Training allows healthcare professionals to develop skills that benefit patients, improve their care and keep them safe. It is an essential aspect of reducing or preventing harm to our patients.
Over the past two decades there has been a significant shift in surgical education away from an apprenticeship model that had existed for centuries towards the use of clinical skills and simulation training. This can be undertaken in a safe environment, allowing healthcare professionals to begin their learning and practice of skills away from patients. Proponents of the ‘new’ system point to the increased availability of simulation equipment, both low (sometimes called basic) and high fidelity (virtual reality high technology systems), in NHS hospitals and university departments throughout the UK. In addition, there is a wealth of evidence supporting simulation as an important educational tool in medicine that has the potential to significantly reduce the chances of harm to patients.
18.1 The Theory Behind Training
18.1.1 Why is Training Important?
Training allows healthcare professionals to develop skills that benefit patients, improve their care and keep them safe. It is an essential aspect of reducing or preventing harm to our patients .
Over the past two decades there has been a significant shift in surgical education away from an apprenticeship model that had existed for centuries  towards the use of clinical skills and simulation training. This can be undertaken in a safe environment, allowing healthcare professionals to begin their learning and practice of skills away from patients . Proponents of the ‘new’ system point to the increased availability of simulation equipment, both low (sometimes called basic) and high fidelity (virtual reality high technology systems), in NHS hospitals and university departments throughout the UK. In addition, there is a wealth of evidence supporting simulation as an important educational tool in medicine that has the potential to significantly reduce the chances of harm to patients [4–6]. Incorporating simulation into healthcare professionals’ training was placed high on the political agenda by England’s Chief Medical Officer in 2008 , and more recently the Department of Health in the UK published the ‘Framework for Technology Advanced Learning’ . This guides universities and the NHS on how to integrate simulation into the training of students and staff.
To ensure patients undergoing any medical procedure, including hysteroscopy, are safe, healthcare professionals must be well trained . The definition of training is ‘to teach a particular skill or type of behaviour through sustained practice and instruction’; to become proficient, ‘sustained practice’ is required (Oxford Dictionary). This is an important consideration when an individual is learning a new skill, but also informs those designing training programmes. Although a one-off course with instruction from experts may be a key component, regular practice must be maintained with further mentoring or support available from an expert to allow a learner to become proficient, and therefore safe, when performing the procedure [10, 11]. In adult education, learners also need to take an active role in the training process, seeking out opportunities to practise and improve their skills.
When designing any training programme, it is crucial to understand the process by which individuals learn and perfect new skills so that the programme is effective and efficient. Suggested goals of an ideal programme are described in Box 18.1.
To deliver an individual able to perform the procedure or task safely and proficiently, equipped to maintain their skill level, and able, if given the opportunity, to develop new and more advanced skills.
To provide the learner with an awareness of their own limitations and the ability to troubleshoot problems in order to practise safely.
Much of this philosophy is based on training pilots in aviation, a process which has much in common with learning a new skill or procedure in healthcare. It relies heavily on the use of simulators during the training, but also once fully competent, to ensure skills are maintained [12–14].
18.1.2 General Principles of Surgical Skills Training
Hysteroscopy involves complex psychomotor (visual–spatial) skills, similar to other types of minimal access surgery, which allow the operator to perform three-dimensional movements while visualising the image in two dimensions. There has been debate among neuropsychologists as to how much impact an individual’s ‘innate’ visual–spatial ability i.e. their natural talent, has on their ability to acquire surgical skills [15, 16]. However, several studies have shown that almost everyone can learn and become competent in performing complex psychomotor tasks on a laparoscopic simulator similar to those skills required for hysteroscopy [17–19].
Acquiring a practical skill is a complex process involving:
An individual’s general (in some cases intellectual) ability
Cognitive processing (how a person understands and makes use of the instructions given to them on how to perform a particular skill)
Rate of perception (for example, how quickly they can recognise patterns of behaviour)
Psychomotor ability .
