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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Recipient of ACS-AEI Fellowship Describes Experience in Growing Surgical Simulation Knowledge
Yasser A. Noureldin, MD, MSc, PhD, FEBU
I am a proud recipient of the Pellegrini-Oelschlager Endowed Fellowship in Surgical Simulation from the University of Washington in Seattle.
My fellowship was conducted in the Department of Surgery between 2016 and 2017 under the directorship of Professor Robert M. Sweet, MD, FACS, executive director of the WWAMI Institute for Simulation in Healthcare (WISH) and the Center for Research and Education in Simulation Technologies (CREST). I also completed a 1-year clinical fellowship from the Endourology Society at the University of Patras in Greece and went back to my home country of Egypt with the intent to invest in the knowledge and skills obtained during these fellowships.
Prior to starting the Surgical Simulation fellowship, my passion for surgical simulation began during a 2-year Endourology Fellowship at McGill University in Montreal. I was granted a Canadian Urological Association (CUA) Scholarship Foundation - Société Internationale d'Urologie (SIU) International Scholarship from the CUA to support a research project, “Assessment of Technical Skills of Urology Postgraduate Trainees Using Virtual Reality Simulators During Objective Structured Clinical Examinations.” During this project, our research team conducted research on the use of simulation for assessment of different urologic skills such as the photo-selective vaporization of the prostate (PMID: 25737763; PMID: 27198163), percutaneous renal access (PMID: 25844094; PMID: 26242727), and robotic skills (PMID: 26892058). We were awarded a travel scholarship from the SIU to present our work at their annual meeting in 2014 in Glasgow and were fortunate enough to win the best presentation award.
My interest developed with how the skills obtained from simulation training were transferable to the operating room. I was granted a Urology Care Foundation Research Scholar Award for a project, “Endourologic Technical Skills Transfer from the Virtual Reality Environment to the Operating Room.” Our research team at McGill University was among the earliest investigators to prove the transfer of ureteroscopy skills (PMID: 27532227) and robotic skills (PMID: 32569567) from the VR simulators to the operating room.
ACS AEI Fellowship
With my arrival in Seattle in 2016, I was impressed with the beautiful city, welcoming team, and collaborative environment. I rapidly started to integrate into the WISH and CREST teams. It was my first time working with a diverse, multidisciplinary team of doctors, educators, administrators, artists, and engineers. During the first month, I got to know more about the hospital, the simulation centers, and the research projects that were running at the time. In addition, my family welcomed a new baby.
I started my simulation fellowship at the University of Washington with four objectives: first, to discover the process of development of new simulators, since the GreenLight SIM used during my research at McGill University was developed by Dr. Sweet’s CREST lab; second, lean how to provide develop, verify and validate simulation-based curricula; third, discover techniques on teaching with simulation; and finally, to learn from WISH staff how to develop and manage a simulation center in my home institution in Egypt.
How New Simulators Are Developed
Since the GreenLight SIM used during my research at McGill University was developed by Dr. Sweet’s team, I was keen to know how they developed this virtual reality simulator and identify the different steps for development, prototyping, branding, and commercialization. To better understand these processes, I worked as a team member to assist in the development of simulators.
Simulators: A. Foley Simulator
During the development process for this simulator, I prepared a cognitive task analysis (CTA) that worked as model for communication between the doctors and engineers who shared the development process. Part of this was the measurement of the resistance and friction forces at different parts of the urethra, as illustrated in the following figures:
In addition, different scenarios or the difficulties during the urethral catheterization processes were simulated as illustrated, in the following figure:
Our next step was 3D printing of the different parts of the urethra, as seen below for bladder and urethra and the corpus spongiosum and corpora cavernosa.
The urethral catheterization processes were followed by prototype development, which included sculpting/molding and a final model preparing for the validation process.
Simulators: B. Advanced Modular Mannikin (AMM)
I participated in the early phases of AMM. This ambitious project, funded by the US Department of Defense-created MoHSES manikin, was an open source integrative simulation platform that was able to connect multimodal virtual and physical modalities to a common physiology engine for simulators from all over the body and medical equipment.
By the end of my fellowship, we wrote a chapter in the book, Surgeons As Educators: A Guide for Academic Development and Teaching Excellence, which was edited by Tobias S. Köhler Bradley Schwartz, and published a standardized process for design and development of simulators under the heading “Modern Theory for Development of Simulators for Surgical Education.” This process began with the concept of “backward design” as part of the Understanding by Design® Framework (UbD™), which was introduced by Grant Wiggins and Jay McTighe J.
We offered simulation development as multidisciplinary and interprofessional processes, which include four phases:
Assessment of the requirements from the physicians’ perspective
Translating physicians’ requirements to engineers’ requirements
Providing Validity Evidence and Incorporating New Simulators into Simulation-Based Curricula
Prior to starting my fellowship with Dr. Sweet, I conducted some validation studies for different simulators. However, it was at the University of Washington where I learned about the concept of “unitary validity” and the “construct,” which is the characteristic that a simulator is designed to measure. Furthermore, Dr. Sweet taught me that the “validation” is not for the simulator itself, but it is a for the interpretation of simulator scores, and it refers to the degree to which evidence and theory support the interpretation of these scores for proposed uses. Therefore, validity is considered a “hypothesis” and evidence should be collected to either support or refute.
I also learned that the process of validity starts with building a “conceptual framework,” including the aspects of the construct which needed to be presented. This conceptual framework should delineate the knowledge, skills, abilities, traits, interests, and competencies that are needed to be assessed, as seen in the following figure.
(adapted with modifications from: Noureldin YA, Sweet RM. A Call for a Shift in Theory and Terminology for Validation Studies in Urological Education. J Urol. 2018 Mar;199(3):617-620. doi: 10.1016/j.juro.2017.10.022.)
