Does a boot camp expand skills rapidly?

Luke McKee Wiggins, MD, M. Mujeeb Zubair, MD, Dominic Emerson, MD, and Richard W. Kim, MD

Innovations like Boot Camp complement resident education.

See Commentary on page 296.

Feature Editor's IntroductionImagine watching an intense volleyball rally that ends with a furious spike down the line to win the match. From the bird's eye view of a spectator, we see bump, set, spike, until gravity eventually prevails. But from the ground, the game is the amalgamation of broken-down technical skills practiced over and over again. The fundamental skills are: passing, setting, spiking, blocking, and serving. Eventually, these skills may be called dimes, roof, no-lookie cookie, cheddar biscuits, block city, or ace. The game, how fluid and electric it is, and ultimately its outcome, comes down to all of the repetitive drills, as well as the practice away from practice. Elite athletes are not only born, they have to be developed, nurtured, and tested. In a training paradigm with duty-hour restrictions and less reps in the operating room, how do cardiothoracic surgery residents get past bump, set, spike? How do they perfect their game? In the manuscript that follows, Wiggins and colleagues highlight the benefits of surgical boot camp in providing early exposure to the fundamental techniques in cardiothoracic surgery and ultimately a structure for self-driven learning. More specifically, the authors discuss the early skill acquisition trainees can obtain at the Thoracic Surgery Directors Association Surgical Boot Camp, which is now overseen by the Society of Thoracic Surgeons. The boot camp setting introduces residents to their fundamental skills such as cannulation for cardiopulmonary bypass, hilar dissection, and coronary anastomoses. While fulfilling the American Board of Thoracic Surgery mandated 20-hour simulation requirement, this technical skills introduction early in cardiothoracic training makes the transition from medical school or general surgery less daunting and instills more confidence in the trainee and faculty alike when stepping foot into the operating room. Among the various cardiothoracic surgery residency programs, a wide array of simulation experiences is available in the form of simple bench models and task trainers, wet labs, animal labs, and cardiopulmonary bypass and robotic simulators. The key to simulation is repetition and executing what you practice. One practice session on the volleyball court can revolve entirely around a single fundamental skill, such as spiking. The various drills, whether they are performed solo, against the wall, with a partner, or with the entire team, solidify the technical lessons: hitting the ball high, snapping the wrist, precision and timing of your footwork, or approach to the net from the 10-foot line. In the simulation lab, the same goes for aortic cannulation. In a single session, you can cannulate the aorta 20 times. You learn too deep, not a good angle, and of course, how to avoid audible bleeding. The correct technique quickly begins to feel familiar. Just as you would not want to learn how to spike against a big block during a match, you do not want to take your first aortic cannulation stitches in a complex case in the operating room. These simulated experiences emphasize training the way you want to perform, so that ultimately residents and their faculty can see a smooth transition and progression in the operating room. To hit that cardiothoracic no-lookie cookie early in training, programs should encourage these robust opportunities for their cardiothoracic surgery residents.

Rachel Kim, MD, and Nahush A Mokadam, MD

In addition to the sound judgment essential to the clinical management of our patients, all surgical specialties require a foundation of technical skills that is difficult to acquire without direct patient experience. Nowhere is this more evident than in cardiothoracic surgery, where even the most elementary cases have fundamental technical demands considerably above that experienced or practiced as a medical student. The skills necessary to isolate and cannulate the great vessels are a far cry from closing skin with a subcuticular suture. Even during the days when surgical residency was routinely longer than a decade and cardiothoracic training did not begin until after the completion of general surgery, the jump-in technical complexity for the trainee was substantial. Over the years, the difficulty has only increased. Lung resections previously performed via open thoracotomy are now routinely performed using thoracoscopic or robotic techniques. Mitral replacements through a sternotomy are a rarity compared with valve repairs from the side. Congenital surgeons are now expected to perform neonatal operations with previously unheard-of expectations of mortality.

Yet despite the duty-hour restrictions demanded by the Accreditation Council for Graduate Medical Education and the recent transition of many programs to an integrated 6-year (I-6) residency, recent graduates are arguably better than ever. It has certainly been our experience that although I-6 trainees are not only considerably less experienced and have vastly less time to learn in the hospital, their clinical capabilities, technical abilities, and depth of understanding have matched those of previous generations by the time they graduate.