Once the steps involved in acquiring the skill have been understood, practice is necessary to improve performance and ultimately become proficient. Some argue that the type of practice undertaken is also important, with the concept of ‘deliberate practice’ emphasised by Ericsson et al. , and popularised by Malcolm Gladwell in his book Outliers . When undertaking ‘deliberate practice’, the learner performs the task they are aiming to perfect many times with informative feedback and the opportunity to correct mistakes. In healthcare, simulators are ideally placed to assist in this type of learning, allowing repetition of a skill in a safe environment away from patients [4, 22]. Feedback, an essential part of learning, is often the most difficult aspect to achieve owing to service pressures and other time constraints within healthcare systems . The presence of an instructor during training has been shown to reduce training time, but not necessarily to improve the performance of students at the end of a training period . Virtual reality simulators often have built-in feedback functions and have been shown to provide feedback as good as that given by experts in some contexts . However, they are very costly and hysteroscopic virtual reality simulators in particular are not widely available.
18.1.3 Designing, Implementing and Evaluating a Training Programme
The experience of attending training courses or undertaking training programmes is common both for students at college or university, and later during career progression. Some experiences are likely to have been more useful than others, but it is worth considering what is involved in putting a course together and what occurs ‘behind the scenes’ during the course.
Simulation has been used as part of many stand-alone courses in obstetrics and gynaecology for more than two decades, such as the Basic Surgical Skills course at the Royal College of Obstetricians and Gynaecologists (RCOG) which uses basic simulators to allow learners to practise suturing and knot tying, for example. In the Managing Obstetric Emergencies and Trauma (MOET) course, mannequins and actors are used to help learners manage challenging obstetric scenarios safely. However, incorporating simulation into the core curriculum has proved a challenge for medical educators  and was only recently taken up by the Royal Colleges within the UK . Designing and running a successful training programme can be complicated and stressful, with ensuring availability of the correct equipment for trainees to use, plus adequate numbers of suitably experienced facilitators to provide appropriate feedback at regular intervals. For a comprehensive list of issues to consider when creating a training programme, see Bath and Lawrence’s Twelve Tips for Developing and Implementing an Effective Surgical Simulation Programme  (Box 18.2).
1. Target skills appropriately to the audience
2. Include mandatory simulation sessions, which are key to successful integration
3. Buy the right tools for the job
4. Provide the right teaching environment for simulation learning
5. Standardise the approach to surgical simulation
6. Maximise teaching effectiveness with experienced proctors
7. Schedule a rehearsal prior to simulation sessions
8. Study and report the results of simulation training
9. Follow the six-step approach for effective skills training
10. Increase simulation learning with situational ‘stressors’
11. Integrate simulation teaching within a clinical scenario
12. Conduct periodic assessment to ensure maximum learning
Learners also have an important part to play in the success of a training programme; for instance, they need to be motivated to participate . In addition, they need to have available resources (simulators and supervisors) at or close to their place of work in order to practise regularly . Participation is more likely if a programme is a mandatory part of a curriculum . Without the backing of a medical college, such as the RCOG, incorporating it within their curriculum, a course may not achieve its desired aims to improve the management and safety of patients .
Learner motivation may also be stimulated by the prospect of regular assessments of progress during the training [26, 28]. Reznick et al. validated assessments of surgical skills using laparoscopic simulators in 1996 and developed global rating scales to score trainees on their levels of performance . Since then, other authors have developed these rating scales further to use in laparoscopic skills assessments using simulators . Global rating scales have also been used with other assessment tools, such as with the Objective Structured Assessment of a Technical Skill (OSATS) used until recently by the RCOG for assessing the clinical skills of trainees [31, 32]. Other investigators have used the time to complete a task as a principal method of assessment . The virtual reality hysteroscopic simulator (HystSim™; VirtaMed, Zurich, Switzerland) uses a multiple metrics scoring system that incorporates the speed and number of movements of instruments, time for completion and number of bleeding episodes during a simulated operation.
