Good evening, welcome to the AUG's Urogynecology webinar series. I am Teni Brown and I'm the moderator for today's webinar. Today's webinar is entitled Simulations in FPMRS Education. We have an exciting program and I'm so excited that you all have joined. Our speakers today are Drs. Elizabeth Shaheen, Robert Kelly, Gina Northington, and Mallory Youngstrom. I'm going to say a few words about these fabulous speakers and then we'll get right into the program after I discuss some housekeeping items. Dr. Shaheen is the Director of OBGYN Simulation at Emory University. She developed and continues to implement the Emory Resident Simulation Curriculum, mid-life simulations, and multidisciplinary OB emergency simulations. She has assisted Dr. Kelly in elevating the resident simulation experience, particularly for FMR and fellows applicability, and established an FPMRS robotic simulation program. Dr. Robert Kelly is the FPMRS Fellowship Program Director at Emory University, where he developed the simulation curriculum for the fellowship program. The curriculum spans vaginal, microscopic, and robotic skills, learned on different simulation models, from low-fidelity part-task trainers to high-tech robotic immersion simulation. Dr. Northington is also on faculty at Emory University. She's a current full professor and the Director of the Division of Female Pelvic Medicine and Reconstructive Surgery in the Department of OBGYN. Dr. Northington's clinical interests include geriatric gynecology, neuromodulation, pelvic organ prolapse, urinary incontinence, and overactive bladder. She participates in several clinical trials and translational research projects investigating mechanisms of pelvic floor disorders. Prior to joining faculty at Emory, Dr. Northington was an assistant professor at the University of Pennsylvania, where she also completed her fellowship training. And most recently, Dr. Northington chaired the AUGS Presidential Task Force on Diversity, Equity, and Inclusion, and is currently serving as the Director-at-Large on the AUGS Board. Dr. Jungstrom is a second-year fellow at Emory University, and her research interests are urogyne simulation and trans health. She has a personal background in crafting and art, so making the simulation materials is one of her favorite parts of simulation. I'm just going to say a few housekeeping items just about how tonight's program is going to run. The presentation will run for about 45 minutes, and there will be a recording of this video of this presentation. The last 15 minutes of the webinar will be dedicated to questions and answers. Throughout the presentation, please feel free to raise any questions, to place any questions that you may have using the Q&A function, and we will make sure that we address them at the end of the presentation. I also would like to remind everyone that AUGS designates this live activity for a maximum of one AMA PRA Category 1 credit. To claim your CME credit, you must log into the AUGS eLearning portal and complete the evaluation following the completion of the webinar. Like I said earlier, the webinar is being recorded and is currently live-streamed, and a recording of this webinar will be made available in the AUGS eLearning portal. And finally, a reminder again that the Q&A function is going to be live throughout the session, and again, please place your questions in there either during or after the presentation, but more importantly, we will get to them at the end of the presentation. And any questions that you place in there will be monitored by the AUGS staff. And so without much further ado, I'm going to turn it over to our speakers, and thank you so much for joining us. Thank you for that wonderful introduction, Dr. Brown. We're excited to be here and are excited to talk about simulation and its best implementation and practices in FDMRS education. And like I love to say about this, the only thing that's real is that for disclosures, I do some past consulting with my clients. So we'll give a little introduction on simulation and its history, and particularly where its use in medicine has come along. There are a lot of definitions for simulation. If you look it up on Dictionaries, there's various different ways to say exactly what this is. Essentially, it is creating an artificial environment for which to train or to teach for a real-life scenario. And it has gotten its foothold in a lot of different industries. We certainly see this in the military with certain exercises. We see it in the aviation industry. We have Delta right here in our backyard, and they have all these airline simulators to see for pilot training. Nuclear power plants have been able to conduct certain drills and certain crisis scenarios. For medicine, it really got into the second half of the 20th century, where simulation became an element of medical training. And the first real good example of this is the Rissussie Ant. A lot of us have seen an example of this in our training, especially for ACLS and BLS training. And the Rissussie Ant was one of these types of trainers that was created by actually a toy manufacturer in 1960. And the idea was to create a part-task trainer, meaning that there is a particular scenario that we need to train, and this is the device to do it. And it was low cost and an effective training model. There was a little bit of controversy. The actual modeling of the face was taken from a death map from somebody who was unknown and drowned in the 1800s, so there's a little bit of controversy on that. But this really was a nice first example of a part-task trainer using medicine. Then it got a little bit more high tech. So there was something called SIM-1, which was a way to simulate all these physiologic changes that could happen, and you used a computer to do so. And this was done in the late 1960s. So you can imagine the amount of computer technology that was needed to run the physiologic simulations of these things, so it was quite expensive. And so it was hard to imagine fitting this type of device, not