Practice makes perfect, and in medical training, there is a push for more practice assisted by technology. Advanced simulation technology for medical education has been widely advocated as a better way to train and demonstrate competency than traditional see one, do one, teach one apprenticeship.

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Multisensory Medical Training

In an era of intense concern over training more and better clinicians and improving patient safety while battling rising costs, simulators allow unlimited practice opportunities. Clinicians can document competency levels without running afoul of U.S. restrictions regarding resident in-hospital hours, now capped at 80 hours a week. Simulators also alleviate the demands on senior clinicians with limited time to teach, assuage concerns about animal rights, and provide an alternative to practicing with cadaveric parts, which are often in limited supply. Some experts assert that as patients have become more involved in making decisions about their healthcare, more are asking clinicians how many times they have performed a given procedure—a question for which every healthcare professional wants to give a reassuring answer.

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The Robotic Surgical Simulator, or RoSS, was created to address the growing need for a realistic training environment for robot-assisted surgery.

As procedural specialization continues unabated, more medical device companies have commissioned advanced simulators to train those who use their complex and often costly products. These advanced medical simulators typically include computer hardware, software, sophisticated 3-D graphics, audio, and, sometimes, haptic (force feedback) devices that provide the highly realistic feel of performing a procedure.

Minimally invasive surgery (MIS) is also a key factor behind the drive for advanced simulators. MIS is performed using a small video camera, a video display, and a few customized surgical tools. For example, in gall bladder removal (laparoscopic cholesystectomy) surgeons insert a camera and long, slender tools into the abdomen through small incisions in the skin. They can then explore the internal cavity and manipulate organs from outside the body as they view their actions on a video display. Because the development of minimally invasive techniques has reduced the sense of touch compared with open surgery, surgeons must rely more on the feeling of net forces resulting from tool-tissue interactions and need more training to successfully operate on patients. Thus, haptics is a valuable tool in training surgeons for MIS.

Certainly, the role of device makers in providing clinicians with anatomical representations is not new, nor is their role in selling training as an adjunct revenue stream. However, these lessons have been transformed of late. Where they once involved just a static mannequin or simple demo devices, now they are virtual experiences offering new levels of realism. Even so-called dummies are far smarter, built as integrated systems wired with sensors, haptics, and body fluids. These computer-based virtual reality simulators are being used to practice blind procedures that require clinicians to operate more by feel than by visual markers. These simulators provide unlimited lifelike rehearsal opportunities that allow surgeons to gain experience without the risks, similar to how pilots train in flight simulators.

The flight simulator metaphor rings particularly true considering the January 2009 forced landing of a US Airways plane in the Hudson River. After a mid-air encounter with birds caused the plane’s engines to lose power, the flight’s simulator-trained pilots saved all 155 people on board. Citing the incident several months later, former chief medical officer of England Liam Donaldson suggested that simulators may be one reason why airline passengers have a one in 10 million chance of dying in an accident, while patients have a one in 300 chance of dying or being seriously harmed during a hospital stay.1 Other reports noted that the flight’s captain, who took several months off following the incident, was required to demonstrate competency in a simulator before he could fly again. FAA rules dictate that commercial pilots perform at least three takeoffs and landings every 90 days, either in a plane or a simulator.

Yet, in medicine, there are few such simulator requirements or competency tests for clinicians. Experts within medical specialties continue to question whether the traditional apprenticeship model of training healthcare professionals is still the best approach.

Sophisticated simulators allow surgeons to practice to perfection, without risk to patients, a blind procedure or the use of a particular device. Simulators help surgeons keep their skills intact and can provide testing and documentation of competency. They’re also becoming more widespread, as designers create shippable, easy-to-carry cases that can bring the training and certification to more clinicians.

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ScanTrainer is a new haptically enabled transvaginal ultrasound simulator.

Simulators Save Money, Time

Dilworth Cannon, MD, professor of clinical orthopedic surgery at the University of California at San Francisco, has spent more than a decade spearheading the creation of a virtual reality simulator for knee arthroscopy, funded in part by the American Academy of Orthopaedic Surgeons and developed by Touch of Life Technologies (Aurora, CO). In a June 2010 paper co-written with Jay Mabrey, MD, and Karl Reinig, PhD, Cannon noted that the literature suggests many orthopedic surgical procedures require steep learning curves for competency.2 He also noted that surgeons who performed specific procedures more frequently were able to perform those procedures more quickly. 

