High Fidelity Cleft Lip Simulation Improves Performance and Self-confidence

BACKGROUND: High fidelity simulation has a growing role in education of plastic surgery trainees, particularly for cleft lip and palate repair. To this end, we developed a haptically accurate cleft lip simulator through collaboration among surgeons, engineers, and special effects experts. But despite good intentions, whether high fidelity simulation results in actual performance improvement and whether that improvement is sustained over time have not been demonstrated. This study tests the hypothesis that cleft lip simulation followed by structured debriefing improves objective performance and self-confidence and that gains persist over time. METHODS/DESCRIPTION: Trainees performed an initial uncoached cleft lip repair on a high fidelity simulator followed by structured debriefing (plus/delta format). Afterward, they performed a second cleft lip repair to apply information discussed. Participants returned 3 months later for a third and final simulation. Procedural videos were blindly rated using the modified Objective Structured Assessment of Technical Skills (OSATS; score range 4–20) and the Unilateral Cleft Lip Repair Competency Assessment Tool (UCLR; score range 18–54). Influence of training level on score was estimated using Pearson R. Self-assessed performance was measured with a previously published scale (score range 6–24) and procedural self-confidence was measured with a validated tool (score range 6–30), both administered at the completion of simulation but before debriefing. RESULTS: Twenty-six individuals participated. Training levels included Integrated PGY 3 (n = 4), Integrated PGY 4/Independent PGY 6 (n = 4), Integrated PGY 5/Independent PGY 7 (n = 8), Integrated PGY 6/Independent PGY 8 (n = 5), and craniofacial fellow (n = 5). Twenty participants (77%) returned for follow up. Mean OSATS score increased from 15.8 ± 3.0 for the first simulation to 17.4 ± 2.0 for the second simulation and decreased slightly to 16.9 ± 2.0 for the third simulation. Mean UCLR score increased from 42.7 ± 7.4 for the first simulation to 47.3 ± 5.6 for the second simulation and was sustained at to 47.6 ± 4.8 for the third simulation. Although training level moderately correlated with OSATS (r = 0.454, P = 0.020) and UCLR (r = 0.550, P = 0.004) for the first simulation, that correlation deteriorated with the second and third simulations. Mean self-assessment score increased from 13.0 ± 3.8 after the first simulation to 17.0 ± 2.4 after the second simulation and further increased to 18.7 ± 2.2 after the third simulation. Mean self-confidence score increased from 15.6 ± 3.6 after the first simulation to 19.9 ± 3.2 after the second simulation and further increased to 21.4 ± 4.0 after the third simulation. CONCLUSIONS: Both objective trainee performance and subjective self-assessment and self-confidence improve with high-fidelity simulation, and that improvement is sustained over time. Moreover, initial differences in performance seen with increasing training level resolve with the combination of simulation plus structured debriefing. This suggests that simulation plus structured debriefing may accelerate junior trainees’ knowledge and technical skill, effectively flattening the learning curve for cleft lip repair.