An immersive “simulation week” enhances clinical performance of incoming surgical interns improved performance persists at 6 months follow-up

The transition from medical student to surgical intern can be intimidating with consequences for patient safety as demonstrated by the “July” or “August” effect.1,2 Anecdotally, trainees have reported feeling ill-prepared and extremely nervous in their first couple of weeks as a surgical intern. Indeed, the prevalence of psychiatric morbidity and burnout has been shown to rise during the intern year.3 Traditionally, “shadowing” the current intern was used to ease the transition. This is a form of work experience, which may be referred to as a subinternship in the United States, where the incoming student follows the incumbent surgical intern to experience their daily duties. Since 2012, this practice has been made compulsory in the UK. The move was in part a response to the so-called August effect, whereby increased patient mortality was found to be associated with the August changeover and arrival of newly qualified doctors.2 The effect of changeover of junior doctors is referred to as the “July effect” in the United States. A recent review found evidence of increased mortality and reduced efficiency in hospitals owing to the changeover of doctors at the end of the year.1 Easing the transition from medical student to intern could potentially provide clinical benefits for patients in addition to making the experience less fear-inducing for the clinician. During shadowing, the exposure to clinical scenarios is largely based on chance occurrences. Moreover, there is a feeling among the profession that 4 days of shadowing is not enough on its own to protect patients.4 There have been encouraging reports of intensive simulated skills courses targeting medical students to prepare them for the transition to junior surgeon.5–8 Studies in the United States have shown that simulated skills courses or boot camp can increase the confidence of junior surgical interns.6,7,9,10 They have largely been small-scale feasibility studies with self-assessed confidence as the primary outcome and no clinical metrics. Subjects on these courses have in particular found the “hands-on” training sessions to be of most benefit.6 There is also some objective evidence of improvement in both knowledge8,11 and technical skills.12 Although the majority of studies have focused on generic surgical skills, specialty-specific boot camps have also been shown to improve technical skills in first year residents.13 In 2012, Fernandez et al14 reported encouraging results from 4 successive years of a simulation-based surgical boot camp. One of the challenges they highlight is the need for protected teaching time and how to balance this against duty-hour regulations. A proposed solution is to implement this type of training before PGY-1. In fact, as early as 2004, the American Surgical Association Blue Ribbon Committee recommended collaboration between the Division of Education of the American College of Surgeons, the Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, surgical boards, and medical schools to develop a surgical preparation curriculum to assist the transition from medical student to surgery resident.15 Progress has been made in the United States; however, there remains a lack of supporting evidence that these encouraging results can be applied to the training system in the UK. Competence in medical school examinations assesses both cognitive and to some extent practical skills. The focus of these examinations is on testing knowledge and targeted technical or practical skills. However, this does not necessarily provide adequate preparation for the real-world situations that a surgical intern faces. The purpose of this study was to develop, pilot, and evaluate an immersive, intensive, simulated 1-week course that recreates experiences and situations that a surgical doctor is likely to face in their first weeks as a clinician. It aims specifically to prepare final year medical students for the transition into their surgical internship. This project allows the subject to learn and practice in a controlled, simulated environment away from the patient.