A High-Fidelity, Tissue-Based Simulation for Cardiac Transplantation.

Several operations in cardiothoracic surgery have been accurately modeled with tissue-based simulations. These have been shown to be beneficial in the training of residents. Cardiac transplantation has not been simulated. We describe a high-fidelity, tissue-based simulation that can be used to teach trainees to perform a cardiac transplant. We modified the existing Ramphal Cardiac Surgery Simulator to accommodate cardiac transplantation. An attending cardiac surgeon successfully performed the simulated transplant, demonstrating each of the component tasks of the operation. We believe our simulation will enhance the training of cardiothoracic surgery residents.

Optimizing Surgical Skills in Cardiac Surgery Residents with Cardiac Transplant in the High-Fidelity Porcine Model.

OBJECTIVES: Simulation is a pivotal tool within cardiac surgery to facilitate learner growth and skill acquisition. There are many methods of simulation and it is possible to develop and implement new curricula incorporating these modalities. The objective of this paper is to describe the feasibility of a high-fidelity cardiac transplant simulation curriculum for surgical residents. METHODS: Our simulation setting was the Animal Resource Center at the University of Calgary. It was set up with 4 separate operating rooms, 2 for donor heart retrievals and 2 for heart implantations. This was done to allow 2 learners to participate with each animal, replicating the true intraoperative environment. Our teaching sessions were facilitated by 2 surgeons experienced in cardiac transplantation. In addition, we had support staff including multiple perfusionists, nurses, and anesthesia technologists. RESULTS: The curriculum was evaluated from many perspectives in real time throughout the simulation as well as afterward in posttest qualitative interviews with all participants. The residents readily identified the acquisition of and increased proficiency in specifically targeted surgical skills. In addition, the residents were able to practice communication, collaboration, and management. Furthermore, the simulation session and our debriefings contributed significantly to fostering a team approach. CONCLUSIONS: The pig is an excellent preclinical model for acquiring and developing the skills necessary for human cardiac transplantation. The residents partaking in the curriculum were satisfied with the learning they received and saw value in the swine transplant curriculum. The overall curriculum was cost-effective, due to the low overall operating costs associated with it.

Surgical Thoracic Transplant Training: Super Fellowship-Is It Super?

OBJECTIVE: The quality of training provided to thoracic transplant fellows is a critical step in the care of complex patients undergoing transplant. The training varies since it is not an accreditation council for graduate medical education accredited fellowship. METHOD: A total of 104 heart or lung transplant program directors throughout the United States were sent a survey of 24 questions focusing on key aspects of training, fellowship training content and thoracic transplant job satisfaction. Out of the 104 programs surveyed 45 surveys (43%) were returned. RESULTS: In total, 26 programs offering a transplant fellowship were included in the survey. Among these programs 69% currently have fellows of which 56% are American Board of Thoracic Surgery board eligible. According to the United Network for Organ Sharing (UNOS) requirements, 46% of the programs do not meet the requirements to be qualified as a primary heart transplant surgeon. A total of 23% of lung transplant programs also perform less than the UNOS minimum requirements. Only 24% have extra-surgical curriculum. Out of the participating programs, only 38% of fellows secured a job in a hospital setting for performing transplants. An astounding 77% of replies site an unpredictable work schedule as the main reason that makes thoracic transplant a less than favorable profession among new graduates. Long hours were also a complaint of 69% of graduates who agreed that their personal life is affected by excessive work hours. CONCLUSION: Annually, almost half of all thoracic transplant programs perform fewer than the UNOS requirements to be a primary thoracic surgeon. This results in a majority of transplant fellows not finding a suitable transplant career. The current and future needs for highly qualified thoracic transplant surgeons will not be met through our existing training mechanisms.

Achieving Accreditation Council for Graduate Medical Education duty hours compliance within advanced surgical training: a simulation-based feasibility assessment.

BACKGROUND: Certain operative cases occur unpredictably and/or have long operative times, creating a conflict between Accreditation Council for Graduate Medical Education (ACGME) rules and adequate training experience. METHODS: A ProModel-based simulation was developed based on historical data. Probabilistic distributions of operative time calculated and combined with an ACGME compliant call schedule. RESULTS: For the advanced surgical cases modeled (cardiothoracic transplants), 80-hour violations were 6.07% and the minimum number of days off was violated 22.50%. There was a 36% chance of failure to fulfill any (either heart or lung) minimum case requirement despite adequate volume. CONCLUSIONS: The variable nature of emergency cases inevitably leads to work hour violations under ACGME regulations. Unpredictable cases mandate higher operative volume to ensure achievement of adequate caseloads. Publically available simulation technology provides a valuable avenue to identify adequacy of case volumes for trainees in both the elective and emergency setting.

Estimating minimum program volume needed to train surgeons: when 4 × 15 really equals 90.

INTRODUCTION: Work-hour restrictions have decreased flexibility in scheduling and reduced exposure to certain operative cases. These restrictions may affect a resident's ability to meet certification requirements, particularly for rare, unscheduled cases (e.g., cardiothoracic transplants). We developed a computer-based simulation model using variables such as case volume and program size to demonstrate the influence of these factors on the likelihood of certifying a set of residents on rare cases. METHODS: We built a simulator to predict the probability of attaining certification for surgical residents, using cardiothoracic transplants as a test case. Inputs to the model included operating times, call schedules, and procurement travel times, as well as information on the distribution of times between transplants. RESULTS: We simulated 100 years of schedules using our current system parameters of an average of 33 heart and 31 lung transplants per year, and assuming an Accreditation Council for Graduate Medical Education-compliant daily-rotating call schedule. Despite having enough transplants to certify all residents for lungs if all opportunities were distributed equally among residents, the certification rate achieved when constrained by arrival time (and call schedules) and work restrictions was only 55%. Our calculations show that meeting minimum transplant-certification requirements for all residents would require at least 1.5 times the expected number of annual transplants. CONCLUSIONS: Our model enables analysis of a given program's ability to certify its residents based on program size and volume. These results could be used to design alternative scheduling paradigms to improve certification rates, without requiring reductions in certification requirements or program size.