18.1.4 Validation of Training, Simulation and Assessment
The growth of minimal access surgery has been followed closely by significant developments and innovations in surgical training because of the unique set of skills required to practise in this surgical field. Simulation-based training programmes and high fidelity virtual reality simulators are now frequently used not only to allow learners to practise skills but also to perform assessments. If these assessments are used as the basis for deciding whether or not a trainee can make progress in training, they and the simulated tasks used must be fully validated for this purpose . However, full validation of training or assessments has proved difficult, if not impossible, for developers of simulator training programmes. What does ‘validation’ of a training programme or assessment actually entail? Several standards of validity have been designed  (Table 18.1).
|Face validity||Performed during the initial phase of development, evaluates if the tool is realistic and ‘useful’ for training; usually involves experts in the field undertaking the training or assessment and then giving their feedback|
|Content validity||Sometimes referred to as logical validity. Uses statistical tests to perform a detailed analysis of each part of the assessment to evaluate if it is an appropriate test for the skill or knowledge required|
|Construct validity||The ability of the assessment to differentiate between an expert and a novice for a particular skill|
|Concurrent validity||Determines whether the scores from the newly developed assessment are ‘related’ to the scores from an established test used to assess the particular skill|
|Discriminative validity||The assessment can differentiate between the ability levels within a group who all have similar experience, for example Year 1 specialty trainees|
|Predictive validity||The extent to which scores for an assessment of a skill predict ‘actual performance’ i.e. surgical skill in the operating theatre|
Face validity, whether the training or assessment is realistic and useful for its purpose, and construct validity, the ability to differentiate between experts and novices, have been established for the VirtaMed HystSim™ [33, 34]. However, the other facets of validation, including predictive validity, which is perhaps the most crucial, have not yet been reported for hysteroscopic simulators. This is in part due to the lack of availability of a reliable assessment tool that can objectively assess surgical performance in simulation or in reality. Reliability can be determined by statistical analysis using the ‘split-test’ method (scores for a single test are split and then consistency calculated) or the ‘test–re-test’ method (the test is performed on more than one occasion) . Both methods allow for the calculation of a reliability coefficient, a measure of agreement in the scores given for the assessments. Correlation coefficients have sometimes been used in the literature to describe the reliability of a tool; however, this is inaccurate, as correlation measures association rather than agreement .
It should also be recognised here that the traditional apprenticeship model of training has never been validated by medical educationalists as an ideal means of training surgeons, although it is often used as the gold standard.
It is clear that developing a fully validated and reliable training programme and method of assessment is a complex and time-consuming process that has yet to be completed for the current training courses available.
18.2 Hysteroscopy Skills and Models
18.2.1 Skills Required for Hysteroscopy
Hysteroscopic procedures can be separated into basic skills, usually diagnostic procedures, and advanced skills, including performing operative hysteroscopy and running an outpatient hysteroscopy service.
Knowledge of equipment (assembly of the hysteroscope, camera, light source, irrigation fluid and any fluid management system)
Instrumentation of the cervix
Use of analgesia and anaesthesia
Insertion of a 30° hysteroscope, or other, into the endometrial cavity under direct vision with irrigation fluid distension
Visualisation of entire endometrial cavity from internal os, including fundus, anterior, posterior and both lateral walls
Identification of both tubal ostia
Identification of abnormalities and anomalies such as polyps, fibroids, synechiae, tumours, bicornuate and arcuate uterus, septum
Documentation of the procedure and findings.
