Training, assessment and competency in gynaecologic surgery

doi:10.1016/j.bpobgyn.2005.09.006

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 20, Issue 1, February 2006, Pages 173-187

https://doi.org/10.1016/j.bpobgyn.2005.09.006 Get rights and content

Abstract

The trainee gynaecologist requires specific teaching to achieve competency in gynaecological surgery. Basic skills such as knot tying and suturing should be acquired outside the operating theatre. They can be learned on simulations, including bench models, using synthetic materials, life-like models and animal tissue. Video training equipment is useful for the development of basic laparoscopic hand–eye coordination. Intermediate and advanced skills require simulations using more sophisticated bench models, live animals and virtual reality computerised systems. Structured teaching and assessment methods are essential. Surgical skills training models should be reliable and valid, and can be incorporated into an objective structured clinical examination, which could be used to assess individual development and allow progression through a training programme. Simulation training does translate into improved operative performance. Supervised operating experience on patients is crucial to training and should be assessed regularly using a global rating form with constructive feedback to facilitate improvement.

Section snippets

How have we been training our gynaecologists?

Historically, we have enjoyed a form of apprenticeship system. Nearly all of the surgical skills are learned on patients. Until recently, there was a surfeit of patients on whom to practice and develop surgical expertise. Most of the training in gynaecology was restricted to operations on the female genital tract and little or no emphasis was placed on the general surgical procedures that might be needed in routine or complicated gynaecological operations. Current trainees in the UK and

Is there a need to change our methods of surgical training?

Educators in obstetrics and gynaecology, and a recently graduated trainee, have documented their concerns regarding the adequacy of gynaecological surgical training and made recommendations for improvement.2, 4, 5 Gurtcheff suggested an emphasis on the basics of surgical training, a solid foundation of anatomical knowledge, excellence in surgical technique, regular appraisal with constructive feedback and lots of surgical practice.²

There are many reasons why our current trainees are unhappy

Which surgical skills are essential for a gynaecological surgeon?

Technical surgery is a ‘core competency’ for a practising surgeon, but is only one of the essential competencies for the modern practitioner (see Box 2). The acquisition and safe performance of a wide range of surgical skills is the accepted business of being a surgeon and must not be devalued. The basic skills outlined in Box 1 can be learned outside the operating room but must be supplanted by advanced skills including the satisfactory performance of specific operations related to the female

What are the principles of teaching and assessing a surgical skill?

The basic surgical skills can be taught on patients but initial training using laboratory models is preferable.⁷ Most operations can be broken down into a sequence of events, all of which require generic skills, such as tissue dissection, knot tying, suturing. These and more advanced skills, such as repair of an enterotomy or laparoscopic suturing, require teaching and learning. The importance of skills training and assessment in general surgery has been reviewed.8, 9

Patients

Patients are commonly used for surgical training, although most would be horrified to think that basic skills were to be learned on them during a possibly complex operation. It makes sense to practise suturing techniques and knot tying on bench models. However, the amalgamation of all the relevant skills into an ‘operation’ is best learned on patients, under intense structured supervision. An operation can be reduced to its component ‘steps’, which can be learned and mastered over a number of

Which skills training and assessment methods can realistically be incorporated into modern surgical teaching?

We recommend that live patients should not be used for basic surgical skills training as many other reliable and valid models are available. Any of the models described above are suitable: synthetic and ex vivo bench models, animals and virtual reality systems. The actual teaching of the skill should be separated from the assessment process.⁴⁵

The choice of training model will depend on the availability of laboratory space, animal facilities, teachers, technical support and funding. Animal

How can we assess the competency of our trainees in performing various surgical operations?

Following satisfactory completion of a laboratory-based skills training programme, our trainees will progress to operating on patients under supervision. We recommend using a global assessment form on a regular basis during the operative training period to provide regular objective formative feedback regarding competence to perform a particular operation. The RANZCOG is currently finalising the incorporation of a global assessment form to document procedural competency in trainees allowing

How can we assess the surgical competence of practising gynaecologists?

