About simulation
Simulation is the replication and modeling of real-life situations for training, testing and other purposes such as scenario planning and design verification.
In Surgery, simulation can help:
increase patient safety by facilitating surgical proficiency and certification;delivering economic benefits for surgical skills centers by delivering cost-effective solutions that increase the speed of learning;Accelerate the pace of adoption of new procedures and devices.Simulation offers surgeons the chance to practice skills, techniques and critical tasks in a real-life context - but in a risk-free and cost-effective way. Training is standardized - whether instructor-led or self-directed - and feedback is objective. Continuous tracking of performance highlights areas needing improvement so that practice is focused on increasing effectiveness and reducing errors. Techniques can be practiced again and again with no time limitations until the set threshold performance is reached - as opposed to the situation now where the achievable proficiency is limited by the fixed time given to training.
And simulators are not just about training in new techniques and procedures. Just as an orchestra `warms up' before a performance, practicing on a simulator after an absence from the OR or before an operation may improve effectiveness in the OR.
While simulation for surgery still focuses on critical procedural tasks, simulators have the potential to offer complete OR and team training as well as enabling scenario planning and practice with unusual pathologies, different anatomies, and uncommon diseases and conditions. Surgeons may even be able to rehearse procedures and patient-specific operations with real data drawn from diagnostic equipment and patient information. And as new standards emerge for surgical skill and performance, simulation has the potential to be used in skill certification by Boards of Surgery.
In instrument design, simulators are being used to verify and compare effectiveness of devices and to prototype new procedures and approaches in a risk-free way. By tracking actual performance of instruments, surgeons and manufacturers have access to previously unknown information on the effectiveness of specific instruments in specific procedures.
Why use simulators?
There are a number of developments that are converging to drive the use of simulation in surgery and medicine generally. These are largely related to challenges represented by external changes, but also by the pace at which surgery itself is developing. With new and more complex procedures emerging there is increasing need for more surgeons to be more proficient in more procedures - and to be faster and more effective at doing so. Yet at the same time, there are increasing external and internal pressures on the time, resources and standards required to deliver effective training.
Challenges in surgical education and training
The key challenges in surgical education and training are:
Less teaching time for physicians and residentsGreater number of procedures - and more complex high risk proceduresOR cost and the efficiency of trainingPatient awareness - and increased resistance to in-OR trainingNational focus on error and cost of medical careMalpractice and insuranceIncreasing resistance to use of cadavers and animals for trainingOne of the reasons simulation is seen to be part of the overall solution to many of the above challenges is its ability to offer:
standard training and objective measurement of performance and proficiencysafe, risk-free, context-rich trainingcost-effective and time-efficient trainingMore effective development of surgical performance and proficiency
Unskilled surgeons present the single biggest risk to patients in the Operating Room. A report by the Institute of Medicine in 2002 indicated that up to 44,000 people die from medical errors in the U.S. every year. The report indicated that training for health professionals was not adequate and that there was insufficient assessment of ongoing proficiency. It recommended that “educators and accreditation, licensing and certification organizations should ensure that students and working professionals develop and maintain proficiency in five core areas:
delivering patient-centered care, working as part of interdisciplinary teams, practicing evidence-based medicine, focusing on quality improvement and Using information technology.” Throughout the surgical community, there is increased acceptance of the need to set agreed standards for surgical performance and proficiency. The surgical associations and boards of certification are involved in developing standard curricula and new metrics for validating and assessing surgical skill. New Centers are being developed to offer certified training and there are few teaching hospitals that are not offering a defined curriculum that matches accepted norms and standards. In addition, there is a growing trend towards mandated and more strenuous requirements and re-certification and re-privileging.
Reduced time for training
The advent of the 80-hour week in the U.S. (and 58-hour week in Europe) has focused the attention of hospitals, physicians and surgeons on efficient use of training time.
With shorter hours available, residents face reduced exposure to the OR and to a range of cases. They also de facto have less time for training. As a result, residents have become more diligent in selecting a teaching hospital that them the most comprehensive and efficient training program. This in turn puts pressure on the hospital to compete to attract the best residents (and keep them).
