Team Overview[edit | edit source]
Team AmoSmile is a collaboration created specifically for the Global Surgery Training Challenge (GSTC) comprised of team members from Operation Smile and AmoDisc Ltd. The team consists of surgical and clinical experts from multiple countries in sub-Saharan Africa who have experience delivering high-quality essential surgical care for burns, trauma, and cleft conditions through short-, medium-, and long-term engagement programs. These endeavors also serve to strengthen local workforce capacity by training local surgeons in these life-saving and life-improving procedures. Along with these surgical clinicians, Operation Smile brings multiple experienced medical educators who work in the surgical training and simulation space throughout sub-Saharan Africa and other regions of the world to develop curricula for surgical training programs and residencies, mentorship programs for rising trainees and new attendings, and leadership development initiatives. AmoDisc also brings extensive educational and technical experience to the team with numerous successful virtual surgical simulation platforms. Given their experience designing, developing and validating these surgical simulation applications, they are well-positioned alongside Operation Smile clinicians and educators to translate the Discovery Award proposal into a functioning, effective, and successful educational platform.
Mission[edit | edit source]
Allow surgical trainees and practitioners to become confident and competent in performing local flap techniques, like Z-plasty, as part of reconstruction for burns, trauma, cancer, and congenital conditions performed in resource-constrained settings within sub-Saharan Africa and beyond.
Vision[edit | edit source]
To provide high-quality and freely accessible training platforms that sustainably facilitate the development and expansion of the surgical workforce in low-resource settings through autonomous systems and self-assessment training modules.
Values[edit | edit source]
1. Autonomy: The local flap training module must facilitate independent study and training with the opportunity for self-assessment and dynamic feedback that will promote meaningful growth through autonomous learning.
2. Sustainability: This platform must be able to sustain itself for the long term both financially and technologically through a well-developed web-based system that can be accessed in low-resource settings and maintained for a realistic cost.
3. Safety: The users of this platform will be taught about safe and high-quality means of applying the learned information in the appropriate clinical context.
4. Resource Conscious: In order to make this training platform feasible for low-resource settings, the virtual platform must function with minimal processing and bandwidth requirements while also implementing an accessible-yet-valuable surgical simulation component.
5. Evidence-based: All procedures taught through this system will require rigorous validation for accuracy and precision of all components of the surgical teaching (i.e., anatomy, clinical relevance, technique, modifications, applications, perioperative care, and complication management).
6. Scalable: The platform developed in the process of involvement in the GSTC should not only facilitate implementation of a training platform for local flap surgery but also possess the necessary functionality that will facilitate scaled growth over time for new medical and surgical content, procedures, simulations, training modalities, and forms of assessment.
7. Dynamic: Given the requirement for a self-directed learning platform with a mixed methods approach to training through virtual and simulation means, the ability of the system to guide individuals through training in a responsive, challenging and personalized manner is critical.
8. Pertinent: The material taught through this platform must not only be scientifically accurate but contextually appropriate. The procedures must be taught in a way that is applicable in a low-resource setting on the relevant patient population and pathologies using the resources available to these trainees.
The Problem[edit | edit source]
Patients in Low- and Middle-Income Countries (LMICs) suffer a disproportionate burden of conditions amenable to treatment by reconstructive surgical procedures, including burns, trauma, infection, cancer, and congenital anomalies. Taken together, these conditions affect 122 million people around the world, resulting in an annual loss of 95 million years of disability-free life - more than threefold the burden of the top five non-reconstructive surgical conditions combined.
Sub-Saharan Africa (SSA) is particularly impacted by these reconstructive conditions with significantly more cases, disability, and death due to these conditions than the rest of the world. Every year, more than 16 million people from SSA are impacted by these conditions causing more than 16 million years of added disability due to their injuries and subsequent wounds and deformities.
