Introduction

Otolaryngology is a highly technical specialty, with otolaryngologists required to develop to a high standard and maintain various skill sets rapidly. To become proficient at performing endoscopic sinus surgery, for example, a procedure performed over 400,000 times per annum in the United States, surgeons must apply visuospatial anatomical knowledge, scientifically literate pathological principles, and refined endoscopic and surgical ability all within a high-pressure environment – the operating theatre.[1] This requires many hours of deliberate practice, knowledge enhancement, and clinical exposure.

Traditionally, surgical education has been delivered with apprenticeship-style training interspersed with traditional didactic teaching and lecturing. However, several factors have recently led to a paradigm shift. Increasing societal pressures exist to deliver demonstrably consistent, high-quality surgical training focusing on patient safety and efficiency. Nevertheless, restrictions on the working hours of higher surgical trainees, such as the European Working Time Directive, have led to a net reduction in total training time. Also, as the total societal cost of providing healthcare increases, there is a renewed focus on ensuring every aspect of surgical training provides value for money and a change of expectations regarding patient safety, specifically reducing preventable patient harm.

Consequently, surgical training is rapidly becoming increasingly competency-based, with an objective and outcomes-based curriculum design and assessments to provide training bodies and broader society with reproducible evidence of surgical competence. Therefore, there has been an interest in simulation as a method of augmenting these traditional training programs to allow for greater efficacy and standardization of skill acquisition and, thus, increase patient safety.

Simulation-based medical education (SBME) exposes trainees to clinical scenarios in an educational environment, allowing for deliberate practice with no risk to patients. These scenarios can vary in scope and fidelity, from polytrauma disaster response scenarios involving many simulated patients, faculty, and learners to inexpensive, low-fidelity tonsil tie simulators utilized by a single learner and trainer.[2][3] A cornerstone of SBME is the concept of deliberate practice. Deliberate practice is a set of educational principles highlighting the importance of well-defined learning objectives, focused and repetitive observed practice, and informative feedback in educationally focused debriefing.[4] A meta-analysis of studies comparing SBME with deliberate practice to traditional educational methodology demonstrated that SBME with deliberate practice is superior for acquiring specific, measurable skills.[4] The apprenticeship model of training can lack standardization, uniformity, and objectivity. SBME can enhance the field of otolaryngology with curriculum-based, standardized, and reproducible training and assessment.

Function

This topic outlines the current usage of SBME in otolaryngology. Broadly, the usage of SBME in otolaryngology falls into 2 categories: the acquisition of technical skills, such as endoscopic sinus surgery and temporal bone drilling, and the acquisition of non-technical skills, known within the educational literature as human factors. SBME is most well-established within the framework of curriculum output. Technical skills and human factors required by training programs can be taught using reproducible and validated simulators and scenarios and also to assess the abilities of otolaryngology team members. SBME can provide guidance and practice in medical decision-making and leadership and provide multidisciplinary teams with continuing medical education (CME).

Issues of Concern

SBME should provide trainees with an education that is valid, feasible, cost-effective, and highly inter-assessor reliable. SBME alone is no more valid than the concept of lecturing – each session is only as efficacious as its content, learner, trainer, and environment. There is, therefore, a large amount of literature regarding the validity of individual SBME courses. There are also concerns within the literature regarding negative bias against the benefit of simulation.[5] Numerous concepts exist regarding simulation validity. Face validity is a descriptor of how realistic a simulator resembles a clinical scenario – how close is it to the real thing? Content validity is a descriptor of whether a simulator can provide trainees with the stated learning objectives – is this simulator able to teach what we want it to teach? Concurrent validity is a term used to describe how well a new simulator compares to the gold standard methodology for that task. Construct validity is a descriptor of the ability of a simulator to discriminate between novice and experienced practitioners. Transfer validity is a descriptor of the ability of a simulator to have the desired effect, which is an increase in technical skill.[6]

The literature controverts the appropriateness of the above descriptors in defining a simulator's efficacy. Newer concepts have been suggested whereby validity is considered unitary, and all validity is just a type of construct validity. Arguments exist that studies should focus on either supporting or refuting the construct validity of simulators by assessing multiple criteria.[7] Regardless of the lexigraphy of validation studies, simulators must provide the otolaryngology community with activities that promote patient safety and technical proficiency while adhering to a pre-defined curriculum.

