TORONTO - It's a pivotal event that comes in the education of all would-be surgeons. At some point, medical students who plan to make a career of opening up and fixing other human beings have to make that first cut.
If Drs. Teodor Grantcharov and Vanessa Palter have their way, however, that first application of scalpel to skin will occur on a computer screen, not on the torso of a living, breathing person.
And not just the first cut. They believe surgical residents ought to achieve an established level of proficiency in a virtual operating room before they start plying their scalpel in a real OR.
"There are studies that show that in the first 50 cases, the risk of major complications is significantly higher than after the next 30 cases. And all these studies are done on real patients," says Grantcharov, an associate professor of medicine at the University of Toronto and a surgeon who specializes in minimally invasive procedures at St. Michael's, one of the university's teaching hospitals.
To Grantcharov, the idea of allowing surgical residents to operate before they've met a set skill level in a virtual OR is outdated.
Simulation tools are now available and are found with increasing frequency in medical schools across North America. They provide an alternate route for surgical residents to climb the early — and risk-filled — part of the learning curve.
"I always found it ridiculous to talk about learning curves on real patients," says Grantcharov, a towering figure decked out in clogs, scrubs and a Toronto Maple Leafs surgical cap.
"We want to see the learning curve in the simulation theatre or on the computer. Talking about learning curves of procedures on patients — I think it's unethical."
And inefficient. Grantcharov and Palter — a surgical resident who is also working on a PhD — recently published a study showing that surgical residents who train first in a simulation lab significantly outperform colleagues who receive only standard surgical training.
The study compared University of Toronto surgical residents who completed a five-month long simulation training module to residents who received conventional surgical training. All the residents performed a laparoscopic right hemicolectomy — an operation where a tumour is removed from the right side of the colon using small incisions, not the large cuts commonly used for operations in the past.
The procedures were videotaped and graded by outside experts. Residents who had trained on the simulators scored an average of 16 points (out of 20) where surgical residents who didn't get the additional virtual training scored an average of eight.
The findings were published this month in the journal Annals of Surgery. But the results were so persuasive the University of Toronto's medical school made the virtual training program mandatory for surgery students even before the study was published.
Grantcharov says the program was first offered in February and was hugely popular among students. He says it's critical to offer the virtual training as part of a curriculum; letting students work on simulators on their own doesn't achieve the goal.
The module they've developed compares students' efforts to those of expert surgeons, allowing residents to see where they need improvement. "So that way, instead of just mindless practice on the simulator, you're actually practising to a specific goal, to essentially be as good as the expert," Palter says.
Dr. Steve MacLellan took the virtual training course. He says it made a difference to be able to practise in a lower stress environment.
"Not having a patient on the table, being able to think through the steps of an operation and physically do it with the simulators — I think it gives you a leg up in the operating room when it comes to actually operating on real patients for sure," says MacLellan, who is now a clinical fellow at the University of Toronto studying a surgical sub-specialty.
For him, the biggest gain was in developing muscle memory, learning how the instruments worked and practising different tasks.
"I think it helped expand the repertoire of skills and provided an ability to test out some techniques that I may not have tried on a patient before."
The idea of requiring residents to show they are competent before they are allowed to operate on people mirrors the approach taken by the aviation industry, where would-be commercial pilots have to prove their proficiency before taking to the skies. "If they fail they don't fly a real aircraft until they've passed," Grantcharov says.
He acknowledges some surgical residents may never reach that level. A study he co-authored a few years ago in Denmark found that eight per cent of surgical residents did not show evidence of a learning curve.
"They did not get any better," he says. "And I checked five years later ... what happened to these people because you can check it on the website of the Danish Medical Association, and none of them is a practising surgeon now."
What will happen if that also proves to be the case with the University of Toronto surgical simulation program? "That's a whole new question that I don't think we're ready to address yet," he admits.
The simulation labs themselves offer a range of training opportunities.
Some allow residents to practise laparoscopic procedures, using tools connected to computers. On the screen are realistic looking computer graphics displaying, for instance, an appendix that needs to be removed. Manipulating the instruments, the residents can run through all the steps required to remove the organ laparoscopically.
Missteps provoke the types of problems they would in an operating room. If a student nicks surrounding tissue, the area will be infused with virtual blood. The program measures how much blood loss the error triggered and how much discomfort the virtual patient would experience as a result.
In addition, simulation theatres contain what are known as full body simulators — life-like mannequins like Harvey, who belongs to St. Michael's.
The simulators have a pulse that can speed or slow. Their chests rise and fall as if they are breathing. They can sweat. They can bleed. They can even die — though Grantcharov says instructors monitoring a simulation will stop it before the virtual patient meets its virtual maker.
Studies have shown residents who "kill" their virtual patients can suffer a real crisis of confidence. Palter says it's easy to forget in these exercises that you aren't working on a real patient — the lessons are that true to the real-life experience. "It's very stressful," she says.
Instructors watch simulations from behind one-way mirrors. They can intervene, tossing a wrench into the proceedings by programming in an unexpected finding or complication. They can also speak for the dummies, projecting a moan, say, if a procedure would have caused pain.
Palter says training on the simulators doesn't simply raise proficiency levels among surgical residents — it also raises their confidence.
"I think knowing that you can do something already, in a dry run and a safe environment and knowing that you've been able to do it once certainly gives you the confidence in the operating room," she says.
"But more importantly, it gives them the skills in the operating room. And our data show that."