Surgical training: Are we ready for simulation and a standardised programme?
Currently, the landscape of surgical training is undergoing rapid evolution, marked by the initial implementation of standardised surgical training programmes, which are further facilitated by the emergence of new technologies. However, this proliferation is uneven across various countries and hospitals.
To provide a comprehensive overview of the existing surgical training programmes throughout Europe, the European Society of Residents in Urology (ESRU), along with the Young Academic Urologists (YAU) Group, the European School of Urology (ESU), and the European Association of Urology (EAU), developed a dedicated survey. This survey focused on the accessibility of simulation resources and standardised surgical programmes.
A comprehensive survey
Distribution of the survey was in May 2022 via the EAU mail list to the Young Urologist Office (YUO), Junior Membership, participants of the European Urology Residents Education Programme (EUREP) between 2014 and 2022, other urologists under 40, and through the EAU Newsletter. It consisted of a 64-item, online-based survey aligned with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). The survey was conducted using the SurveyMonkey platform based in Portland (US).
The study involved an assessment of demographic characteristics, exploring the type of centre, availability of various surgical approaches, presence of training infrastructure, participation in courses, organisation of training, and participants' satisfaction with the training programme. The level of satisfaction was evaluated using a Likert-5 scale. The subsequent sections examined surgical training in open, laparoscopic, robotic, and endoscopic surgery, each explored separately. Additionally, the investigation looked into the presence of a structured training course and availability of a duly validated final evaluation process.
Survey findings
There were 375 respondents, with an 82% completion rate (Figure 1). Among them, 75% identified as male; 50.6% were young urologists, 31.7% senior residents, and 17.6% junior residents.
The majority of participants (69.6%) were affiliated with academic centres. Only 50.3% of respondents indicated the availability of dry lab training facilities, with 46.7% primarily focused on laparoscopy. Virtual and wet lab training centres were even less prevalent, at 31.5% and 16.2%, respectively. Direct patient involvement was reported in 80.5% of cases for open surgery, 58.8% for laparoscopy, 25.0% for robotics, and 78.6% for endourology. In less than 25% of instances, training followed a well-defined standardised programme comprising both preclinical and clinical modular phases. Participant feedback showed that 49.7% expressed a satisfaction rating of either 4 or 5 points concerning the training programme.
In comparing European (EU) and non-EU respondents, EU doctors reported a greater availability of robotic surgery (52.4% vs. 28.9%, p<0.01). Conversely, non-EU doctors more frequently mentioned being trained and evaluated for non-technical skills (53% vs. 37.3%, p=0.01), and they were more likely to undergo direct patient training (75.7% vs. 54%, p=0.02).
Moreover, non-EU respondents received more theoretical preparation for specific tasks before surgical performance (75.7% vs. 60.9%, p=0.02). Limitations of this study included a low response rate, a prevalence of participants from academic centres, and the absence of responses from individuals not affiliated with the EAU network. Upon analysing the findings, there appears to be a slight shift towards simulation-based training for laparoscopy and robotics. Nevertheless, traditional patient-based training remains predominant for open surgery and endoscopy. There's a notable gender difference, with 75% of respondents being male, reflecting that women represent only 20% of practising surgeons and 7.3% of full professors of surgery [1]. Furthermore, only 46.1% had access to robotic surgery, highlighting that laparoscopy and open surgery remain the primary surgical approaches, especially in non-academic hospitals.
Recent years have seen training evolve in two main directions: (1) the development and adoption of methodologies to enable trainees to achieve proficiency; (2) the development and implementation of training models available in dry, wet, and cadaver labs, thanks to technological advancements. Despite these advancements and the abundant availability of models, courses, and training tools, our survey revealed somewhat bleak data.
Summary
In conclusion, the current distribution of surgical training centres falls short in ensuring widespread access to standardised training programmes. While dry lab facilities are relatively widespread, the availability of wet lab resources remains restricted. Additionally, it seems that many trainees' initial exposure to surgery occurs directly with patients. There is an urgent need for continued efforts to establish uniform training routes and assessment techniques across various surgical methodologies.
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This article first appeared in the January-February 2024 edition of European Urology Today.