Curriculum Development

In the UK, the Joint Committee on Surgical Training, the educational oversight board for postgraduate surgical training, recommends using SBME. However, they caution that simulation cannot replace supervised clinical practice. SBME is also widely used within otolaryngology residency programs in the USA.[8] Over 50 simulators relevant to otolaryngology have been described in the literature for this use,  and each has at least 1 validation study exploring their efficacy.[9] Broadly, these can be subcategorized into laryngeal and throat surgery simulators, myringotomy simulators, temporal bone surgery simulators, and endoscopic sinus surgery simulators.[9] These simulators have variable validity in providing formative training for otolaryngology trainees throughout their training programs and have significant roles in preparing and refining surgical techniques for trainees. In addition to elective operating, otolaryngology trainees need to be able to safely manage otolaryngological emergencies such as acute airway obstruction from very early on in their training. Therefore, boot camps have been created in the USA and the UK to prepare trainees to manage this complex emergency, both of which contain SBME to provide this formative training.[10][11]

Clinical Clerkships

In the UK, primary care trainees often spend 6 months in an otolaryngology department rotation. They usually perform routine otolaryngological procedures such as nasendoscopy, otological micro-suction, and peri-tonsillar abscess drainage during this time.[12] SMBE has been introduced in induction courses throughout the UK, with 1 such course demonstrating trainees reporting increasing confidence levels in the above procedures. Some authors recommend that these SMBE induction activities become permanent features within the department.[13] 

Procedural Skills Assessment

Assessment of competence has become an integral part of specialty training programs and, in many countries, revalidation of specialists. Using simulation as an assessment tool is more controversial than a training tool. Simulators require high levels of construct validity to be useful as an assessment tool. In the United Kingdom, simulation of basic surgical tasks, with low face validity but high construct validity, such as tying knots at depth and suturing, have long been a part of the otolaryngology higher training interview process. In the United States, simulation is a feasible adjunct to the oral residency interview process.[14] The authors note that further work is required to assess whether high performance during this simulation can predict future performance. The Accreditation Council for Graduate Medical Education program statement for otolaryngology specifically highlights the assessment of procedural skills, as demonstrated in surgical simulator labs. A simulation-based assessment is also required for several professional certification boards.[8]

Medical Decision Making and Leadership Development

In response to several high-profile healthcare-associated deaths in the USA, the National Academy of Sciences produced a document entitled “To Err is Human: Building a Safer Health System " in 2000. [15] They provided evidence for an estimated 98,000 deaths per annum that could be attributed to preventable medical errors. They outlined a strategy to produce a safer health system, focusing on reducing preventable medical errors. The postulated strategy was broad and encompassed political, economic, clinical, and legislative factors. Reliably safe care, and therefore the minimization of preventable medical errors, requires both a high degree of technical proficiency amongst individual healthcare workers and highly effective non-technical skills—otherwise known as human factors, as discussed above. Human factors encompass person-specific and interpersonal skills, including communication, task management, crisis resource management, task prioritization, decision-making, and leadership.

The aviation industry has long been a pioneer in utilizing evidence-based and validated training to improve safety. A 1979 paper demonstrated how experienced flight crew can and have made significant errors, not due to a lack of technical skills but through poor communication, lack of effective leadership, and inconsistent decision-making.[16] This led to a field of simulation-based aviator education based upon human factors, which is now part of a compulsory, regular simulation training scheme involving both cockpit and cabin crew. Human factors can be formulated, assessed, or evaluated during a simulation. Human factor SBME has long been central to training and practice within anesthesia.[16] SMBE has been shown to deliver significant and demonstrable benefits to team performance and patient outcomes and reduce preventable medical errors.[17] There are few otolaryngology-specific human factor SBME courses in the literature. This presents a significant opportunity to expand this highly effective patient safety intervention.

Continuing Education

Multidisciplinary simulation is an increasingly utilized method of providing departments with continuing medical education (CME). For example – a cardiac arrest scenario involving anesthetists, physicians, nurses, students, and healthcare assistants has higher face validity for inter-professional communication and teamwork than the scenario staffed entirely by anesthetists – as is still common today. This methodology imparts strategies to clinical teams to improve inter-professional communication and teamwork. It has demonstrated its ability to improve team confidence in managing airway emergencies, carotid artery injuries, cleft care, and non-technical operating room scenarios.[18][19][20][21] SMBE is particularly well suited as a method for difficult airway scenario CME. These rare clinical emergencies involve large numbers of disparate team members who may have never worked together and are required to make complex surgical decisions in short periods. A large number of multidisciplinary simulation studies have demonstrated that these courses improve medical confidence in managing difficult airway scenarios.[18][22] Further studies are necessary to demonstrate whether these translate to improved patient outcomes.