to mention the size and the cost of it, into a traditional medical education at that time. So with medical education reform, there was a drive, a spirit to prepare doctors in a better way and improve the training and increase patient safety. And so as all these movements are moving to improving medical care, simulation started to evolve as a natural means for training and education. And it was also a way to streamline teamwork, which is very important, and all of us have spent time in the operating room with that. It helped with postgraduate education, and for those who needed to do more repetition because a particular surgery volume was low, this was a great avenue in which to do so. So with any of these talks, we always want to see the data, right? We want to see if there's any evidence that this actually can help. So there have been a few randomized studies that look at general surgery and their trainees in the operating room, and they found that with the surgical simulation curriculum, the older times that their trainees were served, the task completion was way better, and the error rate was lower. For OB-GYN residents, a randomized study through surgical sim training for laparoscopic procedures such as tubal ligation or salpidectomy, and vaginal hysterectomy and OB laceration repair, also that the trainees had improved performance when utilizing simulation as part of the training. However, trying to figure out what's the best in simulation better than the traditional lectures and videos and didactic, that has not been established yet, but it certainly is emerging as a way to augment what we traditionally have. If we look at some of the use of simulation-based education and the results that they're achieving in these labs, they are very transferable to patient care. That's the important thing to know. If we work on this, does it make a difference in the patient care? Does it promote the enhancement of critical knowledge, attitudes, and skills when you really need it? Residents participated in this study in pre-rotation simulation. These were interns, BDY1, and knowledge was acquired and transferred to improve the bedside skills using simulation. There was a nice translational simulation framework, and the input-output process framework was established to look at effectiveness of the team, quality management, and targets for organizational growth. There's a lot of benefits that we're seeing. So, if we look at FPMRS in particular, you can see a couple of studies looking at a particular urogynecologic procedure. So, in this study, the simulation was a cadet, and the procedure was a trans-operator take procedure. So, there's 34 residents, 17 control, 17 intervention. Didactics used a floating pelvis video, and the intervention was resident trained with half a day of cadaver lab. By assessing the residents, we were looking at the placement of one arm on a custom-designed pelvis model simulator. The results showed an improvement of knowledge over the control, and also the TOT insertion score was higher in residents that had gone through simulation. If you look at actual procedure time, so having a trainer, a training pelvic simulator, prior to doing a mid-duration swing has reduced the operating time and improved the confidence of the residents. So, this is an article from Mount Sinai where I did my fellowship, and I remember when they started working on it, they had a pelvic simulator for passing a mid-duration swing, and the idea was before the procedure, the resident would do the repetitions on the pelvic trainer and then be warmed up, ready to go for the actual procedure. So, I likened this to the on-deck circle in baseball. So, you're doing your warm-up swings, you're using a heavier bat, and by the time you step into the battery box, you're warmed up, you're ready to go. And it's most certainly improved the resident's confidence, which is important. And looking at other types of procedures, an anterior vaginal repair, looking at a construct validity model, they had 37 participants, 13 novices, 18 advanced residents, and experts, and they were able to develop a nice simulation model of the anterior wall. So, now we're seeing simulation starting to work for residents, and now we're seeing some studies emerging showing, okay, we've got a nice workable model that we can adapt across residencies, we can adapt across training programs, and we're starting to pick up the momentum here. And we've all seen the beef tongue model for obstetrics where we're doing a laceration repair, and this is another nice study that shows a how-to of building a simulator, and this paper describes the construction, the resident impression. It's very much like out of a cookbook, and this is something that you can adapt to your own program. Now, it doesn't just end at education and training. Simulation can have some other uses that can be important for the field of medicine as well. So, we're now seeing it being used for new skill development in physicians who are already in practice. You can refine new techniques that you learn, but you can also improve your ability to teach these techniques to residents and fellows. Demonstrate competency, especially when we talked about where volumes might be lower, a simulation might be a good place to demonstrate competency for renewing privilege, for instance. Boot camps and fundamental laparoscopic surgery that all use a simulator. ACS has a fundamental surgery curriculum that also uses a simulated scenario, and then more recently, we see the emergence of surgical coaches, and the simulations and simulated models can aid coaches to help practicing surgeons improve their skills. Now, for us, we actually saw an interesting opportunity through simulation. We wanted to look at a new technique for anterior wall five patients, and we wanted to model it after we were done. Building a simulation model to test an anterior repair allows us to test certain suturing techniques and look at the strength without doing this on a patient, without doing it on a cadaver