Introduction

A soccer player does not train solely by watching and playing matches, just as a pianist does not practice and develop his skills simply by attending and giving concerts. How may it therefore seem adequate for a surgeon to develop their skills exclusively in the operating room while treating real patients?

The established method to train as a vascular surgeon was, for the longest time, the accumulation of theoretical knowledge by studying relevant literature and clinical cases, while also developing operative skills by observation and performance of surgical procedures on patients. After years of education, the trainees are finally tested according to their in-depth knowledge and understanding of the specialty field and their individual operative caseload. Surgical skills were and are mainly acquired by observation and a learning-by-doing approach in the operating room. Although simulation and practice of specific skills and indeed entire surgeries has long been in development [1], it is only during the past two decades that simulation-based training (SBT) has truly begun to establish a foothold in the curriculums of open vascular surgery education [2].

Often-cited reasons for the need for SBT are limited workhours reduced by legislation, and thus reduced caseload and exposure: Additionally, a change in therapeutic approaches, with an ever-growing number of endovascular treatments often resulting in a reduction of open vascular surgery, and finally a waning acceptance in the general public and most importantly among patients themselves of a learning-by-doing approach with education and training being performed on patients have been observed [2,3,4]. The strategy of training inexperienced surgeons by operating on real patients, albeit under strict supervision, to further develop their skillset raises ethical questions [5].

Regarding safety issues in the practice of medicine and surgery in particular, medical professionals have very often found inspiration in other fields, such as the aviation industry. Measures such as redundancy and checklists have been adopted in many areas. The topic of SBT is no different. The training of pilots requires many hours of experience and countless repetition of exactly timed procedures in a very much standardized surrounding. The aviation industry pioneered and has long established this method of learning, providing a safe environment for trainees to acquire, test, and hone their capabilities.

Methods

SBT in vascular surgery was reported to be effective for teaching new and improve existing skills, as well as for increasing the levels of confidence for performing specific procedures [6, 7]. There are several factors that influence the quality and efficacy of training and thereby produce a flatter or steeper learning curve for participants [6]. It is, however, important to note that any type of training is useful [8]. It has been shown that faculty instruction greatly improves the learning curve of residents in complex simulations [9]. Furthermore, the effect of SBT, at least when performed in rather short, compact courses, will reach a plateau of skills improvement. The level of improvement mainly depends on the complexity of the practiced task and the educational level of the trainee. While simple bench models showed little to no significant progress in the skills of more senior trainees, more complex models do show improvement in skills even in senior doctors [4, 6]. To what extent exactly the progress in SBT translates into real-life operative skills is little known, as research is scarce [1].

A commonly used assessment tool for surgical performance is the objective structured assessment of technical skill (OSATS) [10]. OSATS allows the evaluation of a trainee in seven categories by a five-point system in each category.

Monitoring a trainee’s progress is an important part of any educational program. Very effective is constructive feedback by experienced trainers, possibly improving the learning curve and experience of the individual learner as well as the quality of the educator and their teaching methods.

Developing a program for SBT is a complex project which requires more than simply procuring simulation material for practice. Bismuth et al. [4] give an exemplary list of topics to consider when aiming to establish a training center for vascular surgery:

  • Real estate

  • Architectural considerations

  • Audiovisual recording capability

  • Conference room space

  • Managed access

  • Clinical educator, faculty availability, and support staff

  • Curriculum development

  • Simulators and courseware

  • Recurring revenue and financial support

Results

In our approach to establish a center for SBT in vascular surgery at the Graz Medical University, we planned similar to the points listed above. After considering several options for simulators and curriculum, discussions with the relevant decision-makers regarding set-up and financial aspects were initiated.

Real estate

The Steirische Krankenanstaltengesellschaft (KAGes), which owns the majority of public Styrian hospitals, has already established a simulation center at the Graz Medical University Hospital. This center was developed primarily for cardiopulmonary resuscitation and emergency medicine training courses, and has a number of rooms for various simulation trainings.

Architectural considerations

The rooms available in the KAGes simulation center include a mock OR with two operating tables, lights, and anesthesia equipment. There is additional furniture suitable for use as mock operating tables. This allows for a minimum of three surgical teams working simultaneously.

Audiovisual recording equipment

The audiovisual recording equipment is readily available and established within the regular training courses for advanced life support and other disciplines. Media uploads to internal servers and cloud storage are available for decentralized later viewing and evaluation.

Conference room space

This is available within the building housing the training center, but also in the form of auditoriums and small lecture rooms of the Medical University of Graz. These rooms provide state-of-the-art media equipment. This is used not only for obligatory theoretical teaching, but also for individual debriefing and feedback supported by audiovisual recordings of the performed procedures.