Clinical Significance

SBME is a key adjunct in delivering high-quality, consistent, reproducible surgical education. Concerning technical skills and human factors, SBME has increased the otolaryngologist’s confidence and ability. It does not replace the core expertise gained by clinical experience. However, it allows otolaryngologists to hone their skills and practice key patient management principles in standardized and evidence-based environments. Care is necessary when extrapolating increased confidence in managing a scenario to improve patient outcomes. SMBE has been shown, however, to lead to better clinical outcomes with various non-otolaryngological clinical skills.[23][24] A greater focus on patient outcomes in otolaryngology simulation literature is vital to underpin the increasing role SBME has in otolaryngological curriculum development and CME.

Enhancing Healthcare Team Outcomes

SBME is increasingly significant in delivering education for all medical specialties. Otolaryngology departments use simulation to deliver high-fidelity technical training focusing on construct validity. The delivery of a modern otolaryngology service requires a wide multidisciplinary team. Traditionally, training of these teams occurs in isolation; however, SMBE is ideally suited to transform interprofessional teamwork and improve patient outcomes.[16] A comprehensive airway emergency response team simulation course involving anesthetists, otolaryngologists, nursing staff, respiratory therapists, trauma surgeons, and emergency physicians demonstrated that every team member, regardless of their medical background, demonstrated increased confidence, team participation, and objective knowledge.[25] These courses demonstrate the efficacy of simulation as a tool to enhance health team dynamics and outcomes. Future aspects of otolaryngology that may also benefit from multidisciplinary simulation include operating theatre crisis management, epistaxis management, and head and neck trauma management.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Pynnonen MA, Davis MM. Extent of sinus surgery, 2000 to 2009: a population-based study. Laryngoscope. 2014 Apr;124(4):820-5. [PMC free article: PMC4131235] [PubMed: 23900802]

2.

Jung D, Carman M, Aga R, Burnett A. Disaster Preparedness in the Emergency Department Using In Situ Simulation. Adv Emerg Nurs J. 2016 Jan-Mar;38(1):56-68. [PubMed: 26817431]

3.

Duodu J, Lesser TH. Tonsil tie simulator. J Laryngol Otol. 2013 Sep;127(9):924-6. [PubMed: 23962392]

4.

McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011 Jun;86(6):706-11. [PMC free article: PMC3102783] [PubMed: 21512370]

5.

Theman TA, Labow BI. Is There Bias against Simulation in Microsurgery Training? J Reconstr Microsurg. 2016 Sep;32(7):540-5. [PubMed: 27077211]

6.

Van Nortwick SS, Lendvay TS, Jensen AR, Wright AS, Horvath KD, Kim S. Methodologies for establishing validity in surgical simulation studies. Surgery. 2010 May;147(5):622-30. [PubMed: 20015529]

7.

Noureldin YA, Lee JY, McDougall EM, Sweet RM. Competency-Based Training and Simulation: Making a "Valid" Argument. J Endourol. 2018 Feb;32(2):84-93. [PubMed: 29437497]

8.

Deutsch ES, Wiet GJ, Seidman M, Hussey HM, Malekzadeh S, Fried MP. Simulation Activity in Otolaryngology Residencies. Otolaryngol Head Neck Surg. 2015 Aug;153(2):193-201. [PubMed: 26019133]

9.

Musbahi O, Aydin A, Al Omran Y, Skilbeck CJ, Ahmed K. Current Status of Simulation in Otolaryngology: A Systematic Review. J Surg Educ. 2017 Mar-Apr;74(2):203-215. [PubMed: 27839694]

10.

Malloy KM, Malekzadeh S, Deutsch ES. Simulation-based otorhinolaryngology emergencies boot camp: Part 1: Curriculum design and airway skills. Laryngoscope. 2014 Jul;124(7):1562-5. [PubMed: 24375482]

11.

