Comprehensive Cardiac Surgical Training: Individual to Team-Based Training
Creators: White, Abigail
Publisher: name: University of Alberta Library
Year: 2023

<p>Simulation-based training is widely adopted amongst surgical specialties that have a minimally invasive approach such as laparoscopic surgery and predominantly open surgical specialties such as cardiac surgery remain in an apprenticeship model.  The growing complexity of cases, scrutinized outcomes and increased focused on patient safety has changed the training environment. As a result, there is a growing body of evidence that suggests surgical trainees are ill prepared for independent practice by graduation.<br>
Every educator knows the importance of simulation-based training, but because of small sample sizes, poor compliance with training programs and limited time and resources, simulation is not widely adopted amongst Canadian cardiac surgery programs. Based on an initial needs assessment we identified a desire amongst Canadian programs to use more simulation both in the context of training technical skills and nontechnical skills. The overarching purpose of this thesis research was to clarify the barriers to achieve independent practice and provide an example of a holistic approach to training, focusing on both technical and nontechnical elements of a surgeons.<br>
        To achieve the general research goals, we conducted semi-structured interviews of program directors in Canada (n = 9) and cardiac surgery trainees (n = 7). We used both a content and thematic analysis and identified that while the goal of surgical training should be an autonomous surgeon, we are producing competent, not autonomous surgeons. A recurring theme was the importance of nontechnical skills for an early career surgeon but due to the constraints of present-day training, we do not effectively teach or assess those skills.<br>
        Identified in the needs assessment was the desire for more opportunities for home practice, specifically for coronary artery bypass and aortic valve replacement. To facilitate simulation-based training for technical skills, we developed a portable, adjustable, patient specific task trainer based off intraoperative patient measurements. We used a combination of 3D printing and silicone casting to replicate an aortic root and distal coronary artery. We evaluated the model for its educational value and functional task alignment using a group of novices (n = 5), intermediates (n = 4), and experts (n = 4). Applying Messick&#39;s framework of validity, we provided initial sources of evidence towards content, response process, internal structure, and relation to other variables. We identified that there was high functional task alignment, and high educational utility of our model.<br>
        To further delineate the educational value, we conducted a learning curve study with four junior cardiac surgery trainees. Using BORIS (Behavioral Observation Research Interactive Software), a video analysis program, we conducted both a subjective and objective assessment of their performance while completing a distal coronary anastomosis and an aortic valve replacement. We found that there was a statistical improvement in their performance using the subjective assessment, but on the objective assessment, their performance did not reach statistical significance for both the coronary model and aortic valve model.<br>
The results from the needs assessment identified a need for non-technical skills training. Every surgeon knows, effective teamwork is critical to the success of an operation. As mentioned previously, there is little focus on multidisciplinary team training in cardiac surgery. Using an immersive simulated operating room environment, we evaluated team communication using crisis scenarios. Video analysis was used to identify communication patterns and quality of communication. Each scenario consisted of a trigger where the task complexity increased. We evaluated communication pre and post trigger. We found that communication patterns differed amongst surgical team members and that communication pattern differed pre- and post-trigger. Surgical trainees were less likely to give a demand post trigger and were more likely to provide explanation and goal-sharing with team members. This is likely because of knowledge gaps and decreased confidence post-trigger. Identifying these knowledge gaps in a safe, simulated environment can help prepare trainees for the operating room. We also evaluated performance of the trainees using the NOTSS scale (nontechnical skills of a surgeon) and found that over the course of the simulation sessions, nontechnical skills improved. The thesis concludes with a summary of findings, explores the limitations of the work, and provides plans for the creation of a comprehensive training program nationally.</p>