Simulation for Teaching Orthopaedic Residents in a Competency-based Curriculum: Do the Benefits Justify the Increased Costs?

BACKGROUND: Although simulation-based training is becoming widespread in surgical education and research supports its use, one major limitation is cost. Until now, little has been published on the costs of simulation in residency training. At the University of Toronto, a novel competency-based curriculum in orthopaedic surgery has been implemented for training selected residents, which makes extensive use of simulation. Despite the benefits of this intensive approach to simulation, there is a need to consider its financial implications and demands on faculty time. QUESTIONS/PURPOSES: This study presents a cost and faculty work-hours analysis of implementing simulation as a teaching and evaluation tool in the University of Toronto's novel competency-based curriculum program compared with the historic costs of using simulation in the residency training program. METHODS: All invoices for simulation training were reviewed to determine the financial costs before and after implementation of the competency-based curriculum. Invoice items included costs for cadavers, artificial models, skills laboratory labor, associated materials, and standardized patients. Costs related to the surgical skills laboratory rental fees and orthopaedic implants were waived as a result of special arrangements with the skills laboratory and implant vendors. Although faculty time was not reimbursed, faculty hours dedicated to simulation were also evaluated. The academic year of 2008 to 2009 was chosen to represent an academic year that preceded the introduction of the competency-based curriculum. During this year, 12 residents used simulation for teaching. The academic year of 2010 to 2011 was chosen to represent an academic year when the competency-based curriculum training program was functioning parallel but separate from the regular stream of training. In this year, six residents used simulation for teaching and assessment. The academic year of 2012 to 2013 was chosen to represent an academic year when simulation was used equally among the competency-based curriculum and regular stream residents for teaching (60 residents) and among 14 competency-based curriculum residents and 21 regular stream residents for assessment. RESULTS: The total costs of using simulation to teach and assess all residents in the competency-based curriculum and regular stream programs (academic year 2012-2013) (CDN 155,750, USD 158,050) were approximately 15 times higher than the cost of using simulation to teach residents before the implementation of the competency-based curriculum (academic year 2008-2009) (CDN 10,090, USD 11,140). The number of hours spent teaching and assessing trainees increased from 96 to 317 hours during this period, representing a threefold increase. CONCLUSIONS: Although the financial costs and time demands on faculty in running the simulation program in the new competency-based curriculum at the University of Toronto have been substantial, augmented learner and trainer satisfaction has been accompanied by direct evidence of improved and more efficient learning outcomes. CLINICAL RELEVANCE: The higher costs and demands on faculty time associated with implementing simulation for teaching and assessment must be considered when it is used to enhance surgical training.

Impact of an Inexpensive Anatomy-Based Fetal Pig Simulator on Obstetric Ultrasound Training.

OBJECTIVES: The purpose of this study was to construct an inexpensive anatomy-based obstetric ultrasound task trainer and investigate whether introduction of this trainer into a hands-on obstetric ultrasound course improved course participants' ultrasound scanning skills. METHODS: The trainer was created by placing fetal pigs into preservative-filled heat-sealed polyethylene bags. Twenty-four participants in an obstetric ultrasound course at Wake Forest School of Medicine were randomized to receive hands-on scanning with pregnant women or hands-on scanning and fetal pig simulation. Biometric scans were performed before and after the course. The time to complete the scans, margin of error of biometric measurements, and number of technically adequate images per scan were compared between groups. RESULTS: Twelve participants were randomized into each group. Although a direct comparison of postcourse biometric scans demonstrated no difference between groups, participants that received simulation training showed significant improvements in the time to complete the biometric scan (P < .05) and number of technically adequate images obtained (P < .05), whereas those who did not receive simulation training did not show significant improvements. CONCLUSIONS: Addition of the fetal pig ultrasound task trainer resulted in improvements in the course participants' scanning efficiency even after very limited exposure. Incorporating the task trainer earlier and more broadly into obstetric ultrasound training may benefit trainees.

An inexpensive yet realistic model for teaching vasectomy.

PURPOSE: Teaching the no-scalpel vasectomy is important, since vasectomy is a safe, simple, and cost-effective method of contraception. This minimally invasive vasectomy technique involves delivering the vas through the skin with specialized tools. This technique is associated with fewer complications than the traditional incisional vasectomy (1). One of the most challenging steps is the delivery of the vas through a small puncture in the scrotal skin, and there is a need for a realistic and inexpensive scrotal model for beginning learners to practice this step. MATERIALS AND METHODS: After careful observation using several scrotal models while teaching residents and senior trainees, we developed a simplified scrotal model that uses only three components-bicycle inner tube, latex tubing, and a Penrose drain. RESULTS: This model is remarkably realistic and allows learners to practice a challenging step in the no-scalpel vasectomy. The low cost and simple construction of the model allows wide dissemination of training in this important technique. CONCLUSIONS: We propose a simple, inexpensive model that will enable learners to master the hand movements involved in delivering the vas through the skin while mitigating the risks of learning on patients.

An inexpensive yet realistic model for teaching vasectomy

Purpose Teaching the no-scalpel vasectomy is important, since vasectomy is a safe, simple, and cost-effective method of contraception. This minimally invasive vasectomy technique involves delivering the vas through the skin with specialized tools. This technique is associated with fewer complications than the traditional incisional vasectomy (1). One of the most challenging steps is the delivery of the vas through a small puncture in the scrotal skin, and there is a need for a realistic and inexpensive scrotal model for beginning learners to practice this step. Materials and Methods After careful observation using several scrotal models while teaching residents and senior trainees, we developed a simplified scrotal model that uses only three components–bicycle inner tube, latex tubing, and a Penrose drain. Results This model is remarkably realistic and allows learners to practice a challenging step in the no-scalpel vasectomy. The low cost and simple construction of the model allows wide dissemination of training in this important technique. Conclusions We propose a simple, inexpensive model that will enable learners to master the hand movements involved in delivering the vas through the skin while mitigating the risks of learning on patients. .

