Introduction

Otolaryngology is a highly technical specialty, with otolaryngologists required to rapidly develop to a high standard, and maintain, a wide variety of skillsets. 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 a mixture of apprenticeship-style training interspersed with traditional didactic teaching and lecturing. However, several factors have recently led to a paradigm shift. There are increasing societal pressures to deliver demonstrably consistent, high-quality surgical training, focusing on patient safety and efficiency. Nevertheless, restrictions on 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, with a specific focus on 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 to putatively increase patient safety.

Simulation-based medical education (SBME) exposes trainees to clinical scenarios in an educational environment to allow for deliberate practice with no risk to patients. These scenarios can vary in their scope and fidelity, from polytrauma disaster response scenarios involving large numbers of 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 (DP). DP is a set of educational principles that highlights the importance of well-defined learning objectives, focused and repetitive observed practice, and informative feedback in the form of educationally focused debriefing.[4] A meta-analysis of studies comparing SBME with DP to traditional educational methodology demonstrated that SBME with DP 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 article will outline the current usage of SBME in otolaryngology. Broadly, the usage of SBME in otolaryngology falls into two 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 medical 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 has high inter-assessor reliability. SBME alone as a concept 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 – will this simulator achieve an increase in technical skill?[6]

There are on-going controversies within the literature about the appropriateness of the above descriptors in defining the efficacy of a simulator. Newer concepts have been suggested, whereby validity is considered unitary and that 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 (JCST; the educational oversight board for postgraduate surgical training) recommends using SBME, although they caution that the use of 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 one 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 a surgical technique for trainees. In addition to elective operating, otolaryngology trainees need to be able to manage otolaryngological emergencies such as acute airway obstruction safely from very early on in their training. Therefore, to prepare trainees to manage this complex emergency, boot camps have been created in the USA and the UK, both of which contain SBME to provide this formative training.[10][11]

Clinical Clerkships

In the UK, primary care trainees often spend six months in an otolaryngology department rotation. During this time, they must usually perform routine otolaryngological procedures such as nasendoscopy, otological micro-suction, and peri-tonsillar abscess drainage.[12] SMBE has been introduced in induction courses throughout the UK, with one such course demonstrating trainee’s 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. The utilization of simulation as an assessment tool is more controversial than as 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 has been demonstrated to be 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 (ACGME) program statement for otolaryngology specifically highlights the assessment of procedural skills, as demonstrated in surgical simulator labs. Simulation-based assessment is also required as part of the assessment 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 in 2000 produced a document entitled “To Err is Human: Building a Safer Health System.”[15] They provided evidence for an estimated 98,000 deaths per annum that could be attributed to preventable medical errors and outlined a strategy to aim to produce a safer health system, with a focus 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 but also highly effective non-technical skills – otherwise known of human factors, as discussed above. Human factors encompass person-specific skills and interpersonal skills, including communication, task management, crisis resource management, task prioritization, decision-making, and leadership.

The aviation industry has long 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 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, and 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. Within anesthesia, human factor SBME has long been central to both training and practice.[16] SMBE has been shown to deliver significant and demonstrable benefits to team performance, patient outcomes, and reducing preventable medical errors.[17] There are few otolaryngology-specific human factor SBME courses in the literature. This presents a significant opportunity for the expansion of 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 that involves anesthetists, physicians, nurses, students, and healthcare assistants has higher face validity for inter-professional communication and teamwork than the same scenario staffed entirely by anesthetists – as is still common today. This methodology imparts clinical teams with strategies to improve inter-professional communication and teamwork and 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 amounts of disparate team members, who may have never worked together, who are required to make complex surgical decisions in short periods. There have been a large number of multidisciplinary simulation studies demonstrating 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, and reproducible surgical education. Concerning technical skills and human factors, SBME has demonstrated an increase in 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 actual improved 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 playing an increasingly significant role in the delivery of education for all medical specialties. Otolaryngology departments are utilizing simulation to deliver high fidelity technical training with a focus 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 team-working 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.