She didn’t know it at the time, but when Elif Bilgic answered a McGill classified ad in 2012 looking for participants to take part in a skills acquisition study led by Dr. Melina Vassiliou, this marked the beginning of her longstanding relationship with the Steinberg-Bernstein Centre for Minimally Invasive Surgery (MIS Lab) at the Montreal General Hospital. Elif was studying anatomy and cell biology at McGill University; she had a strong interest in medicine and was looking for opportunities to get involved in areas of research that extended beyond basic science. When the study ended, Elif contacted Drs. Melina Vassiliou and Liane Feldman, expressing a desire to do research at the MIS Lab. “They were very open and encouraged me to learn more about what they were doing,” says Elif. “I think I just kind of fell in love with the research I was doing and the people I was surrounded by. It meant a lot to me.”
Elif continued to be involved in many educational research projects at the MIS Lab and the Henry K.M. de Kuyper Education Centre in the ensuing years. She finished her Bachelor’s degree and then completed a PhD in Experimental Surgery where her research focused on the assessment of laparoscopic suturing skills.
As she explains, “Medical students first learn open suturing. This method offers a pretty good range of motion, with your hands and wrist providing 360° maneuverability. But this is limited in laparoscopic surgery, which involves using long instruments and looking through a camera that shows on the monitors. You’re working with a 3D area but looking at a 2D monitor, so there are issues with depth perception. There is a lack of dexterity that requires more experience and exposure to master.”
There are many different simulation tools and models that can be used to practice laparoscopic suturing—including ex vivo animal tissues, augmented virtual reality with added haptics, cadavers and live anesthetized animals—but inanimate models are often the most cost-effective. “You don’t always need a high-fidelity model to teach the skill,” emphasized Elif. “Simulation training is an adjunct to their exposure, designed to help the learners, not to replace their clinical exposure. If, in simulation, they can be exposed to advanced laparoscopic surgery techniques, we can help them learn when to change the angle of a needle, how to penetrate a tissue properly, how to do suturing when the tissue is under tension. If they already know how to do this in the OR, they can focus on other aspects of the operation that are more difficult to teach through simulation.”
Assessment drives learning
“A lot of our focus has been on suturing because that was identified as one of the main skills required in the OR that could benefit from simulation training. As part of the McGill team, we developed advanced suturing tasks to better reflect the complexities of the current operations. Our goal is to use these platforms for assessment and training purposes. The tasks are one component, an instrument to teach and learn, but if you don’t know how to assess or what to look for within the performance, it’s hard to actually improve,” stresses Elif. “Assessment is a big part in all simulation work. The more proof we have that something works, the more likely it is that people are going to understand the value of it. That’s where research comes in, and it takes years to build this.”
Evolving needs require updated training methods
Elif is currently completing a postdoctoral fellowship at McGill’s Steinberg Centre for Simulation and Interactive Learning under the supervision of MIS pioneer Dr. Gerald Fried, Edward W. Archibald Professor and Chairman of the Department of Surgery at McGill, and Surgeon-in-Chief of the McGill University Health Centre. Dr. Fried established minimally invasive surgery as a clinical and academic program at McGill in 1990. Over the years, he and his colleagues have made significant advances towards the training of surgeons and the process of introducing innovation into clinical practice.
As Dr. Fried explains, “For over a century, surgery was taught by the apprenticeship model whereby surgeons learned by practicing on patients. The introduction of minimally invasive surgery not only transformed clinical care but allowed us to redesign our educational paradigm. The use of simulation-based training and verification that the learner has actually achieved the learning goals through reliable and valid measures of performance have improved the efficiency of learning and enhanced patient safety. Elif has identified an unmet learning need, advanced laparoscopic suturing, and developed a simulation curriculum and performance measures to address this need. Her work will be extremely valuable by ensuring that all surgeons will be capable of suturing using laparoscopic tools and can apply these skills in challenging situations.”
Research takes time
For anyone who is interested in pursuing a career in research, Elif wants them to know that research takes time: “You need time to learn, to figure out your objectives and the area you want to focus on, to figure out your methodology, to talk to the right people, to conduct the study. Residents, faculty and students all have big time constraints; it’s not easy to get them to participate. You need to build a connection with them, to encourage participation. It takes a lot of time and work before you can publish. Some people feel down because it takes a long time, but that’s normal. Eventually it will happen. You just have to be patient. That’s what I learned. I think also you need to like what you’re doing, the area you’re working in. You’ll work more passionately and do a much better job if you like what you do.”
