Should we use virtual simulators for surgical resident selection?

To the Editor: we read with great interest the article by Gardner et al. entitled “How Much Are We Spending on Resident Selection?” recently published by Journal of Surgical Education [1]. Gardner et al. put the attention on the importance of a rigorous selection process to identify applicants who will be the best fit for training programs. In this analysis authors revealed the significant time and resources spent for the current resident selection process, with the average program spending approximately $100,000 annually. Moreover, examining the amount of time and efforts dedicated to applicant screening activities, they observed that residency coordinators were shouldering much of the burden, spending over 132 hours on the process. Gardner et al., rightly, stressed the importance for program leaders to assess the efficacy and efficiency of their current selection procedures and identify additional methodologies to make the process more efficient. A key point of the high costs is the large number of interviews conducted. For these reason, Gardner et al. highlighted the importance of reducing the number of on-site interviews, administering customized assessments to eligible applicants early in the process to help the identification of candidate's potential, fit, and alignment with the program’s values and expectations. Moreover, according to a survey, 30% of program directors from Fellowship Council in North America believe that graduates entering fellowships cannot independently and safely perform routine operations [2]. Therefore, it is important to adopt more efficient screening tools, such as online assessments, phone or video interviews, or assessment centers, to decrease the burden for both applicants and programs, but also to choose candidates with higher possibilities to become competent surgeons. In this context, the use of simulators could represent a valid option. The use of simulators for the training of surgical resident is increasingly widespread nowadays. However, in our opinion a possible alternative use of surgical simulators could be as tests for resident selection during their initial assessment. Indeed, there is an increasing interest for a reliable test as an objective assessment of the innate ability for psychomotor manipulative skills for surgery and as an integral component of the selection process for the many interns or house officers’ intent on a surgical career. Moreover, the restrictions on working hours in the USA and even more extremely in EU member states has increased the importance of such innate aptitudes for surgery because surgical resident should acquire technical skills quickly, or at least efficiently. As pointed out by Gardner the selection procedure of surgical residents students is currently very complex because it includes many phases. But it is very important to ensure a high probability of selecting the most promising candidates in view of such high costs.. Unfortunately, at present the selection process does not consider manual dexterity among the determining factors, an increasingly important aspect after the advent of minimally invasive surgery that requires psychomotor skills (hand-eye coordination, lack or reduction of tactile feedback,…). Since virtual simulators are able to objectively evaluate psychomotor competences, an aptitude test based on a virtual simulator may complement the evaluation process. For example, two studies were done using virtual simulators for robotic surgery to evaluate the innate ability for surgery among medical students. [2,3]. Although the two studies differ in design, participants and used simulators, they have found very similar results. In fact the two studies showed almost the same distribution of the three groups with 6.6% and 5.8% exhibiting outstanding performance, and 11.6% and 11.0% with low level ability for manipulative skills compared to their peers. [3]. These data are in agreement with data reported by a study on medical students using a simulator for laparoscopic appendectomy that revealed a 15% of medical students with low aptitude to reach proficiency [4]. Furthermore, the value of simulators as an aptitude test on technical skills has been demonstrated in the Republic of Ireland by a study on candidates entering a higher surgical residency training program (equivalent to a Fellowship in the USA), which confirmed a high correlation between score at surgical simulators and overall assessment, based on education and academic records, progress in clinical surgical performance, research output, and interview assessment [5]. In conclusion, the use of virtual simulators for objective testing could be included to complement the selection process of residents. However, if in the future the simulators were added among the tools for the resident selection, the costs of the purchase of the simulators and of the dedicated personnel should be considered in the total costs. However, thanks to the increasing diffusion of laparoscopy and robotic surgery, the number of simulators for these surgical approaches is constantly growing and this could reduce purchasing costs. Moreover, their use could save on training costs during the residency because it would give the possibility to invest on the most promising candidates and not to invest on those with less potential