or animal, but actually work out some of the mechanics ahead of time and have a simulated model in which we could try different things in a safe environment, and we feel that simulation here might be great for testing out these new novel surgical techniques, as opposed to just trying them out in the old way, and this is a really nice example of that. So, at this point, I am going to turn this over to Dr. Sahini, and we're going to talk about simulated patients and environments, and we're going to do a little demo. I'm very happy to be here. Thank you so much for having me and us to present this. So, I think that simulation is just such a wonderful adjunct for clinical teaching. We all know that we're in the OR and our residents are tired or they are getting calls from the nurses about patients, and they are maybe stressed, and so they don't really aren't focused as well. They haven't learned all the techniques as well. If they have gone through simulation and they've really been able to really practice the steps and they've really gotten it into their muscle memory, then it really helps them to be very more straightforward, be able to be more confident, and to really be able to command those kind of things, just like if you drive to work, sometimes you know that so well you forgot, did I even pass that truck that's always there or whatever? It's the same kind of thing for residents. So, I think that the most important thing is when you're looking at how do I create a simulation, the most important thing is to look, what do I need? Where are my weaknesses in my program or do I not have enough volume? And a good way is just to do like a survey monkey or a poll and find out from your faculty, your residents, your fellows, what is it that they feel they don't have enough experience in? Or if you have feedback from your faculty that residents or fellows have some weakness in some area, you can go for that. You can also look at where your didactics are and how to sort of combine that didactics with your simulation. Once you've established what type of simulation you need or want, then it's important to sort of identify if it's more of a task or a circle type based simulation or whether it's sort of a scenario based multidisciplinary OB emergency or operating room emergency. Or is it something that you want to look at these non-technical skills? How does the resident deliver bad news? How do they manage an emergency? And then the other part is, who is your learner? And because that's going to affect a little bit of how your simulation runs and what skills you're really trying to establish for them. So what I usually do is I think about what simulation I want and then I think about what is the actual part of the procedure that is the challenge. Once I've sort of thought through the steps of the procedure, I usually go ahead and do a quick Google search to see if anyone's going to make a model because why should we recreate the wheel? And there are some marvelous ideas and marvelous low-fidelity trainers out there if you don't have the funds. If you are already a trainer in some kind of model or trainer in your department, you can use that of course. A lot of times they can be morphed to what you want. You can reach out to other departments and to use them across different specialties. The most important thing is that you know that your model, whether it is a low-cost model or not, has that fidelity that you need to learn the actual procedure or the steps that you need. The other thing that's really important in it of course is how to make it engaging for everyone, your faculty, your residents, your fellows, the medical students. And usually I always say if you can teach it, you know it. So it can start with faculty, making sure the faculty all is on the same page and that the, you know, any variations make sense and it's good from an anatomic standpoint. Fellows being able to teach a senior resident or take them through a procedure, whether it's real or simulated, is very helpful because it helps them to really identify those critical steps as well as going to a junior resident. And then junior residents are able to help medical students learn how to do exposure and different types of things so they can actually see it and understand a little bit more about the anatomic things about it. Does this help? We keep coming back to this because translational assessment is always a little bit harder. Usually numbers on simulation research are a little bit low and superpower is a little bit lower. Ultimately, we're doing all this so that we can have better patient outcomes. But we do know that we do have shorter operating times. They have increased same-day discharges. And so in general, the gestalt is that it improves our patience. I know that it improves my patience in the OR when my residents and fellows have done simulation because they know the steps. They're comfortable with the dissections and they can move forward in a pretty nice manner. We're going to demonstrate this particular poproplysis model. I edited this particular model from a video I found online for 2016. It was created by Dr. Petrovic and Dr. Mahajan on poproplysis, and I basically took it and made a report out of it in the poproplysis, and I modified where it is, and then we created this urethane lubricant and suspension model. Many of my models often start with socks, it's a running theme. Any kind of difference in sock, and then usually the nylon in this case is the peritoneum, sort of that fascial, peritoneal fascial layer. For the coproplysis model, this would be all you would do in terms of making your initial setup. For the Laporte model, in order to create the cervix, you're going to put a knot in it, because that helps to create a little knot area, a little cervical area that you'll be able to see when the model is created. In order to create the actual prolapse, I used fluff. In the original model, or the original model that I modeled this after, edited this after, they used cotton balls, which I found