====Retention of skills after simulation-based training in orthopaedic surgery =====

====Abstract====
Simulation-based surgical skills training has become essential in orthopaedic practice because of concerns about patient safety and an increase in technically challenging procedures. Surgical skills training in specifically designed simulation laboratories allows practice of procedures in a risk-free environment before they are performed in the operating room. The transferability of acquired skills to performance with patients is the most effective measure of the predictive validity of simulation-based training. Retention of the skills transferred to clinical situations is also critical. However, evidence of simulation-based skill retention in the orthopaedic literature is limited, and concerns about sustainability exist. Solutions for skill decay include repeated practice of the tasks learned on simulators and reinforcement of areas that are sensitive to decline. Further research is required to determine the retention rates of surgical skills acquired in simulation-based training as well as the success of proposed solutions for skill decay.

====Commentary====

  * This review article starts with usual reasons for adopting simulation
  * It discusses the importance of transferability and retention
  * Transferability has been shown in orthopaedic simulation, but is affected by variables 
    * "The transferability of skills is not guaranteed in simulator-based training, however; other factors, such as inherent learning style, the nature and type of feedback, and opportunities for learning reinforcement, also determine whether acquired skills are successfully applied at high levels outside the laboratory."
  * Skill retention
    * Time frame
      * immediate (minutes to hours), 
      * short-term (up to 3 months), and 
      * long-term (3 months to years).
    * Few studies in Orthopaedics
      * Casts ([[jnl:Sonnadara2011]] and [[jn:Sonnadara2012]])
      * Arthroscopy
        * Shoulder
        * Meniscal repair (Jackson)
      * Decay is variable: Shoulder yes, knee meniscal no -- perhaps depends on the task and learner? It is context and task specific
        * Studies from other specialties over long term suggests that you must use the skills or they will deteriorate
  * "The goal of simulation-based courses should be to make training to proficiency levels quicker and safer than with traditional methods, not necessarily to make surgeons expert in the long term"

===Table 1 (which is available online and I included as a sample below) provides a summary of Studies on Retention of Skills After Simulation-based Training in Specialties Other Than Orthopaedic Surgery ===

^Study  ^ No. of Subjects  ^Skill ^ Assessment ^ Follow-up Time ^ Results and Critical Notes ^
|Stefanidis et al17 |15; Simulator group (n = 11) versus control group (n = 4)|Laparoscopic suturing |Performance scored on the basis of time and errors| immediate and 5mo | The simulator group had better performance than did the control group at both immediate and 5mo tests (P ,0.001). The simulator group performance deteriorated at 5 mo in the absence of practice (P ,0.05). No further training or surgical exposure occurred in either group during follow-up.|

=== Other Notes===  
  * [[co:Spaced Learning]] or practice helps retention. Article suggests "spaced rehearsal", increasing the amount of time between practices (much like the idea behind flash cards). 
  * Use of simulation as "warm up" or "rehearsal". Rehearsal with simulator before test improved laryngeal mask insertion.
  * lapse in practice does cause decay in skills learnt in a simulator. Tasks that are more difficult to learn decay faster
  * There is a need: "Program directors of orthopaedic surgery residency programs in the United States think that formal skills training is important at the junior level. In a 2013 survey, most program directors indicated that the primary learners for skills training were ortho- paedic junior residents (95%) and orthopaedic senior residents (70%).39"
  * Is boot-camp style concentrated practice (i.e. massed learning), better than longitudinal experience (spaced learning)?
  * ABOS does not currently assess surgical competency: "Independent external evaluation of surgical skills is not included in orthopaedic board certification; however, the ABOS is assessing mechanisms to develop and validate surgical skills tests as part of this process."

====Source====
Atesok, K., Satava, R. M., Van Heest, A., Hogan, M. C. V., Pedowitz, R. A., Fu, F. H., … Hurwitz, S. R. (2016). Retention of skills after simulation-based training in orthopaedic surgery. Journal of the American Academy of Orthopaedic Surgeons, 24(8), 505–514. https://doi.org/10.5435/JAAOS-D-15-00440