The social isolation and economic destitution that too often marr the lives of those living with untreated reconstructive conditions further compound this burden. Nearly 70% of all jobs in the world require manual labor, yet untreated reconstructive conditions, which often result in severe physical disability, precludes many people from being able to acquire and maintain jobs. Beyond the work-related impact of their disability, people with untreated reconstructive conditions deal with stigma, chronic pain, social isolation, mental health illnesses, and educational barriers – all of which greatly impact quality of life. It is because of this immense global burden of untreated reconstructive conditions and their severe impact on quality of life that it is imperative we train surgical providers how to treat these debilitating and disfiguring conditions with reconstructive surgery.
The Impact of our Training Platform[edit | edit source]
A broad armamentarium of reconstructive procedures exists for addressing defects arising from burns, trauma, infection, cancer, and congenital anomalies. Local flap techniques form the foundational basis from which much of these procedures derive. Local flaps constitute the surgical elevation and transfer of skin and underlying subcutaneous tissues to reconstitute an adjacent tissue defect. Chief among their many benefits is their readiness to adaptation. That is, local flaps can be specifically and uniquely tailored to meet the aesthetic and functional requirements of a seemingly infinite range of tissue defects that occur in any area of the body due to countless pathologies. When addressing a myriad of challenging reconstructive conditions in LMICs, one of the primary barriers for patients who require reconstructive surgery is finding a surgeon with the right skill set who has the necessary equipment, infrastructure, and supporting staff to successfully execute an effective reconstruction. Fortunately, local flaps are highly compatible for application within resource-constrained settings given their ideal requirements of modest operative time and only the most basic surgical instruments. Further still, the principles and techniques that underlie their use can be learned and mastered by a broad spectrum of providers within the surgical ecosystem, irrespective of surgical specialty.
Innovation Through Mixed Methods Simulation[edit | edit source]
The significant advantage of this platform over traditional approaches to teaching this skill is that trainees can repetitively practice all steps of the procedure both virtually and physically without requiring a mentor, the right patient, or a healthcare system in which to perform the surgery.
To date, there have not been any mixed methods (combined virtual and physical simulation) platforms for teaching local flap surgery to surgical practitioners in low-resource settings. Our resource-conscious physical simulator is designed to replicate the relevant anatomy and step-by-step process of performing local flap surgery while ensuring access due to the low-cost, locally-sourced, re-usable, and easily-accessible nature of our design.
Our customizable virtual interface coupled with a comprehensive curriculum and an advanced virtual surgical simulation model that integrates with the physical simulator adds to the unique structure of the overall system. Since no electricity or internet access is required to build or operate the simulator, it is portable and accessible anywhere in the world.
This innovative platform will ensure that users can acquire evidence-based knowledge on the key aspects of local flap surgery through clinically-oriented simulations even without internet, electricity, or complex instrumentation.
Developing an Innovative Platform[edit | edit source]
In order to accomplish the task of creating a low-cost, easily-assembled, and locally-sourced platform which maintains high clinical translatability and surgical fidelity, extensive testing within SSA and other LMICs (e.g. Colombia and Peru) was performed through a data-driven process. Ongoing iterative testing with surgical trainees and practitioners from South Africa, Colombia, Peru, Rwanda, the UK, and the US has directly guided app (features/interface/navigation) and physical simulator (materials/assembly/instructions) development. Feedback was provided via REDCap surveys that contained standardized questions on accessibility, feasibility, and fidelity for the app and simulator. Using REDCap to collect user surveys streamlined data aggregation and analysis to create a dynamic, responsive feedback loop which maintained steady growth and progress towards an improved platform. Weekly meetings with a global team including LMIC surgeons and trainees were held to discuss real-time qualitative feedback and brainstorm new ways of enhancing the features and practicality of the platform. Following this iterative process, the foundational curriculum, teaching theory user for technical skills, and methodology of self-directed and automated assessments was enhanced and refined. Along with user and trainer feedback on the app and simulator, we also leveraged decades of resident teaching experience from our surgical experts who work in LMIC settings both as local providers and international trainers to contextualize the content and infrastructure that was created.