Pressure to reduce costs in the OR
Alongside reduced working hours has come increased pressure to reduce the cost of surgical procedures - resulting in some cases in there being no time for teaching in the OR. (Having a trainee in the Operating Room can add $500 to the cost of a single operation.)
New developments and more complex procedures
With the pace at which surgery is developing, surgeons are faced with continuous learning just to keep up-to-date with advances in their own discipline. An efficient, effective method of acquiring new techniques and skills must be found to enable surgeons to engage in a continuous loop of training while maintaining their day-to-day practice. And hospitals are finding themselves increasingly needing to facilitate this loop in order to retain the best physicians and their position in the ever increasing competitive marketplace that is healthcare in the 21st century. Hospitals (including non-teaching hospitals) are seeking ways to offer continuous learning environments to surgeons, but are looking for low-cost, effective tools that can be moved to different locations and easily stored.
Patient safety
Reduced patient errors and deaths - and therefore surgical proficiency - has become a national priority. Surgeons and hospitals face an ever more knowledgeable and aware patients, who have access to physician and hospital track records and who know that proficiency and frequency of procedure is an indicator of error rates. There is a growing move to apply standards to performance of surgical procedures and to keep records of surgeon competence.
There is a recognized global trend towards a more transparent and accountable system of training. Pressure is also mounting from the insurance industry to ensure that surgeons (and all healthcare workers) have up to date training records as part of their effort to control increasing litigation.
Resistance to use of animals and cadavers
There is increasing resistance to the use of animals and cadavers in training. Notwithstanding the legal, ethical and financial issues, there is also acceptance that animals and cadavers are limited since they have no feedback or assessment and cannot incorporate scenarios or various pathologies.
Simulators are effectiveThere is an increasing body of evidence indicating the effectiveness of simulation in surgical training:
“Surgeons who trained on computer simulations performed the operation 29% faster and made 7 times fewer errors”.
. . . the financial return (for the simulator) was estimated at $127k in the first year . . . was shown to generate $228k from time savings, and savings of $25k p.a. from reduced errors.
In aviation, one hour in the simulator saves a half hour in the air.
After 8 hours of training on the simulator, trainees' skill level could equal a physician with several years' worth of experience.
The simulator results did predict surgical outcome.
Simulators meet adult learning needs
Simulators, apart from cost and time efficiencies, offer a more targeted, engaging learning experience. Surgical training in the past largely relied on an `apprentice' model of `see one, do one, teach one'. This, by its nature, lacks objectivity, delivers inconsistent results and is cost- and time-intensive. It also does not meet the needs of learners for self-directed, individually-focused training. Simulation, by its nature, delivers autonomous, self-directed learning. Inherent to simulation design is a structured, replicable learning experience that builds on prior experience, resources and mental models. Within this structure, users can often adapt the content and complexity of their experience to meet their own defined needs.
Structured tasks also meet another requirement for effective adult learning: adults when learning need to know why they are learning something, what they are about to learn and how they are going to learn it. The `content' of simulation exercises is best when they are problem or task-centered and are contextual: surgeons learn best when they are set tasks that are surgically-relevant, and where they have knowledge and understanding of why these particular tasks will deliver a set of particular surgically-relevant results. Simulators are essentially an action learning experience, but with their multi-media capabilities can offer a complete set of conceptual knowledge, sensory knowledge and error avoidance as well as comprehensive feedback during and following practice tasks.
The motivation and readiness of the learner is also important: learning occurs when the learner understands and accepts the gaps in their knowledge and skill and are intrinsically motivated to bridge that gap. Simulators are useful in achieving this by delivering objective assessment of learning needs and being available when the learner wishes to engage in learning, rather than at an appointed `class' time.
ProMIS™ surgical simulator
ProMIS™ is an innovative simulator, designed to train surgeons in the basic skills of minimally invasive (or laparoscopic) surgery. It comprises a number of Modules designed to develop and evaluate surgical proficiency.
