Original ReportsUnanticipated Teaching Demands Rise with Simulation Training: Strategies for Managing Faculty Workload
Introduction
Using simulation for teaching and assessing learners represents a powerful approach to training. Simulation has been widely incorporated by various industries as an efficient and a cost-effective way to teach new skills, improve safety, and reduce costs.1, 2 The airline industry is often referenced in the simulation literature, and United Parcel Services has built a simulated town to teach new drivers how to efficiently and safely deliver packages with the goal of improving driver retention and safety.1, 3 Simulation has proven effective in surgery at decreasing the time it takes for medical students and beginning surgeons to become proficient at basic tasks such as suturing, placing catheters, and early laparoscopic skills.4, 5, 6, 7, 8, 9
There is no doubt that simulation is here to stay and is a valuable part of surgical education. In 2008, the Residency Review Committee mandated that a surgical skills laboratory be available for all general surgery residency programs. To meet the needs for simulation training, the American College of Surgeons, the Association of Program Directors in Surgery (APDS), and the Association of Surgical Education have put tremendous resources into building accessible surgical simulation-based curricula for residents and medical students.10, 11, 12 Since 2010, the American Board of Surgery has stated that surgical chiefs (graduates) must pass the Fundamentals of Laparoscopic Surgery in a simulated environment to sit for their boards, and by 2017 to 2018 they will also be required to pass the Fundamentals of Endoscopic Surgery using endoscopic trainers. It is likely that assessment in simulated environments will become more (not less) prevalent in future years as programs seek to measure competencies needed for semiannual milestone reviews for residents and fellows.
However, the implementation of a brisk surgical skills simulation curriculum comes with a cost. Some authors suggest that education in the simulation suite is less expensive than the operating room.4, 13 Many authors working to address the issue of cost and have focused on strategies such as reducing the price of simulators, using low fidelity simulators, reducing the number of disposable items, taking advantage of free items or grants from industry, and developing regional training sites.14, 15, 16, 17, 18 An issue commonly discussed but undocumented and unresolved in the literature is the issue of faculty time. We suspect that as surgical education moves from the operating room to the skills laboratory, it comes with a significant hidden cost in faculty time, even after curricula have been developed, adapted, and matured.16, 17, 18, 19, 20, 21 The accurate estimates of faculty time and related costs are difficult to obtain; values of $100 to $500 per faculty hour have been conservatively estimated.16, 22
Some simulators are built to be used independently by learners. This method is very efficient for faculty, but it still requires faculty involvement for providing overall direction and motivation, coaching, and assessment of the learners’ skills.19, 22 Most of the published surgical simulation curricula require hands-on involvement by faculty and low learner-to-instructor teaching ratios to ensure sufficient practice, feedback, and positive learner outcomes. Anecdotal, experiential wisdom strongly suggests, therefore, that the addition of required teaching assignments in the skills laboratory (on top of teaching during conferences and in the operating room) has resulted in increased faculty demands on their time and by extension, on costs to their departments. To our knowledge, however, the extent of these influences has not been formally reported in the literature. The purpose of this article is to estimate these influences by retrospectively studying changes in faculty workload that occurred at our own institution from 2006 to 2013, and by conducting a national survey of APDS program directors. Our research questions are:
- (1)
To what extent did the number of formal teaching assignments (hours) and associated teaching costs at the University of Minnesota (UMN), Department of Surgery, change with the advent of simulation-based training (2006-2014)?
- (2)
For what purposes do current APDS program directors use simulation-based approaches, and how do they staff these sessions?
- (3)
How do APDS program directors perceive the effect of simulation-based training on faculty teaching load?
- (4)
What strategies have APDS program directors found most effective for filling simulation teaching assignments and rewarding faculty for their involvement?
Section snippets
Methods
This is a descriptive study involving administrative data from the UMN Department of Surgery, and a volunteer sample of APDS program directors responding to an anonymous survey. In terms of the UMN setting, we are an academic program with approximately 80 clinical (full-time and adjunct) faculty members located at 5 hospital sites in the Twin Cities. We are approved to enroll 6 categorical general surgery residents per year. Our postgraduate year (PGY)-1 class averages 25 individuals, including
Results
Our first research question was to understand the effect of simulation-based training on our own program. As shown in Table 1, the total annual instructor workload for teaching medical student and resident events more than doubled from the AY2006 (498 hours) to the AY2010 (1148 hours). This increase was owing to not only implementing new curriculum, but also a number of multi-institutional research projects that we were conducting involving simulation. Between AY2010 and AY2013, we scaled down
Discussion
In this study, we attempted to fill a void in the literature on the quantitative influence of simulation on faculty workload and department costs. Using our program as an example, we used a centrally scheduled database to document the increase in faculty engagement in formal teaching events at 3 separate time points over an 8-year period. One of the strengths of this study is the completeness and accuracy of this database. Based on our data, we can say clearly that simulation has definitely
Summary
A robust simulation curriculum provides an efficient method to front-load skills for the learner, but it increases the time commitment for the faculty. Surgery education has always been expensive and will continue to be so. With the current environment of decreasing reimbursement, increased clinical demands, and reduction in graduate medical education funding, the cost shift of surgical education from the operating room to the simulation laboratory creates a significant expense for surgery
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