Brandon V Henry MD, MPH Philip Clark MBA Ranjan Sudan MD Duke University Medical Center

1. Cost and Logistics of Implementing a Tissue-based Surgical Skills Curriculum for General Surgery Residents of all Clinical Years Brandon V Henry MD, MPH Philip Clark MBA Ranjan Sudan MDDuke University Medical Center

2. No financial conflicts to disclose

3. 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

4. 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.

5. Objective • To determine the costs and administrative logistics associated with a residency-wide implementation of the ACS/APDS Surgical Skills Curriculum

6. 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

7. 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

8. Dry Simulation Modules

9. Animal Tissue Modules

10. 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

11. Total Cost • 36 Modules • $111,240 total • Approx. $3,200 per resident (n=35) • $22,075 in faculty teaching • 111 hours

12. Comparing Fidelities Dry Simulation $26,354 $220 Ease of reproduction No ethical problems Lower fidelity Capital simulator costs Animal Tissue $11,890 $240 Live Specimens Anatomy Regulatory barriers Ethics of animal use Human Fresh Tissue $72,050 $940 Anatomical accuracy Expensive Specimen quality issues Annual Cost: Per Resident Per Module: Pros: Cons:

13. Comparison to Previous Reports Rooney, et al* Danzer, et al** 38 PGY1, PGY2 32 Modules Annual budget: $476,000 $12,500 per resident No low-end budget $30,000 in faculty payment Henry, et al • 35 PGY1-5 • 36 Modules • Annual budget: $111,240 • $3,200 per resident • No low-end budget • $22,075 estimated faculty time • 14 PGY1 residents • 13 Modules • High-end budget: $187,200 • $13,400 per resident • Low-end budget: $21,500 • $1,540 per resident • No estimation of teaching cost **Danzer E, et al. Journal of Surgical Education 2011; 68(6): 519-525. *Rooney D, et al. Surgery 2010; 147(5): 614-621

14. 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 cost-effective method of delivering high-fidelity tissue-based training

15. Thank You