This is a controversial area. Most continuing professional development programmes rely on the accumulation of ‘points’ obtained from various postgraduate educational activities, including attendance at scientific meetings, surgical and other workshops, practice and outcome audit, and completion of self-directed learning tasks. None of the specialist Colleges requires revalidation of surgical competency, although the profession is under significant scrutiny by the public and the media. We

Summary

Surgical training should commence in the laboratory using simple simulations to learn basic surgical skills. This should be followed by intensely supervised surgical experience on patients in the operating room. More sophisticated models should be used to develop advanced skills, which can then be incorporated into complete surgical operations in a supervised environment. Structured and objective assessment of both laboratory and operating room performance should be an integral part of any

Acknowledgements

We thank Dr Russell Land for his constructive review of our manuscript. We thank the RANZCOG for allowing us to reproduce the proposed schema for global competency assessment of trainee performance of surgical procedures.

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Midwifery students' opinions about episiotomy training and using virtual reality: A qualitative study
2024, Nurse Education Today
The use of simulations and digital technologies in education in the health field is common. Virtual reality technologies, which offer three-dimensional (immersive) simulation environments, have become easily accessible and cost-effective in recent years and this has this has increased this use of this technology in educating students who will work in the health field.
The aim of the study was to investigate the views of midwifery undergraduate students about the current episiotomy education they received and their expectations when related education is given with virtual reality technology.
Students in their third or fourth year of undergraduate midwifery who have taken prior episiotomy education.
The research was carried out as a phenomenological design for qualitative research. Data were collected between December 2022 and January 2023 at a public university in Türkiye, with institutional ethical approval.
Participants were asked open-ended questions to collect qualitative data. Data were analysed using content analysis by MaxQDA.
Data were analysed, and four main themes were determined. These main themes consisted of 16 sub-themes, and included midwifery department students' positive and negative opinions about the current episiotomy education and their expectations in cases where the education is carried out using virtual education environments.
Although the current episiotomy education has positive aspects, such as suturing ability, it does not give a sense of reality, is not repetitive, and has many negative aspects, such as cost. It was determined that in virtual reality episiotomy education environments, students' expectations are similar to the real birth environment, and they have expectations of simulating risky situations because they think it will be more useful.
Changing the way we train surgeons in the 21th century: A narrative comparative review focused on box trainers and virtual reality simulators
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
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Minimally invasive surgery is considered the preferable surgical approach for a variety of benign and malignant gynaecologic conditions [4,5]. The introduction of highly sophisticated endoscopic equipment facilitates advanced laparoscopic surgery [6], but at the same time requires a minimum level of surgical expertise, prior to applying this technology in a real setting [7]. The concept of simulation offers the opportunity of problem-solving and familiarization with the advanced technological equipment of endoscopic surgery, in a controlled and safe environment.
The traditional method of acquiring surgical skills by observing and assisting in surgical procedures involving human beings has been challenged during the past several years. Lessons obtained from aviation suggested that the use of simulators is related to reduced costs, increased efficiency in performing certain tasks and above all safety. A shift in paradigm is also required in modern surgical training. The development of endoscopic surgery allowed for the incorporation of medical simulators into training programmes. A review of the literature was conducted using specific inclusion and exclusion criteria, for articles published up to July 31th, 2018. Relevant studies were identified using computerized bibliographic searches of MEDLINE database. The keywords that were used in various combinations were: “Medical Simulators”, “Surgical Training”, “Laparoscopy”, “Surgical Skills”, “Box trainers”, “Virtual reality simulators”, “Surgical Education”. Surgical training with box trainers and/or virtual reality simulators confers a significant benefit in terms of surgical skills development, increases patient safety and reduces costs. Nevertheless, the use of virtual reality simulators was significantly more expensive. Simulation training allows trainees to learn from their mistakes, to repeat surgical tasks multiple times so as to establish muscle memory, and enhance skill competency with the aid of informative feedback. Simulators are necessary for the development of the skills required to meet the specific needs of endoscopic surgery in the 21st century. Teaching hospitals should introduce simulation training programmes in order to increase efficiency, reduce costs and improve patient safety. As medical advancements continue to transform the way we perform surgery day by day, simulation training will play a pivotal role in every surgical specialty.
Effect of episiotomy training with beef tongue and sponge simulators on the self-confidence building of midwifery students
2018, Nurse Education in Practice
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During simulation-based training, the use of materials, which are considerably similar to human tissues, is critical for the long-term success of training while performing episiotomy on laboring women (Hammond and Karthigasu, 2006). The necessary skills for episiotomy may be gained via simulation-based training on a synthetic material or dead animal tissue (Hammond and Karthigasu, 2006). As a synthetic material, sponge is easy to prepare, cheap, and simple; whereas, as a dead animal tissue, beef tongue, takes time to prepare and is expensive.