when I originally did, it was too firm, it didn't mold enough, they couldn't actually invert it for the coproplysis. And for the Laporte model, the important thing is to get that around the knot so that you actually create a small little cervix, so that you have a cervix and that will help you when you're teaching a Laporte versus the coproplysis model. And once you get that made, you just put a knot in the stocking, and then depending on your learner, oftentimes I will take some dilute Elmer's glue and put it on that outside before we fold over the stock, because it gives it a little bit of adhesion so that on more advanced learners, they have to do that dissection technique and not actually tear the nylon stocking. So it does give them a little bit of that tactile sensation that they need where they have to use both hands. So as you can see this here, you have your little cervix at the top right there. This one has been glued, it's a little bit firmer. And then because I usually do multiple models for multiple residents at a time, I found that these little Ziploc containers make a very nice vagina. And so then the most important thing is just putting that in there and making sure that you have the urethra marked such that when you show the prolapse, there's enough distance and they can figure out about that. I usually secure the foam on the bottom on a table and then you can just pop a new model in and once it's secured, this is the prolapse, you make sure that you can make that incision and you have enough room for your medical sling or whatever. And that's part of that dissection and how they will do that. And then as they cut out that and they may either look forward and make the tunnels or whether they use that multiple times if they have hands-on. So this is residents doing another one of our models in terms of the incubant hair, but it looks very similar. We also then did this, you are safe for looking at a suspension model and we're going to go through both of these models in construction. This is the vagina and it's made out of a baby sock and a nylon stocking. In order to make these one, I sewed around it and then these are reusable. Unlike the copepolysis models, which are one and done, these are ones that you can reuse multiple times. And then we use a square Ziploc container and we use this particular size because it fits in a laparoscopic training box with the right sort of perspective for them to do a laparoscopic either a staple or a suspension. This is the bladder. It has a very loose amount of air in it. I initially did water. That was too messy air. It's okay. And then these are the ureters. And so there's a sense of where the ureters are in relation to the uterus. And that's part of when you're creating your models. You just want to think about what are those anatomic parts that you want to really look at. So this is a closed, a closed cup. And then this is the uterus staple suspension that's been completed by the residents. So we're going to switch cameras now and just kind of go through. This was kind of a faster highlight of the uterus staple, but we're going to switch cameras now. And so just some overhead, some techniques and how some of the finer ways of putting this together so that we can all see in real time. Dr. Kelly. I think you have to stop sharing your screen first. Absolutely. All right. Is that better? I'm muted now. Hi, I'm going to unmute. Can you hear me now in a fairly normal way? All right. All right. Can you hear me? Just someone nod. Okay. It's unmuted for me. Yeah. All right. I guess so. All right. So this is the model. It's attached to the bladder. You can use hot glue. This is the vagina open, and this is the uterus staple ligaments here with the ureters and the attach to the bladder. And I'll show you sort of the step by step real quickly here. So first I usually make a bladder with the ureters on the sides. Usually you have to clamp them and tie it, and there's a little bit of air in that. The next part that I usually do is I'll mark an idea where I want to put holes. And usually I'll start with the ureters. And I use little binder clips initially and put holes in and set that in. And then I'll put it in so that my constructed vagina and uterus staple ligament is in there. And you can then also pull that through holes and make binder clips until you're happy sort of with the process, how far things are. And again, this is a Ziploc container and balloons. You can change it if it doesn't work for you. And then I usually tie the ends and then duct tape this together. And then as you could see from our other one, we put a little bit of cardboard there just so you wouldn't see through. So that's pretty simple, and it can be used multiple times. Initially, we used this straight shoestring, but alternatively, we liked really the round one better. The other thing is to make sure that you can sew this in here closed a little bit so it looks more like a uterus staple angle. So in order to make that vagina, that's probably the trickiest part of everything. And so you'll take a baby sock that has some kind of cuff and you cut it so that you have the two sides of the cuff basically. And then what you're going to do is you're going to put that nylon stocking through like this. And hopefully you can all see that. And fold it over a little bit like that. And then what I do is I take the shoelaces, and usually you don't need too much, you get one set. And I'm going to put it through here so that it comes up to the top of the vagina on both sides. It'll go in through here and through that. And so I will then usually sew all of this around. Now you can hot glue this. I've stapled it when it's been late and I was behind, and it works fine. The suturing though is nice because you can reuse it and it's pretty hardy. So here's one that I sutured on the inside. So here I will turn it back over. And a lot of times I'll use the binder clips or something just to hold everything in place and then I just sewed around this. And then once you have