Sim Lab Trains Surgeons

TORONTO - It's a pivotal event that comes in the education of all would-be surgeons. At some point, medical students who plan to make a career of opening up and fixing other human beings have to make that first cut.

If Drs. Teodor Grantcharov and Vanessa Palter have their way, however, that first application of scalpel to skin will occur on a computer screen, not on the torso of a living, breathing person. And not just the first cut. They believe surgical residents ought to achieve an established level of proficiency in a virtual operating room before they start plying their scalpel in a real OR.

"There are studies that show that in the first 50 cases, the risk of major complications is significantly higher than after the next 30 cases. And all these studies are done on real patients," says Grantcharov, an associate professor of medicine at the University of Toronto and a surgeon who specializes in minimally invasive procedures at St. Michael's, one of the university's teaching hospitals. To Grantcharov, the idea of allowing surgical residents to operate before they've met a set skill level in a virtual OR is outdated. Simulation tools are now available and are found with increasing frequency in medical schools across North America. They provide an alternate route for surgical residents to climb the early — and risk-filled — part of the learning curve.

"I always found it ridiculous to talk about learning curves on real patients," says Grantcharov, a towering figure decked out in clogs, scrubs and a Toronto Maple Leafs surgical cap. "We want to see the learning curve in the simulation theatre or on the computer. Talking about learning curves of procedures on patients — I think it's unethical."

And inefficient. Grantcharov and Palter — a surgical resident who is also working on a PhD — recently published a study showing that surgical residents who train first in a simulation lab significantly outperform colleagues who receive only standard surgical training.

The study compared University of Toronto surgical residents who completed a five-month long simulation training module to residents who received conventional surgical training. All the residents performed a laparoscopic right hemicolectomy — an operation where a tumour is removed from the right side of the colon using small incisions, not the large cuts commonly used for operations in the past.

The procedures were videotaped and graded by outside experts. Residents who had trained on the simulators scored an average of 16 points (out of 20) where surgical residents who didn't get the additional virtual training scored an average of eight. The findings were published this month in the journal Annals of Surgery. But the results were so persuasive the University of Toronto's medical school made the virtual training program mandatory for surgery students even before the study was published. Grantcharov says the program was first offered in February and was hugely popular among students. He says it's critical to offer the virtual training as part of a curriculum; letting students work on simulators on their own doesn't achieve the goal.

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