Surgical Skills Competition Teaches Vital Lessons

General surgery training is progressively transitioning from a time-based, apprentice-style system toward a competency curriculum with emphasis on a healthy work and learning environment.

With the increasing complexity of patients and broadening of operative techniques, trainees require more than a prescribed number of hours or cases to become proficient and safe surgeons.

Use of simulation provides patient-independent opportunities to accelerate the learning curve, improve dexterity and efficiency, and evaluate competency.^1-3 While most surgery departments in the US have established simulation activities, effective implementation of these courses is limited by multiple factors, including cost, logistical infrastructure, and learner/teacher engagement.

Gamification, through competition, can encourage increased trainee participation in simulation, with studies demonstrating participants spend more time in simulation preparing for events, which can result in an increase in technical skills.^1,4,5

In 2017, the Resident and Associate Society of the American College of Surgeons (RAS-ACS) founded the “So You Think You Can Operate” (SYTYCO) skills competition at the annual ACS Clinical Congress. The competition was designed to engage a diverse group of resident teams from across the country in friendly competition while demonstrating a variety of skills, ranging from laparoscopic maneuvers to emergent open procedures.

The successful execution of the competition led to its inclusion as a regularly scheduled event as part of the ACS Surgery Resident Program at Clinical Congress. Learning from our experiences, we identified five key components for the successful execution of a surgical skills competition (see Table 1). This article describes the components necessary to develop a successful technical skills competition, while also discussing tips, tricks, and lessons learned during the SYTYCO programming.

Component 1: Determine Purpose and Participants

Before creating your skills competition, it is helpful to explicitly define the objectives for your event.

• Do you intend for your competition to be educational, instructive, simply for fun, or maybe all three?
• What do you want participants and observers to take away from the event? 

Having clearly defined objectives and a central focus are helpful in developing your proposal for administration, conference committees, or potential funding sources and will help you keep your event on track throughout station development, overall organization, and execution.

Once you define your event objectives, it is critical to determine the event stakeholders, including those individuals whose approval is required to start executing the vision. After you have the support of stakeholders, think about who will be competing (i.e., medical students, residents, nursing/advanced practice providers, or faculty) and who the audience—if any—will be.

Early determination of your participants will help guide competition structure (individuals versus teams), and the number of institutions or teams involved. These decisions, in turn, help dictate how many and what kind of stations will need to be developed, the number and type of personnel needed to staff the event, and they even can direct venue selection.

For SYTYCO, we had eight competing teams to allow for varying skills levels, a broad assessment of teamwork, and camaraderie. Teams consisted of a senior resident (clinical fourth or fifth year) and a junior resident (clinical first through third year). Other team considerations include senior versus junior resident, trainee versus faculty, interns versus fourth-year medical students, or other unique combinations. 

Component 2: Recruit Event Personnel and Role Assignment

Orchestrating a skills competition can require a significant amount of personnel to fill a variety of required roles. While the necessary staff will vary between competition types, a few standard positions exist and can be adapted to your specific event.

Event Chair

The chair of the event is the primary leader of the competition. In the development stages, the chair is responsible for constructing the timeline, assembling the team, creating a budget, and selecting the venue. The role also includes frequent check-ins and coordination with the various team members.

As planning progresses, the chair should ensure that event organizers are staying on task and adhering to the overarching goal of the competition, which already should have been established. On the day of the event, the event chair serves as overall coordinator and time monitor and is the primary touchpoint for any issues that arise and help problem solve.

Station Developers

The station developers create, test, and perfect each station to confirm it is possible to perform the tasks in the time allotted. They are responsible for defining the station’s educational objectives and creating a clear grading rubric for judges to use on the day of the event. Depending on availability, the station developers may function as the station lead or judge on the day of the event. While stations may be developed through the collaborative efforts of more than one individual, we suggest having a head developer to serve as point person.