Ensuring Accessibility[edit | edit source]
The curriculum was designed to allow any surgical practitioner – regardless of specialty – to learn these skills which maximizes impact, reach, and scalability. The educational content, mobile app, and physical simulator together allow anyone with an understanding of anatomy and basic surgical skills to go through this training module and safely perform a successful flap reconstruction. In order to further eliminate access barriers and content gatekeeping we created a module that is innovative in its design and content delivery - allowing users to fully engage in the training modules either directly on the AmoSmile app or alternatively through Appropedia’s easy-to-use interface.
We intentionally designed the Appropedia content to completely integrate with our mixed methods approach of virtual and physical simulation so surgical practitioners from around the world can freely access the entire training platform without barriers due to cost, resources, or technology.
The virtual aspect of our dual method approach utilizes a mobile app that guides learners through a completed surgical curriculum including step-by-step simulations and dynamic, customized training with competency tracking. This app is compatible with Apple and Android smartphones as well as all web browsers, which ensures that regardless of how people connect to the virtual platform, they have uninhibited access. To ensure global accessibility, our app works using AWS appsync datastore technology. Data is streamed to and from the smart phone’s internal storage regardless of internet connectivity. Then, when there is a good connection, the data is automatically synced with our cloud-based servers. This is ideal when working in areas with poor or inconsistent connectivity.
The physical component of our training platform that facilitates psychomotor skill acquisition utilizes a low cost, easily assembled, and entirely locally sourced physical simulator with the ability to simulate key steps of the procedure in a manner that is self-directed, accessible, and clinically translatable. Since no electricity or internet access is required to build or operate the simulator, it is portable and accessible anywhere in the world.
Team Members[edit | edit source]
|Zachary J. Collier||Team Leader, Clinical||Operation Smile Global Surgery Fellow||Operation Smile, USC Division of Plastic & Reconstructive Surgery||MD, MS||USA||Burn & reconstructive surgery, surgical capacity building in the Middle East and Sub-Saharan Africa, Surgical curriculum design for plastic & reconstructive surgery training programs (Malawi, Rwanda)|
|Priyanka Naidu||Clinical||Operation Smile Global Surgery Fellow||Operation Smile South Africa||MBChB, MSc||South Africa||Global Surgery Leadership & Research, National Surgical Obstetric and Anesthesia Plans & Implementation in Sub-Saharan Africa, Low Resource Training in Sub-Saharan Africa|
|Maria Fernanda Tapia||Clinical||Operation Smile Global Surgery Fellow||Operation Smile Colombia||MD||Colombia||Pediatric Reconstructive Surgery (Colombia, Bolivia, Peru), Surgical Training & Education in Low Resource Settings, Burn & Hand Surgery|
|John Dutton||Clinical||Operation Smile Global Surgery Fellow||Operation Smile International, Rutgers University Department of Surgery||MD||USA||General Surgery, Capacity Building in Low Resource Countries (Latin America & Sub-Saharan Africa), Workforce Strengthening, Surgical Metrics & Evaluation for Quality Improvement (Latin America & Sub-Saharan Africa)|
|Ankur Pandya||Clinical||Consultant Plastic Surgeon, Wing Commander RAF, Associate Dean Defence Deanery||Operation Smile UK, Portsmouth Hospital, Southampton University Medical School||MBBS, MS, MCh, FRCS(Plast),Eur Dip Hand Surgery, DMCC||UK||Surgical education & training, global surgery research, cleft, pediatric, burn & hand surgery in LMICs (Ethiopia, Malawi, Madagascar)|
|Anthony Dwyer||Educator||Vice President of Medical Technology and Innovation||Operation Smile, University of Illinois College of Medicine at Peoria, Healthcare Engineering Systems Center - Granger College of Engineering, University of Illinois||MS, AHFP||USA||Surgical Education & Simulation systems, Artificial intelligence (AI) algorithms for surgical simulation, Health Systems Engineering|
