I was thrilled to be selected as one of the two American College of Surgeons (ACS) 2013 International Surgical Education Scholars. As the director at the time of the surgical skills center at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, I viewed this scholarship as a great opportunity to interact with simulation experts in North America, gain more knowledge on simulation training, and to learn about recent developments in the field.
My specific goals during the scholarship were to:
- Design new simulation curricula for surgical and nonsurgical health care workers
- Develop tools for assessing the quality of training at our center in Zaria
- Improve my management and administrative skills
However, at the conclusion of the scholarship, I achieved more than I had originally set out to accomplish and even had to reprioritize my objectives.
Arrival in the U.S.
The trip from Nigeria to Washington, DC, for the 2013 ACS Clinical Congress was long but pleasant. Staying at the hotel recommended for the scholars attending the conference had an added advantage, as I had fruitful discussions over breakfast and during shuttle bus rides with scholars from other parts of the world. Of note were my interactions with Stephen Smith, MB, BS, BSc, MS, FRACS, who runs the endoscopy skills center at the University of Newcastle, Australia.
My first activity at the meeting was participation in the Surgical Education: Principles and Practice Postgraduate Course on October 6. The program, moderated by Anne T. Mancino, MD, FACS, associate professor of surgery, University of Arkansas for Medical Sciences, Little Rock, was well-organized and highly interactive. I learned the rudiments of adult learning and the value of obtaining feedback from learners with a view toward determining their needs and expectations. The need for feedback obtained through deliberate, scheduled sessions at the end of the learning experience recurred at all the institutions that I visited in the U.S.
The Clinical Congress comprised plenty of attractions and interesting sessions, many of which took place simultaneously. I found the Trauma Update 2013 Postgraduate Course on October 7 to be very informative, especially the prehospital session, as that aspect of emergency health care is often neglected in my country, and the resuscitation session, which focused on the fluid regimen for trauma patients. The How to Mentor a Newly Trained Partner session was beneficial in raising issues that are rarely discussed during or after residency training.
A high point of the Clinical Congress was the College’s International Scholars and Travelers 2013 session. This was a whole afternoon meeting where the ACS scholars presented works from their areas of interest, covering a variety of topics. The History and Current Role of the International Relations Committee presented by the other 2013 International Scholar for Surgical Education, Giuseppe Nigri, MD, PhD, FACS, FRCS, assistant professor of surgery, Sapienza University of Rome, Italy, contained many tips that proved useful during my subsequent tours of U.S. health care institutions. In addition, Ajit Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education, offered advice to both of us at the conclusion of the Clinical Congress.
Post-Congress educational visits
During the Clinical Congress, I had the pleasure of meeting John Daly, MD, FACS, dean, Temple University School of Medicine, Philadelphia, PA, who had earlier agreed to serve as my mentor. We had frequent correspondence prior to my arrival in the U.S., and he arranged for me to visit other institutions of interest in the Philadelphia area, including Pennsylvania State University Simulation Center, Hershey; Children’s Hospital of Philadelphia; and St. Christopher’s Hospital for Children.
My tour began at the William Maul Measey Institute for Clinical Simulation and Patient Safety at Temple University. I was given an in-depth tour of the facility by Richard Milner, the institute’s professional and technical associate director. The facility had many impressive high-fidelity mannequins, which appeared expensive and out of reach for use in my center. However, I was also shown some innovative, low-cost models that could easily be adapted to my center back home. I observed a number of simulated sessions where the medical students used standardized patients and interactive mannequins to learn about teamwork, communication skills, and decision making in emergency situations. Each module was followed by a debriefing session in which the processes were broken down into specific concepts and thoroughly discussed. The need to maintain professionalism was also highlighted.
One afternoon, I had a one-on-one discussion with Selwyn Rogers, Jr., MD, FACS, surgeon-in-chief, Temple University Health System. He gave me useful insights into career development and fulfilling my goals as a surgeon and an educator.
At Children’s Hospital of Philadelphia, I attended grand rounds on bowel management following surgical treatment of anorectal malformation. However, I spent most of my time at the Pediatric Endoscopic Surgical Training and Advancement Laboratory (PEDESTAL), a simulation center managed by Thane Blinman, MD, FAAP, assistant professor of surgery, Perelman School of Medicine, University of Pennsylvania. The multipurpose PEDESTAL allows different modules to be conducted within the same space at different times. Most of the curricula focus on commonly encountered clinical conditions and equipment, and simulations are deployed to make teaching such procedures as endotracheal intubation and suturing as practical as possible.
I then visited the Pennsylvania State University Medical Simulation Center, which is located in an abandoned operating theater away from the main hospital, allowing participants to concentrate fully on the simulation without interruption by clinical demands. Every available space is used for training, with specific areas dedicated to the debriefing sessions. A Fundamentals of Laparoscopic Surgery (FLS™) course took place while I was visiting, so I was able to observe first-hand the processes of this important aspect of surgical training with a view toward getting our surgical residents to undergo the course in the near future. While discussing the FLS course with one of the instructors, Kristoffel Dumon, MD, FACS, I realized that curriculum development was more important than acquiring mannequins and other simulation equipment.
My last visit in Philadelphia was the St. Christopher’s Hospital for Children, where ACS Regent Marshall Z. Schwartz, MD, FACS, surgeon-in-chief, chief of pediatric surgery, served as my host. I spent time with the department of pediatric surgery, attending academic conferences. Medical students and junior and senior residents studied together in the same room, which is quite different from how teaching takes place in Nigeria. Residents were also encouraged to practice basic instrument handling using laparoscopic trainers before going to the operating room to assist in cases.
Multispecialty meetings on management protocols were convened, and I believe these discussions would greatly enhance patient outcomes.