Comparison of modified Thiel embalming and ethanol-glycerin fixation in an anatomy environment: Potentials and limitations of two complementary techniques.

Thiel-fixed specimens have outstandingly lifelike visual and haptic properties. However, the original Thiel method is expensive and requires an elaborate setup. It is therefore of principal interest to modify the Thiel method in order to make it available to a broader user group. A modified Thiel embalming method will be described in detail and compared to ethanol-glycerin fixation with the help of illustrative examples. The visual properties, haptic properties, the usability for performing histological investigations, costs and potential health aspects will be considered. Tissues fixed with the modified Thiel technique gave results similar to the original method, providing more realistic visual and haptic properties than ethanol-glycerin embalming. However, Thiel fixation is significantly more expensive and requires more precautions to minimize potential health hazards than ethanol-glycerin-fixed tissues. In contrast to ethanol-glycerin-fixed specimens, the Thiel-fixed specimens are not suitable for histological investigations. Both modes of fixation are inappropriate for biomechanical testing. Modified Thiel embalming simplifies the availability of body donors with lifelike properties and has cost-saving advantages to the original technique. Thiel-embalmed body donors are ideally suited for clinical workshops but have restrictions for student dissection courses in facilities with limited storage space, air circulation or technical staff. Vice versa, ethanol-glycerin-fixed body donors are well suited for student dissection courses in such an environment but are limited in their use for clinical workshops. Modified Thiel embalming therefore ideally complements ethanol-glycerin fixation in order to provide customized solutions for clinical workshops and student dissection courses in a wide range of applications.

Status of pharmacy practice experience education programs.

OBJECTIVE: To assess financial, personnel, and curricular characteristics of US pharmacy practice experiential education programs and follow-up on results of a similar survey conducted in 2001. METHODS: Experiential education directors at 118 accredited US pharmacy colleges and schools were invited to participate in a blinded, Web-based survey in 2011. Aggregate responses were analyzed using descriptive statistics and combined with data obtained from the American Association of Colleges of Pharmacy to assess program demographics, faculty and administrative organizational structure, and financial support. RESULTS: The number of advanced pharmacy practice experience (APPE) sites had increased by 24% for medium, 50% for large, and 55% for very large colleges and schools. Introductory pharmacy practice experience (IPPE) sites outnumbered APPEs twofold. The average experiential education team included an assistant/associate dean (0.4 full-time equivalent [FTE]), a director (1.0 FTE), assistant/associate director (0.5 FTE), coordinator (0.9 FTE), and multiple administrative assistants (1.3 FTE). Most faculty members (63%-75%) were nontenure track and most coordinators (66%) were staff members. Estimated costs to operate an experiential education program represented a small percentage of the overall expense budget of pharmacy colleges and schools. CONCLUSION: To match enrollment growth, pharmacy practice experiential education administrators have expanded their teams, reorganized responsibilities, and found methods to improve cost efficiency. These benchmarks will assist experiential education administrators to plan strategically for future changes.

Do we pay our community preceptors? Results from a CERA clerkship directors' survey.

BACKGROUND AND OBJECTIVES: Family medicine clerkships depend heavily on community-based family physician preceptors to teach medical students. These preceptors have traditionally been unpaid, but in recent years some clerkships have started to pay preceptors. This study determines trends in the number and geographic region of programs that pay their community preceptors, identifies reasons programs pay or do not pay, and investigates perceived advantages and disadvantages of payment. METHODS: We conducted a cross-sectional, electronic survey of 134 family medicine clerkship directors at allopathic US medical schools. RESULTS: The response rate was 62% (83/132 clerkship directors). Nineteen of these (23%) currently pay community preceptors, 11 of whom are located in either New England or the South Atlantic region. Sixty-three percent of programs who pay report that their community preceptors are also paid for teaching other learners, compared to 32% of those programs who do not pay. Paying respondents displayed more positive attitudes toward paying community preceptors, though a majority of non-paying respondents indicated they would pay if they had the financial resources. CONCLUSIONS: The majority of clerkships do not pay their community preceptors to teach medical students, but competition from other learners may drive more medical schools to consider payment to help with preceptor recruitment and retention. Medical schools located in regions where there is competition for community preceptors from other medical and non-medical schools may need to consider paying preceptors as part of recruitment and retention efforts.

The cost of teaching an intern in New South Wales.

OBJECTIVE: To determine the cost of formal and informal teaching specifically provided for interns and to determine how much of an intern's time is spent in these activities. DESIGN, SETTING AND PARTICIPANTS: Costs of formal teaching for 2012 were obtained from the New South Wales Health Education and Training Institute (HETI) and costs of informal teaching by a survey of all interns in a random sample of prevocational networks. MAIN OUTCOME MEASURES: The cost of formal intern education provided by HETI; the number of hours of formal teaching provided to interns in hospital; intern estimates of the amount of non-timetabled teaching received in a typical week. RESULTS: The cost of formal teaching was $11 892 per intern per year and the cost of informal teaching was $2965 per intern per year (survey response rate, 63%) - a total of $14 857. Interns spent 2 hours per week in formal teaching and 28 minutes per week in informal teaching, representing 6.2% of a 40-hour week. CONCLUSION: The time of professionals paid by NSW Health represents most of the expenditure on teaching interns. An increase in time spent on intern teaching beyond the current 6.2% of an intern's 40-hour week would be an investment in better health care.