgical
skills and validate an objective assessment tool: the Northwestern Objective Microanastomosis Assessment Tool (NOMAT) [abstract]. Presented at: Congress of Neurological Surgeons Annual Meeting; San Francisco, California, October 1923, 2013. 5. Burchiel KJ: Simulation training in neurological surgery [commentary]. Neurosurgery 73(Suppl 1): 6-7, 2013.
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6. Dagi TF: The roles and future of simulation in neurosurgery [commentary]. Neurosurgery 73(Suppl 1):4-5, 2013. 7. Dreyfus SE, Dreyfus HL: A five-stage model of the mental activities involved in directed skill acquisition. University of California, Berkeley. DTIC Document, 1980. 8. El Ahmadieh TY, Aoun SG, El Tecle NE, Nanney AD 3rd, Daou MR, Harrop J, Batjer HH, Bendok BR: A didactic and hands-on module enhances resident microsurgical knowledge and technical skill. Neurosurgery 73(Suppl 1):51-56, 2013. 9. El Ahmadieh TY, El Tecle NE, Aoun SG, Yip BK, Ganju A, Bendok BR: How can simulation thrive as an educational tool? Just ask the residents. Neurosurgery 71:N18-19, 2012. 10. Fann JI, Calhoon JH, Carpenter AJ, Merrill WH, Brown JW, Poston RS, Kalani M, Murray GF, Hicks GL Jr, Feins RH: Simulation in coronary artery anastomosis early in cardiothoracic surgical residency training: the Boot Camp experience. J Thorac Cardiovasc Surg 139:1275-1281, 2010. 11. Fargen KM, Arthur AS, Bendok BR, Levy EI, Ringer A, Siddiqui AH, Veznedaroglu E, Mocco J: Experience with a simulator-based angiography course for neurosurgical residents: beyond a pilot program. Neurosurgery 73(Suppl 1):46-50, 2013. 12. Faulkner H, Regehr G, Martin J, Reznick R: Validation of an objective structured assessment of technical skill for surgical residents. J Assoc Am Med Coll 71:1363-1365, 1996. 13. Ganju A, Aoun SG, Daou MR, El Ahmadieh TY, Chang A, Wang L, Batjer HH, Bendok BR: The role of simulation in neurosurgical education: a survey of 99 United States neurosurgery program directors. World Neurosurg 80:e1-8, 2013. 14. Grober ED, Hamstra SJ, Wanzel KR, Reznick RK, Matsumoto ED, Sidhu RS, Jarvi KA: The
educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg 240: 374-381, 2004.
deliberate practice can achieve equivalency to senior surgery residents. J Thorac Cardiovasc Surg 145:1453-1458; discussion 1458-1459, 2013.
15. Harrop J, Lobel DA, Bendok B, Sharan A, Rezai AR: Developing a neurosurgical simulationbased educational curriculum: an overview. Neurosurgery 73(Suppl 1):25-29, 2013.
23. Price J, Naik V, Boodhwani M, Brandys T, Hendry P, Lam BK: A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: the role of deliberate practice. J Thorac Cardiovasc Surg 142:496-503, 2011.
16. Harrop J, Rezai AR, Hoh DJ, Ghobrial GM, Sharan A: Neurosurgical training with a novel cervical spine simulator: posterior foraminotomy and laminectomy. Neurosurgery 73(Suppl 1): 94-99, 2013. 17. Jabbour P, Chalouhi N: Simulation-based neurosurgical training for the presigmoid approach with a physical model. Neurosurgery 73(Suppl 1):81-84, 2013. 18. Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchison C, Brown M: Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:273-278, 1997. 19. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD: The effect of bench model fidelity on endourological skills: a randomized controlled study. J Urol 167:1243-1247, 2002. 20. McCaslin AF, Aoun SG, Batjer HH, Bendok BR: Enhancing the utility of surgical simulation: from proficiency to automaticity. World Neurosurg 76: 482-484, 2011. 21. Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick R: Teaching surgical skills: what kind of practice makes perfect? A randomized, controlled trial. Ann Surg 244:400-409, 2006.
24. Ray WZ, Ganju A, Harrop JS, Hoh DJ: Developing an anterior cervical diskectomy and fusion simulator for neurosurgical resident training. Neurosurgery 73(Suppl 1):100-106, 2013. 25. Satterwhite T, Son J, Carey J, Zeidler K, Bari S, Gurtner G, Chang J, Lee GK: Microsurgery education in residency training: validating an online curriculum. Ann Plastic Surg 68:410-414, 2012. 26. Schirmer CM, Elder JB, Roitberg B, Lobel DA: Virtual reality-based simulation training for ventriculostomy: an evidence-based approach. Neurosurgery 73(Suppl 1):66-73, 2013. 27. Singh H, Kalani M, Acosta-Torres S, El Ahmadieh TY, Loya J, Ganju A: History of simulation in medicine: from Resusci Annie to the Ann Myers Medical Center. Neurosurgery 73(Suppl 1): 9-14, 2013.
Citation: World Neurosurg. (2015) 83, 4:419-423. http://dx.doi.org/10.1016/j.wneu.2014.12.006 Journal homepage: www.WORLDNEUROSURGERY.org
22. Nesbitt JC, St Julien J, Absi TS, Ahmad RM, Grogan EL, Balaguer JM, Lambright ES, Deppen SA, Wu H, Putnam JB: Tissue-based coronary surgery simulation: medical student
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Call for Neurosurgery and the Arts World Neurosurgery is changing the cover art and filler art motif. This motif involves the display of art by neurosurgeons. Hence, we are seeking art, in any visual form, for this endeavor on an ongoing basis. Such art might naturally include photography, photographs of sculptures or paintings, prose or poetry, etc. We ask Neurosurgeons to submit high resolution images of such art. These images will be considered for future World Neurosurgery journal covers and for filler art. When submitting your images, please include a brief description. These can be submitted directly to [email protected].
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