days of veterinary MIS, surgeons had few options other than progressing rapidly into live surgery on patients, after a short introductory course. Such an approach to training is becoming less and less acceptable, due to increasing patient safety concerns, especially as training options outside the OR are becoming more available. If veterinary MIS is to expand unimpeded, effective simulation training may become necessary.
Extensive amounts of research have provided comprehensive information on training program design. What follows is a discussion of current evidence‐based information, with comparative aspects to our experience of veterinary training in the VALT laboratory.
Basic Skills
Ideally, training initially focuses on basic skills task training before progressing to specific surgical procedure training. Skills training such as the VALS program should be considered only the starting point of MIS training. Currently, our institution train all first‐year residents in a VALS‐like curricula in the VALT lab and test competency before proceeding to primary surgeon's role. The resulting improvement in OR performance is not only often dramatic but also highly individually variable. Preliminary data show that inexperienced surgeons are able to perform the highly complex procedure of suture‐ligated ovariectomy, immediately after the training [37].
Life‐like‐High Fidelity‐ Training
In addition to the fundamental psychomotor skills, the complex skills of MIS surgery require an additional variety of training; in lifelike scenarios such as fresh cadavers, live animal models, and apprentice training in surgery. (Figure 1.13) In particular, surgery training programs who lack experienced MIS surgeons on staff, may have problems providing a broad and varied training program to their residents. Also, surgery practitioners wanting to develop MIS skills are limited in options. Currently, industry‐supported commercial short courses, utilizing live models, provide training opportunities for veterinarians. Limited live training opportunities using ovariectomy as a model surgery is also available for ACVS residents. Hopefully the future brings a concerted effort to combine similar efforts into a comprehensive and effective training program for all veterinary surgeons.
Very few high‐fidelity veterinary simulation models are commercially available. Ideally, such analog models should be low cost, physiologically and anatomically similar to dogs and cats, and with inherent means of objective assessment of the skills. For training of M.D. surgeons, a number of procedures have been identified for which simulator models have been developed. Hopefully, the future will see a similar development on the veterinary side. Until then, some of the models used for M.D. surgeons may have value. However, prior to training programs investing in costly tools, the models need validation. Validation evidence is a complex subject [38, 39], but as a concept aims to show that the model represents the intended skills and is clinically relevant. This often starts with face and content validation. If a veterinary expert, with ample experience of successfully performing the particular surgery, is not able to do the simulated procedure effectively, the model content may be faulty (“too hard”). The model anatomy or physiology may be different enough to not effectively simulate veterinary conditions. Conversely, if a novice seems to perform the procedure more effectively than a laparoscopic expert, the model content may not be of appropriate challenge level (“too easy”). Even if the content of the model is validated, simply having the model available for trainees will not reach educational goals. Use of such models does not circumvent the need for principles of deliberate practice. The trainee needs to be at the appropriate training level for the modeled procedure, know the training goals and objectives, and will need individual feedback to truly benefit.
Figure 1.13 Graphic representation of an ideal training program, balanced with concern for patient safety. Training starts with simulation task training such as a VALS‐like curriculum until passing competency assessment. Thereafter high‐fidelity models such as training in fresh cadavers takes place, prior to training on a live animal model. After these steps, the trainee should be ready to perform basic MIS procedures on patients, under supervision of an experienced MIS surgeon. Advancing the level of surgeries would ideally start with fresh cadaver exercises followed by practice in a live model, before attempting advanced procedures on animal patients. It is likely that training of a fully competent MIS surgeon, able to safely do advanced procedures on patients, is beyond the goal of ACVS resident training. Training such as ACVS Fellowship may be required to reach that level.
Starting a Simulation Skills Training Curriculum
For a program director interested to develop a simulation skills training program, there is vast evidence on best practices. More important than the type of simulation model one has access to is that the practice is deliberate [40]. Expertise is not gained by simply spending time practicing but by engaging in a specific type of practice. The concept of deliberate practice [40] outlines the critical elements of optimal learning, that is, tasks with (i) well‐defined goals, (ii) motivation to learn, (iii) feedback, and (iv) opportunities for repetition and refinement.
Tasks and Goals
Training tasks can be selected based on construct validity (i.e., tasks in which performance has been demonstrated to correlate with higher skill levels). However, face value is also important (i.e., experienced surgeons confirming that a training task is using the same skill sets as those required in clinical practice). All tasks need to be demonstrated clearly and effectively for superior learning. Ideally, trainees have unlimited access to high‐quality video tutorials and demonstrations, complementing and significantly decreasing the need for expert instructor involvement [41].
Training goals in the form of performance targets are generally accepted as superior to time‐based training because individuals may differ considerably in how fast the target is reached. For MISTELS‐based training, performance goals have been clearly defined [24]. For other practice tasks, speed, accuracy, or even motion metrics have shown severe limitations, and appropriate training goals for trainees at different levels of training remain work in progress [41]. A training study in the VALT laboratory failed to document advantages of proficiency goals compared with time control [7], and this observation has also been made by others [42]. Perhaps as the medical field learns more about simulation training, we will become increasingly successful in setting appropriate goals. Despite our experiences in the VALT laboratory, we consider proficiency goals valuable because we have noted that training goals appear to add motivation to practice.
Motivation
Internal motivation is a prerequisite for learning but cannot be relied on as the sole driving source for a successful training program. Surgical residents and practicing surgeons are affected by long working hours, limited free time, and seemingly endless clinical responsibilities. Not surprisingly, studies on voluntary participation of skills training in a busy residency showed the participation rate as between 6 and 14% [41, 43]. Also, 82% of ACVS residents reported that lack of time was the main barrier to practice [15].
These studies showed that providing dedicated regular time for mandatory training, known ahead of time to trainees and their faculty, greatly improved participation. For a laboratory with limited resources, this may be hard to accomplish. In the VALT laboratory, we have had success with mandatory training sessions but with timing flexibility through an online sign‐up policy, so each trainee can choose the time that works best for him or her without affecting the clinic or crowding the laboratory. The importance of dedicated laboratory personnel, keeping track of the trainees' sessions,
