Better and safer training for surgeons

2 May 2014

The first large-scale study into simulation-based medical training finds that proficiency-based training produces a significantly superior skill-set when compared to a traditional training programme.

The study carried out by the Arthroscopy Association of North America (AANA) was led by Richard L. Angelo, M.D. (Past President, AANA) in collaboration with Richard K.N. Ryu, M.D. (Past President, AANA), Robert A. Pedowitz, M.D., PhD,  and Anthony G Gallagher (Professor, ASSERT for Health Centre, University College Cork, Ireland).

The Arthroscopy Association of North America has a long history of providing cutting edge arthroscopic skills training.  The Copernicus Initiative has revolutionized the value of Proficiency-Based Training (PBT) methods on arthroscopic skill acquisition making better, safer training for surgeons.”   J.W. Thomas Byrd, MD, President, AANA.

The objective of the study was to analyse whether proficiency-based training for a complex minimally invasive arthroscopic surgical procedure produces better surgical skills and an increased margin of safety.  At their annual clinical conference Dr. Rick Angelo will report on the results which addresses the question of ‘How Do We Optimally Educate and Train Surgeons to perform Arthroscopic Surgery? Lessons Learned from the Copernicus Project’. He will describe and explain the results from the largest and most comprehensive multicentre, prospective, randomized, blinded assessment of proficiency-based progression simulation training for a surgical procedure (i.e., an arthroscopic Bankart repair).   

The Arthroscopy Association of North America (AANA) has had teaching and education at it's forefront since its inception over 30 years ago.  The Copernicus Project, conceived and nurtured by Dr. Angelo, is the latest and an excellent illustration of that education mission.  The metric development and verification process have been challenging and time consuming.   We congratulate Dr. Angelo and his committee's dedication and landmark accomplishments! Dr Bill Beach, MD.

Background: Traditionally, surgeons have trained in an apprenticeship model in which observation, exposure to surgery, and graduated practice serve as the framework and working long hours over many years is the norm. Changes in work practices and medical technology have considerably challenged this approach to learning procedural medicine such as surgery.  There appears to be an emerging global consensus from professional bodies and health care training organizations that basic procedural skills training should not occur on patients in the operating room. Procedure-based trainees, including surgeons, should acquire basic procedural skills outside of the surgical theatre before operating on patients. For the past two decades, proficiency-based progression coupled with simulation has been proposed as a viable method to support and augment current training practices.  A number of well controlled studies provide quantitative evidence supporting this conclusion. These studies have, however, been single site or institution investigations and it is unclear whether the enhanced training effect is generalizable to other programs and trainees.

A Bankart surgical procedure involves reattachment and tightening of the torn labrum and capsule of the shoulder. This is usually done using sutures and small bone anchors using a minimally-invasive surgical technique. The glenohumeral joint provides 60% of shoulder motion and is a modified 'ball and socket joint'. The humeral head moves in a complex manner over the glenoid with a combination of rolling, gliding and sliding actions.

Method: Orthopedic surgical residents in Post Graduate Year 4 and Year 5 from 21 ACGME (Accreditation Council for Graduate Medical Education) approved residency training programs across the US completed a weekend arthroscopic shoulder course.  Surgical residents were randomized to traditional training (Group A), a modified Bankart curriculum adding the use of a shoulder model simulator (Group B) and the exact same curriculum with a requirement to demonstrate the ability to meet a quantitatively defined proficiency benchmarks at various technique stages before being permitted to progress in training (proficiency based progression or PBP: Group C). At the end of the weekend course all residents completed an assisted but un-aided three-anchor Bankart procedure. Their performance was videotaped in its entirety and assessed independently by two senior surgeons blinded as to the subject or training group.

Results: The PBP group (Group C) made significantly fewer objectively assessed intra-operative errors (i.e.,~ 60%) than the traditionally trained group and ~46% less than the modified Bankart (simulator) curriculum group. 83% of residents from Group C,. 50% of Group B, and 36% of Group A were able to attain a pre-defined skill benchmark at the completion of the week-end course.  Logistic Regression Analysis of the data also revealed that those who met the intermediary proficiency benchmarks in Group C were 9 times more likely to achieve the proficiency benchmark on the final repair than the control group (A), and simply participating in the Group C training protocol (those who did and those who did not achieve intermediate proficiency) were over 5 times more likely to meet the final proficiency benchmark than the control group.

Conclusion: This is the most robust clinical validation trial of proficiency-based training employing simulation for a surgical procedure. It is also the first large-scale national study of this design which has been conceived, conducted and led by a professional surgical organization. The results show that PBP simulation training produces a significantly superior skill set and greater margin of safety when compared to a traditional and an archetypal training curriculum.

“The Copernicus Initiative represents a true paradigm shift in surgical training.  Historically surgical education has been intuitive and based on repetition, believing that operating room competency was the end product.  For the past three and half years, under the leadership of Rick Angelo and his team, heretofore unrealized surgical metrics have been painstakingly ascertained which has led to PBT (Proficiency Based Training), the preferred and now scientifically validated standard for surgical training at all levels, “ Dr. Richard Ryu.

Dr Robert Pedowitz said, “The Copernicus project is likely to be a landmark study in Orthopaedic education.  In my opinion, we are embarking upon a paradigm shift from apprenticeship education to proficiency-based training in the surgical fields.  These changes will fundamentally affect curriculum design and assessment of surgical competency. The Copernicus project is an important milestone in this significant transition.”