Simulation is a key element in the optimization of training in thoracic surgery

In recent years, training has become more challenging for the thoracic surgery resident. This is due to a combination of reduced exposure in the operating room and the prioritization of patient safety and excellent outcomes. Experts in the field recognize that resident training needs to evolve for the better. These circumstances mean that alternative teaching strategies are increasingly necessary, and the role of simulation in teaching surgical techniques is becoming more important [1]. The aforementioned aspects were presented in detail in the paper by Haidari et al. entitled ‘Consensus of technical procedures for simulation-based training in thoracic surgery—an international needs assessment’ [2]. On behalf of the EACTS Residents Committee, we would like to congratulate the authors for this work. The fact that a panel of 34 worldwide experts in thoracic surgery have discussed the need for simulation-based training and the selection of procedures that should be mastered during residency not only reflects the importance of training residents but also demonstrates the impact of a simulation-based teaching approach. In addition, we are pleased to note that there is much overlap between the 17 interventions suggested by the Delphi experts and those proposed as index operations in our recently published paper entitled ‘Basic principles of cardiothoracic surgery training: a position paper of the European Association for Cardiothoracic Surgery Residents Committee’ [3]. The consensus of the Delphi experts will be indispensable in our profession in the future; however, there are several limitations. The elephant in the room that requires urgent attention is the lack of simulators widely available for the majority of the procedures outlined in the article. Therefore, the timely integration of simulation into the thoracic surgery curriculum is unexpected. In our opinion, simulation is extremely valuable, but in its current form, it is not suitable. Future work should focus on the development of high-fidelity simulators and their incorporation into resident training. Furthermore, for simulation to have its desirable effect, there is a need for thoracic surgeons to have regular access to simulation with objective and constructive feedback so that they can target their training [4]. To implement an optimal simulation programme for residents, we believe that the following aspects should be considered. In the current daily routine of a resident, there is no dedicated time for simulation training. Consequently, the residents' work routines ought to be changed to accommodate regular simulation. Typically, there is no designated location in training hospitals where simulations could be conducted, and if they do, then they are not regularly renovated with lack of simulators or their parts. There should be areas dedicated for simulations that are easily accessible to all surgeons. At a time when all processes are geared towards profit, high investment costs sometimes stand in the way of the introduction of simulation methods [5]. It should also be the industry's concern to overcome these obstacles. Although our trainers are extremely busy and have a lot of responsibility far beyond our training, it is essential to establish a regular exchange between trainer and trainee where structured feedback is provided via a validated technical skill assessment [6]. In addition to increasing training efficiency, it will improve training transparency and allows comparisons to be made with other programmes [7]. Despite all efforts, there is still no clear scientific evidence that simulation training leads to better patient outcomes in thoracic surgery (i.e. lack of predictive validity). Therefore, there is an urgent need for research to support the value of simulation in the context of training and patient outcomes [8]. As residents, we often contemplate on how simulations should supplement training in an ideal scenario. After finishing the operating list, the resident should have access to intraoperative recordings of the VATS or robotic procedure that they have performed to allow review of steps revealing own shortcomings and how to improve them next time. The resident should then have access to a simulator in their own hospital including out of hours, to allow flexibility to practice at their own pace. Access to these simulators should be encouraged by the hospital and allocated time should be provided to residents in their work rota. When learning new steps of an index procedure, it should be assessed by an allocated trainer. Regular objective assessments that are curriculum aligned both on the simulator and in theatres should be performed and discussed with senior surgeon. Reviews and self-awareness of own operative fluency followed by dedicated simulation practice with frequent constructive feedback from trainers certainly would improve a resident’s operative skills in theatre, thus making them into better surgeons. The EACTS Residents Committee currently comprises 9 members whose training in cardiothoracic surgery could not be more diverse. We have been given the opportunity to write this Invited Commentary on the work of Haidari et al. on behalf of our committee. We see this invitation as a recognition of our tireless work within our committee, from which not all members can appear as authors. Therefore, we would like to thank our colleagues—Soi Avgeridou, Polina Danchenko, Kirolos Jacob, Felix Nägele and Leo Pölzl—for their support. Without you, this work would not have been possible.