|Madison Lowerre||Educator||Education Coordinator||Operation Smile||BA||USA||Health education administration, curriculum coordination & implementation|
|Ad Gandhe||Technical & Digital Artwork||CEO & Founder of AmoDisc Ltd, Orthopaedic Surgeon||AmoDisc Ltd, Portsmouth Hospital||BSc, MBBS, FRCS, Dip Graph Des||UK||Clinical: Orthopaedic Consultant and Trauma Director at Portsmouth University Hospital,
Education: International and UK faculty for AO Technological: Expert in surgical simulation and App development (founder and inventor of Touch Surgery, a global surgical simulation app). Founder and creator of Amodisc suite of medical education apps and animations
|Oliver Wylie||Technical||CCO & Founder of AmoDisc Ltd||Amodisc Ltd, Sevendials Consulting Ltd, Piper Health Ltd||BSc||UK||Commercial: Consultant to multiple high-profile health startups/ SMEs including Pando, CareRooms, Qdoctor. Building insurtech/medtech fund. White paper co-author with Rt Hon Stephen Dorrell (former secretary of state for health), Accelerating Digital Health
Health Education: Wessex Academic Health Sciences Panel member
|Matt Wallis||Technical||Chief Development Officer||AmoDisc Ltd||BSc||UK||Software architect & web-based application developer with extensive experience in web design, Content Management Systems (CMS), Mobile application R&D|
|David Wybourne||Technical||Chief Commercial Officer||Fissara, Oxford University||BSc||UK||Designing, implementing & executing strategic growth plans in technology sector, Experienced specialist in mobile workforce software for health systems maintenance & engineering sectors|
|Desmond Jumbam||Health Policy Expert||Health System Strategist||Operation Smile Ghana, BioMedCentral||MSGH||Ghana||NSOAP BMC Health Services Research Editorial Board Member|
|Ruben Ayala||Policy||Chief Medical Officer||Operation Smile||MD, MPH||USA||President of G4 Alliance for Global Surgery, Facilitating National and Global Inter-sectional Partnerships through WHO & Operation Smile, Chief Strategist for NSOAP development in LMICs, Policy expert on national surgical capacity building & training programs|
|Tamlin Abrahams||Regional Liaison||Senior Regional Director||Operation Smile South Africa||MPH||South Africa||Expert on Sub-Saharan Africa Health Policies (national + regional), health systems infrastructure development, surgical training design in Sub-Saharan Africa|
|Justin Gillenwater||Surgical Expert||Assistant Professor of Plastic and Reconstructive Surgery, Director of LACUSC Burn Center||Operation Smile, University of Southern California||MD, MS, FACS||USA||Burn and reconstructive surgery, Complex wound management, USC Residency instructor and surgical mentor, LMIC surgical capacity building (Sub-Saharan Africa, Southeast Asia)|
|Tom Potokar||Surgical Expert||Director of Interburns, Professor of Plastic Surgery||Interburns; Swansea University, UK||MBChB, FRCS||UK||Director of Interburns International Network for Training, Education and Research in Burns; Developer of comprehensive burn surgery curriculum and training program for low-resource settings (Ethiopia, Morocco, Rwanda)|
Training Modules[edit | edit source]
High-level Overview[edit | edit source]
Who: Surgical trainees & practitioners providing reconstructive surgical care
Where: Resource-constrained settings such as LMICs in sub-Saharan Africa
What: Essential local flap techniques like Z-plasty, rotation-advancement, V-Y advancement, Rhomboid, and Bilobed flaps.
Why: Reconstructive surgery is essential for treating many common conditions like burns, trauma, cancer, and congenital conditions, which each year, are responsible for substantial morbidity and mortality (annual global burden: >122 million patients, >1.4 million deaths, >95 million Disability-Adjusted Life Years).
How: Innovative mixed methods training platform (i.e. both virtual & physical simulation) using a free mobile app (works offline and on web browser) that guides learners through an entire curriculum including step-by-step simulations and dynamic, customized training with competency tracking as well as a physical simulator that is low cost (<$5 USD), easily assembled (15 minutes), and entirely locally sourced (common items, multiple alternatives per component) with the ability to simulate key steps of the procedure in a manner that is self-directed, accessible, and clinically translatable.