ProMIS™ is the first hybrid simulator for training in laparoscopic skills: it uses augmented and virtual reality to deliver optimum learning and feedback. For example, the user interacts with high fidelity graphics and virtual organs to learn how to use a Laparoscope, but uses real sutures on physical tissue when learning suturing and knot-tying. To deliver its engaging, effective approach, ProMIS™ draws on technologies from a range of areas, including virtual reality games, intelligent tracking and image analysis.
As well as its own ProMIS™ product, Haptica designs and develops simulators for specific procedures and instruments.
Validation
ProMIS™ is based on a validated curriculum and offers surgeons objective feedback as they practice tasks and techniques. In developing ProMIS™, the developers have worked closely with a number of universities and surgeons from around the world.
The ProMIS™ curriculum draws on documented and validated approaches to surgery and surgical training. At Haptica, we work in a continuous iterative development process with surgical advisors and development partners. These advisors are key to our ability to develop an effective, validated product. We value the support and input of the Royal College of Surgeons in Ireland (RCSI) for content, beta-testing and validation. We also work with a number of key surgical advisors including Professor Sir Ara Darzi at Imperial College London and Dr. Anthony Gallagher and Professor Dan Smith at Emory University.
Each has published the results of studies that validated the effectiveness of ProMIS™ in 2004. These studies show that ProMIS offers an effective approach to surgical training and assessment.
“The attractive feature of ProMIS is that a wide variety of MIS tasks can be used to train and assess technical skills”; “ProMIS demonstrates the ability to provide objective measures of laparoscopic performance on a video trainer, using standardized tasks. These measures can be used to provide objective feedback to junior surgeons.”
Two further important validation studies are underway. One is a multi-center VR-to-OR study that will demonstrate skills transfer from ProMIS to the OR. The second study is being conducted by Dr. Gerald Fried at McGill University, Montreal: it is comparing ProMIS and SAGES-FLS simulator assessment of the same Tasks.
Awards
Haptica and ProMIS™ were recognized in 2004 with three prestigious awards. ProMIS™ was recognized at the Society of Laparoendoscopic Surgeons 13th International Congress and Endo Expo 2004 in New York as a 2004 Innovation of the Year.
ProMIS™ and Haptica have also been selected for an IST prize. This prize recognizes technical excellence and innovation and is awarded by the EU Commission. And in November 2004, ProMIS™ was awarded the Technical Innovation Award by the Irish Software Association.
For more information on ProMIS, click here >>>.
References
Bowyer @ MICCAI 2003 Tutorial
Bowyer, Mark W. @ MICCAI 2003 Tutorial
Institute of Medicine Report 2002
Gauger, Paul C. http://www.um-surgery.org/reports/milestones/2004/summer/
Laparoscopic GI Surgery: The Cost of Resident Training Smith, Farrell, Hunter. Emory 1999
Sinanan, Mika, Society of Laparoendoscopic Surgeons 2004
Dr Anthony G. Gallagher, Annals of Surgery 2002 and American Surgical Association, April 2002
Re. AccuTouch Endoscopy Simulator. Frost & Sullivan, 2004
Assessing a Virtual Reality Surgical Skills Simulator Johnston, Bhoyrul et al 1996
University of California at San Diego, 2002 re. AccuTouch Endoscopy Simulator
Ahlberg, et al Karolinksa 2002 (re MIST-VR)
Knowles, Malcolm S. et al. The Adult Learner : The Definitive Classic in Adult Education and Human Resource Development (Managing Cultural Differences) Butterworth-Heinemann 1998
Ericsson, Anders K. (Editor) “The Road to Excellence: Acquisition of Expert Performance in the Arts and Sciences, Sports and Games” Lawrence Erlbaum Associates, Inc 1996
McCluskey, D; Van Sickle, K; Gallagher, AG Relationship Between Motion Analysis, Time, Accuracy, and Errors during Performance of a Laparoscopic Suturing Task June 2004
Hance J (MBBS), Aggarwal R (MBBS), Undre S (MBBS), Patel H, Selvapatt N, Darzi A (MD).Evaluation of a laparoscopic video trainer with in-built measures of performance. 2004