Skill Decay Refresher Training

Skill Decay Refresher Training

Bryan Mathieson

23 May 2016

The old adage of “use it or lose it” is becoming more prevalent in today’s deploying military medical providers. This decay of skills has likely been occurring for many years, but its prevalence is likely secondary to an increased awareness among military providers. In a study by Deering, et al (2011), most surgical specialists perceived that it took 3 to 6 months to return to their pre-deployment clinical and surgical performance baseline.

To address the skill decay in surgical specialties, one could recommend a variety of refresher training. The training could consist of case exposure, didactics, or simulation. Each specialty would require a varying training modality, but this program will specifically address laparoscopic cholecystectomy. This skill is chosen because the opportunities to practice laparoscopy in a deployed setting is minimal. Oftentimes the general surgeon is placed in a trauma czar role focusing on trauma surgery and is not focused on the general surgical needs of patients. These patients are often sent out for their semi-elective procedure, thus freeing up space, resources, and staff for incoming trauma patients. One could see how this very technical skill could begin to degrade over a six month time period.

The training program would include the use of didactic refresher training that includes pertinent anatomy of the cystic duct, cystic artery, common bile duct, Triangle of Calot. This review should be brief and should not require a comprehensive anatomical discussion. After the physician feels comfortable with the aforementioned anatomy, then move on to the simulation suite where they begin working with a task trainer such as LapSim by Surgical Science Inc (Minneapolis, MN). The product uses a haptic hardware platform to achieve tactile feedback in conjunction with a virtual reality type simulator. During this module they physician would go about basic laparoscopic skills such as: camera navigation, instrument navigation, coordination, grasping, cutting, catheter insertion, lifting & grasping, bowel handling, fine dissection, and suturing. One deemed competent in each of the basic skills, the surgeon would move onto the full laparoscopic cholecystectomy procedure.

Given the complexity of the gallbladder bed and the frequency of cholecystitis in Western culture, the general surgeon will be required to achieve a certain level of performance in this task. The performance will be measured based on two key tasks: Dissection of the peritoneal coverings to expose the cystic duct/artery and the separation of the gallbladder from the liver bed. The first should be accomplished within 280 seconds of dissection. The later should be completed within 300 seconds from beginning of the gallbladder separation. Once these time constraints are met in a reproducible fashion, the student would be deemed competent to perform the procedure. Given this is refresher training, no further instruction or observation would be required.