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 2008-2009 E.J. Wylie Traveling Fellowship Report

Erica L. Mitchell, MD
Oregon Health & Science University
Portland, Oregon

I devoted my E.J. Wylie Traveling Fellowship to enhancing my knowledge of surgical education with the eventual goal of becoming a leader in vascular surgical education. I would like to thank the Lifeline Research and Education Committee of the American Vascular Association for their courage and insight in recognizing surgical education as an important current and future component of vascular surgery and a valid course of academic pursuit. The E.J. Wylie Memorial Travelling Fellowship provided me the opportunity to meet with, and learn from, world leaders in surgical education, specifically with regards to surgical simulation and the development of surgical skills laboratories. Every program I have visited and contact I have made has in some way impacted my academic focus, line of research, and career as a surgical educator. The friendships that I have made and the mentoring relationships that have developed out of this fellowship have and continue to play a role in my career advancement, academic goals, and have enriched my life tremendously. For all this I am very grateful to the Lifeline Research and Education Committee.

Background

As we all recognize the current trend in surgical training is a move away from the traditional Halstedian apprentice model of graded responsibility to a more structured curriculum-based approach requiring documentation of proficiency. Traditional resident educational paradigms have shifted as a result of changes in health care over the past decade. Given these changes my application for the Wylie Fellowship was directed towards the science of surgical education.

Imperial College-St. Mary’s Hospital, London, UK

The Department of Biosurgery and Surgical Technology, headed by professor the Lord Ara Darzi of Denham, is a leading center internationally for virtual reality simulation training research.  Much of the work on technical skills training and assessment has been conducted here, and the department boasts a virtual reality simulation laboratory, virtual operating suite, and strong collaboration between scientists and clinicians.

I was honored on my visit to Imperial College, London to be hosted by Mr.  John Wolfe. Mr. Wolfe has conducted the majority of studies on open vascular surgical skills training and is well known for his contribution to open vascular skills training through the Pontresina Vascular Workshops. Mr. Wolfe introduced me to the concept that whereas basic models or partial task trainers allow for simulation of a specific or individual skill; procedure-specific trainers, such as utilized in his research, allow for simulation of a group of tasks in chronological order of an operation or part of an operation. John Wolfe and colleagues demonstrated that a synthetic bench top carotid endarterectomy model (Limbs & Things, Bristol, UK) is a valid tool for the evaluation of basic technical skills in the performance of CEA and allows for acquisition of the basic skill components of a CEA (order of the clamp placement and removal, site of the arteriotomy incision and basic considerations of the endarterectomy) before moving to the operating room.

Mr. Wolfe kindly made arrangements for me to me to meet with Dr.’s Isabelle van Herzeele and Raj Aggarwal who are responsible for most of the work, in collaboration with Nick Cheshire, on endovascular simulation training. Dr. van Herzeele has just completed a PhD from Ghent University Hospital, Gent, Belgium, focusing on virtual reality endovascular simulation. Dr. Aggarwal is known internationally for his work on open and laparoscopic simulation training, team training and curriculum development. The work conducted by this group at Imperial College is impressive. Their research has sought to demonstrate the face and construct validity of virtual reality endovascular simulators. Although the transferability of endovascular skills acquired by computer-based simulation to real life remains to be proven, their effectiveness as training tools has been validated.

My visit to Imperial College consolidated my desire to focus my academic pursuits on vascular surgical education. I am now enrolled in the Masters of Surgical Education program at Imperial College to start this fall. The visit also resulted in collaborative work with Dr.’s van Herzeele and Aggarwal. We have just completed a chapter on “Simulation in Vascular Surgery” to be published in the first edition of the Textbook of Simulation, Surgical Skills and Team Training.

Sheffield Vascular Institute, Sheffield, UK

My tour to the United Kingdom also included a brief visit to Northern General Hospital in Sheffield to meet Dr. Jonathan Beard. Dr. Beard is a leader in the assessment of surgical skills in the laboratory and the operating room and has been involved in setting national standards for the assessment of operative competence. Dr. Beard discussed with me the current work being conducted in the UK with regards to development of problem based assessment forms for operative evaluation and the development of a rating system for surgeons’ non-technical skills. I received encouragement from Dr. Beard to develop similar evaluation tools here in America. As a result of this visit and the influence of Dr. Beard I have developed operative evaluation forms for core open vascular procedures to be utilized in the vascular surgery residency at our university.

Southern Illinois University School of Medicine, Springfield, IL

The Southern Illinois University (SIU) Department of Surgery, chaired by Dr. Gary Dunnington, is internationally renowned for their work in surgical education and the development of surgical skills laboratories.  Dr. Rob McLafferty, a former Oregon Health & Science University (OHSU) vascular resident, and his family graciously hosted my visit to SIU. I met with Jenny Bartlett and Janet Ketchum the surgical skills lab coordinators responsible for coordinating the activities in the lab. They were instrumental in showing me the essential components of the lab and lab curriculum. Reed Williams, PhD and Vice Chairman for Educational Affairs, also directed me on how to incorporate modules for the verification of proficiency into the OHSU vascular skills lab curriculum. Dr. Williams and Dr. Hilary Sanfey provided advice on how to develop and validate the assessment tools I am working on for the assessment of open operative performance. I also had the privilege of meeting with Dr. David Rogers, the current president of the Association of Surgical Education (ASE).  Dr. Rogers strongly influenced my decision to pursue formal training in the surgical education. Through his direction I applied for and was accepted to the SERF program (Surgical Education Research Fellowship) sponsored through the ASE. This program pairs novice researchers with mentors experienced in surgical education research.  Through this program I am conducting research on the educational value of morbidity and mortality conference. My mentor, Nick Sevdalis PhD, is a lecturer in patient safety at the Imperial College in London. In addition to providing insightful career advice, Dr. Rogers also provided invaluable support for a course I will be providing at OHSU for 4th year medical students. This course mirrored on the “resident readiness” course at SIU and offers an intense one month program designed to prepare students already matched in surgery for the rigors of internship. I am grateful to Maggie Boehler and Cathy Schwind for all of the help they provided as well in this area.

