Simulation in Surgery

Simulation: the imitative representation of the functioning of one system or process by means of the functioning of another—Webster’s Collegiate Dictionary, seventh edition.

For the last several years, a group of “seasoned” cardiothoracic surgeons from around the country gather in Chapel Hill, North Carolina, where they are joined by many young surgeons who are starting their residency in the specialty. The meeting is three days of intensive training using simulation models to replicate surgical situations the residents will be confronting during their surgical training. Getting familiar with the instruments, scopes, dissection techniques, heart lung machine, valve replacements, and small vessel suturing are some of the basic skills learned.

The “boot camp”, sponsored by the Thoracic Surgery Directors Association, is a rare opportunity for the residents to get individualized training with some of the most experienced surgeons in the field.

Historically, surgical training involved the resident getting graded levels of responsibility for doing procedures in the operating room (OR) and at the bedside. The training also involved pre and post-operative care but technical skills, cognitive knowledge, and clinical acumen were usually dependent on real patients in the operating room. The residents work one on one with an “attending” surgeon who will supervise as the resident does parts of the procedure.

Jonathan Nesbitt, M.D., director of the Cardiac Simulation Program at Vanderbilt University and one of the teachers at the Chapel Hill program, says “[b]y immediately imparting these skills early in training, we significantly compress the learning curve to allow [the residents] to work effectively and safely in the clinical realm.” Not only do the residents get to learn the basic technical skills required in the specialty, they get to experience realistic models of surgical catastrophes so they can learn what to do before a real patient’s life is on the line.

The rise in simulation in surgical training is being driven by several factors. Minimally invasive surgical techniques make it difficult for the attending to first assist in such a way as to keep the trainee out of trouble. Only one person can drive the robot or the scope. Reductions in duty hours, mandated by law, cuts down on the actual OR time a resident may have to learn what to do and how best to do it. And, of course, the ethicists are now making it more difficult to justify allowing inexperienced physicians to learn on actual patients.

Under the stresses brought on by the Affordable Care Act, many surgeons have become employees of hospitals or medical groups. This model has forced the surgeons into a productivity model based on fees generated for services rendered. The employer looks to the surgeon to generate income and the surgical education component of the practice is suffering. The surgery residents, generally slower than the attendings, are getting to do fewer cases so the attending can generate more income.

As third party payers are moving to pay based on quality models, attending surgeons may be even more inclined to do the operations themselves instead of helping a surgical trainee. One of my attendings in the surgical training program I went through believed that the best surgeon in the room should do the operation. Since he was always the best surgeon in the room, the resident could do no more than first assist. First assisting was frowned upon by us residents, but we did it the best we could so as to learn from this superb surgeon. However, there is no substitute from being the primary surgeon.

Although the simulators are good for teaching the basic skills, they have not reached the level needed to teach the skills that must be acquired when things go terribly wrong or when the dissections are difficult from aberrant anatomy or intense scarring.

In a patient with previous surgery, the scarring can be so dense that the blood vessels may not be seen until they are cut. The sudden fear felt by a surgeon who is confronted by hemorrhage that is so brisk as to be audible can lead to a complete inability to cope with the situation and may lead to the death of the patient. The same feeling of horror can occur with unintentional injuries to other structures like the common bile duct, ureter, heart, and brain. How to handle these potential disasters is hard to teach on the simulators.

Simulators are costly and the restrictions of the 80 hour work-week make it difficult for residents to find the time to use them. Dedicated simulation time, such as that provided in Chapel Hill, is very valuable.

Some facilities have built simulation centers that are recreating whole operating rooms, delivery suites, intensive care units, and endoscopy suites. The University of Tennessee where I work is finishing a new building devoted totally to simulation. I would expect that these large facilities can be used to train health care providers from other areas who will come in for specific training.

It is hard to prove that skills learned from simulation training will lead to improved care for patients but I think it does based on what I see from the residents I worked with at Chapel Hill. Small sample sizes and the ability to detect small changes in skill sets make training assessments difficult. However, since practice makes perfect and since there are not enough patients to go around, I believe the role for simulation in surgery will only increase in importance.

Another benefit of simulation is to learn how to deal with possible catastrophes before confronting them with a real patient. Brilliant saves rarely occur the first time a problem is seen; saves do occur in subsequent cases.

Teaching residents to act in a professional manner is usually done by surgical mentors who serve as role models. This training could be enhanced by using actors in vignettes presented in videos which can be viewed by the residents—a form of simulation.

Outcomes research and cost comparisons need to be done but simulation is here to stay. There are cognitive skills and communication skills which are also very important in surgery and there is a role for simulation in these areas which will need to be developed—sort of like the “mock trials” that law students have to go thru. For now, we are concentrating on technical skill enhancement.

Although surgical simulation does not replace the skill sets learned from actually operating on patients, the models do allow for repetitive practice of the basic technical skills needed by the surgeon without having to rely on actual patients. The attending surgeon is more inclined to let the resident do more if the basic skills are being demonstrated on a daily basis.

I think the time spent on simulators should not count towards the statutory mandated 80 hour work week restriction. I would consider it as time spent studying and unrelated to actual patient care. The time spent on patient care in the hospital setting is critical for surgical training and should not be further diminished.