For us, 2 essential changes occurred that helped our surgical residency adapt to the changing face of medical education and changed the direction of training for our residents. First and foremost was the acceptance and recognition that the purpose of surgical residency was for the education of the trainee rather than for the clinical enterprise of the institution. Second was the recognition that, for the most part, our trainees were dedicated and mature learners who, given the opportunity, would take the responsibility of their education into their own hands outside of the hospital. Of course, all of us have been disappointed at times with the effort that some residents have put into self-directed learning, but when validated educational opportunities such as a clinical boot camp fall in line with smart, capable, highly motivated residents, the results can be rapid, highly effective gains in knowledge, confidence, and ability.

In 2008, following efforts by each of the national cardiothoracic surgery organizations to develop and institute a new educational model for surgical training, the Joint Council for Thoracic Surgery Education and the Thoracic Surgery Directors Association created the first cardiothoracic surgery “Boot Camp.” Since its inception, about 30 residents per year have participated in the course. Using both simulation and didactic sessions over a 2- and a half-day course, the Boot Camp program provided an opportunity for surgical residents to gain exposure to some of the fundamental techniques in cardiothoracic surgery under direct supervision of practicing surgeons. The areas of emphasis were coronary anastomoses, cardiopulmonary bypass and cannulation, pulmonary resection, bronchoscopy and mediastinoscopy, and aortic valve surgery. The curriculum was meticulously orchestrated to maximize the efficacy of training for new trainees. Key elements of surgical simulation training and learning were instituted, such as component task training and deliberate practice. Participant's progress was tracked and recorded in a scientific fashion using the verified Objective Structured Assessment of Technical Skills global rating scale. Training sessions used low-fidelity models that offered instruction on key surgical techniques of the task being covered. Participants were then advanced to high-fidelity models as their experience and understanding allowed for learning of the additional contextual information provided by these more realistic models. The Boot Camp schedule even took into account the philosophy of distributed practice (practice interspersed with rest), which has been proven to lead to more efficacious skills acquisition and retention.

It is, of course, no longer a surprise that simulation itself can be a helpful adjunct to traditional resident education. As we know, participation in 20 hours of simulation is now required by the Accreditation Council for Graduate Medical Education. What is a surprise, and remarkable about efforts such as Boot Camp, is the speed at which the application of simulation techniques can lead to measurable improvements in students’ abilities. In the initial reports following the institution of the thoracic surgery Boot Camp, Fann and colleagues demonstrated that a training module as short as 4 hours improved the ability of trainees to perform critical skills such as the performance of a coronary anastomosis. When Feins and colleagues implemented an expanded curriculum of 39 training modules and trained residents on critical cardiac procedures or scenarios, not only were there clear improvements in the overall performance of resident trainees such as an improved ability to handle adverse events, not to mention a perception of more confidence in the operating room, and a greater comfort level of the faculty with the trainee, but much of the improvement in assessment scores occurred between the very first and second module repetition.

To be clear, Boot Camp could not be supposed to replace the lessons that can only be learned from time in the operating room and time in the hospital. However, residency and fellowship today are necessarily very different environments than the ones in which many of us grew up. There is less time for residents in the hospital. There is less time to acquire the knowledge and skills critical to our field. With educational objectives like the Boot Camp, while the benefits of the subject material will always be subject to question, what is irrefutable is that students are exposed to a well-validated method of how to teach themselves. They learn methods of how to practice and can apply these techniques to any subject matter in a manner that works best for them. Boot Camp can establish expectations and goals for learning and using them, students can come away with purposeful techniques to help themselves progress to become a successful cardiothoracic surgeon. Simulation has helped us to keep up our ability to teach the next generation of cardiothoracic surgeons amidst constantly evolving technological advances. The leaders of our field who took it upon themselves to invest in these innovative training initiatives as residency programs underwent a transformation should be applauded. As a discipline, we should continue to invest in the ongoing optimization of these educational objectives as our field continues to grow, expand, and develop.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.