Abstract
Although proficiency training will never completely replace the apprenticeship model, improvement in arthroscopic surgical-simulator technology permits students to spend less time observing and more time doing. The best models and simulators allow measurement and documentation of skill-based progression. Once basic skills have been satisfactorily demonstrated, trainees transitioning to actual operative arthroscopy should be expected to contribute to safer and more efficient patient care while continuing to learn and improve.
“Practice is the best of all instructors.”-Publilius Syrus, c. 50 BC
Since 1918, when Japanese Professor Kenji Takagi used a cystoscope to view the interior of a cadaveric knee, surgeons have been attempting to improve the education of future generations of arthroscopic surgeons. Initially, trainees participated in one-on-one apprenticeships, but using this approach, hapless students primarily observed the back of their mentors' heads because intra-articular visualization was through a single eye piece allowing only one eye at a time to gaze through the lens. Training was painstaking because when the surgeon offered the student a peek, the arthroscope would frequently move during the resultant hand-off, changing the field of view before the student had an opportunity to see the pathology. The subsequent development of a “teaching scope,” an arthroscope with a beam splitting arm enabling both surgeon and student to view simultaneously through separate eyepieces, was a breakthrough that greatly enhanced instruction and learning. Today, with the advent of modern optics and video cameras, everyone in the surgical suite is able to view the surgical proceedings.
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Nonetheless, arthroscopic techniques were still taught one-on-one when AANA Past President, Dr. Robert W. Jackson visited Japan and studied under the “Father of Modern Arthroscopy,” Dr. Masaki Watanabe. Jackson is credited for bringing the arthroscope to North America, and soon thereafter, as the value of arthroscopy became widely manifest, one-on-one apprenticeship training was no longer practical. Beginning in 1968, instructional courses such as those taught at the American Academy of Orthopedic Surgeons Annual Meeting as well as the Metcalf Course were developed to teach surgeons in groups.
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But arthroscopic surgery requires technical skill, and observation does not guarantee proficiency. The leadership of our nascent Arthroscopy Association of North America realized that surgeons needed a permanent facility in which to learn and practice arthroscopic skills, and under the leadership of AANA Past Presidents John McGinty and Howard Sweeney, the Orthopaedic Learning Center (OLC) was developed in Rosemont, Illinois. With donations from industry and volunteerism on the part of countless surgeons, the OLC became a home for surgical training.
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Naturally and intuitively, a question was raised and persists to this day: What is the best method to train surgeons?
At the OLC and elsewhere, a model that proves popular includes a combination of didactic lectures and small group cadaveric stations, where many student arthroscopists can participate in active, hands-on learning. Unfortunately, cadaver specimens do not fully simulate live surgery. Several obvious limitations include the absence of bleeding, structural deficits affecting typical soft tissue tension (e.g. quadriceps and biceps tendon laxity), disarticulated limbs, and advanced degenerative changes. Moreover, cadavers are expensive, training sessions are variable, and in the end, surgeons require extensive experience to treat live patients. This brings us back to the apprenticeship model, typical of residency and fellowship training programs, and back to the broad question: What is the best method to train surgeons while maintaining patient safety and efficiency?
Thus, AANA Past Presidents Felix (Buddy) Savoie and Richard Angelo started the Magellan Project,
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attempting to “sail the world” in order to answer this question. What was discovered in other fields and on the Internet, was a concept of proficiency-based progression (PBP) as an effective method to optimize learning of technical and procedural skills. PBP entails a stepwise approach and requires mastery of basic skill tasks before advancing to more complicated tasks. Of course, the term “proficiency” requires precise definition. For example, what is a proficient knee diagnostic arthroscopy? Is it the ability to view all compartments within a certain period of time? Or, the ability to view all compartments without iatrogenic scuffing? Or both? And, once a definition of proficiency (for any given procedure) is determined, a reproducible measure of such proficiency must then be created.3
Recently, there have been many studies trying to do just this, using virtual-realilty simulators and benchtop devices4
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and even wearable sensors to measure economy of motion.12
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Once a model is deemed reproducible, it then needs to be validated.
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Using an Alex shoulder model as a simulator, and then a cadaveric model, Angelo, Ryu, Pedowitz, Gallagher, and other AANA leaders and scholars compellingly identified reproducible and measurable steps representing proficiency in performing an arthroscopic Bankart repair.17
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This was the AANA Copernicus Initiative, and as a result, PBP training, rather than classical apprenticeship training, is developing as the avowed new center of our arthroscopic training solar system.3
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So how is PCP training being implemented at the OLC today?
At the AANA Resident Courses, trainees no longer rush straight to the cadaver lab. Rather, the first day of the 3-day Resident Course is spent in a dry lab, where residents learn and perform basic arthroscopic tasks at knot-tying stations, Fundamentals of Arthroscopic Surgery Training (FAST) workstations,
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and computerized arthroscopy simulators.4
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In the experience of our first author and frequent AANA OLC Resident Course Co-Chair, Michael Feldman, M.D., Resident Course participants would historically be frustrated because they attempted to perform complicated procedures before mastering the basics. For example, in a shoulder lab, a perfectly placed Bankart anchor would be wasted if the trainee went on to tie an “air knot.” Today, knot-tying stations are an example of the PBP training model. The first knots are tied using a large rope; once proficiency is demonstrated, knots are then tied using suture over a post. After additional proficiency is evident, knots are then tied using a knot pusher under simulated arthroscopic conditions, and furthermore, such knots are then evaluated by measuring quantifiable knot and loop security. In other words, participants receive immediate feedback on their technique, and must show proficiency before being allowed to progress. Absent such a demonstration, remedial instruction is implemented immediately, and by the time the student performs the Bankart shoulder instability repair, the air knot is not likely!17
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FAST workstations
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take things to the next level, allowing dry lab acquisition of basic arthroscopic tasks such as camera skills (centering, steadying, and tracking), ambidexterity, and triangulation. Trainees progress by first being permitted direct visualization of their surgical targets through a clear dome, and then being limited to arthroscopic (indirect) visualization as an opaque dome is introduced. As a first-hand witness to the introduction and development of PBP training, Dr. Feldman attests to the tangible and objective benefits of the dry lab curriculum.The addition of computerized, virtual-reality arthroscopic-simulator training to the OLC curriculum adds another level of sophistication to PBP training by providing trainees with spatial and tactile feedback while performing simulated arthroscopic maneuvers. Research clearly shows that simulator training can improve performance
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(on the simulator), and we anticipate that future research will demonstrate improved performance on real patients. Advantages of simulator training include less reliance on cadaveric specimens (which are limited), real-time tactile and visual feedback, ability to document and quantitate performance and progression, absence of degradation of specimens, and no limit to the number of procedures that can be performed. At the most recent Resident Courses, participants overwhelmingly extolled the benefits of the virtual-reality simulator session and noted that PCP training resulted in improved arthroscopic skills prior to their cadaveric training.What is the future of arthroscopic surgical education? Your editors are firm believers in PBP training using simulators, as well as PBP training using cadavers, as evidence-based teaching tools.
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Students of arthroscopy could spend less time observing and more time improving their skills. Only after basic and then advanced skills are satisfactorily demonstrated should trainees participate in hands-on care of patients, presumably to the benefit of all parties involved.References
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© 2017 by the Arthroscopy Association of North America