Advanced Skills (Dependent Upon Equipment Available in the Working Environment)
Knowledge (including assembly) of the equipment and fluid management systems used
Troubleshooting for each procedure/technique
Accomplished at the basic skills
Use of 0° and 12° hysteroscopes
Use of hysteroscopic scissors, graspers and cup forceps
Use of bipolar needle electrodes
Fibroid and endometrial resection
Morcellation of fibroids
Endometrial ablation techniques
Analgesia and anaesthesia for procedures
Running an outpatient hysteroscopy service including training of support staff and nurse practitioners, quality assurance, audit and tariffs
Clinical governance in hysteroscopy (see Chapter 17)
18.2.2 Virtual Reality Models with Computer Simulation
Virtual Reality (VR) simulators support the development of surgical skills, as advocated by Stefanidis and Hersiford, by enabling trainees to undertake practice that is deliberate, distributed and variable .
The hysteroscopy surgery simulator HystSim™ was developed by the Swiss company VirtaMed in 2007 following collaboration between gynaecologists and electrical and software engineers. The company specialises in the production of VR endoscopic simulators for medical training and the hysteroscopic simulator was the first device produced. The instruments used with the simulators are the same as those found in clinical practice, but with the addition of sensors. HystSim™ uses an adapted hysteroscope with an operating channel and a resectoscope; they can be removed and re-inserted. As they are original instruments, the scopes have inlet and outlet valves for control of fluid. There are three virtual cameras, 0°, 12° and 30°, and a working element for electrosugery. The simulator is available on two platforms: one allows visual tracking and the other uses a pelvic model to enhance tactile feedback (Figure 18.1).
Figure 18.1 The VirtaMed HystSim™ with pelvic model.
The training programme consists of three modules that were developed with the aim of teaching best practice. The first covers initial hysteroscopy skills, the second moves through diagnostic and commonly performed operative procedures, and the third (more advanced) module includes treatment of multiple polyps, multiple myoma, synechiae and uterine septum. Each module has clear learning objectives and a variety of cases of increasing difficulty are presented (Figure 18.2).
Figure 18.2 Examples of cases presented within the essential skills module in the HystSim™. (a) Easy diagnostic hysteroscopy. (b) Medium difficulty diagnostic hysteroscopy. (c) Easy polypectomy. (d) Medium difficulty fibroid.
Complications can be added during a training session, such as intrauterine bleeding, uterine perforation and fluid overload. In the first module, the exercises consist of tasks that focus on specific basic steps of the procedure: gaining entry into the cervix, distending the uterine cavity, navigating inside the cavity, identifying the important landmarks and any visible pathologies, removing a small polyp with graspers or scissors and treating minor synechiae. The trainee is guided by instructions, coloured hints, ghost tools and outside views to improve performance. Throughout the programme, extensive feedback on performance is provided post-procedure, with attention to visualisation, economy of movement, safety and fluid handling. The instrument path can be viewed and the procedure replayed.
The developers of HystSim™ have sought validation of the simulator as a training device and both face and construct validity for diagnostic hysteroscopy have been confirmed. Construct validity was established for fluid handling and ergonomics (i.e., intervention time, stability and path length), as those with experience performed significantly better than novices . However, construct validity was not demonstrated for the visualisation or safety modules. In fact, the reverse was the case for safety, with novices achieving higher scores. A possible explanation for this was that in order to perform the procedure safely and avoid perforation and reduce pain, participants were required not to touch the uterine wall or cervical canal during diagnostic hysteroscopy. This could be something that experienced clinicians, used to performing therapeutic procedures that necessitate touching the uterine surface, may consider unimportant .
The design of the HystSim™ training programmes allows participants to undertake deliberate practice by focusing on a specific skill and performing it many times until learnt, distributed practice by repeating it at regular intervals and variable practice by undertaking the procedure for as long as needed until the skill is fully mastered. However, the role of VR in surgical training, and specifically of HystSim™ in hysteroscopic surgical skills training, though potentially useful, remains unconfirmed. Further steps in the validation process are required, ultimately establishing discriminative and predictive validity . A potential limitation of HystSim™ is its high cost, which may reduce the number of devices available and limit opportunities for distributed and variable practice. However, the system is portable, so it can be shared across a number of institutions, thus mitigating some of the cost; in this way, once set up, its availability need not be limited.