“It used to be that simulation was something trainees could do in their spare time, if they had any,” Dr. Ashamalla says. “The University of Toronto is the first general surgery training program in the country to include simulation in the core teaching curriculum. Trainees have always had teaching time with lectures and now we have integrated simulation into that.”
Simulation sessions with Dr. Ashamalla focus on basic and advanced technical skills, like knot-tying in minimally invasive surgeries. “The goal is to create a pre-trained novice,” he explains. “The simulation isn’t meant to replace the participation in the operating room. It is meant to enhance it. No one would say to someone, ‘Here’s a violin, watch closely while I play it. Practise it once a week on your own and then you are going to perform a concert.’”
When Dr. Ashamalla’s surgical trainees enter the operating room, they already have the basic skills. They are much more comfortable and confident, and therefore are much more prepared to learn.
“If a trainee enters the OR and their main focus is how to hold the instruments while the attending surgeon is teaching a more complex aspect of the surgery, the trainee will absorb very little of this,” he says. “They are concentrating on holding the scalpel right. Through simulation, holding the instrument becomes routine for the trainee and so they can absorb the other important information from the teaching surgeon – and become more advanced. This improves their technical skill at a much more efficient pace. Whether it’s swinging a golf club, playing the piano, landing a jet or removing a cancer, technical skill will always be dependent on intense practice and repetition, and there lies the value of simulation.”
For cardiac surgeon Dr. Fuad Moussa, using simulation to teach the highly technical off-pump coronary artery bypass procedure just made sense.
After a heart attack – caused by a narrowing or blockage in the arteries that supply blood to the heart – a cardiac surgeon builds a graft to go around the blockage and open the blood flow. Usually, the heart is stopped and the grafts are created. During off-pump coronary artery bypass (or beating-heart surgery) the cardiac surgeon builds the graft while the heart continues to beat on its own.
“It’s highly technical and challenging,” Dr. Moussa says. “Where I learned, 99 per cent of cases were done on a beating heart. To have the boss turn to you and say, ‘Okay, now your turn,’ it’s overwhelming. When I came to Sunnybrook, I knew I would have to teach this procedure. I thought, there has to be a better way to teach this than the way I learned it. There just has to be.”
Dr. Moussa set out to complete his master’s degree in medical education and develop a better way to teach beating-heart surgery, using simulation. Working in collaboration with engineers from Colombia, and an educational scientist at the Wilson Centre for Research in Education in Toronto, Dr. Moussa mapped out the operation. The team analyzed the steps involved and found certain reproducible elements throughout the procedure. They arranged the tasks from the lowest level of complexity to the highest, then broke them into four different learning steps in a workshop. From there, Dr. Moussa worked with engineering students at the Universidad Pontificia Bolivariana in Colombia to build the beating-heart simulator.
“We were then able to conduct the workshop with surgical residents,” he explains, “and found that the education using this framework for off-pump coronary bypass was effective and well-received by the participants.” He has since received a grant through the Sunnybrook Education Research Committee to study it further with the hope it will be added to the cardiac surgery curriculum at the University of Toronto in the near future.
Post-graduate cardiac surgery resident Dr. Dimitrios Tsirigotis participated in Dr. Moussa’s simulation session in August 2011. He was quite early in his surgical development at the time and reports the exercises were beneficial.