Intended Users & Training Barriers[edit | edit source]
This training platform is designed for any formally recognized surgical practitioner or trainee whose scope of practice would include the surgical treatment of wounds or defects that arise due to burns, trauma, cancer, infection, and/or congenital malformations. These users may be surgeons, obstetricians, clinical officers, and other healthcare practitioners who possess accreditation to perform surgical procedures for reconstructive conditions like those mentioned above. These providers need access to affordable, reliable, effective, and adaptable training that will provide them with the skill set necessary to reconstruct a wide spectrum of surgically-relevant pathologies that are highly prevalent and impactful within their communities. The platform must account for limited-to-absent internet access, low computer/phone processing capabilities, limited capacity to receive packages or access mail, electrical outages, and variable access to other resources to facilitate simulation.
While addressing these potential barriers to utilizing the platform, the training must also account for variable levels of background knowledge and experience among the trainees and be able to adapt to their level of competency to ensure that they stay engaged and learn the material as efficiently as possible. This is where the pre-test and dynamic self-assessment system in the app plays a major role. Regardless of an individual’s starting point, the program will identify those starting at a higher competency level and challenge that individual with more difficult questions than a novice.
Additional Details on the Physical and Virtual Simulators[edit | edit source]
Our training platform consists of a physical simulator aimed at cultivating psychomotor skills and a virtual simulator optimized for clinical and surgical knowledge acquisition to facilitate safe, effective, and reproducible training that will allow trainees to perform a multitude of local flap surgeries. By combining the physical and virtual simulators, they work synergistically to overcome the limitations of the other and provide a more comprehensive simulation experience. The physical simulator has the necessary components to execute every step of the procedure from flap design to elevation and inset so that trainees can practice the key psychomotor skills for every step of the procedure that will be performed in a clinical setting. While the physical simulator facilitates iterative practice and psychomotor skill acquisition, the virtual simulator provides the foundational anatomical and surgical knowledge along with clinically-oriented step-by-step guidance to fill in any gaps that exist when physical simulators are used alone. This ensures that the combination of clinically applicable psychomotor skills learned on the physical simulator and the clinically-oriented knowledge base acquired from the virtual simulator provide a comprehensive curriculum for a clinically translatable learning process. The ways in which each simulator works and fits into the larger training platform are described in greater detail below.
Physical Simulator[edit | edit source]
The physical simulator is a low-cost, easily-assembled, and locally-sourced platform for the self-directed training and mastery of reconstructive techniques. It was designed using common materials that are widely available, inexpensive, and quickly assembled using just a hammer or screwdriver and glue. Requiring neither electricity nor internet, it’s both portable and universally accessible. Most importantly, the physical simulator serves as a high-fidelity model of the composite tissue substrate on which local flap surgery is based with anatomic representations for epidermis, dermis, subcutaneous tissue, and fascia. Using just a marking pen, scalpel, forceps, hemostat, and needle driver, the user is able to physically perform all of the maneuvers constituting flap design, elevation, and inset in nearly the same manner required of an in vivo model. Furthermore, our singular physical simulator is adaptable to a variety of local flap surgeries without requiring any additional components or modifications. This ensures that the simulator is translatable throughout the continuum of local flap surgery and affords trainees with the ability to practice a wide array of local flap procedures.
Virtual Simulator[edit | edit source]
Trainees also go through the procedure virtually in a more directed manner, similar to walking through a case with a surgical mentor. This step-wise simulator uses an interactive tactile system to teach each individual step while taking into account the relevant operative anatomy, skin tension lines, flap orientation, instrument selection, and clinical pearls and pitfalls. Interactive three-dimensional models help trainees better explore the relevant anatomy and core concepts upon which local flaps are designed. Questions on instrument selection and medical judgement are built into the simulation for each step of the procedure to ensure active engagement with the simulation while optimizing translation to clinical practice. Throughout the virtual simulation, this approach keeps the trainee’s mindset oriented towards real life implementation of the procedure. This is taken one step further with discussion of pre- and post-operative considerations as well as the intraoperative and post-operative management of surgical complications. As in other areas of the virtual platform, our dynamic self-assessment system will adjust the difficulty of questions according to the user's competency level while also referring the user back to the relevant content chapters in the event of incorrect responses and repeated errors. In this way, we have developed a learning process that is unique to each individual trainee in order to ensure that the self-directed learning is relevant regardless of baseline training and knowledge.
