Team Training in Surgical Education: The Successful Surgeon of the Future Needs to Be a Team Player

The increasing complexity of the health-care environment has changed the delivery of health care and has increasingly led to the formation of multidisciplinary provider teams that replace the more traditional individualistic doctor-nurse-patient relationship.¹ Even though individualism still influences surgical practice, this change is also affecting how surgical care is delivered, and chances are the process will continue. This novel approach to care requires certain new skill sets that have not been part of the traditional curricula for surgical residency programs. There is mounting evidence that well-functioning health-care teams provide safer patient care,^2,3 but also that poorly trained teams could introduce additional risk for error and result in poor patient outcome.^4,5 Unlike the medical education community, the aviation industry had implemented curricula focusing specifically on team-based competencies for quite some time. In medicine, this process began almost 20 years ago when Gaba and colleagues started to use crisis resource management (CRM) for team training, which they based on crew resource management curricula from flight crew training.^6,7 Their approach was adopted early on within anesthesia training programs⁸ but did not immediately gain much traction within other medical disciplines.

Due to the increasing national focus on patient safety, triggered by the publication of “To Err is Human” in 1999,⁹ team training concepts quickly reached a much more receptive medical audience. Specialties like emergency medicine, obstetrics, and intensive care medicine that rely heavily on well-functioning team performance began to integrate team training into their postgraduate curriculum.^10-14

More recently, surgical educators have become increasingly interested in team training for their specialty. In 2008, the American College of Surgeons (ACS) and the Association of Program Directors in Surgery (APDS) jointly published Phase III of the National Curriculum, which provides a collection of team training modules directed toward surgical care.¹⁵ The idea behind this project was to aid the surgical education community to get started with team training by providing a collection of tested simulation scenarios for this purpose. The process of developing these scenarios is time consuming, tedious, and costly. Many general surgery residency programs do not have the expertise and manpower to perform this course of action on their own. Another problem with implementing such curricula is competition with other clinical and educational activities in surgical residency programs.¹⁶

Currently, the curriculum contains 11 modules: an introduction for teaching faculty and program administrators, and 10 clinical simulation scenarios that were constructed for use with a human patient simulator. The main learning objectives for the scenarios focus on various aspects of team-related competencies (Table 1) but also integrate the Accreditation Council of Graduate Medical Education (ACGME) core competencies. Some of the modules contain their own assessment tools, but it is also feasible to use other instruments, like the NOTECHS scale in one of its modifications.¹⁷

Table 1: Team-Related Competencies
Communication Skills
Critical Language
Assertive Communication
Closed-loop Communication
Active Listening
Leadership
Briefing and Planning
Resource Management
Seeking Advice and Feedback
Coping with Stress
Decision Making
Global Awareness

Some effort has been made to develop standardized curricula for health-care providers working in teams. One example is the “Team Strategies and Tools to Enhance Performance and Patient Safety” (TeamSTEPPS) program, which was developed by the Department of Defense and made available to the public in 2005. At its core, the program focuses on competencies in leadership, situation monitoring, mutual support, and communication (Figure 1).¹⁸ Despite its background, there is limited scientific evidence regarding its effectiveness. In a recent study performed at our institution, however, we were able to show that a TeamSTEPPS curriculum provided for senior medical students that had matched into surgical residency programs could significantly improve their self-efficacy, knowledge, and performance as team leaders.¹⁹

Figure 1: Concepts of the TeamSTEPPS framework.

Measuring team performance is important to improve interprofessional teamwork.²⁰ A variety of instruments to measure performance of teams in the medical field have been developed.^21-23 Recently, a modified NOTECHS scale was reported to assess surgical teams training with good reliability.¹⁷ The latter instrument appears to be a good evaluation tool for a TeamSTEPPS-based curriculum, as it covers all of its four competencies. To assess the effectiveness of a training program Kirkpatrick describes four levels on which the success of the curriculum can be evaluated, namely learner reaction, learning, behavior, and results (level I to IV).²⁴ Level I assesses the participants' reaction toward the program, level II whether any learning occurred, level III looks at how the learners’ behavior was influenced by the intervention, and level IV evaluates measurable real world outcomes caused by the intervention.²⁵ Whereas the first two levels can usually be assessed fairly easily, levels 3 and 4 often pose significant challenges. This situation may explain why assessing the effectiveness of team training in regards to patient outcomes, which would represent the highest level, remains difficult,^26,27 even though evidence is emerging that training in team-based competencies positively effects team performance.²⁸ Due to this difficulty many studies focus their assessment on learner reaction to the curriculum and self-efficacy scores.^14,29-31 This assessment may be misleading, however, as recent publications suggest that self-belief and self-assessment seem to be rather poor indicators of performance, especially in novice learners.^32,33

Observation and assessment of behavioral change in real-life environments can be very challenging and is therefore not done frequently.^34,35 Even when attempted, the measured outcome often is not direct observation of behavior or outcomes, but personal impressions of the participants,³⁶ which may or may not reflect true change. This difficulty makes the use of simulation for evaluation purposes very attractive.³⁷ Simulation in medical education makes it possible to gain immersive experiences individually or as a team by dealing with challenging situations without putting a patient at risk.³⁸ It is also possible to adjust the scenario to the specific needs of the learner. A large study with emergency room physicians has shown that didactic team training results in a positive effect on team performance,³⁹ but adding additional simulation scenarios to this training appears to lead to further improvement.^40,41

Whereas the traditional educational emphasis in surgery was directed toward technical skills and patient management in the “captain of the ship” model, the new paradigm of health care focuses increasingly on interdisciplinary teams as its core delivery unit. This shift makes it necessary for surgical educators to modify their curricula in an effort to prepare their trainees for their future jobs. The challenges to do so are substantial, as we are already faced with a tight competition between patient-care-based education and educational activities away from clinical service, especially in the 80-hour environment. Prepackaged educational content as provided by the ACS/APDS curriculum phase III or TeamSTEPPS may be very helpful to get the process started. The learning curve for team-based education is fairly steep, and it may be a good strategy for surgical educators with limited expertise in this arena to collaborate with colleagues that have done this form of training for a while.

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