The Incorporating of 3-Dimensional Skills on Surgery Education Would Improve Curricula

This article refers to:

Design of a Proficiency-Based Skills Training Curriculum for Our Newly Validated 3-Dimensional (3D) Laparoscopic Models, Using MISTELS

Surgical education is currently under pressures never seen before. The romantic idea of the Halsted method of learning surgery through “see one, do one, teach one” next to an expert surgeon who transfers his personal experience to future surgeons has been left behind. This classic method does not allow for the objective evaluation of surgical practice, which has become a necessity as defensive medicine driven by the desire of patients to obtain better surgical care has been increasing. A recent review from the USA showed that the main causes of claims paid were inadequate performance (55%) and technique (10%), which generated a cost of $1,868,476.00 [1]. Similarly, in UK the cognitive or motor trans-operative skills (failure/delay of treatment, intraoperative problems, inappropriate treatment, or delay in performing the operation) account for 52.8% of successfully closed claims [2]. On this topic, our residents are the most vulnerable population [3]. Although the causes of legal claims are multiple (e.g., the subjective appreciation of the patient, psychosocial pressures, etc.), these findings are indirect indicators of how we are failing to train and therefore teach our surgeons. The creation of more effective methods for learning surgery that allow for critical evaluation and therefore self-correction of surgical care has become obligatory, and international councils have tried to homogenize their curricula to accomplish this objective [4].

Over the years, new methodologies for surgery education have been created. These methodologies include problem-based learning, evidence-based medicine, and, more recently, entrustable professional activities [5]. All of these methods consider the learning of theoretical knowledge through pedagogical methods and the acquisition of technical and nontechnical skills, both motor and cognitive, to be the main objectives of the surgeon’s curriculum [6]. From this point of view, the teaching of surgery is a multidimensional process that includes a wide variety of activities with the aim of obtaining autonomy when performing specific surgical procedures. Nevertheless, the main core of surgical education is the achievement of advanced perioperative care skills, which involves the preoperative (communication and preparation of the patient for surgery), postoperative (evaluation of the strategy used and the results of the procedure), and the intraoperative (includes the application of cognitive and motor skills for a specific procedure) periods [7]. This last aspect is where the article that is the subject of this commentary adds interesting findings aimed at implementing a new curriculum on laparoscopic surgery to increase the effectiveness of skill acquisition [8].

The authors recruited 12 expert surgeons to carry out a simulation according to one widely validated method used routinely in laparoscopic training, the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills, with the variant of using a 3- instead of a 2-dimensional simulation. They designed scores based on the efficiency and time invested in carrying out five specific tasks. Once the tasks were completed, the three highest scoring surgeons designed the curriculum of a teaching plan for the surgeons in training. Although this is a good step in the right direction, it has deficiencies that can be improved. The authors eliminated surgeons accredited by the Fundamentals of Laparoscopic Surgery course, but it would have been more relevant to compare surgeons already certified to those not certified. Also comparing the efficiency between 2- and 3-dimensions could highlight the effectiveness of the results. Eliminating 9 out of 12 skilled surgeons can cause an internal consistency error because the “n” is too small for a formal analysis to be done to determine reliability. A later study could improve this error by making an intra-group comparison, establishing cutoff points to graduate the effectiveness of the technique between low, medium, and high efficiency. New prospective research oriented toward specific procedures and adapted to each surgical specialty is required. The differences between apprentices and experienced surgeons still need to be addressed, which could be done by comparing a control group with surgeons who just started their residencies and advanced surgeons to establish a learning curve. Despite these deficiencies, the objective of establishing a baseline is met to subsequently make a competency-based curriculum for surgical education.

The most important advance in this article is the addition of the simulation in 3 dimensions, which is closer to the reality of the intraoperative processes. Creating scenarios that are more like reality with its multiple controllable and noncontrollable variables is the desired point to achieve and evaluate the autonomy of the student in surgical education. Could we evaluate performance in a totally objective way through biological markers? Brain activity changes according to the temporal space location. This has not been sufficiently covered in the learning of surgery, but there are some interesting advances [9].

Does this approach result in a loss of humanity? On the contrary, the patient-centered with shared-decision medicine approach [10] must complement these new strategies, which are destined to improve surgical training by taking into consideration the patient’s needs. Defensive medicine has made us view surgical education as a procedure subject to traditional capitalist methods of offer and demand. As a result, we consider our apprentices to be future adversaries and eventually train our residents to be the opposition that would take users (patients) away from us, when the logic should be the complete opposite. We must think of our apprentices should be better than us at our age because it is the only way to guarantee a continuous improvement in the teaching of present and future surgeons. Progressive education only makes sense when our students exceed our achievements so they can demand the same from their respective students. That is what I call real-education.

Finally, we must think about what surgical procedures we are offering and how we are offering them to our patients. I suggest viewing each patient as the most loved person in our life and treating him/her accordingly. Otherwise, it would be better not to treat the patient at all because we would mistreat him/her. Once we consider the patient to be an entity that lives and suffers like any of our loved ones, the need to learn in the best way and therefore offer the best treatment will be just a repercussion. This is what be-loved-centered medicine means to me.

It is time to rebuild the practice of surgery with new bases that incorporate the best features of patient-centered medicine with shared-decision making, real-education, and be-loved-centered medicine. The acquisition of new technological tools and therapeutic strategies will be the logical consequence of having the ethical care of the patient be our highest priority.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

Author’s contribution

SC is the only author and responsible for the content and writing of this article.