Learning by -Not Really Doing – Surgical Simulators for Education — and Fun

It may look like a video game, but this virtual reality system represents the future of medical education. A simulator like the one pictured will be in the exhibit hall at the 2006 AANS Annual Meeting for use in the “Top Gun: Neurosurgery Challenge” presented by the AANS Young Neurosurgeons Committee. Participants will receive scores for their competency, and the top scorer, the Neurosurgical Top Gun, will receive a prize. (Photo courtesy of ImmersiveTouch Inc.)

As a medical student, I performed my first pelvic exam on a “standardized patient” — an actor specifically trained to model behaviors that simulate a clinical experience. Since this early exposure to medical simulation, nearly every first experience I have obtained has been at a real patient’s expense.

Most of my surgical training was completed through the “watch one, do one, teach one” apprenticeship model. However, this “learning by doing” approach can produce significant variability in educational experience. Today a number of developments are converging to drive the use of simulation in surgery: resident work hour restrictions, national focus on patient safety and reducing medical errors, cost of healthcare, and increased patient resistance to training in the OR. These challenges, as well as the pace at which surgery itself is developing, make the need to develop and refine surgical simulation technology a national healthcare priority.

In response to this growing interest, the Society for Medical Simulation was established in January 2004, and many companies have organized to provide education on the value of medical and surgical simulation. The American College of Surgeons has identified several ways simulators potentially can improve patient safety. These include permitting learning in a risk-free environment; refreshing techniques for surgeons returning to practice after an extended absence; correcting case-mix inequalities during training; and allowing prototyping of new procedures and testing of new devices.

The types of medical simulators can be categorized as computer-based training systems, mannequins, part-task trainers, complete or self-contained systems, and total immersion virtual reality.

Computer-based training systems increasingly have incorporated mannequins. Although mannequin systems originally had little or no computer assistance, they now are sometimes indistinguishable from part-task trainers, which focus on skills that need to be acquired in the context of a larger curriculum. Examples include chest tube insertion training, central line insertion, endoscopy, laparoscopy, and neuroendoscopy. Force-feedback and auditory cues are frequently incorporated to enhance realism and increase skills acquisition. Complete training systems provide a comprehensive training course as well as an integrated simulator and have been used in courses such as advanced cardiac life support.

Total immersion virtual reality, while still only in the research phase, seeks to replicate the environment of the procedure as well as the procedure itself. An augmented virtual reality system has been developed for neurosurgical applications such as ventriculostomy.

The use of simulators for training is one thing, but their potential use for assessment and certification brings up many concerns. Although traditional observational methods of technical skill assessment vary in reliability and validity, Auger and colleagues recently reviewed surgical simulation with attention to validation methodology in the journal Surgical Laproscopy, Endoscopy and Percutaneous Techniques. They found that “the surgical literature is replete with editorial, concept, and feasibility articles describing the potential of surgical simulators [but that] relatively little data has been obtained so far that examines the validity of simulators for the training and assessment of surgical skills.” During the past five years, attention has focused on validation of surgical simulators, and a higher correlation between scores on simulators and clinical performance is likely as experience with the devices increases.

The future role of simulators in surgical training and practice will be defined by several factors: refinement of simulation technology, identification of the appropriate context for their use, reduction of cost, identification of a proper set of metrics, and validation of surgical simulators for training and assessment.

Meanwhile, the Young Neurosurgeons Committee is exploring the use of surgical simulators by sponsoring “Top Gun: Neurosurgery Challenge” for residents and fellows at the 2006 AANS Annual Meeting. Events such as this can encourage our specialty to lead, rather than follow, in the field of surgical simulation and computer-assisted surgery.

Michael Oh, MD, is director of the Institute for Computer Assisted Neurosurgery (ICAN). He is co-director of the functional neurosurgery program, Allegheny General Hospital, Pittsburgh, Pa., and co-director of the stereotactic and functional neurosurgery program, West Virginia University, Morgantown, W.Va.

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