It is said that surgeons do four things unique to patient care. These are (1) control hemorrhage; (2) drain pus; (3) restore normal (functional?) anatomy, and (4) train future surgeons. By participating in the boot camp at Chapel Hill, I am helping with #4. I enjoy doing it very much.

darrylweimanby Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in on February 17, 2016. 

Health Insurers Are Pulling Out Of Exchanges

As the election of 2016 draws closer, it is not surprising that more and more articles relating to the Affordable Act of 2010 (ACA) are appearing on the front pages. If the republicans win the Presidency, they will probably move to repeal the ACA and start a process to replace it. If the democrats win, repeal will be off the table, but changes will still be inevitable. The most pressing of several contentious issues relates to several large insurers who are planning to pull out of the health care exchanges starting in 2017 unless premiums are allowed to go up significantly.

In Tennessee, my home state, Cigna and Humana have received permission to raise premiums by 46 and 44 percent, respectively. Blue Cross Blue Shield of Tennessee, losing an estimated $500 million on the state’s exchange by the end of 2016, has been given permission to raise premiums 62 percent for 2017.

Texas Blue Cross has lost a billion dollars on the state exchange and is requesting a 60 percent premium increase for 2017. Blue Cross Blue Shield of Minnesota has pulled out of that state’s exchange as losses over the last three years are $500 million.

The average premium rise for plans being offered on the state exchanges will be 24 percent for 2017. The rates must rise to offset losses due to the risk profile of those buying insurance being much worse than originally expected.

Insurance companies were early supporters of the ACA. They envisioned millions of healthy people forced to buy health insurance with higher premiums mandated by the law. The higher premiums were meant to off-set the lower premiums being paid for those with pre-existing conditions. The lower premiums were, again, mandated by the law under the “community standard” provision.

What the insurers failed to properly predict were the millions of healthy people who elected to not buy insurance; instead paying the penalty (tax?) which was much lower than the premiums required. The insurers found themselves paying more for health care than they were receiving in premium income. Predictably, many insurers suffered significant financial losses; many have opted out of the health care business.

One of these large insurers, Aetna, has recently announced that it will pull out of 11 of the 15 states where it currently offers health insurance on the exchanges. This is following the lead of United Health Group which is also planning to withdraw from several exchanges in the same time-frame. If Aetna follows through on its plan, it will only offer exchange plans in 242 counties, down from the current level of 778. In those counties where it is pulling out, consumers will find there are fewer plans to choose from or, in some instances, no plans on the exchanges at all.

Aetna’s decision to roll back on its coverage comes on the news that its planned merger with Humana is going to be blocked by the Justice Department. The Justice Department also has moved to block a similar merger contemplated by Anthem and Cigna. The Justice Department believes that consolidating the health insurance industry to just a few key companies will lead to monopolistic practices; there will be less competition and as a result, consumers will face higher costs.

If the consumer is unable to find a suitable plan on the exchange for their county, they have the option of buying their own health insurance from companies who are not participating in the exchanges. However, these buyers would not be eligible for premium and cost sharing supports which are only available for those who buy insurance on the exchanges. Medicaid would be an option but not for those whose income is too high to qualify.

It is foreseeable that state or federal regulators will try to convince some insurers to enter into the counties which have lost their carriers. They could do this by promising the approval of high premiums or perhaps, governmental subsidies to offset any potential losses. High premiums, no competition, and governmental subsidies would be a win for the carrier.

Under the ACA, many people have gained health care coverage through the loosening of restrictions on Medicaid. Many more have gained coverage through the exchanges. Those with pre-existing conditions cannot be denied coverage due to the individual mandate of the law and those same people will not be charged higher premiums due to the community rating requirement. These are all good things.

Medicaid contractors, used to delivering lower cost care, are surviving.

The ability to buy health insurance at any time of the year is another factor leading to healthy people holding off on buying until they needed to be covered. These factors led to healthy people not buying insurance and those who need to use the insurance to buy it now. Not getting the premiums of the non-users has been a game changer for the insurers. Aetna has claimed $430 million in losses on individual products since January 2014.

Promised governmental subsidies to insurers are being blocked by the Congress that has not yet appropriated those funds; the funds are not likely to be appropriated so long as the House is under republican control. Seeing the political lines in the sand, the insurers are not relying on the promise of future funding while their losses continue to pile up.

In order to get the healthier patients to buy insurance, the penalties for not participating will have to be increased. To help off-set the rising costs that the insurers are seeing from the unhealthy patients who are now buying insurance, the premiums and deductibles will have to go up. There will need to be a time frame in which no one will be allowed to buy on the exchanges or apply for Medicaid; these steps are needed to get the healthier people to buy insurance now. These non-users of health care will be subsidizing those who are users but that is how insurance is supposed to work.

As the election draws closer, these rising costs are going to result in political consequences. The democrats passed the law and there was not a single republican vote in support. As the ACA is looking more and more like an entitlement, politics will make reforms more difficult, even unlikely. It will be interesting to see how the press handles this conflict. My guess is that little will be reported until after the election.


by Darryl S. Weiman, M.D., J.D.

Professor, Cardiothoracic Surgery, University of Tennessee Health Science Center and Chief of Surgery, VAMC Memphis, TN

MORE ABOUT THE AUTHOR: Darryl Weiman is a featured expert in on February 17, 2016.