this, you're going to flip it inside out. Make sure everything comes through. And then you can decide on how long you need that vagina. So here, of course, we have a lot of nylon stocking you don't need. And here's this part. So what I would do is then I would measure what I need. I would cut off the excess. And then you can, again, hot glue, whatever you want to do. Whatever you want to do this part together. And I usually make sure that I secure those uterus sacral ligaments in their spot down here. And then once that's completed, then you have this all done. And if you want, you can put a little stitch there. You can modify this however you want. That meets with whatever you need. And then my only suggestion is not to have as much vagina. We have a little bit more vagina in these initial ones. They needed to be on a little bit more stretch. If you make them a little shorter, you can really focus more on the uterus sacral ligament and really have your residents or fellows practice going through that uterus sacral ligament and being able to tie and compress that when this is in a FLS box. Fantastic. So I'm just going to show everybody just how it will look with the, if we were doing this with an actual cobalt chiasis model. So this is a reformed model. So and, you know, we have it in this sort of can format. It can be a cobalt chiasis in a can. This would be great for the residents and fellows to take on that one. And fellows to take on that long flight to Portland for the scientific meeting. But very important. So one of the things you saw in the picture is that we had ways to kind of secure this down. So that's important. So here we'll just use some tape and really sort of just kind of secure this to the table because it can move around and roll around a little bit. So now you have your exteriorized vagina and uterus. And just like you would teach a regular, you know, in the operating room, you're going to mark off where you want to do your cobalt chiasis. And then you can have your trainees mark off where they would do this part in the operating room. And of course, marking off on both sides and coming down. And it's really a great way to do instruction. Now, the reason that we're going to show you a little bit how we start doing this is there are some nuances that, you know, we have to kind of get through on a cotton sock model. So traditionally, you would use your scalpel. Here, you're actually going to need to use a sharp pair of scissors. And the sharp pair of scissors is what's going to allow you to get into the get underneath this cotton sock. So even though you can explain to your trainees that typically you would use some sharp scissors and just sort of get them practicing the dissection like so. And you can see, as this is happening, it's starting to show you that, quote unquote, fascial layer that we're all looking for in the operating room. So you can see that here. And then they can even practice with some more traditional scissors at this point because of the glue. It allows you, if you wanted to, thank you. And it also teaches you how to work with your assistants. So you can work on dissecting underneath that layer with scissors. And it moves through the glue with enough resistance that it really does feel like a real life scenario. And so you can spread, you can push and spread, and you can get that there just like you would want them to do in the operating room. And you can also use other things like your, yeah, you can put a tenaculum on and maybe give some resistance there. But once you have that dissected on both sides, then you can start suturing the layers just like you would. And eventually this will get to the point where you can re-imagine it. And this really does, you can see it on a close-up, you can see how this sort of sticks together, but not too much. Just allows you enough so you can really dissect. It really does have a nice effect there. And then you can have them do the same approach on the opposite side as well. So this is really a nice trainer. It is a one-use only for this as opposed to the utero-sacral ligament suspension one that you can put into a laparoscopic trainer and use that on a couple of occasions as well. So it's nice to have this sort of demo. So we're going to switch back over to the traditional slides and round out this conversation talking about how this can be incorporated into your training program. And we will turn this over to Dr. Morton. Let me share my screen. There we go. Yep. Thank you, Dr. Kelly and Dr. Shaheen for those great demonstrations. So I'm just going to briefly kind of go over some best practices for implementing the simulation curriculum into your fellowship program. Next slide. So as Dr. Kelly already pointed out, talking a lot about the history and some of the literature that's available about surgical simulation and medical education, there are multiple reasons why one should consider incorporating simulation training into your fellowship program if you haven't already done that. And some of the often cited ones are decrease in surgical volume, increasingly complex pelvic reconstructive surgeries as our surgeries evolve to try and to become more durable, more robust, to involve implant procedures, to look at more increasingly complex areas of anatomy. Simulation really has a place. Another reason is the increase in new technologies as well as the new techniques and devices in gynecology and urogynecology. And then finally, another often sorted reason is the limitations in work hours that our trainers must adhere to for patient safety. Next slide. So we all want our learners to progress in level of competency and autonomy through each year of their fellowship. So for most FPMRS fellows who come in from OBGYN programs, they start as PGY-5s and go on to PGY-7s, which is when they will graduate. And so even though there are various levels in skill levels that PGY-5s have when they're entering a surgical fellowship, in large part, our objective in their training is for them to observe, assist, and