Cost and Logistics of Implementing a Tissuebased Surgical Skills Curriculum for General
Surgery Residents of all Clinical Years
Brandon V Henry MD, MPH
Philip Clark MBA
Ranjan Sudan MD
Duke University Medical Center
• No financial conflicts to disclose
Background
• In 2007, ACS and APDS jointly released the Surgical
Skills Curriculum for Residents in response to a need
for a standardized technical skills training curriculum.
• Three Phases
– Phase 1: Basic Skills (20 modules)
– Phase 2: Advanced Procedures (15 modules)
– Phase 3: Team-Based Training (10 modules)
• Wide-spread adoption across institutions and different
levels of residency training has been limited.
*Scott DJ, Dunnington DL. J Gastrointest Surg 2008; 12:213-221
Existing Literature
• Rooney et al. implemented 13 modules
over 20 weeks for 14 PGY-1 residents
• Danzer et al. implemented 32 modules
over 4 weeks for 38 PGY-1and -2 residents
• Primarily Phase 1 modules
• Minimal tissue-based modules
*Rooney D, et al. Surgery 2010; 147(5): 614-621
**Danzer E, et al. Journal of Surgical Education 2011; 68(6): 519-525.
Objective
• To determine the costs and administrative
logistics associated with a residency-wide
implementation of the ACS/APDS Surgical
Skills Curriculum
Methods…
• Performed a needs assessment survey of
residents and faculty
– Strongly desired more tissue-based simulation
• Assembled the Curriculum Steering Committee
– Program leadership, key faculty, resident
representatives
• Obtained departmental financial support
• Recruited faculty according to area of expertise
• Protected simulation activity time
Methods
• Created a 36 Module final curriculum
– 7 animal tissue lab sessions
– 11 cadaveric lab sessions
– 18 dry simulation lab sessions
• Organized in graduated fashion
– Basic/Dry-sim modules for juniors
• Ex: Knot tying/suturing, Central Lines, Urinary Catheterization
– Complex/Tissue labs for seniors
• Ex: Lap Sigmoidectomy, Lap Nissen, Gastric Resection
• Implementation supported by simulation center
administrative staff
• Costs and logistical notes were tracked
Dry Simulation Modules
Table 3. Cost of Dry Simulation Modules (in dollars)*
ACS Phase
1
1
1
1
1
1
1
1
1
1
1, 3
2
2
2
2
3
3
Module
Knot Tying/Suturing
Urethral and Suprapubic Catheterization
Airway Management
Chest Tube and Thoracentesis
Central Line Insertion/Monitoring and Arterial Lines
Vascular Anastomosis
Laparotomy Open and Closure
Colonoscopy
Stapled Gastrointestinal Anastomosis
Basic Laparoscopy Skills
Advanced Laparoscopy/Laparoscopic Crisis
Laparoscopic Ventral Hernia Repair
Open/Lap Common Bile Duct Exploration
Appendectomy Laparoscopic
Appendectomy Open
TT: Trauma Team Training
TT: Patient Handoff/Preop Briefing and Checklists
Facility Equipment/
Simulator Overhead Materials
Estimated
Total Module
Simulator
Cost†
Cost‡
Cost
Teaching Cost
Cost
--462
1400
613
2,475
Trauma Man
3
462
487
613
1,565
Trauma Man
35
462
875
613
1,985
SimMan, TraumaMan
157
462
-613
1,232
Central Line Man
238
462
435
613
1,748
--462
1050
613
2,125
-86
462
231
613
1,392
Immersion VR
247
462
-613
1,322
--462
364
613
1,439
Trauma Man
123
462
-613
1,198
-123
462
-613
1,198
Lap VR Mentor
70
462
-613
1,145
-196
462
529
613
1,800
-123
462
385
613
1,583
-123
462
385
613
1,583
SimMan 3G
123
462
-613
1,198
SimMan
291
462
613
1,366
TOTAL
1,938
7,854
6,141
* Donated or shared equipment instruments and disposable materials not calculated into cost
† Estimated as hourly cost derived from total cost amortized over 5 years (assuming 8hr ave weekly usage)
‡ Includes human resource costs. Calculated from annual overhead of $320,000
10,421
26,354
Animal Tissue Modules
Table 4. Cost of Animal Tissue Modules (in dollars)
ACS
Phase
1
1
1
2
2
2
2
Module
Surgical Biopsy†
Upper Endoscopy†
Hand Sewn Gastrointestinal Anastomosis†
Laparoscopic Colon Resection‡
Laparoscopic Sigmoid Resection‡
Open Colon Resection‡
Laparoscopic Nissen‡
Specimen
Cost
170
170
170
608
608
608
608
Facility Use
Fee*
190
190
190
1,001
1,001
1,001
1,001
Equipment
Cost**
-87
------
Estimated
Teaching Cost
613
613
613
613
613
613
613
TOTAL
2,942
4,574
87
4,291
* Instruments and disposable materials cost covered in Vivarium facility use fees (not itemized)
** Donated/loaned equipment not calculated in total cost)
† Explant material module
‡ Live porcine module
Total Module
Cost
973
1,060
973
2,222
2,222
2,222
2,222
11,894
Human Fresh Tissue Modules
• Cost per lab largely constant
– Flat $300 fee per module for
space and equipment
– Specimens cost $2,000-6,000
per module
• Total for 11 Modules:
$72,050
– Specimens: $62,000
– Facility Use Fees: $3,300
– Approx. $6,750 in estimated
teaching time
Total Cost
• 36 Modules
• $111,240 total
– Approx. $3,200 per
resident (n=35)
• $22,075 in faculty
teaching
– 111 hours
Comparing Fidelities
Dry Simulation
Animal Tissue
Human Fresh Tissue
Annual Cost:
$26,354
$11,890
$72,050
Per Resident
Per Module:
$220
$240
$940
Pros:
Ease of reproduction
No ethical problems
Live Specimens
Anatomical accuracy
Lower fidelity
Capital simulator costs
Anatomy
Regulatory barriers
Ethics of animal use
Expensive
Specimen quality issues
Cons:
Comparison to Previous Reports
Rooney, et al*
Danzer, et al**
• 14 PGY1 residents • 38 PGY1, PGY2
• 32 Modules
• 13 Modules
• High-end budget: • Annual budget:
$476,000
$187,200
– $13,400 per resident
• Low-end budget:
$21,500
– $12,500 per resident
Henry, et al
• 35 PGY1-5
• 36 Modules
• Annual budget:
$111,240
– $3,200 per resident
• No low-end budget • No low-end budget
– $1,540 per resident
• No estimation of
teaching cost
*Rooney D, et al. Surgery 2010; 147(5): 614-621
• $30,000 in faculty
payment
• $22,075 estimated
faculty time
**Danzer E, et al. Journal of Surgical Education 2011; 68(6): 519-525.
Conclusions
• ACS/APDS Skills curriculum with a
significant tissue-based component is feasible
for programs with appropriate infrastructure
• The curriculum is costly and small institutions
may need to form regional partnerships in
order to access necessary resources
• Animal modules may be the most costeffective method of delivering high-fidelity
tissue-based training
Thank You