For most of its history, surgical education has relied on the operating room as the main source of learning. Residents—who spent over 100 hours per week in the hospital—learned by observing and operating under supervision, taking on the cases and procedures that came through the OR. The thinking behind this model was that, over the course of several years of almost nonstop operations and patient care, a resident would have all of the necessary skills for their professional practice as a surgeon.
By 2003, the Accreditation Council for Graduate Medical Education (ACGME) limited duty hours, reducing the maximum time a resident could spend in the hospital to 80 hours each week. While 80 hours is still a lot—twice the full-time American workweek—this reduction addressed the exhaustion many residents faced from working back-to-back 24-hour shifts, and optimized patient safety.
Although surgical residents were expected to spend fewer hours in the operating room, it was still important that they receive thorough training while in residency. Fortunately, advancements in technology and curriculum have produced a solution: simulation training.
The history of simulation training at Washington University School of Medicine in St. Louis demonstrates the value of partnership, healthy growth in an innovative field and commitment to the medical school’s educational mission.
Simulation at the Center of it All
The Washington University Institute for Surgical Education (WISE) Center is a 4,000-square foot educational space centrally located in the Clinical Sciences Research Building (CSRB) at the School of Medicine. WISE offers a variety of surgical skills labs and simulators. These include simple foam rubber simulators for suture practice, as well as high-tech robotic surgery and virtual reality simulators.
At the head of this large and varied educational center is Michael M. Awad, MD, PhD, Associate Professor of Surgery and Director of WISE.
“I have a passion for education and curriculum,” asserts Awad. When he joined the Department of Surgery in 2009 as Associate Program Director for the General Surgery Residency, Awad saw an opportunity to grow the simulation and lab training aspects of the program. “I was eager for residents to have more intentional training.”
Awad began by formally introducing the WISE Center in 2010.
WISE built on the existing surgical skills lab—founded by Mary E. Klingensmith, MD, the Mary Culver Distinguished Professor and Vice Chair for Education in the Department of Surgery—by providing a multidisciplinary approach to advancing patient care and safety, education and research in the field of surgery and its subspecialties. Awad notes that Klingensmith, who is now a Vice President of the American Board of Surgery, founded the original simulation facility at the School of Medicine in 2001, making it possible for WISE to grow as it has.
The WISE Center started small. Awad recalls the original space being a single room on the 9th floor of the Wohl Building. Even during these humble beginnings, WISE boasted useful training tools, including a laparoscopic tower for residents to practice their skills in minimally invasive surgery. Laparoscopic procedures differ from open surgery in that they require smaller incisions and allow the surgeon to operate by inserting long-reach instruments into the abdominal cavity through straws called trocars. These procedures have a number of benefits over open surgery, but require the surgeon to possess a particular set of skills. The opportunity to practice these skills in an educational setting is part of the benefit of the WISE Center: education no longer relies solely on the operating room. Simulation, in this case, means practicing surgical skills without a real, live patient.
“I like to think of it as a distinction between education by accident and education by intention,” Awad illustrates. “We make sure that people are well trained. The first time you operate a laparoscopic instrument, or any device, should be in a simulated environment, where it’s OK to take your time and learn. In the clinical arena, the focus must always be on the patient. In a simulated environment, education can be foremost.”
Initially, this training was specifically for general surgery residents. As WISE grew and developed a reputation as a center for excellent skills training, more members of the School of Medicine came for training. Rather than each department or division attempting to form their own simulation center, WISE embraced this opportunity to train more medical professionals. WISE now provides training to practicing surgeons, physicians and residents from other disciplines, medical students, allied health professionals and nurses. These new learners at WISE include Obstetrics & Gynecology, Orthopedic Surgery, Gastroenterologists, EMTs and Emergency Medicine Physicians, Pulmonologists, Nurses and Nurse Practitioners and Surgical Technology students from St. Louis Community College, among others. WISE also offers nationally attended training courses and education through community outreach in the Great St. Louis Region.
With over 700 activities annually and thousands of individuals visiting the center each year, WISE has grown in both its offerings and physical space.
“Our physical footprint increased from maybe 100 square feet when I arrived to about 4,000 square feet today,” Awad says. This growth was gradual, the result of Awad acquiring more space in the CSRB as it became available. To keep pace with this growth, WISE staff increased, as well. This team, including Peggy Frisella, Administrator of WISE and Manager of Research Operations for the Institute for Minimally Invasive Surgery, and Surgical Skills Coordinators Karen Schubert and Angelia DeClue, coordinate and administer trainings in the busy WISE Center. “They keep the center going,” Awad says, recognizing their important role in operations. Jeffrey Blatnik, MD, Assistant Professor of Surgery, serves as Director of Surgical Programs at WISE. “The two of us,” Awad says of himself and Blatnik, “we really tag-team the leadership of WISE.”
A major landmark in the history of WISE was becoming accredited by the American College of Surgeons(ACS) as a level 1 simulation center. This accreditation defines the WISE Center as a world-class institute for surgical education.
“There are only about 90 of these accredited centers around the world,” Awad says. “Sixty of which are in the United States. This distinction tells anyone who wants to use our center that we have achieved a high level of educational excellence. Our high-quality courses and curricula show potential trainees what we are able to offer.”
Funding for the center plays a critical role in advancing training, research and patient care in surgery. Seeing the ACS accreditation reinforces for charitable donors that WISE is committed to its educational mission.
In 2018, WISE established a simulation fellowship—a one- or two-year opportunity for a resident to focus on simulation education. The first fellow is Eileen Smith, MD, who joined the WISE fellowship in 2019 and is learning more about the creation of curriculum and the administration of a simulation center.
The history of WISE tells a story of surgeons and educators passionate about the future of surgery at the School of Medicine. Residents, who work hard to master their craft in the operating room, have new opportunities to practice their skills in a safe learning environment. Accreditation, expansion and recognition are all excellent ways of showing the work being done by the WISE Center, but, as Awad emphasizes, it is important to keep WISE’s mission in mind above all else: “Promote the education of health care professionals. Advance the field of surgical education through educational research. Improve the welfare of the greater patient community.”
This mission is achieved by ensuring that residents, faculty and medical professionals from around the community have access to the best quality education and training in a world-class simulation center. The training spans the entire course of surgical education, from low-tech skills practice to the most advanced robotics and virtual reality, allowing all WISE learners to feel confident in their ability when they enter the operating room.
“When you’re learning to play tennis,” Awad says for comparison, “you first learn the basic components: How to hold the racket; how to formulate your swing; how to throw the ball in the air to serve; how to forehand and backhand. Eventually, you put that all together into a game. Similarly, with surgery, you learn the basic skills first: how to load the needle; how to move it through the tissue; how to tie it in a knot. Then you put those skills together into the performance of a procedure.”