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Macfie R, Walcott-Sapp S, Watson J, Haley C, Dewey E, Schipper P. Association Between Simulation Curriculum and Learners’ Confidence and Interest in Cardiothoracic Surgery. JAMA Surg. 2018;153(10):968–969. doi:10.1001/jamasurg.2018.1762
The use of simulation-based training for teaching new procedures is rapidly progressing; however, best practices have yet to be defined.1,2 We describe the association between a longitudinal simulation curriculum and learners’ interest and confidence in performing cardiothoracic (CT) surgery.
Medical students (n = 31), general surgery residents (n = 26), and CT fellows (n = 15) participated in 7 unique, tissue-based simulations proctored by CT faculty (n = 6) from July 2015 to July 2017. Faculty proctored simulations relevant to their specialty. Following each simulation, participants completed an 11-question survey developed for this curriculum rating their confidence and interest levels before and after participation.
The Oregon Health and Science University Institutional Review Board approved this study. Oral informed consent was obtained from all participants in the study.
Seventy-two learners participated (Table). The median year of training was postgraduate year 3. Training level was proportionately represented across the simulations (mean level of training PGY-4 for heart transplant; PGY-3 for tracheal anastomosis; PGY-2 for lobectomy, large-vessel anastomosis, chordal replacement; PGY-1 for open thoracotomy; MS4 for coronary anastomosis); P = .57 for association between level of training and simulation.
Participation in the CT simulation curriculum significantly increased learners’ operative confidence across training levels (Table). Of participants who were not confident prior to participation, 75% (33 of 44) increased their confidence by 1 or more level; 39% (17 of 44) increased by 2 or more levels.
Participation in the simulation curriculum increased participants’ interest in CT surgery (Table), and the magnitude of increase was significantly greater for learners early in their training (magnitude increase, 43.06 for medical students, 29.17 for postgraduate year 1-4, and 27.78 for postgraduate year 5 to fellow level; P = .001). Across experiences, 82% to 100% of participants ranked the simulations as good or great in effectiveness; 100% would recommend the curriculum to a colleague.
Tracheal anastomosis, lobectomy, and chordal replacement most positively affected interest; 83% of participants (25 of 30) in these simulations reported a moderate or significant increase in interest. Heart transplant least positively affected interest, with 67% of participants (2 of 3) reporting a moderate or significant increase in interest.
Learners of all levels were challenged; 41% to 80% of participants ranked each simulation as difficult or very difficult. Moderate to much guidance across all simulations was needed by 50% to 100% of the participants.
We face a projected shortage of CT surgeons.3 To our knowledge, this is the first study documenting increased interest in CT surgery after participation in a simulation curriculum.
Two participants reported decreased confidence: 1 went from very to moderately confident in large-vessel anastomosis, and the other moved from a little to not at all confident in open thoracotomy. We believe that these results relate to our finding that participants of all levels found these simulations challenging. The combined results suggest that the curriculum is a valuable learning tool across training levels.
Training level may influence change in interest. Fellows have committed to CT surgery; therefore, simulation may have a smaller influence on their interest than for medical students. This difference in interest is reflected in the weaker positive result of the heart transplant simulation in which the median training level was fellow level. However, when responses are sorted for neutral or negative results compared with any increase in interest, there are no significant differences in responses across levels of training.
Our survey was designed to capture subjective variables, including self-reported change in confidence and interest. Although this is not an externally validated tool, it is modeled on other surveys used for subjective evaluation of the simulation experience.2 Simulation has been shown to improve technical skills4,5; however, we have not established the contribution of this curriculum to technical development.
Although participants reported an increased interest in a CT surgery career, longitudinal studies are required to evaluate whether simulation participation translates into completion of CT fellowship. This was a single-institution study with trainees of various levels, which limits the generalizability.
This longitudinal cardiothoracic simulation curriculum significantly increased participants’ operative confidence and interest in CT surgery. Learners accepted these methods and would recommend them to colleagues. Simulation-based training can help to attract and train the next generation of cardiothoracic surgeons.
Accepted for Publication: March 31, 2018.
Corresponding Author: Rebekah Macfie, MD, Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L223, Portland, OR 97329 (email@example.com).
Correction: This article was corrected on November 7, 2018, to fix a misspelling in an author name.
Published Online: July 11, 2018. doi:10.1001/jamasurg.2018.1762
Author Contributions: Dr Schipper had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Walcott-Sapp, Watson, Haley, Schipper.
Acquisition, analysis, or interpretation of data: Macfie, Walcott-Sapp, Watson, Haley, Dewey.
Drafting of the manuscript: Macfie.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Macfie, Dewey.
Administrative, technical, or material support: Macfie, Haley, Schipper.
Conflict of Interest Disclosures: None reported.
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