Skills training in minimally invasive surgery in Dutch obstetrics and gynecology residency curriculum

The Dutch obstetrics and gynecology residency curriculum has a clear structure regarding the training of MIS skills. A mandatory basic surgical skills course is established for residency training which is nationwide accepted and has a broad Dutch faculty. Intentionally, the course has to be attended during PGY 1 or PGY 2. Additionally, residents may attend advanced courses and congresses focusing on laparoscopy and hysteroscopy. This structure enhances the implementation of basic MIS skills training into the residency curriculum.

Basic MIS skills can be trained on simulators. Simulators have shown great potential for training and objectively assessing laparoscopic skills [17, 18]. The skills acquired are transferable to real operative procedures [19‐21] and skills training is shown to decrease patient complications [22]. For every resident, there is a learning curve to achieve proficiency in performing MIS. Presumably, acquiring basic MIS skills by simulator training leads to progression along the first part of this learning curve resulting in better prepared residents for the actual surgery. After achievement of the basic skills, more attention can be paid to the specific procedure during surgery on real patients. With the growing evidence of valuable aspects of MIS simulator training, we feel there is no excuse for depriving residents of this training.

The nationwide basic surgical skills course provides an introduction in simulator training for acquiring MIS skills. However, distributed practice is superior above massed practice, which is provided during a two-day course, for actually achieving these skills [23, 24]. Consequently, MIS skills can only be acquired if residents continue simulator training and evaluation in their own clinic. A first precondition for this continuance of training is the presence of simulator facilities in every cluster of teaching hospitals. A second precondition is that residents really do use these facilities. The first precondition is partially met. All 46 Dutch teaching hospitals are grouped in eight clusters and simulator training is offered in at least one teaching hospital of each cluster. However, the equipment varies widely among these hospitals. The advantage of training on the simulators used during the Cobra-alpha course is that these are easily fabricated and inexpensive. Besides, the exercises for the laparoscopic box trainer have been validated and a performance standard has been established. Regarding the second precondition, unfortunately, only one third of residents actually train on a simulator if training is offered on a voluntary basis [10]. The fact that most residents do not voluntarily train is in contradiction with the residents’ opinion that simulator training is an important addition to their residency program [10]. Hence, formal mandatory MIS training is urgently needed in every training hospital, which has to be scheduled in the busy practice of the residency program.

In spite of structured training, proper evaluation of skills contributes to the learning effect [25]. However, the majority of residents’ surgical skills are evaluated informally and in a non-standardized fashion. There is a growing need for objective assessment tools. An example of such a tool is the Objective Structures Assessment of Technical Skills (OSATS). This evaluation method consists of a global rating scale and has proven high reliability and construct validity for simulators [25, 26].

Regarding surgical competence, the requirements essential for certification in obstetrics and gynecology are clearly defined in the Netherlands. These requirements are set on a total number of each procedure a resident minimally has to perform. Additionally, the number performed on competence level 4 is established. Level 4 is defined “able to perform without supervision” on a 1 to 5 global rating scale (see Table 1) [27]. The target numbers for the laparoscopic and hysteroscopic procedures are expressed in Table 2 [27]. Although numbers of procedures are easily quantifiable, total numbers do not represent the actual competence of a resident due to individual difference in learning curves [6, 28]. Assessing a residents surgical skills and comparing these skills to an established performance standard would be more suitable than counting the number of procedures. In this way, the individual training demands can be met. This emphasizes, on one hand, the importance of objective assessment tools for evaluation of surgical skills and to set a performance standard. On the other hand, simulator training can fulfill the individual training demands, as a source of unlimited training while the training possibilities on real patients in the OR are scarcer. Ultimately, every resident should be able to achieve the predetermined level of skills at the end of residency.

Although some adaptations have to be made to incorporate continued training and evaluation in daily practice, a uniform introduction to MIS training on simulators is guaranteed for every resident in the Netherlands by a mandatory basic skills course, while advanced courses and congresses provide possibilities for enhanced education. Hopefully, this will facilitate and accelerate the implementation of MIS techniques in the gynecological surgical palette.