Is it time for integration of surgical skills simulation into the United Kingdom undergraduate medical curriculum? A perspective from King’s College London School of Medicine

PURPOSE: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there is no basic surgical skills (BSS) programme integrated into undergraduate curricula in the United Kingdom. We explored the role of a dedicated BSS programme for undergraduates in improving confidence and influencing careers in King's College London School of Medicine, and the programme was evaluated. METHODS: A programme was designed in-line with the established Royal College of Surgeons course. Undergraduates were taught four key skills over four weeks: knot-tying, basic-suturing, tying-at-depth and chest-drain insertion, using low-fidelity bench-top models. A Likert-style questionnaire was designed to determine educational value and influence on career choice. Qualitative data was collected. RESULTS: Only 29% and 42% of students had undertaken previous practice in knot-tying and basic suturing, respectively. 96% agreed that skills exposure prior to starting surgical rotations was essential and felt a dedicated course would augment undergraduate training. There was a significant increase in confidence in the practice and knowledge of all skills taught (p<0.01), with a greater motivation to be actively involved in the surgical firm and theatres. CONCLUSION: A simple, structured BSS programme can increase the confidence and motivation of students. Early surgical skills targeting is valuable for students entering surgical, related allied, and even traditionally non-surgical specialties such as general practice. Such experience can increase the confidence of future junior doctors and trainees. We advocate the introduction of a BSS programme into United Kingdom undergraduate curricula

How educational theory can inform the training and practice of plastic surgeons

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger’s theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky’s theory); (3) skill acquisition and retention (Dreyfus’ and Dreyfus’, and Fitts’ and Posner’s theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson’s theory); and (5) the assessment of competence (Miller’s triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons

Wound drainage after axillary dissection for carcinoma of the breast.

BACKGROUND: Axillary dissection is commonly performed for breast carcinoma. It is uncertain whether insertion of a drain reduces complication rates. OBJECTIVES: To assess the effects of wound drainage after axillary dissection for breast carcinoma on the incidence of postoperative seroma formation. Secondary outcome measures include the incidence of infection and length of hospital stay. SEARCH METHODS: We searched the Cochrane Wound and Breast Cancer Group's Specialised Registers (22 February 2013), MEDLINE (1950 to 22 February 2013), EMBASE (1966 to 22 February 2013), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (22 February 2013) for all prospectively registered and ongoing trials (22 February 2013). Reference lists of included studies were handsearched by two independent review authors to look for additional eligible trials. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing wound drainage versus no wound drainage in individuals after axillary dissection for the treatment of breast carcinoma were included. All disease stages were considered. Breast-conserving surgery and mastectomy were considered. Patients undergoing sentinel node biopsy without axillary dissection were not included. No limits were applied to language or study location. Two review authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data for each included study using a predesigned data extraction proforma and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Discrepancies were resolved by consensus discussion with a third review author. Dichotomous variables were analysed using a Mantel-Haenszel model to produce odds ratios (ORs). Continuous variables were analysed using an inverse variance model to produce a mean difference (MD). MAIN RESULTS: Seven RCTs including 960 participants were identified. The quality of trials was generally low, with several studies at risk of selection bias, and no studies used blinding during treatment or outcome assessment. There was a high level of statistical variation between the studies, which therefore reduces the reliability of the evidence. The OR for seroma formation was 0.46 (95% confidence interval (CI) 0.23 to 0.91, P = 0.03) in favour of a reduced incidence of seroma in participants with drains inserted. There was no significant difference in infection rates between drainage and no drainage groups (OR = 0.70; 95% CI 0.44 to 1.12, P = 0.14). The mean difference in length of hospital stay, reported in four trials consisting of 600 participants, was 1.47 days greater in the drained population (95% CI 0.67 to 2.28, P = 0.0003). A mean difference of 0.79 fewer postoperative seroma aspirations was found in the drained population (95% CI 1.23 to 0.35 fewer, P = 0.0004) in two trials including 212 participants. No significant difference in volume of seroma aspirations was reported (MD -19.44, 95% CI -59.45 to 20.57, P = 0.34) in three trials including 519 participants. No significant difference in the incidence of lymphoedema was noted (OR 2.31 favouring no drainage, 95% CI 0.47 to 11.37, P = 0.30), with only six instances reported in three trials of 360 participants, nor was any significant difference in the incidence of haematoma observed (OR 1.68, 95% CI 0.33 to 8.51, P = 0.53), with only five instances reported in two trials of 314 participants. AUTHORS' CONCLUSIONS: There is limited quality evidence that insertion of a drain following axillary lymphadenectomy reduced the odds of developing a seroma and reduced the number of post-operative seroma aspirations. These benefits should be balanced against an increased length of hospital stay in the drained population