Managed access

To insure not only the safety and completeness of the equipment but also a controlled environment and continuous logging of data, access to simulation training is managed by the chief/manager of the simulation-based training program for vascular surgery. Training sessions are planned monthly to ensure an optimal learning curve in accordance with the respective roster.

Clinical educator, faculty availability, and support staff

Training sessions are always held with at least one faculty supervisor in attendance. The KAGes simulation center employs several full-time support staff who manage storage, maintenance, assembly, and cleaning of the models and facilities. Booking of the facilities as well as scheduling of courses and separate training sessions is coordinated by members of the support staff and faculty supervisor.

Curriculum development

It is essential for optimal use of course time as well as an efficient and preferably steep learning curve to implement a well-structured curriculum, with clear and adequate theoretical teaching and instructions as well as hands-on training with simulators. The measurement of progress and debriefing of trainees and providing constructive feedback appears to be equally important.

Simulators and courseware

A variety of simulations and training modalities were considered and assessed, with differing degrees of complexity and realism. Ultimately, the decision was made to acquire perfusion models with a high level of realism and low levels of maintenance and operational cost and effort. The following four simulator platforms made by the Swiss-based Vascular International Foundation (Vascular International Foundation, Stansstad, Switzerland) were acquired:

  • Abdominal model for open aortic surgery (Fig. 1)

  • Arm model for shunt surgery (Fig. 2)

  • Carotid simulation model (Fig. 3)

  • The “VI-box” for a variation of different simulator inlays (Fig. 4)

Fig. 1
figure 1

Abdominal aortic aneurysm simulator (Vascular International Foundation) after completion of aneurysm exclusion by tube-graft and replantion of the inferior mesenteric artery

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Fig. 2
figure 2

Model of an arm for arterial procedures and venous access surgery (Vascular International Foundation) with selection of surgical instruments

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Fig. 3
figure 3

Carotid artery simulator (Vascular International Foundation) during thrombendarteriectomy

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Fig. 4
figure 4

The “VI-box” (Vascular International Foundation) with gel block inlay

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Several vascular inlays, full sets of surgical instruments, and consumables were procured for every simulator.

Recurring revenue and financial support

The initial expenses of purchasing simulators, material, and instruments were financed through the generous overall budget of the simulation center provided by the hospital owner. Revenue will be generated through fees charged for regularly held courses.

In the mid- and long-term strategy for inclusion of SBT at the simulation center, we are aiming to establish two parallel programs, one catering primarily for staff members of the Clinical Division of Vascular Surgery at Graz Medical University Hospital. The aim is to provide the possibility for regular training to ensure a continuous learning curve and steady progress. Trainees will be offered a continuous program with frequently held sessions for two to three participants, repeatedly training specific procedures (Fig. 5). To ensure oversight over the development of every participant’s skills, a simple logbook will be kept to note the time needed for procedures, number of leaks, and number of additional sutures needed to achieve satisfactory sealing, as well as photodocumentation of the end result. The OSATS score will be calculated intermittently.

Fig. 5
figure 5

Advancing vascular surgical skills as a team

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The second program will offer full-day courses several times a year for basic skills to all surgical staff within the KAGes. Both will be faculty supervised and include theoretical instructions as well as trainee and trainer evaluation.

Discussion

Publications have shown the positive effects of SBT on trainees and the high demand for such programs among young surgeons. Participation in such courses within the KAGes is generally encouraged by the employer, but also the Austrian Medical Board and the state government, as these qualify as continuing medical education (CME). As the attendance of such courses is financed internally by specially allocated funds for every department within the KAGes, the courses for KAGes employees are free of charge to the attending trainees. In contrast to other medical specialties in the case of vascular surgery, undergoing SBT is not a mandatory part of the curriculum for residents. A lack of participants seems improbable though. With reduced total numbers of open vascular surgical procedures and limited working hours for surgeons and trainees, the benefit of SBT to increase exposure and improve skills appears self-evident.

The intent, time, and capacity to learn and therefore attend courses and skills training seems obvious. Additional incentive is provided for junior and senior doctors by awarding credits for the Austrian CME program to participants.

Conclusion

Implementing and further developing SBT for open vascular surgery will improve the quality of education for junior surgeons. As an additional means to practice and gain experience and confidence in their technical abilities, this training facility will help to compensate for lower numbers of operations performed and less time spent in the operating room in a way that is safe for patients and reassuring for residents. Furthermore, the selective inclusion of interns and medical students into the program will support staff recruitment by encouraging graduates to consider a career in vascular surgery.

Practice makes perfect, and while simulation cannot substitute for real-life surgery, it can be a valuable tool to learn and maintain basic skills in vascular surgery. Thus, we hope to establish SBT for vascular surgery as a fixed program in the KAGes simulation center in Graz.