Station Lead

The station lead understands the learning objectives and logistics of the assigned station, ensures station execution on the day of the competition, and provides each team with the goals and rules for the station, including the designated time limit. In between rounds, the lead resets the simulation for the subsequent team. Depending on the station, he or she may assist the judge with scoring or function as the station judge, if necessary.

Judges

Judges assigned to a station are responsible for scoring each team according to the developed rubric and for submitting scores to the scorekeeper in between rounds. They should understand the learning objectives and judging criteria to ensure consistency and objectivity for all teams. If there are concerns or clarifications required, the judges should engage the station lead or event chair.

Master of Ceremonies (MC)

For events with a planned audience, the MC maintains and amplifies audience engagement. An engaged MC will circulate around the event and provide station play-by-plays, foster friendly rivalry, and interact with audience members to encourage a sporting event-like atmosphere. Important factors to consider when selecting an MC include desire to participate in resident activities, energy, and a sense of humor. A willingness to dress in costume also is a plus.

Ushers

For larger event spaces or competitions with multiple teams and rounds, ushers escort teams between stations and help the flow of the competition. This role becomes especially important if the sequence of stations is not consecutive.

Scorekeeper

The scorekeeper is responsible for collecting the scores after each round and displaying a running tally to encourage competition. Scores can be displayed using a projector or on an easel pad. We have found that using a group messaging app between the judges and scorekeeper to be the most effective way of communicating real-time results at the conclusion of each round.

While several of these positions may overlap if personnel limitations exist, we strongly recommend the event chair, scorekeeper, and MC (if desired) remain separate as the demands on these positions can be sizable during an active competition.

Component 3: Station Development

Station development is arguably one of the most critical hurdles in skills competition programming. Multiple factors must be considered for each station, including time, cost, difficulty of station set and re-setting, and reproducibility. The main design elements that are included in SYTYCO station creation are detailed in Table 2. Full station examples can be accessed at: facs.org/media/ooajqorr/acs_chapter_skillscomptoolkit.pdf.

Development of individual stations should start with defining why and how the chosen skill fits the event objectives. Each station should include details related to the skill’s relevance, educational objectives, and a clear definition of the technical and clinical knowledge to be assessed. Clear objectives also help keep the station learner-centric and prevent drift toward the entertainment factor or equipment use just “for show.”

After the station objectives and skills have been developed, the next step involves determining what station equipment and consumable materials are needed. There are numerous low-cost, low-fidelity models described in the literature^6,7 and higher-fidelity models available for purchase that can be used for stations.

It is important to select the proper level of simulation model fidelity required to meet your educational objectives, but keep in mind that not every station requires near-real tissue or blood simulation. Overly complex models focused on achieving extreme fidelity can be distracting, costly, time-consuming to reset, and take away from the educational experience of a simulation.

Inspiration for stations can come from anywhere such as established simulations from residency programs, variations on national skills tests, and novel ideas developed by your planning committee. Each year, we produce stations focused on a handful of technical themes, including laparoscopic surgery, suturing, trauma, endoscopy, and vascular surgery. These stations test similar, yet distinct, skills in order to maintain the novelty of the program.

The final component of station creation is to develop station instructions and a scoring rubric. The instructions should briefly orient the participant to the task at hand. The scoring sheet should specifically address elements of the learning objectives with enough granularity to separate participants.

Once the station is completed, trial runs with neutral third parties should be performed to ensure smooth execution. This allows you to help check for any missing or overlooked equipment, confirm instruction clarity, and evaluate task timing. The process should be repeated for each station to allow for adjustments before the day of the event. The need for this pretest can be reduced or eliminated if prepackaged skills stations are used such as those created by the RAS-ACS. 

Component 4: Logistical Considerations

Having a well-developed logistical plan that considers the interplay of the infrastructure, personnel, and participants is crucial to ensuring a smooth execution. Some common areas that require preemptive logistical planning include game flow, event timing, and team recruitment.

