1. Training the Trainer in advanced Laparoscopic surgery-LAPCO TT
Nader Francis & Mark Coleman

2. Contents Scope for Training the Trainer (TT)
Development and structure of LAPCO –TT
Assessment and evaluation of TT
Summary & take home message

3. Challenges with training in advanced laparoscopy
Technical
Limitations of laparoscopy
Challenging pathology
Long learning curve
Non-technical
Situation awareness
Decision making
Task management
Leadership
Communication and teamwork
Organisational context
Time constrains
Financial constrains
Meeting targets

4. Learning curve in laparoscopic colorectal surgery
Conversion
Complications
152
143
103
Op time
Blood loss 96 87
LN harvest
Hospital stay
103
Miskovic et al Learning curve and in laparoscopic colorectal surgery: systematic review

5. NTP in Laparoscopic Colorectal surgery - England
Welcome to LAPCO
National Training Programme for Laparoscopic Colorectal Surgery The National Training Programme for Laparoscopic Colorectal Surgery has been developed by the Department of Health to train NHS consultant colorectal surgeons in England. The aim is to give all suitable patients with colorectal cancer access to a fully trained laparoscopic colorectal surgeon according to the 2006
206 surgeons Engaged with NTP- 1/3 Colorectal Consultants in England.
139 consultants undergoing training
67  NTP Trainers

6. Scope of Lapco TT Need to structure the framework of training
Efficacy and efficiency of training
Shorten the learning curve
Ensure patient safety
A national course to provide training tools to all national trainers
Evaluate the impact of TT course
Course aims 6

7. Lapco TT ▪ JAG Endoscopy Training the Trainer model
(Roland Valori and John Anderson)
▪ Designed a Lapco TT course curriculum
Piloting TT in laparoscopic colorectal surgery
Roland Valori
John Anderson

8. Pilot Lapco TT 2010

9. Lapco TT - Course Faculty
Course Facilitators: Mark Coleman & Nader Francis
Funded by Cancer Action Team (DoH)
Course Faculty: ● Greg Wynn ● John Griffith ● Tom Cecil ● Charles Maxwell Armstrong ● Amjad Parvaiz ● Rob Longman ● Ian Jenkins ● Andrew Miller ● Matthew Clarke ● Austin Acheson
Course Organiser & NTP Programme Manager Laura Langsford

10. DAY 1 – Core competencies
Conscious competence
Framework of training
(Set- Dialogue & Closure)
Taking over in theatre
Performance enhancing instruction
Performance enhancing feedback
Assessment of training
Optimising the training environment
Dealing with difficult trainee

11. Day1 – Dry skills training

12. Day 2 – Live theatre ● Review of learning objectives and re-visit
The training framework
● Coaching local trainee for 20 minutes
● Debrief ○ Trainer debriefs local trainee ○ Facilitator debriefs trainer
● Course review and evaluation

13. Unconscious Incompetence
Conscious competence
Unconscious Incompetence
Conscious
Incompetence
Unconscious
Competence
When it comes to the technical skill teaching side; the model of conscious competence is very relevant. If we consider our earliest experiences of practical skills learning, such as walking, or later – driving we may remember a period of conscious incompetence….
Brief description of the diagram with examples such as learning to walk, learning to drive, then group discussion on conscious competence for LCS – which box do the group fall into? Is it easy to teach a skill when you are unconsciously competent yourself?
take home message
Knowing your stage and appreciating the role of conscious competence in performance and training 13

14. Framework of technical skills training
From TCT Endoscopy Guide-with permission

15. Progress with TT LAPCO Pilot course Plymouth-March 2010
First course Portsmouth June 2010
3 courses a year (2 facilitator/ 4 faculty and 6 delgates)
To Date: Run 7 courses at Bradford, St Marks, Basingstoke, Colchester, Portsmouth, Nottingham
47 national trainers/ experts in laparoscopic colorectal surgery have attended the course with very positive feedback

16. Lapco TT - Educational Assessment
10 minute recorded simulated training session before & after course
Mini STTAR for training and behaviour – 2 assessors
Trainers interviewed on attitudes pre and post course qualitative evaluation
Assessment using Observer XT behavioural analysis software by two assessors
Hugh Mackenzie

17. Structured Training Trainer Assessment Report (STTAR)
Structure
Teaching Behaviour
Attributes
Role Model
Training Structure
Training behaviour during case
Characteristics demonstrated
Technical and non-technical skills
1-7
N/A
SET
Contextual conversation 
Ground rules
Motivated
Communication with team
Define aims
Knowledge
Confident
Takes control
Align agendas
Concerns
Insight into ability
Ensures patient safety
Environment preparation
Case-specific
Non-threatening
Foresight
DIALOGUE
Standard part of procedure
Aims focused
Guiding verbal input
Approachable
Competence
(Overall)
Ability matched task
Questioning/ option generation
Articulate
Strategic
Deconstruction
Encouraging, positive reinforcement
Listens
Knowledgeable
Accessible demonstration
Corrective feedback
Patient
Patient-focused
Particularly in difficult part
Stretch (allow to struggle)
Warning verbal input
Calm
Excellent decision making
DIALOGUE (Difficult)
Informing
Strategy justification
Comfortable in silence
Leader
Take over when appropriate
Directing verbal input
Supportive/rescuing
Team skills
Active assistance/facilitating
Controlling verbal input (stop)
Emotionally intelligent
CLOSE
Ask trainee’s opinion
Encourage self-reflection
Honest
Excellent teacher
Appropriate use of materials
Positive and negative reinforcement
Professionalism
Performance critique
Analytical
Self-reflects
Excellent communicator
Learning point agreement
Approachable (allows discussion)
Inspirational
Seeks feedback
Sub-total scores:
TOTAL
Comments:

18. STARR form Assessment - Overall

19. STARR form Assessment - Stages

20. Software analysis of events
Pre – Course Scenario
Post – Course Scenario
SET length
1 minute 14 seconds
1 minute 59 seconds
Identifying trainee knowledge
8 times
14 times
Identifying concerns
1 time
5 times
Laying Ground rules
0 times
6 times
CLOSURE
No Trainers
One Trainer

21. Conclusions
Changes In behaviour can be demonstrated immediately after the TT course
Trainers use a more structured approach to training, increasing the time and detail within the ‘Set’
Further studies are required to ascertain whether these changes are maintained whilst training in their own clinical environment

22. Summary
Advanced laparoscopic surgery is technically challenging and requires comprehensive training to achieve competence
A structured framework of teaching is required
This can be achieved at a national level and potentially could be adapted to other specialities in advanced laparoscopic surgery
Course aims 22

23. Acknowledgements Course Development Roland Valori John Anderson
Fiona Carter
Co-facilitator Mark Coleman
Course organiser Laura Langsford
Educational Assessment
George Hanna
Hugh Mackenzie
Tamzin Cuming
Susannah Wyles

24. Thank you