Our team collaborated with the University of Southern California (USC) in Los Angeles to research work for providing part of the validity evidence to our vesicourethral anastomosis “VUA” model, and I was happy to meet and work with Inderbir Gill, MD, and Andrew Hung, MD, and their research team. We had one abstract,“Validation of 3D Printed VUA Model Utilizing Automated and Manually Observed Metrics, Featuring Tissue Feedback Measures,” presented as a podium during the American Urological Association (AUA) annual meeting in 2018 (https://doi.org/10.1016/j.juro.2018.02.122).
In addition, I conducted research to provide part of the validity evidence for the Fluoroless Breathing C-Arm Trainer (Supine & Prone fluoroless CAT), which was developed at CREST for training percutaneous renal access and is potentially associated with highest radiation exposure during percutaneous nephrolithotomy. This step is often done by interventional radiologists (IR) and training urologists to do it in a risk-free ad radiation-free environment. It is extremely important for the procedure to be done at one time, and this will give urologists the independence to do the procedure at any time without the need for IR.
Creating a Simulation-Based Curriculum
I worked among the team of the Department of Urology, and I participated in teaching our urology residents different simulations-based curricula during the URISTI morning training. I also worked with Medical students during the TeamBITS (Capstone) training. By the end of my fellowship, using my new skills in simulation-based curriculum development, I developed four curricula:
Percutaneous Access curriculum
Urethral Catheterization curriculum
Ureteroscopy curriculum
Advanced Robotic Urologic Surgery curriculum, which had four scenarios
Robotic Pyeloplasty
Robotic Vesico-Urethral Anastomosis (VUA)
Robotic Partial Nephrectomy
Robotic Major Vessel Injury (MVI)
In terms of research, I conducted one study for providing part of the validity evidence for the C-Arm trainer hands on training course for PCNL during the 2017 annual AUA meeting in Boston, Massachusetts. The 38 physicians who attended the course voluntarily participated in the study, and the CAT simulator was considered useful for training the percutaneous renal access procedure. There was significant improvement in the qualitative and quantitative assessment parameters after the post-test compared with the pre-test (PMID: 29455253).
Furthermore, we published an editorial comment in the Journal of Urology, “A Call for a Shift in Theory and Terminology for Validation Studies in Urological Education,” which invited all our colleagues who publish in medical education to adopt the new taxonomy for validation (PMID: 29455253).
A third research work applied the new taxonomy for validation to translate the literature evidence, considering validity as a “unitary construct” with a focus on interpretation of simulator data/scores in a review article.
We included all studies that used simulators for assessment of endourologic, laparoscopic, and robotic urologic skills. We also compared the studies in terms of the year, number of participants, the assessment tool and the type of the assessment tool, and the application of the five evidences of validity, including test content, response processes, internal structure, relation to other variables, and consequences. Our findings showed that only 56.8% targeted the validity evidence in terms of the content, 18.9% targeted the response processes, 37.8% studied the internal structure, 97.3& looked at relation to other variables, and only 27% of the studies targeted the consequences (PMID: 29437497).
Following completion of my fellowship, I conducted an important research project with colleagues from the University of Arkansas, wherein we developed a nationwide survey which was sent to all urology program directors in the US to assess the simulation-based training in urology residency programs (PMID: 30534446). We obtained responses from 43 centers, and the data showed that 97% had access to a simulation education center, 60% incorporated simulation into their curriculum, 87% acknowledged the role for a standardized simulator training curriculum, 75% agreed that simulators would improve operating room performance, and 38% see that presence of a simulation program would reduce patient risks and complications.
Developing and Managing a Simulation Center in Egypt
My ultimate goal was to learn how to develop and manage a simulation center in my home country. Therefore, I participated in the administrative and course planning meetings for WISH, and I collaborated with Dr. Sweet for a 1-week experience directing UWMC-WISH. In addition, I attended the preparatory meetings for the NWH-WISH move and attended the annual WISH board meeting and participated as member of Curriculum and Assessment Council (CAC). In the meantime, I completed the Train-the-Trainer (TOT) sessions for new faculty/instructors/staff and the TeamSTEPPS Master training course.
Following completion of my fellowship and upon returning to Egypt, I tried to disseminate the culture of simulation-based training and the need to include simulation in our training curricula, as well as garnered interest and major support from my peers and professors.
The project started with a proposal and design for the functions of a simulation training center at Benha University. All the faculty, president of Benha University, the vice-president for postgraduate affairs, the vice-president for education and student affairs, and dean of the faculty of medicine started to look for sponsors. It took few years until the National Bank of Egypt decided to finance the simulation center, and the Benha University Medical Skills and Simulation Center (BUMSSC) was successfully launched. It serves three medical colleges, including the faculty of medicine, faculty of physiotherapy, and the faculty of nursing with a total of more than 10,000 interns, nurses, residents, and fellow trainees. At 2.000 square meters, it is one of the largest centers in Egypt. The BUMSSC includes an ER unit, virtual OR unit, Pediatrics unit, OB/GYN unit, and GS unit. Each unit contains different mannikins and bench model for different tasks.
This video was produced and provided as a courtesy by Benha University
I would like to express my sincere gratitude to the American College of Surgeons Fellowship program, as well as to Dr. Sweet and his team at UW for their unlimited support throughout my academic career.
About Yasser A. Noureldin, MD, MSc (Urol), PhD (Urol), FEBU
Dr. Noureldin is an associate professor of urology, Faculty of Medicine, Benha University, Egypt; assistant professor of urology, Northern Ontario School of Medicine University, ON, Canada; urologist, Sault Area Hospital, Sault Ste. Marie, ON, Canada.