University of California- Davis, Sacramento, CA

I travelled to California to visit the University of California, Davis (UC Davis) and Stanford programs. The timing was coordinated so that I could observe Dr. David Dawson’s 2009 Endovascular Simulation Training for Vascular Fellows program at the Center for Virtual Care: Simsuite Facility, UC Davis and participate in a collaborative research study. The study “Endovascular Procedure Simulation as an assessment Tool for Vascular Surgeons” evaluated the use of simulation as a standardized tool to assess skills and knowledge of vascular surgery fellows. Dr. Dawson and I are continuing to work collaboratively on validation of open and endovascular assessment tools.

Stanford University, Stanford, CA

Stanford has created a world leading integrated center, The Goodman Simulation Center, for immersive and simulation-based learning. The vascular component of the simulation based training is directed by my good friend Dr. Jason Lee. He has developed and implemented an active educational and research endovascular curriculum for medical students, residents and vascular fellows. My visit to Stanford was marked by my interactions with the residents in the research lab. The visit started with surgical research resident, graduate education student, and education research fellow presentations. The different learners described their ongoing research activities. This was followed by a tour of the Goodman Simulation Center and meetings with some of the other Stanford vascular faculty Dr.’s Ronald Dalman and John Harris, both graduates of the OHSU vascular residency. I also met with Dr. Fritz Bech to discuss research ideas and research opportunities at the Veterans Administration Hospital. As a result of this Stanford experience I have made arrangements to support Dr. Eliza Long, one of the Stanford surgical residents, with her research project titled “Gender Differences in Confidence Levels of General Surgery residents”. This study will also be conducted at OHSU. I am also collaborating in a research project spearheaded by Jason Lee. This long term project will look at the impact of a simulation-based endovascular curriculum on trainee performance and clinical outcomes in vascular surgery.  Jason and I are also developing and validating endovascular rating forms for core cases.

University of Rochester, Rochester, NY

My final trip supported by the traveling fellowship was to visit Dr. Karl Illig at the University of Rochester in Rochester, New York. Dr. Illig is recognized for his strong interest in medical student and resident education. He was responsible for the University of Rochester developing one of the first integrated 0-5 training programs in the US. During my visit I presented my work on our comprehensive vascular skills lab at OHSU and discussed the role of simulation in vascular surgical training.

Conclusions

To summarize as a direct result of my Wylie Fellowship I have:

  1. Developed and implemented a stepwise proficiency based vascular skills laboratory curriculum at OHSU. This multilevel curriculum includes modules for both open and endovascular skills and utilizes bench top models, cadaver and porcine models, as well as an endovascular virtual reality simulator. Non-invasive vascular lab interpretation and vascular imaging modules are also included in this comprehensive vascular skills lab.
  2. Conducted a randomized controlled study evaluating the impact of distribution of practice of a vascular skill in a vascular specific skills lab on the durability of skill acquisition and the clinical transferability of the skill to a realistic setting.
  3. Enrolled in the Master of Surgical Education Program at Imperial College, London to commence in the fall of 2009.
  4. Written a chapter in collaboration with Dr.’s Isabelle van Herzeele and Raj Aggarwal on the utility of simulation in vascular surgical training.
  5. Developed and am currently validating operative evaluation forms for core open vascular procedures.
  6. Enrolled in the SERF program sponsored through the ASE. The SERF study will examine the effects of presentation format at morbidity and mortality conference. Specifically, presentation format can improve the educational value and perceived quality assurance of surgical morbidity and mortality conferences.
  7. Designed and integrated a 4-week elective for 4th year medical students. The “Transition to Surgical Internship” course at OHSU focuses on teaching basic technical and patient management skills expected of any surgical intern using a hands-on approach and case-based scenarios.
  8. Collaborated with my colleagues Dave Dawson and Jason Lee in assessing endovascular procedural competency on a simulator.
  9. Enrolled in a multi-center study, spear-headed by Jason Lee, designed to evaluate the impact of a simulation-based endovascular curriculum on trainee performance and clinical outcomes in vascular surgery.
  10. Served as a mentor to multiple medical students and residents now involved in educational research studies at OHSU.
  11. Served on the Society for Vascular Surgery Residency Program Development Committee and Resident and Student Outreach Committee.

Clearly I have greatly benefited from the opportunities the E.J Wylie Memorial Fellowship has provided. The fellowship has provided friendships, scientific collaboration, and most importantly focused guidance in my career path. The insights gained and opportunities bestowed would not have been possible without exposure to all of the above listed leaders in surgical education. I look forward to earning a Master’s degree in Surgical Education at Imperial College, London, continuing the expansion of the vascular skills laboratory, developing validated assessment tools to assess competence and proficiency in open surgical and endovascular skills, and importantly having a rewarding career in vascular surgery as a surgical educator.

I would like to repeat my gratitude to the Lifeline Programs of the American Vascular Association for the award and the opportunities granted to me through the fellowship.

Posted June 2010

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