perform, depending on competency, various pelvic reconstructive procedures, either open, laparoscopic, or vaginal. And then by the time they're PGY-7, we want them to primarily be performing most of these procedures with some guidance, but mostly the ability to perform these procedures safely and competency. And what we believe, and others have shown, is that simulation can augment this training so that we can ensure, regardless of the clinical volume, regardless of the trainee's skill level when they enter fellowship, that we're all sort of at that same level by PGY-7. Next slide. So first, you have to start with learning objectives. So what is it that you want to learn? What is it that you need to learn? And Dr. Shaheen kind of alluded to this already, looking at finding out what the actual needs are before setting up a simulation model and or curriculum. So in our experience, in our fellowship program, we wanted to assess the volume of surgeries for specific procedures and then decide whether or not simulation is needed. Certainly, if there are high volumes of certain procedures and a high level of competencies reached relatively early, there's probably no need for simulation in that respect. And the other thing to consider in this step, actually, is also how are you going to evaluate your learners' progress during the simulation? And so what we think is most prudent is to utilize some of the same things that you're already utilizing between mobile apps or evaluation cards where you're rating learners every time they do a case with you, using these same evaluation tools and adapting them for the simulation cases so that as learners do both real cases and simulation, they have a similar gauge at which to see where they are in their level of progress and how they're moving forward. Also, we have found providing some coaching techniques. So if you Google clicker for surgical training, there are various publications out about how using what you might use for coaching, you know, a basketball team or a football team or in some other arena where coaching is quite predominant, how that can also help particularly with surgical trainees as they're progressing through their skill development. And then review and evaluations by PGY year to ensure that you are meeting the objectives that you've set out. Next slide. So step two is then developing the simulation models. And what we think is really important, and one of our fellows is joining us here for this webinar, is to involve the fellows very early as you develop your simulation models. We have a certain perspective, having done so many cases, having a certain amount of operative experience, but if a learner isn't going to be able to get the skills that they need to get from the models that we've developed, then, you know, we've sort of spend our wheels and we have to go back to the drawing board because it's not working. So the earlier you have a trainee involved, and by that I mean someone who's done or at least assisted on several cases and has enough skills to sort of understand what we're trying to teach them and then get them involved in, yeah, you know, that really helps me as I'm learning how to dissect better or as I'm learning how to suture better. Understanding, getting that perspective from the learner early will help you make models that are much more robust. And some of the models that we demo today are just that, models that our trainees have been involved in and involved in helping us make them better and more innovative. We find that using a combination of low and high fidelity models is helpful and it really does also depend on the skills you need to master. And then you want to test and retest models to ensure that you are developing the skills that you set out to develop in your objective and also assess for competency with use of these models. Next slide. So a little bit about skill assessment. We talk a lot about skill transfer versus skill generalization and what are the differences between these. So skill transfer is the practice of a particular procedure which is replicated in a simulation environment. So this might be not tying on a segment of bowel or performing a hysterectomy on a cadaver or animal model or things like that. Whereas skill generalization is much more fundamental in that you're practicing basic skills that you might need for multiple different types of procedure. And the fundamentals of laparoscopic surgery or FLS is a really good example of developing the skill generalization. And for those that become certified in FLS, this really helps with your laparoscopic technical skills that are really quite transferable to multiple different procedures. Next slide. So these are some photos of our fellows over probably the past four years in our simulation lab at Emory. Our department of surgery houses a very large simulation lab that can be used by all of the accredited residency and training programs. And you can reserve the lab and use the resources and tools that they have to develop your low fidelity models and also use some of their higher fidelity equipment. And this helps us as an institution share costs while still benefiting from some of the higher fidelity, higher cost models. So for those of you at large academic centers, I would encourage you to work with departments that already have high fidelity learners and look to adjusting them for your learning objectives. Next slide. So with skill transfer, comparing that with skill generalization, skill transfer can be costly because it's more specific to a given procedure. It tends to involve more elaborate models, and it can also be more time consuming. Skill generalization, on the other hand, is simpler to implement. The realism is not necessarily needed to master some of the more basic skills. And it's more likely, you're more likely to develop muscle memory, and you can practice repetition with skill generalization. And again, the FLS is a good example of this. Next slide. So with repetition, it's important for skill mastery. And this