A simulation consortium meeting took place while I was in Philadelphia, which brought together professionals from all disciplines. A representative from each participating center gave an oral presentation on their programs and progress and presented simulation-related scientific papers. It was an evening of brainstorming to find ways to encourage collaboration and cooperation among the various centers. I witnessed the invaluable role that simulation technicians play in the development and implementation of new modules.
My experience in Canada
I then flew to Montreal, QC, for the next phase of the tour. The cold October weather greeted me at the airport in sharp contrast to what I had experienced in Philadelphia. Kevin Lachapelle, MD, FACS, a cardiac surgeon and director of the Arnold and Blema Steinberg Medical Simulation Centre at McGill University, was my host in Montreal. Despite his busy schedule, we were able to meet regularly to discuss a variety of surgical education topics—mainly how to develop and implement a simulation curriculum at my center with the resources at my disposal. He encouraged me to do a needs assessment and identify a core group of surgeons who would be committed to my vision.
The administrative and organizational structure of the McGill Center caught my attention. Considering the large number of different courses that run concurrently, the ease of registration by various participants was worthy of note. This led to a series of discussions over coffee with Ronald D. Gottesman, MDCM, FRCPC, FAAP, FCCM, division chief, pediatric critical care medicine, at the center; and Linda Crelinsten, RN, MA, assistant director and manager of the center. I discovered that previous communication with prospective participants as well as coordinating experts from related specialties who teach at the center were keys to the smooth running of the center. The debriefing is essential to the learning process.
I was privileged to meet with ACS Regent Gerald M. Fried, MD, FACS, chair, department of surgery, McGill University, in his office at Montreal General Hospital. He gave me a tour of their simulation center and the DeKuyper Education Center, where I had roundtable discussions with the research fellows, mainly on curriculum development.
I also spent an afternoon with David M. Fleiser, MDCM, MSc, FACS, FRCSC, associate professor of surgery and director, McGill Molson Medical Informatics Project, in the picturesque Royal Victoria Hospital. He introduced me to the world of the “virtual patient,” which is a cost-effective, highly interactive bridge between formal lectures and simulation training that has the capacity to enable learners to put into practice many concepts taught in class in various scenarios. Feedback from the learners was an integral part of the process, akin to the debriefing process.
The ninth Annual Harvey H. Sigman Lecture took place at the Jewish General Hospital during my time in Montreal. John D. Mellinger, MD, FACS, professor of surgery at Southern Illinois University School of Medicine, Springfield, delivered an inspiring lecture on surgical education. He had earlier spoken on the Core of Competence at the grand rounds, and during the tea break, he and I discussed challenges to surgical education in developing countries.
I then visited the Montreal Children’s Hospital under the guidance of Sherif Emil, MD, FACS, director, division of pediatric general surgery. I spent the day in a series of academic meetings, including the grand rounds where professional development was discussed.
The annual Simulation Summit took place in Vancouver while I was in Canada. Dr. Lachapelle was able to arrange for a discounted fee for me to attend, despite my late registration, so I took the long flight to Vancouver and was met by the warmer weather of the Canadian west coast. At the Summit, l learned how to develop a template for a standardized simulation curriculum, which was one of my main goals, and during a special workshop, the steps, structure, and process of debriefing were thoroughly analyzed. One evening, Karim Qayumi, MD, FRCSC, and Susan Brien, MD, FRCSC, hosted a dinner at a traditional Afghan restaurant, giving the international participants the opportunity to unwind and network.
Following my return to the U.S., I spent a few days at the VirtuOHSU Surgical Simulation Center of the Oregon Health and Science University, Portland. The center is run by Donn Spight, MD, FACS, with modules based on the ACS and Society of American Gastrointestinal and Endoscopic Surgeons curriculum. Teaching of non-technical skills, such as communication, team building, and professionalism, were emphasized. Residents have 24-hour access to the center, which enables them to practice modules at their own pace. I also attended academic meetings at OHSU and carved out time to visit the beautiful sites and wineries in the Portland area.
Plan of action in Nigeria
From the early stage of my tour it became obvious that a paradigm shift was necessary to run a successful simulation center upon my return to Nigeria. Instead of concentrating on acquiring expensive, high-fidelity mannequins and equipment, my emphasis had to be on developing a curriculum tailored to meet the needs of our subregion. I plan to employ the standardized steps learned using the ACS training template as a guide to fashion workable curricula for implementation in our center. I will incorporate the debriefing process into our already existing modules, allocating up to one-third of the time to debriefing alone with a view toward identifying and clarifying any misinformation and misconceptions to ensure that the participants have acquired the right knowledge and skills.
I will identify and involve clinicians both within and beyond the department of surgery who are interested in simulation training to help in curriculum development; this goal may be achieved in part via information collected from structured questionnaires aimed at determining specific needs. This process will broaden the scope of the courses as well as increase the pool of surgical experts available to the center. I plan to maintain the rich network of simulation experts that I developed during my visits, and I hope they will serve as my guides and advisors throughout implementation. I also plan to attend relevant courses on surgical education and simulation to keep abreast of recent advances and improve my teaching skills.
A nonsurgical lesson that I learned was to have my business cards with me at all times. Surgeons are not considered business people back home, so I didn’t bring any and often felt that I may have lost some valuable links with useful experts because they didn’t have my contact information handy.
One suggestion that I would offer regarding the program is that scholars have the option of undertaking the educational visits before attending the Clinical Congress. This sequence of events may enrich their Clinical Congress experience as it would allow more familiarity with the American health care system and enable the scholars to determine which sessions would have more impact on their practices.
I extend my profound appreciation to the ACS International Relations Committee and the Division of Education for granting me the unique privilege to be an International Surgical Education Scholar. The experience has widened my view and horizon, and has heightened my passion to train future generations of surgeons.