This study assesses the efficacy of simulation-based episiotomy training (SBET) with beef tongue and sponge models in terms of the self confidence of midwifery students while performing episiotomy. Third-year midwifery students from Cumhuriyet University in the fall semesters of 2011 and 2012 were enrolled in the sponge and beef tongue model groups (n = 36 and n = 37, respectively). A checklist was prepared on the required skills for performing episiotomy which can be broken into three main parts, namely preparation, cutting and repairing and completion. According to the checklist, a Likert type questionnaire was developed including 5 items for preparation, 11 items for cutting and repairing, and 6 items for completion. After SBET with the sponge and beef tongue models in our laboratories of Midwifery Department, the students performed episiotomy steps in laboring women in Sivas State Hospital and then they filled in the questionnaire to indicate whether they gained self-confidence in performing episiotomy or not. Although, participants of both groups have successfully completed all the steps of episiotomy, overall, beef tongue model was found to be more successful regarding their self-confidence (p < 0.05), including the skills in performing local anesthesia; choosing needle holder, suture material and scissor for cutting; identifying apex, hymen and skin; using needle holder properly while penetrating into the skin, suturing vaginal mucosa until hymen, knotting, and suturing perineal muscles and skin. Our results suggest that while SBET with both models are applicable for episiotomy training of midwifery students in the laboratory setting, SBET with beef tongue model provides an additional increase in their self-confidence in the clinical settings.
A model to teach concomitant patient communication during psychomotor skill development
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However, the evidence also suggests these skills should not be taught concurrently, because doing this places both inexperienced and experienced clinicians into cognitive overload. Currently, psychomotor skills are taught and acquired in simulation-based or patient-based learning environments using a range of skill teaching models (for examples see George and Doto, 2001; Walker and Peyton, 1998; Raman and Donnon, 2008; Hammond and Karthigasu, 2006). Some of these models include an instructional routine which requires the learner to verbalise the skill step(s) before performing the task (for example Walker and Peyton, 1998; George and Doto, 2001).
Many health professionals use psychomotor or task-based skills in clinical practice that require concomitant communication with a conscious patient. Verbally engaging with the patient requires highly developed verbal communication skills, enabling the delivery of patient-centred care. Historically, priority has been given to learning the psychomotor skills essential to clinical practice. However, there has been a shift towards also ensuring competent communication with the patient during skill performance. While there is literature outlining the steps to teach and learn verbal communication skills, little is known about the most appropriate instructional approach to teach how to verbally engage with the patient when also learning to perform a task. A literature review was performed and it identified that there was no model or proven approach which could be used to integrate the learning of both psychomotor and communication skills. This paper reviews the steps to teach a communication skill and provides a suggested model to guide the acquisition and development of the concomitant -communication skills required with a patient at the time a psychomotor skill is performed.
Construct Validity of a Simple Laparoscopic Ovarian Cystectomy Model Using a Validated Objective Structured Assessment of Technical Skills
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To determine the construct validity and interrater reliability of a laparoscopic ovarian cystectomy simulator using a global rating scale.
Prospective blinded observational study (Canadian Task Force classification II.3).
Academic teaching hospital.
A total of 26 postgraduate year (PGY) 1 to 4 gynecology and obstetrics residents were recruited (15 junior residents, postgraduate year PGY 1–2 and 11 senior residents, PGY 3–4).
We developed a simple, low-cost laparoscopic ovarian cystectomy simulator and incorporated it into our simulation curriculum. The simulation was directed at junior residents with instruction and immediate feedback in a scheduled simulation session once during the academic year. At the end of the year resident skills assessment, all levels were recorded with video using this model to assess the construct validity between junior and senior residents. Resident performance was later evaluated and scored by 2 blinded, experienced laparoscopists using a validated Objective Structured Assessment of Technical Skills (OSATS).
Each resident received a unique identification number and the simulated laparoscopic ovarian cystectomy procedure was filmed during the end of the year assessment. Two blinded raters evaluated the video of each resident with the modified Global Rating Scale (OSATS), using 5 of the 7 domains (respect for tissue, time and motion, instrument handling, flow of operation and knowledge of specific procedure). An average of the 2 ratings was computed for each domain, and comparisons were made using the Mann-Whitney U test. Interrater reliability was calculated using the Kendall tau β correlation coefficient. Construct validity was determined by comparing the rank scores of the junior to senior residents in each domain. Construct validity and interrater reliability was demonstrated in all of the measured domains except for respect for tissue.
This simple, low-cost model can be used to teach important laparoscopic ovarian cystectomy skills. Construct validity discriminating between junior and senior residents was demonstrated using this model.
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Simulation technology offers the added benefits of repetition, the ability to be used at the learner's own pace, and the generation of learner-centered performance evaluation with objective feedback [11]. While each of the above discussed modalities has been noted to be helpful in surgical training, whether it be inanimate models, cadaveric dissections, or animal-based procedures, this does not negate the fact that supervised inpatient training is also needed [12]. Thus, while other surgical training modalities can supplement the surgical education of gynecologic oncology fellows, the caseload exposure must also be addressed.
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We queried the University HealthSystem Consortium (UHC) database to determine the total number of urinary diversions performed from October 2008 to August 2012. This data was used to estimate the mean number of urinary diversions performed each year. Gender, primary diagnosis, type of diversion, gynecologic oncologist involvement, and medical center were explored.
Of the nearly 21,000 urinary diversions performed in UHC participating hospitals during the study period, 6180 (29.5%) were performed in women. On average, 1648 urinary diversions are performed in women each year, with gynecologic malignancies accounting for 6.8% of cases. We estimate that a gynecologic oncologist was involved with 87 cases per year at nonprofit academic medical centers in the US. With approximately 112 clinically active fellows per year during the study period, this equates to less than one diversion per clinical fellow per year if cases are equally distributed among centers. However, the majority of urinary diversions with gynecologic oncologist involvement were performed at just a fraction of centers. Thus, only a small contingent of fellows may be getting the greatest exposure to urinary diversions.
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10Training, assessment and competency in gynaecologic surgery