is very helpful with the skill generalization that I just talked about. A number of repetitions and the time between depends on the experience of the learner and the procedure. So obviously, as more as you get more advanced, less repetitions are necessary. Deliberate practice involves engaging learners in focus, effort, skill, repetition, and progressive exercises that provide informative feedback. And this comes from Thomas et al., from the orthopedics literature and published in 2014. Practice with experts who can also throw a curveball or create some unexpected circumstances that might be encountered in the operating room can be very helpful, particularly for the more experienced learners. Next slide. With respect to curriculum development, you want to assign skills based on the PGY level. You want to incorporate new skills with each PGY level, such that, you know, the PGY-6s aren't doing the same things that they were doing as PGY-5s. You want them to progressively advance and be able to translate this into the operating room. And then you want to determine some set training times for teaching the skills and allowing for practice and coaching. And then really, which is key, is encouraging independent practice. This is key. These are adult learners. We are all adult learners. And the way we get better is primarily through independent practice after we've been shown a skill, been demonstrated that skill, and have been provided some brief coaching episodes. Next slide. So, for our simulation curriculum, I'm going to just use robotics as an example. We have FLS, which all of our fellows and residents are certified. And so, we wanted to sort of use that as a base to build a concrete robotic surgical simulation training. Our overall simulation program is three-pronged, and it includes skills for vaginal surgery, as well as laparoscopy and robotics. The guidelines for our skill acquisition during our fellowship can be achieved at a faster rate, so things don't have to only be done in PGY-3 or PGY-5. There are trainees that are going to come in, for instance, who have an outside certification in robotics. And so, they don't have to progress through the various objectives by PGY level. They may complete that in their first PGY year just because of their experience, but they may need more time for the progression for vaginal. And so, we tried to adjust our curriculum to make sure that we account for that variation in skill level upon entry. Next slide. So, with respect to robotics, we wanted to incorporate various parts of robotics into our curriculum, from understanding the role and application of robotic surgery for what we do, understanding the components of robotic operating system and how they interact with each other, positioning, docking, instrumentation during surgery, as well as safety and troubleshooting issues. We have our fellows sort of progress, as I said, through levels of proficiency and kind of complete or kind of come to the end of that curriculum with doing consult surgeries independently. And ideally, of course, our goal is to safely perform core FPMRS procedures. Next slide. So, this is just sort of a snapshot in terms of the three-year timeline for our fellows as they advance to our robotic training, where phase one is bedside, phase two is console training, and phase three is console operating. And again, depending on competency upon entry, these can progress much more quickly for some of our trainees. And so, something similar you can set up for laparoscopy and something similar you can set up for vaginal training as well. And what we try to do in between the bedside assist as well as the console operating is incorporate simulation in between all of that so that every time there is the bedside assist or the console operating, the skills are all the more developed with each successive case. Next slide. So, with that, I'd like to conclude the didactic portion of the webinar and invite any questions from our audience. Thank you so much for that presentation. The Q&A is actually full with some questions. I'm just going to start posing that to the team if that's okay. So, just a comment and question. Thank you so much for your demonstration. What resources are there for simulation programs for rare urologic procedures, if any, that we perform? For example, ureteral implantation, complex fistula repair, arch? Yeah. So, I think the way that we're hoping with this presentation is sort of encourage some creativity. So, I think if you're thinking about fistula, we can certainly adapt some of the models that we have with the bladder and vagina, maybe something similar to this where you have the vagina and you have the bladder, and you can make your connection between the two and work on dissection, repairing both separately, right? There's really a lot of different materials and models, and as Dr. Sahin said, sometimes it's already out there, and you can do a Google search and see, you know, has there been a training model set up for this? The other thing, too, is, you know, you can inquire with industry sometimes, especially if it's a ureteral implant, and say, you know, go to a particular company that makes stents and say, I realize you have stent placement simulation. Is there such a thing that we could do a ureteral re-implantation or to spatulate and repair a ureter over one of your products, that sort of thing? I think the possibilities are endless, and that's what makes it exciting in a way, to kind of tap into that creativity and come up with those, the idea of what you want to study, what skills you want to teach, or what skills you'd like to do. So, I think it's really an open deal. Yeah, sometimes the models from industry, you can ask them if you can actually have one or destroy one, especially if you have one that where they practice putting in stents, if you could actually cut the ureter and extend it so that you can practice doing the re-implantation with that already constructed model. I mean, sometimes they won't let you, or you can use, you