Current status of simulation training in plastic surgery residency programs: A review <s> DISCUSSION <s> The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experience does not invariably lead people to become experts. When individuals are first introduced to a professional domain after completing their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one’s basic endowments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capacities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain. <s> BIB001 </s> Current status of simulation training in plastic surgery residency programs: A review <s> DISCUSSION <s> Principles of effective assessment have become increasingly popular topics in graduate medical education. Changes in the structure of plastic surgery training demand a thorough understanding of the state-of-the-art in assessing surgical trainees. Moreover, the authors' understanding of different domains and methods of assessment and the available tools continues to grow.The authors reviewed the available literature regarding assessment in graduate medical education, specifically as it pertains to plastic surgery. In addition, the authors present principles of effective assessment and report on the currently available assessment methods.Assessment is multifaceted and impacts everyone, not just the individual learner. For assessments to be useful, they need to possess validity and reliability. Moreover, there is a necessary pragmatism limiting different methods and tools for assessing learners. Some types of assessment are universally familiar and include examples such as written examinations and procedural logs. Other emerging areas that are actively being researched involve simulation, nontechnical skills, and procedure-specific technical assessments.Updating the thoroughness and multidimensionality with which plastic surgery trainees are assessed is an evolving area and one that is ripe for continued research. <s> BIB002
The digital age has greatly expanded the potential for technological advancement to enrich residency training programs, but the majority of existing techniques for teaching surgical skills and simulating operative experiences have thus far been developed in surgical specialties outside of plastic surgery. The relative paucity of plastic surgery simulation tools, especially outside of virtual reality programs, may be related to the difficulty in producing soft tissue models that look and feel like the real thing. Unfortunately, realistic replication of tactile surgical experience remains one of the greatest hurdles in simulation training, and a sophisticated synthetic model has yet to be developed. Compared to the expense of an OR, synthetic models are cost effective and wield the potential to both improve technical skills and effectively replicate relevant surgical anatomy. Design and implementation of synthetic anatomic models for use in plastic surgery training programs has significant potential. While many of the contemporary models discussed focus exclusively on finite technical skills like suturing, large scale, synthetic models can also be developed to evaluate more significant training milestones. This would give residents the opportunity to learn more complex procedures in a controlled environment outside the OR. At NYU Langone Health, we are in the preliminary stages of evaluating a full-scale synthetic model for abdominal free flap breast reconstruction. Initial resident feedback has been positive, and once we have finalized the prototype, we will begin formally incorporating it into our training curriculum in conjunction with virtual simulation programs. Using our theoretical design as an example, we plan to structure our simulation-based training curriculum in a manner that underscores the importance of correctly identifying anatomical landmarks and procedural steps. Step-wise employment of diverse simulation-based training models (virtual and synthetic) will provide deliberate training BIB001 . We plan to assess educational milestones across all stages of residency, in accordance with the ACGME Plastic Surgery Milestones  . Progress will be measured in terms of technical mastery and improvements in patient care and OR outcomes. To ensure the acquisition of foundational skills prior to clinical application, our program would begin with pre-tests (e.g., multiple choice questions designed to mimic the architecture of InService Exams) to evaluate baseline knowledge of anatomical structures, tissue planes, key procedures, indications, contraindications and common complications. Next, depending on student training levels, simulators could include a wide range of materials: e.g., in early postgraduate years, synthetic materials may be deployed to refine dexterity and increase student confidence in the manipulation of surgical tools; in later years, residents could proceed to cadaveric simulation of full procedures. Parameters for resident evaluation would be clearly outlined and defined, then monitored by faculty instructors. In addition, senior-level residents could be tasked with teaching and evaluating junior-level residents on milestones they have already achieved BIB002 . Each resident would be evaluated in accordance with the defined milestones, with a passing grade required to advance. Interaction with faculty for questioning and reflection would immediately follow resident interface with the simulators. Furthermore, post-tests (similar in design to the pre-tests) would be administered to evaluate student progress and milestone accomplishments. To ensure mastery, each milestone would culminate with performance evaluations in a live operative setting. We believe that implementation of this tiered learning approach-that is, deliberate simulator training that culminates in a live operative setting-may improve the efficacy of competency-based training in plastic surgery education. Although the simulation curriculum outlined above is theoretically sound, a number of limitations have precluded its formal adoption and implementation at our own institution. To start, simulation training remains in the developmental phase insofar as few studies have sought to comprehensively compare the efficacy of simulation-based models with that of traditional methods of plastic surgery education. In addition, although synthetic models appear to be promising, they remain expensive, they may not accurately represent the tactile feedback of soft tissue, and there is not yet evidence that they improve knowledge transfer in a cost-effective manner. Equally important, the implementation of simulation-based training curriculum will inevitably require significant time commitments on the part of both residents and faculty, apart from already-busy clinical duties. In order to justify this, robust evidence to demonstrate the utility of simulation technology in plastic surgery training curriculum is necessary. At this time, this evidence does not yet exist.