The surgical education landscape is ever-changing, driven by restricted work hours, rapid development of health care technologies, patient safety initiatives, rising health care costs, and the Affordable Care Act. These factors, combined with the digital native generation of learners who are now entering health care training programs, have compelled surgeons who trained in more traditional apprenticeship programs to take an introspective look at what it means to be a modern-day surgical educator. Gone are the days of “see one, do one, teach one.”
The use of a technology-based educational assessment, such as simulation, has been alluring to some educators and students. However, its application in health care has met with resistance from other educators and institutions that demand evidence of the efficacy of simulation from a learning and cost standpoint—and rightly so. Those of us at the forefront of simulation science in surgical education have realized that our training programs have not adequately prepared us to be effective educators, administrators, or simulation scientists, and, as a result, we have turned to our colleagues in related fields for help. Education psychologists, psychometricians, computer scientists, material scientists, medical device manufacturers, health care administrators, human factors scientists, engineers, graphic artists, sculptors, and even patients have heeded the call to help us in this important and altruistic endeavor.
This diversity of expertise, however, comes with a varied set of backgrounds, standards, theories, motivating factors, cultures, values, working styles, and nomenclature. Although physicians interact with individuals every day in the hierarchical setting of patient care, collegial work with such a diverse group presents many challenges, which, again, we were not formally trained to address.
The American College of Surgeons (ACS) began to address the use of simulation to enhance surgical education in 2002 with the development of the Accredited Education Institutes (AEI) Program under the leadership of Co-Chairs Carlos A. Pellegrini, MD, FACS, FACSI(Hon), before he was ACS President, and Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education. More recently, the College has taken this endeavor one step further by starting the ACS AEI Fellowship Program to train surgeons in the development of accredited surgical simulation educational institutes.
The AEI Program
To launch the AEI Program, through which, the fellowship was born, the ACS brought together thought leaders in the field of surgical-based simulation education and training to form a committee with the goal of examining the concept of accrediting institutions that provide simulation education. The committee made several on-site visits to various “skills labs,” as they were initially called, to examine the depth and breadth of the types of facilities already in place. By visiting these facilities, the committee was able to undertake a benchmarking process to determine the requirements an institution would need to meet in order to apply for accreditation.
As a result of those visits and subsequent discussions, the committee decided that the accreditation model should be criterion-referenced and that institutions applying for accreditation must be able to demonstrate how they meet each criterion. These criteria served as a catalyst for innovative, front line surgical educators and their colleagues to develop centers of excellence that deliver quality surgical education using simulation to enhance patient safety.
The program was formally launched at the 2005 Clinical Congress in San Francisco, CA. The first set of accreditation decisions was made in June 2006, when six institutions were granted AEI accreditation. Since then, the AEI Program has accredited 79 institutions worldwide. Currently there are 13 international AEIs, including four in Canada, two in Sweden, and one in each of the following countries: the U.K., France, Greece, Italy, Saudi Arabia, Spain, and, most recently, Argentina.
The AEI Program was established as an interdisciplinary endeavor. Although surgeons may have championed and led the development of these centers, many found themselves in the position of enlisting colleagues in related fields to help build the educational, technical, and evaluative foundation of these facilities, as well as to expand or consolidate myriad health care simulation-based training initiatives at their institutions. While some of these initiatives served surgical departments, others served medical schools, academic health centers, hospitals, and health systems. Some were privately run institutions; others were military or government-run centers. Despite their different constituencies, the strong basis for the AEI’s criteria for excellence remained the common bond that united these programs.
As the centers grew in size and sophistication, the early adopters from different backgrounds began to develop a basic understanding of the different disciplines involved. It became clear that a new “science” was emerging in health care that represented the intersection between clinical, educational, and technical/engineering: simulation science for health care. On the surgical side, there was a lack of formal training and knowledge related to educational methodology and technology, thus challenging our abilities as education leaders to ensure the growth and development of the field. To recalibrate surgical education, it became clear that a strategic plan was necessary to facilitate the rapid spread of simulation in emerging markets worldwide.
Establishment of the Fellowship Program
Recognizing the need to train individuals to carry out the mission of the ACS AEI Program and spread the benefits of the AEI worldwide, the program known as SimPORTAL (Simulation PeriOperative Resource for Training and Learning), at the University of Minnesota, Minneapolis, became a Level 1 Comprehensive Education Institute in 2007. By achieving this accreditation, SimPORTAL was able to secure funding and developed a series of one-year surgical simulation fellowships with a comprehensive curriculum to train international leaders to be facile in the emerging field of simulation science. The goal of this program was to provide a foundation for creating international leaders in the development, evaluation, and delivery of medical education curricula enhanced through the use of simulation technologies. Once this one-year fellowship was completed, the Surgical Simulation Fellow would be knowledgeable about simulation education theory, competent in its practice, and interested in further developing his or her own technical skills through an array of simulation activities. The fellow’s “thesis” project was to create a blueprint for developing the center in their home country.
Between 2007 and 2012, the ACS took the concept under consideration. In 2012, renewed interest in technology-based education combined with a definite need for leadership and collaboration led to the development of a committee to create a fellowship in simulation-centered education based within the accredited AEIs.
