Simulation for Attending Physicians Helps Laparoscopic Surgeons Sustain and Improve Their Technical Skills


Once a surgeon is credentialed, very little oversight exists to assure the maintenance of surgical skill. This lack of quality control was identified by a group of clinical leaders in gynecology who noted that a high percentage of their members were low-volume surgeons. David L. Feldman, MD, MBA, FACS, Senior Vice President of Healthcare Risk Advisors (HRA) and Chief Medical Officer of TDC Group, received feedback from leadership in this specialty at five academic medical centers in New York City, where they observed a major discrepancy among attending ob/gyn physicians, many of whom performed certain surgical procedures only rarely—and when they did, took up to twice as long to complete them as physicians who were far more familiar with the surgery and performed it on a regular basis. This lack of familiarity and experience posed potential patient safety risks, yet despite this, surgeons were being re-credentialed with few checks on their current abilities or technical competence.


Dr. Feldman and his colleagues identified simulation training as a way to improve overall familiarity, confidence, and competence with these surgical procedures for attending physicians. While simulation training is an accepted method for improving surgical performance among residents, few attending physicians had the same opportunity to participate. To overcome that imbalance, HRA sourced a state-of-the-art laparoscopic surgery simulator, then created and facilitated an entire simulation program.

Dr. Feldman sought and received support for the program from the ob/gyn leadership. With a goal of improving familiarity, increasing overall competence, and shortening operating times, they made taking a simulation a requirement to maintain or renew a surgeon’s hospital credentials for over 300 attending gynecologists. All ob/gyns with laparoscopic privileges were required merely to participate in the training, beginning with completing a pre-simulation survey and self-assessment. The physicians then completed three basic skills tasks (enforced peg transfer, lifting/grasping, and cutting) using the LapSim virtual reality laparoscopic simulator.


This study identified numerous outcome measures that correlate with surgical volume.

All three simulated tasks had value in the objective assessment of laparoscopic skills. In addition to total time, at least one other objective performance measure significantly correlated with surgical volume for each of the three tasks. Tissue damage was significantly correlated in both the lifting/grasping task and cutting task. Left and right instrument and angular instrument path lengths were not always correlated with handedness, as one would expect; however, in the cutting tasks, all four of these measures were significantly correlated with monthly case volume.

It was also possible to use this simulator data to identify surgeons who required additional training. Setting a cutoff in performance level at two standard deviations above the mean (the higher the score, the poorer the performance) identified 66 physicians as falling into this category (19 percent).

Lastly, despite being credentialed to operate on patients, six ob/gyns declined to take the simulation and elected to give up their privileges for these procedures rather than have their levels of surgical skill examined and categorized.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.