Lessons from the surgical experience with simulators: incorporation into training and utilization in determining competency.

Simulation technology in laparoscopic surgery has developed in response to a need to teach fundamental surgical skills in a safe environment. The skill set needed was defined carefully according to the classic educational model of needs assessment. Once defined, the skills were modeled in a simulator. The recognition that a simulator need not have high fidelity to achieve significant educational value was important in keeping costs reasonably low. Intrinsic to an effective simulation program is a set of metrics or measurements of performance. These metrics provide motivation for the student and allow comparison among students. Once shown to be reliable and valid, the simulator metrics can be used to set reasonable goals and standards for certification. Although simulators permit verification of learning, point simulation testing cannot by itself be used at present to ensure competence. Until the predictive value of these tests has been validated further, competence still needs to be determined by expert assessment of observed performance in real cases and by measurable outcome variables from real procedures. Simulation training is most beneficial when incorporated into a curriculum that teaches the accompanying knowledge and judgment essential for safe practice of the skills taught in the simulator. The FLS program distributed by the Society of American Gastrointestinal and Endoscopic Surgeons and the American College of Surgeons is an example of a carefully planned and validated program that incorporates these principles in laparoscopic surgery education. The lessons learned from development of the FLS program can be useful in designing a similar program for flexible gastrointestinal endoscopy.