Mark S. Adams, BS, RDCS, FASE

As we integrate these changes and increasing complexities with the educational needs of a resident, fellow, staff, or other allied health professional, the basic principles of learning remain unchanged. The trainee must learn a skill, master a body of relevant data, achieve proficiency, pass a written test, and achieve performance competencies. Within this framework, there are work-hour limitations, personnel shortages, bundled care considerations, competing responsibilities for a trainee’s time, and increased complexity of patient management procedures. Typically, training in the performance of TEE is incorporated into a cardiac anesthesia fellowship or cardiology rotation/fellowship, with lectures and learning on the patient during the procedure or operation. This method is limited by the concomitant care of the patient, the variability of the number of TEEs performed in a day to gain proficiency, and often by the need for quick assessment or diagnosis.

Simulation training is now universally recognized as part of the curriculum requirement for general and cardiac surgery. In addition, simulation technology continues to evolve in both surgical and other clinical areas to meet the growing demand for the training of residents and clinicians. Currently, both transthoracic (TTE) and TEE simulators are available and in use. Two companies offer a beating heart simulator model: Heartworks (Inventive Medical Ltd., London, United Kingdom) and Vimedix (CAE, Montreal, Quebec, Canada). These training simulators provide a unique adjunct to education in many ways.

• 1.
  

  Simulation presents a “standardization” that levels the training of normal anatomy, basic views, and rudimentary pathology models for the trainee.

  
  
• 2.
  

  It eliminates the patient liability factor in basic training.

  
  
• 3.
  

  Simulation allows unlimited repetition. Repetitive tasks include: probe position/manipulation, obtaining standard on axis views, and recognizing anatomy, obtaining and recognizing normal color flow Doppler.

All of these contribute to an understanding of three-dimensional relationships of the heart. Furthermore, the trainee can then assimilate these steps and learn to perform a “complete exam” in a specified time frame. This cognitive pattern development allows for recognition and memorization, which then transforms into the mastery of tasks and ultimately to understanding. When translated to patient care, the trainee then has the ability to appropriately apply the learned technique to the clinical setting. Ajit K Sachdeva MD, the founding director of the American College of Surgeons’ Division of Education says, “There is a lot of evidence that one needs repeated and deliberate practice coupled with specific and timely feedback to reach a level of mastery. Simulation helps to achieve that faster and in a more predictable fashion. Also, residents are able to achieve higher levels of skills earlier in their training.”

This is the same principle as a new driver taking drivers’ education classes and passing a test before being allowed to drive a car on the road.

• 4.
  

  Simulation can also help relay the sense of urgency when performing the TEE in the operating room and other clinical areas. It has been proven that the environment of the simulation laboratory provides enough appropriate stress to allow for optimal learning. Some skeptics may say: After a while one gets tired of playing on the practice field, but every sport requires “spring training” before the real season begins.

  
  
• 5.
  

  Simulation can help in building team skills between various trainees if incorporated into a simulation operating room setting.

Models for simulation training are being implemented and data is being collected to determine the impact on training. Surgical simulation training requirements currently exist. Residents must complete assigned modules and pass examinations on these modules prior to being allowed to perform these tasks in the operating room. Maintenance of Certification also requires successful completion of simulation protocols. The educational content and tasks performed in the modules are standardized, as is the examination for each to assure a minimum competency. TEE education must accomplish the same goal by training health care providers to more than a minimum level of competency. A TEE simulation curriculum that fulfills the same training guideline as the well-established surgical simulation programs would be a valuable step to improve TEE education.

The challenge of providing adequate training in TEE increases with the expanding health care providers in the operating room, such as cardiac sonographers and certified registered nurse anesthetist. Health care providers have varied background, education and training experiences. This mandates standardization of a TEE core curriculum with required competencies and mandatory examinations prior to the clinical performance of a TEE exam.

Simulation technology is at the leading edge for educating health care workers. With clear goals, training guidelines can be established that will assure the proper education of trainees. Standardization of teaching protocols and examination criteria with the incorporation of simulation training will allow for appropriate levels of competency to be achieved regardless of the background of the trainee. So, maybe the prevailing question is not “who’s left holding the probe,” but how do we get whoever is performing the exam to be the best trained he/she can be?