know, balloons and or tubing. It doesn't have to be the same size necessarily. It's more, what is the process? Do they know how to do it? What are the pitfalls? How do they spatulate? How do they decide where to implant it in the bladder? Those kind of things, you know, where there's no tension, etc., etc. So, I think that it's important to sort of see what's there, see what you have, and then just be a little creative. And also, you know, a lot of times there are a lot of forums and people are working on similar things. And so, it's always helpful to get, you know, two minds are better than one. And so, that's always a good thing. And quickly, I'll put in the fun for the OGS forums that we have going. This is a great place to do, you know, ask research questions and simulation questions could be another great place for the OGS community. So, a little fun for that. The second comment says, I like this COPA crisis model. What are some of the feedback that residents provided after undergoing this program? I would put that one to Mallory. As a resident at Emory and a beneficiary of the Residency Simulation Program and now to FPMRS, I think that would be great, Mallory, to get your perspective. So, I've been lucky enough to train underneath all three amazing physicians here. And Dr. Shaheen's simulation from first year of residency all the way now to PGY-6 here has really, really been beneficial. I can say we have, as residents, been very used to simulation and has really helped me be able to not only just look at something online like YouTube and look at a COPA crisis and read about it in the book, but actually tactically understand what that surgery looks like and then actually practice some of the skills that you need to be able to come into the OR. So, instead of going into my first COPA crisis as a resident, completely confused, I felt empowered. I felt much more confident than I would have before and got to do a lot more and been able to progress with my skills throughout my time as both a resident and a fellow here through the different simulations. For the uterus sacral ligament suspension as well, I helped develop that with Dr. Shaheen my fourth year of residency. And then when I became a fellow, I was able to actually do them and understand and knew the muscle movement of what I'm looking for, how I'm supposed to do it before even ever seeing the procedure in person. So, I think it really helps with the learners' confidence, but also the muscle memory of being able to feel confident enough to start doing actually part of the procedure when you're able to. Thank you. Excellent demo. Have there been studies demonstrating changes in fellows' surgical performance? And I think Dr. Youngstrom sort of touched on this. Is this more so targeted for residents only based on your experience? And it sounds like not just residents, correct? No, I've used it from residency through fellowship. And I think in residency, you're learning what is a uterus sacral ligament suspension. And then in fellowship, you're learning the different ways to be able to do one and the smaller, more higher level skills. And so, it really, really works for all levels in different ways. I'm sorry. I was just going to add on to what Dr. Youngstrom said. What we've really encouraged with our fellows is to use these models to augment what they're doing in the operating room and really challenge themselves. So, I'm often challenging the fellows to really do some things that their bodies aren't used to doing with holding the needle drive or putting them in really crazy places. And they can really practice those advanced skills that they're developing on simulation models. And they're not really necessarily focusing on how do you do one like they did as a resident. They're focusing on really challenging themselves with suture placement, with getting to difficult anatomy and things like that. How often do you need to create written guides for the residents to make learning objectives clearer during the sim education? Well, I do reading and reading material. I give them all reading material and learning objectives for all of the simulations that we have. They're expected to have that baseline reading done. It doesn't always happen, but one of the nice things that I have started to do is we'll do a little quiz on the reading before the simulation. And we sort of go through the questions. So, even if they didn't do the reading, which sometimes doesn't happen, we're able to sort of reinforce those most important learning points. And then they go directly into the simulation. And so, they sort of have that didactic understanding or reinforcement. And then we go in and most and all of the faculty when they're, you know, prompting these, because I definitely can't do it alone. Dr. Kelly comes, the fellows come, Dr. Youngstrom. And they also reinforce that didactic and learning objectives into the hands-on simulation. Yeah. And that's a good point because another thing that I meant to point out with my part of the presentation was that as fellows advance, yes, we're adding different things to the simulation for them as they advance. But also, we want them to teach. And that even helps them even more when they're trying to teach simulation to a novice learner. So, that's something else to consider, you know, as you're developing skill-based or, you know, competency-based learning as a fellow progresses. I think we're just about at time now. So, I'm going to conclude the session. On behalf of AUGS, I'd like to thank all of our faculty today, as well as Dr. Youngstrom for this excellent webinar. For our participants, please be sure to register for our upcoming webinar, which is going to be on February 15th. And that's going to be presented by Dr. Akira Gillingham, entitled Exposures, Infections, and Obstructions, Avoiding Mesh Complications in Urogynecology. Again, thank you so much for your time, and everyone have a wonderful night. Thank you. Good night, everyone.

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