Burns education: The emerging role of simulation for training healthcare professionals

Burns education appears to be under-represented in UK undergraduate curricula. However current postgraduate courses in burns education provide formal training in resuscitation and management. Simulation has proven to be a powerful modality to advance surgical training in both technical and non-technical skills. We present a literature review that summarises the format of current burns education, and provides detailed insight into historic, current and novel advances in burns simulation for both technical and non-technical skills, that can be used to augment surgical training. Addressing the economic and practical limitations of current immersive surgical simulation is important, and this review proposes future directions for integration of innovative simulation strategies into training curricula

Wound drainage following groin dissection for malignant disease in adults.

BACKGROUND: Groin dissection is commonly performed for the treatment of a variety of cancers, including melanoma, and squamous cell carcinoma of the skin, penis or vulva. It is uncertain whether insertion of a drain reduces complication rates, and, if used, the optimum time for drain removal after surgery is also unknown. OBJECTIVES: To assess the current level of evidence to determine whether placement of a drain is beneficial after groin dissection in terms of reducing seroma, haematoma, wound dehiscence and wound infection rates, and to determine the optimal type and duration of drainage following groin dissection if it is shown to be beneficial. SEARCH METHODS: In September 2014 we searched the following electronic databases using a pre-designed search strategy: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library). In November 2013 we searched Ovid MEDLINE; Ovid MEDLINE (In-Process and Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing wound drainage with no wound drainage in individuals undergoing groin dissection, where the most superior node excised was Cloquet's node (the most superior inguinal lymph node). No limits were applied to language of publication or trial location. Two review authors independently determined the eligibility of each trial. DATA COLLECTION AND ANALYSIS: Two review authors, working independently, screened studies identified from the search; there were no disagreements. MAIN RESULTS: We did not identify any RCTs that met the inclusion criteria for the review. AUTHORS' CONCLUSIONS: There is a need for high quality RCTs to guide clinical practice in this under-researched area

Wound drainage following groin dissection for malignant disease in adults

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the current level of evidence regarding whether placement of a drain is beneficial after groin dissection in terms of reducing haematoma, seroma, wound dehiscence and wound infection rates. If it is, the optimal type and duration of drainage following groin dissection will also be determined. </p

Heterotopic ossification in Dupuytren's disease: clinical and histological significance.

We report the case of an 82-year-old man who underwent fasciectomy for a severe Dupuytren's contracture, during which an ossified lesion was encountered within the contracture and surrounding the neurovascular bundle. The abnormal tissue was removed with difficulty and heterotopic ossification was confirmed histologically. We believe this is the first report of heterotopic ossification in Dupuytren's disease

Using "The Burns Suite" as a Novel High Fidelity Simulation Tool for Interprofessional and Teamwork Training.

Educational theory highlights the importance of contextualized simulation for effective learning. The authors recently published the concept of "The Burns Suite" (TBS) as a novel tool to advance the delivery of burns education for residents/clinicians. Effectively, TBS represents a low-cost, high-fidelity, portable, immersive simulation environment. Recently, simulation-based team training (SBTT) has been advocated as a means to improve interprofessional practice. The authors aimed to explore the role of TBS in SBTT. A realistic pediatric burn resuscitation scenario was designed based on "advanced trauma and life support" and "emergency management of severe burns" principles, refined utilizing expert opinion through cognitive task analysis. The focus of this analysis was on nontechnical and interpersonal skills of clinicians and nurses within the scenario, mirroring what happens in real life. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's alpha was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twenty-two participants completed TBS resuscitation scenario. Mean face and content validity ratings were high (4.4 and 4.7 respectively; range 4-5). The internal consistency of questions was high. Qualitative data analysis revealed two new themes. Participants reported that the experience felt particularly authentic because the simulation had high psychological and social fidelity, and there was a demand for such a facility to be made available to improve nontechnical skills and interprofessional relations. TBS provides a realistic, novel tool for SBTT, addressing both nontechnical and interprofessional team skills. Recreating clinical challenge is crucial to optimize SBTT. With a better understanding of the theories underpinning simulation and interprofessional education, future simulation scenarios can be designed to provide unique educational experiences whereby team members will learn with and from other specialties and professions in a safe, controlled environment