Smith ME, Trinidade A, Tysome JR. The ENT boot camp: an effective training method for ENT induction. Clin Otolaryngol. 2016 Aug;41(4):421-4. [PubMed: 27373444]

12.

Townsley R, Burkes M. Tips for GP trainees working in ENT. Br J Gen Pract. 2011 May;61(586):363-4. [PMC free article: PMC3080224] [PubMed: 21619773]

13.

Bhalla S, Beegun I, Awad Z, Tolley N. Simulation-based ENT induction: validation of a novel mannequin training model. J Laryngol Otol. 2020 Jan;134(1):74-80. [PubMed: 31865923]

14.

Masood MM, Stephenson ED, Farquhar DR, Farzal Z, Shah PV, Buckmire RA, McClain WG, Clark JM, Thorp BD, Kimple AJ, Ebert CS, Kilpatrick LA, Patel SN, Shah RN, Zanation AM. Surgical simulation and applicant perception in otolaryngology residency interviews. Laryngoscope. 2018 Nov;128(11):2503-2507. [PubMed: 29696657]

15.

Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. National Academies Press (US); Washington (DC): 2000. [PubMed: 25077248]

16.

Higham H, Baxendale B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. Br J Anaesth. 2017 Dec 01;119(suppl_1):i106-i114. [PubMed: 29161386]

17.

Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014 May;23(5):359-72. [PMC free article: PMC3995248] [PubMed: 24501181]

18.

Lind MM, Corridore M, Sheehan C, Moore-Clingenpeel M, Maa T. A Multidisciplinary Approach to a Pediatric Difficult Airway Simulation Course. Otolaryngol Head Neck Surg. 2018 Jul;159(1):127-135. [PubMed: 29484924]

19.

Calcagno HE, Lucke-Wold B, Noles M, Dillman D, Baskerville M, Spight D, Ciporen JN. Integrated Otolaryngology and Anesthesia Simulation Model for Crisis Management of Cavernous Carotid Artery Injury. Arch Neurol Neuro Disord. 2018;1(1):30-41. [PMC free article: PMC6100789] [PubMed: 30135961]

20.

Kantar RS, Ramly EP, Almas F, Patel KG, Rogers-Vizena CR, Roche NA, Zgheib E, Munoz-Pareja JC, Nader MK, Kummer AW, Flores RL, Van Aalst JA, Hamdan US. Sustainable Cleft Care Through Education: The First Simulation-Based Comprehensive Workshop in the Middle East and North Africa Region. Cleft Palate Craniofac J. 2019 Jul;56(6):735-743. [PubMed: 30426759]

21.

Rochlen LR, Malloy KM, Chang H, Kim S, Guichard L, Cassidy R, Zisblatt L. Pilot One-Hour Multidisciplinary Team Training Simulation Intervention in the Operating Room Improves Team Nontechnical Skills. J Educ Perioper Med. 2019 Apr-Jun;21(2):E624. [PMC free article: PMC6972973] [PubMed: 31988985]

22.

Leeper WR, Haut ER, Pandian V, Nakka S, Dodd-O J, Bhatti N, Hunt EA, Saheed M, Dalesio N, Schiavi A, Miller C, Kirsch TD, Berkow L. Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program. J Surg Educ. 2018 Sep-Oct;75(5):1264-1275. [PubMed: 29628333]

23.

Cox T, Seymour N, Stefanidis D. Moving the Needle: Simulation's Impact on Patient Outcomes. Surg Clin North Am. 2015 Aug;95(4):827-38. [PubMed: 26210974]

24.

Barsuk JH, Cohen ER, Williams MV, Scher J, Jones SF, Feinglass J, McGaghie WC, O'Hara K, Wayne DB. Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial. Acad Med. 2018 May;93(5):729-735. [PubMed: 29068818]

25.

Tsai AC, Krisciunas GP, Brook C, Basa K, Gonzalez M, Crimlisk J, Silva J, Grillone GA. Comprehensive Emergency Airway Response Team (EART) Training and Education: Impact on Team Effectiveness, Personnel Confidence, and Protocol Knowledge. Ann Otol Rhinol Laryngol. 2016 Jun;125(6):457-63. [PubMed: 26658070]

Disclosure: Christopher Hogan declares no relevant financial relationships with ineligible companies.

Disclosure: Ryan Winters declares no relevant financial relationships with ineligible companies.