Game Flow

There are several different game flow designs that can be used in a skills competition. For SYTYCO, we have used a round-robin format with all participating teams rotating through each of the skills stations, with the top two teams competing in a final head-to-head station to determine the overall winner.

Other formats that can be considered, depending on time and facility constraints, include team relay events or tournament brackets. In the era of COVID-19, we explored the use of asynchronous, remote events with prepackaged skills stations mailed to participants. Skills completion for scoring was submitted via video or social media postings.

Event Timing

Event time limitations may be driven by administration, conference committees, room reservations, and cost of facilities rental. Deciding on the final number of stations and participants ultimately may be determined by the total available time for the event or facility location and size. Even with unlimited time, audience and participant attention spans are limited, and complex, multicomponent tasks may not be best. We have found that 10-minute stations allow sufficient time for skills execution, while still retaining participant and audience interest. 

Team Recruitment

Depending on the target audience and venue, participant recruitment may be as simple as sending an email to the residents in your participating program. However, if the venue is larger and involves multiple institutions, it may require further recruitment initiatives.

For our event targeting nationwide participants and audience, we advertised the competition and recruited teams through the ACS Program Director listserv and local ACS chapters.

Team selection can be based on a variety of criteria depending on event objectives. We have found that recruiting a diverse spectrum of teams from different program sizes, academic affiliations, and geographic locations fostered the best sense of competition and audience engagement. Team names, promotional photos, and videos also were used to publicize the event on social media and create pre-event rivalry and hype. The winners from the previous year also were invited to return and defend their title. 

Component 5: Day of Execution

On the day of the skills competition, communication and timekeeping are key to a successful event. The event chair serves at the day’s lead and must delegate tasks to their station leads, judges, and ushers while still maintaining open lines of communication.

Clear communication with a central organizer (event chair) will allow for flexibility and adjustments as required. It is recommended that station leads and judges arrive at the venue prior to the event start, and each station should have a checklist of supplies and set-up times to ensure that each station is ready before the event starts.

No surgical skills competition can be completed without an award. Whether that prize is in the form of a plaque/certificate or something as simple as bragging rights, the inevitable competitive spirit that comes with a skills event warrants acknowledgment.

Using social media as part of this celebration not only promotes the winners, it also increases engagement and future interest in the event. Participants receive small gifts (such as surgical caps or socks), and the winners of the overall competition receive plaques or certificates—along with bragging rights—to commemorate their achievement.

Challenges, Tips, and Tricks

The keys to the success of any surgical skills competition are flexibility and contingency planning. No matter how well-organized an event may be, something will undoubtedly go wrong on the day of the competition: the laparoscopic simulator does not arrive, a competing team is stuck 4 hours away with a flat tire, or you discover you ordered 200 Penrose drains in the wrong size. Planning for as many of these unexpected challenges as possible can help mitigate any complications that may arise during the competition.

For our event, contingency planning begins with team selection. In addition to the eight participating teams, we invite two teams as alternates who are available to fill in if one of the primary teams is unable to compete. It also is helpful to plan a backup skills station that you can deploy quickly.

The backup often is one of the lower-fidelity stations (such as suturing or knot-tying) from a previous year that requires very limited materials and has the added benefit of previous field-testing.

Organizing a surgical skills competition requires a meaningful amount of planning and, depending on host resources, can be financially costly. There are various ways to reduce the financial burden of these competitions by leveraging resources from local and regional hospitals, ACS Accredited Education Institute simulation centers, industry sponsors, and ACS chapters.