Abstract

Section snippets

How have we been training our gynaecologists?

Is there a need to change our methods of surgical training?

Which surgical skills are essential for a gynaecological surgeon?

What are the principles of teaching and assessing a surgical skill?

Patients

Which skills training and assessment methods can realistically be incorporated into modern surgical teaching?

How can we assess the competency of our trainees in performing various surgical operations?

How can we assess the surgical competence of practising gynaecologists?

Summary

Acknowledgements

American Journal of Surgery

Lancet

American Journal of Surgery

Obstetrics and Gynecology

American Journal of Surgery

American Journal of Surgery

Obstetrics and Gynecology

American Journal of Surgery

American Journal of Surgery

Gynecologic Oncology

Gynecologic Oncology

Obstetrics and Gynecology

Gynecologic Oncology

Obstetrics and Gynecology

Journal of the American College of Surgeons

American Journal of Surgery

The Journal of the American Association of Gynecologic Laparoscopists

The Journal of the American Association of Gynecologic Laparoscopists

American Journal of Surgery

American Journal of Obstetrics and Gynecology

American Journal of Surgery

American Journal of Surgery

Journal of the American College of Surgeons

American Journal of Surgery

British Journal of Obstetrics and Gynecology

American Journal of Surgery

Anatomy of complications workshop: an educational strategy to improve performance in obstetricians and gynaecologists

The Australian & New Zealand Journal of Obstetrics & Gynaecology

Training the gynecologic surgeon: a (recently graduated) resident's perspective

Obstetrics and Gynecology

Training the gynecologic surgeon

Obstetrics and Gynecology

Training of a gynecologic surgeon

Obstetrics and Gynecology

A comparison of operative experience for basic surgical trainees in 1992 and 2000

The British Journal of Surgery

Objective assessment of technical skills in surgery

The British Medical Journal

10
Training, assessment and competency in gynaecologic surgery