Self-Assessment System & Objective Feedback[edit | edit source]
The AmoSmile training platform prioritizes a multi-modal approach to self-assessment which provides guided feedback with quantitative data for productive practice and valuable reflective observation. This section touches upon the different types of self-assessment and the feedback they provide. Each form of feedback has its own unique criteria for assessing confidence and competency.
Pre- & Post-Test (app)[edit | edit source]
Before starting any new module, trainees will take a pre-test to establish their baseline knowledge of the procedure, relevant anatomy, indications, complications, and postoperative management. This pre-test identifies a trainee’s starting competency in order to determine the initial difficulty level of the questions they are given at the beginning of the module. After proceeding through the module and all the associated virtual content, a post-test assessment is provided which helps trainees determine their mastery level of the material. Depending on their scores, they will be directed to sections of the module that correlate with questions they got wrong. In this way, trainees can repeat this post-test assessment until they have achieved sufficient understanding (>90%) of the material to proceed to the physical simulator. The delta between the pre- and post-test also helps trainees appreciate overall progress, which is tracked in their personal user page.
Integrated Dynamic Assessment System (app)[edit | edit source]
Building upon that initial baseline assessment, integrated assessments throughout the module help keep learners on track with their goals and the learning objectives. A combination of true-false, multiple choice, and open-ended questions are used after different content sections as well as throughout the stepwise simulator in order to identify any trouble areas with the material and challenge users with increasingly difficult questions for effective and efficient learning. Drawing from a question bank of over 100 questions with variable answer options minimizes gaming or memorization rather than true learning. Questions advance from true-false to multiple choice to open-ended as content mastery improves.
NASA Task Load Index [TLX] (physical simulator)[edit | edit source]
For psychomotor skills acquisition, we integrated the validated NASA Task Load Index (TLX) self-assessment form into the app, which allows longitudinal, comparative tracking of scores to guide technical growth via the physical simulator. Along with the automatically-graded true-false, multiple choice, and open-ended questions that are provided to all individuals before and after the module; trainees will use the NASA TLX form that is also built into the app to provide self-reflective scores related to the physical and mental workload of performing the task - a.k.a. the surgical procedure for that module. The NASA TLX form has been well-validated over the past 40 years as a reproducible method of assessing skill acquisition in astronauts, surgeons, and other high-demand, high-skill professions. This form will facilitate reflective feedback on mental demand, physical demand, and temporal demand as it relates to performance, effort, and frustration. The scores interpretation guidelines help trainees understand their scores and ways in which they can target their practice to address different core competencies within the module to improve their understanding of the material, reduce physical and mental workload, and enhance performance.
OSATS - Objective Assessment of Surgical and Technical Skills (physical simulator)[edit | edit source]
The OSATS evaluation system is a well-established method of clinical feedback that surgical mentors often use to provide standardized evaluations to their mentees. We have taken this system and are developing a computer-automated system that will evaluate uploaded videos of physical simulator practice sessions and create a scaled score report that directs trainees towards specific areas requiring additional practice. In the interim, a surgical master filmed performing the simulation will be used as a rubric against which trainees can grade themselves with an OSATS. The OSATS form includes assessments of tissue and instrument handling, economy of motion, surgical cadence, and procedural knowledge.
Surgical Modules[edit | edit source]
Local Flap Surgeries[edit | edit source]
Future Local Flap Modules[edit | edit source]
- Advancement (Basic)
- Rotation (Basic)
- 5-Flap Z-Plasty (Jumping Man)
- Square Flap
- O-to-Z Flap