If a relationship exists between a surgical industry representative and your hospital, these resources may provide access to higher-cost equipment and also may provide funding opportunities for non-material-related costs such as room rental, audiovisual equipment, or prizes. If you are pursuing industry sponsorship, you should use caution to ensure an appropriate and ethical relationship is maintained. Guidance for these relationships can be found in statements published by the ACS Committee on Ethics.⁸

Through the RAS-ACS Education Committee, many of the stations created for the ACS Clinical Congress SYTYCO Competition have been published and made available for use by regional and ACS chapter meetings. As noted in a May 2016 Bulletin article, a skills competition can greatly increase resident engagement in chapter meetings—especially if skills stations are well designed.9 Creating engaging stations is more important than producing an extraordinarily challenging task. Stations as simple as blind instrument identification and laparoscopic Pictionary have proven to be some of the most popular events at Clinical Congress. 

Finally, consider holding the competition just before or after an event. Alternatively, it can be planned during an adjacent reception to allow audience members to walk in and out, as the competition can provide excellent entertainment for surgeons at all career stages and settings.

As stated earlier, promoting the event on social media via platforms such as Twitter, Instagram, Facebook, and TikTok can significantly increase the reach of the event. Creating a hashtag that is advertised before the event and posted around the room during the competition can create a significant online presence and energy. The hashtag #SYTYCO22 for the 2022 competition resulted in 385,000 unique impressions.

Conclusion

Over the course of 6 years, the SYTYCO skills competition has become a staple of the ACS Clinical Congress programming and a highly anticipated event with significant engagement. Participation surveys from the 2022 SYTYCO competing teams found 63% of all participants intentionally increased their simulation practices by an average of 3.7 hours per week in anticipation of the event, with a range of reported practice times spanning from 1 to 10 hours. Competitors practice a variety of skills, with 50% focusing on laparoscopic skills, 19% practicing robotic skills, and 6% reviewing open bowel and vascular anastomosis. These results demonstrate that the educational benefits of surgical skills competitions extends beyond the events.

Dr. Rachel Hanke is a general surgery resident at Penn State Health in Hershey, PA, and current chair of the RAS-ACS Education Committee.

References

1. Gostlow H, Marlow N, Babidge W, Maddern G. Systematic review of voluntary participation in simulation-based laparoscopic skills training: Motivators and barriers for surgical trainee attendance. J Surg Educ. 2017;74(2):306-318.
2. Hashimoto DA, Gomez ED, Beyer-Berjot L, et al. A randomized controlled trial to assess the effects of competition on the development of laparoscopic surgical skills. J Surg Educ. 2015;72(6):1077-1084.
3. El-Beheiry M, McCreery G, Schlachta CM. A serious game skills competition increases voluntary usage and proficiency of a virtual reality laparoscopic simulator during first-year surgical residents’ simulation curriculum. Surg Endosc. 2017;31(4):1643-1650.
4. McCreery GL, El-Beheiry M, Schlachta CM. Local and national laparoscopic skill competitions: Residents’ opinions and impact on adoption of simulation-based training. Surg Endosc. 2017;31(11):4711-4716.
5. Mokadam NA, Lee R, Vaporciyan AA, et al. Gamification in thoracic surgical education: Using competition to fuel performance. J Thorac Cardiovasc Surg. 2015;150(5):1052-1058.
6. Ritter KA, Leifer D, Orabi D, et al. How we do it: Creation of a low-cost endoscopic skills model for Fundamentals of Endoscopic Surgery training. J Surg Educ. 2019;76(6):1456-1459.
7. Pepley DF, Sonntag CC, Prabhu RS, et al. Building ultrasound phantoms with modified polyvinyl chloride: A comparison of needle insertion forces and sonographic appearance with commercial and traditional simulation materials. Simul Healthc. 2018;13(3):149-153.
8. American College of Surgeons. Statement on Guidelines for Collaboration of Industry and Surgical Organizations in Support of Continuing Education. Available at: http://www.facs.org/about-acs/statements/36-collaboration-industry-surgical. Accessed January 13, 2023.
9. Ardestani A, Sheu EG, Nepomnayshy D, et al. Surgical skills competitions at ACS chapter meetings can increase resident engagement. Bull Am Coll Surg. 2016;101(5):44-45.