1. On the Road Again: Surgical Simulation is Rural Practice D.R.Antonenko, MD.PhD. Professor of Surgery Director of Surgical Simulation Center University of North Dakota School of Medicine and Health Sciences

2. Simulation in Rural Surgery Objectives Describe the educational background for simulation training in surgery To describe the possible role of simulation in rural/community surgical practice using a mobile simulation center To discuss how on site simulation training might help attract and retain surgeons in rural practice

3. Physician Learning Patient focused learning Resource accessibility Clinical applicability Familiarity with the resource Return on investment in time

4. Physicians and Learning Relevance to clinical practice needs Scheduling conflict Cost of attendance

5. Simulator Skills Training Curriculum Sound educational principles Goal oriented Sensitive/objective performance metrics Appropriate instruction/feedback

6. Simulator Skills Training Curriculum Deliberate/distributed/variable practice Allow overtraining Provide maintenance training Must have cognitive component

7. Simulator Skills Training Curriculum Deliberate/distributed/variable practice Allow overtraining Provide maintenance training Must have cognitive component PROFICIENCY BASED

8. Simulation = Deliberate Practice Move learning curve out of the OR BUT performance still required Reduce stress of learning Focus is on learner, not the patient Feedback improved

9. Simulators

10. Procedural (task) trainers Computer screen (micro-simulators) VR trainers Patient trainers

11. ACS/APDS Core skills Curriculum Phase I Curriculum Modules Asepsis/instruments Knot tying Suturing Tissue handling wound management Advanced tissue handling/flaps/grafts Catheterization Airway management Chest tubes Central lines Surgical biopsy Vascular anastomosis Laparotomy Bone Fixation/casting Inguinal Anatomy Upper endoscopy Colonoscopy Basic laparoscopic skills Advanced laparoscopic skills Hand sewn anastomosis Stapled anastomosis.

12. Simulation Center Equipment

13. Phase II Modules Lap ventral hernia Lap/open inguinal hernia Lap/open colon resection Lap/open CBD exploration Abdominal wall stomas Lap appendectomy Lap Nissen fundoplication Sentinel node biopsy/ALND Lap/open splenectomy Lap/open cholecystectomy Thyroidectomy parathyroidectomy Gastrectomy

14. Simulation Center Equipment

17. `ACS/APDS Core Skills Curriculum Phase III: Team Based Training

18. Simulation Center Equipment Team Based Training

19. Rationale For Simulator Training in Rural Surgery Fiscal Restraints Changing technology Ethical Concerns Patient Safety

20. Advantages of Simulation in Rural Surgery Maintain skills Enhance skills Increase practice opportunities Increase income Reduce malpractice premiums (?)

21. Simulation for Rural Surgery Surgeon specific Site specific High fidelity Timely Cost effective Distributed vs. massed practice

22. Simulations for Rural Surgery Minimally invasive Ultrasound ATLS procedures(?) Airway management Procedure specific Endoscopy upgrades

23. The Future of Simulation for Rural Surgery Tele-simulation Tele-proctoring Tele-mentoring 3 dimensional reconstruction COST

24. Rural/Community Surgeons Your Thoughts/comments