Mitchell Goldman, MD, FACS, chair, department of surgery, University of Tennessee-Knoxville, was selected to serve as committee Chair, and Robert Sweet, MD, FACS, was chosen to serve as Vice-Chair. (Both physicians are co-authors of this article.) Committee members included the following individuals: Raj Aggarwal, MD, PhD, FRCS, Imperial College of London; Karim Qayumi, MD, PhD, FRCSC, University of British Columbia; Carla Pugh, MD, PhD, FACS, University of Wisconsin-Madison; and John Paige, MD, FACS, Louisiana State University, New Orleans. Under their leadership and with the hard work of the ACS AEI staff, a new fellowship program was created. Development of the standards and criteria for the fellowship program was a committee-wide effort. Each member provided unique experiences and views, which resulted in the creation of a strong and rigorous fellowship program.
Perspectives on the following topics were shared in the development phase: components of the curriculum that a fellow would undertake during the year-long fellowship; templates and documents to capture the processes involved in training the fellow; examples to be included in the application to demonstrate compliance; and policies and procedures that would guide not only the overall program, but also the leadership of the individual program and fellow.
Goals of the program
The collective mission of the committee is to improve the quality of surgical care by developing future leaders and scholars in the area of surgical education, simulation, and training. The specific goals of the ACS AEI Fellowship Program are:
- To train scholars in the field of simulation-based surgical education and training
- To ensure that fellows possess the requisite knowledge and skills to serve as local and national resources in the field of simulation-based surgical education and training
- To ensure the development of surgeons with a thorough understanding of education theory in simulation and practice
- To train fellows to serve as future leaders of simulation centers and to run an AEI
- To enable fellows, through the use of their own resources, to enhance the efficacy of their own programs
- To have fellows develop expertise in simulation-based surgical education and training activities
- To ensure fellows are trained in the creation and implementation of major research and development projects involving simulation-based surgical education and training, including the management of research grants
For an institution to qualify for application to the Fellowship program, it must demonstrate compliance with a series of requirements aimed at ensuring a strong curriculum, including the presence of assessment, operational, resource, and governance procedures, and evidence that the sites are advancing the field of simulation-based surgical education. Candidates should have at least a master’s degree in a related field and have demonstrated leadership capabilities in previous roles to benefit from the program. The ACS AEI sponsoring the Fellowship Program must have achieved the status of full accreditation with no areas of partial or noncompliance identified.
Much like the ACS AEI Program, the Fellowship Program has six governing standards and criteria, which are as follows:
- Standard I: Curriculum Requirements
- Standard II: Assessment Requirements
- Standard III: Operational Requirements
- Standard IV: Resource Requirements
- Standard V: Governance Requirements
- Standard VI: Advancement of the Field Requirements
Although the Fellowship Program is relatively new, soon after its December 2012 launch a number of AEIs showed interest in applying to participate in the initiative. Initial applications were due in July 2013; staff collected the applications and committee members reviewed them in the fall of 2013.
Approving applications was a multi-step process: The Fellowship Review Committee made its accreditation recommendations, which were then sent to the ACS AEI Accreditation Review Committee (ARC). The ARC met in December 2013 and made the final accreditation decisions. One of the unique aspects of this accreditation program is that it is a paper-based model; in other words, no on-site visit or inspection takes place, which is likely a cost-savings factor for the AEI applicant. A total of four Fellowship Programs were accredited. Two Fellowship Programs received full accreditation, and two received provisional accreditation. The granting of provisional accreditation status was because those programs did not have a fellow in place at the time of accreditation. It should be noted that once a fellow is accepted and in place, the Fellowship Program becomes fully accredited once the ACS is notified. The four AEI Fellowship Programs with ACS AEI accreditation are as follows:
- The Mayo Clinic, Rochester, MN
- University of Minnesota, SimPORTAL, Minneapolis
- Ohio Health, Columbus
- Uniformed Services Health University, Bethesda, MD
Benefits of participation
Sanket Chauhan, MD, was in the SimPORTAL Fellowship Program when it was accredited and became the first graduate of an AEI-sponsored Fellowship. Consistent with the primary objective, Dr. Chauhan has assumed a leadership position with the Focused Education Institute at Baylor University Medical Center, Dallas, TX. Dr. Chauhan said that “the fellowship helped me understand the educational foundations for the development of curriculum and assessment tools and the science behind the validation of simulations. It also gave me insight into building and running a simulation program from scratch.”
Dr. Chauhan has been appointed to the Fellowship Committee along with David Farley, MD, FACS. Both physicians will be invaluable members of the committee because of their unique points of view—one a fellow who completed the fellowship and the other the director of an AEI Program that submitted an application for the fellowship accreditation.
There are many benefits for surgeons who participate in the Fellowship Program, including the opportunity to be groomed for leadership positions at simulation centers. The fellows also benefit from being immersed in a stimulating environment by working side-by-side with the leaders and staff, along with the faculty and learners that use their AEI every day for simulation training and education. One of the ongoing benefits of the program is that it brings together all ACS AEI fellows annually to present individual research and initiate opportunities to develop multi-institution studies and educational projects. This investment in these innovative young men and women and in the future of surgery will pay dividends for the members of the College and the patients they serve.
For information about the program or to receive a copy of the standards and criteria document, contact Kathleen Johnson, EdM, Senior Manager, ACS Program for AEI at firstname.lastname@example.org.