Learning curves can vary. When performing microendoscopic discectomy surgery, surgeons became proficient after 10–20 cases, while surgeons performing pedicle screw fixation required 80 cases before showing significant improvements in proficiency. Other surgeons performing endoscopic anterior scoliosis surgery required up to 100 cases.2 Training can be very costly. However, the authors said the literature shows that hospitals training surgeons in laparoscopic surgery via simulators recouped their investment in the simulators by reducing time in the operating room.

Outside of the literature, Cannon noted considerable variability in the proficiency level of community-based surgeons performing arthroscopy, likely related to the number of procedures they perform in their practices. Simulators could assist in competency certification and continuing education. What’s critical, Cannon asserted, is that the trainee be given intuitive and autonomous experience that recreates the feeling of performing the procedure with lifelike anatomy, not simply a textbook-like didactic with cartoon-like imagery.

Device makers and pharmaceutical companies are driving the creation of advanced simulators as training costs rise and the need for new and better types of practice experiences expands. The following are some recent examples.

RoSS—da Vinci Robotic Surgery Training

Robotic surgery is in high demand. An estimated 70% of prostate surgeries in the United States are performed using such systems as the da Vinci robotic surgery platform, from Intuitive Surgical (Sunnyvale, CA). Yet, training surgeons to use multi million–dollar surgical systems such as the da Vinci is problematic. In practicality, most training on the da Vinci is unstructured. Until recently, surgeons often had to practice with plastic models to develop necessary skills and have the opportunity to perform key steps of the procedure. Intuitive Surgical offers courses with porcine models for a fee, but once a limited number of practice incisions are made, the tissues can no longer be used.

Khurshid Guru, MD, staff physician in urology and director of the Center for Robotic Surgery at Roswell Park Cancer Institute (Buffalo, NY), says while there is no gold standard for da Vinci practice levels, literature cites the need to perform between 100 and 150 cases in order to gain proficiency (although many other factors also play an important role). If using a simulator can provide this opportunity outside the OR, it will immediately make robot-assisted surgery more accessible to residents and fellows.

To that end, in 2010, Thenkurussi Kesavadas, PhD, head of the Virtual Reality Lab at the University at Buffalo and adjunct faculty member at Roswell Park Center Institute, collaborated with Guru to create the Robotic Surgical Simulator (RoSS). RoSS is a stand-alone cart containing a computer, monitor, and two Phantom Omni haptic devices from Sensable (Wilmington, MA) running customized hands-on surgical training (HOST) software that provides the real-time feel and touch of robotic surgery. Kesavadas and Guru cofounded Simulated Surgical Systems LLC (Williamsville, NY) to commercialize RoSS. Residents at Roswell Park Cancer Institute already train using RoSS, and RoSS units also are being used by other leading robotic programs in the United States, such as the Henry Ford Medical Center (Detroit) and Robert Wood Johnson University Hospital (New Brunswick, NJ).

Leveraging research done by the Virtual Reality Lab at the University at Buffalo, the Center for Robotic Surgery, and Roswell Park Cancer Institute, RoSS immerses the surgeon in the experience of performing da Vinci procedures. The system uses Sensable’s haptic devices and OpenHaptics software development toolkit and an interactive checklist-based process. A stand-alone unit that does not require access to an operating room, RoSS can be set up in a location that maximizes training access, such as a resident break room. Training can be unsupervised, freeing up senior staff time and maximizing training opportunities. A built-in data management system measures and records trainee performance for self or instructor review.
Via a series of training modules viewed on a stereo high-definition display, RoSS software provides a curriculum for developing motor and cognitive skills. The system covers basic skills, such as the feeling of cutting tissue, tying knots, and suturing. A basic orientation module provides practice in using the camera during the procedure and using both the dominant and nondominant hands. Depth perception is critical; RoSS provides a safe environment for doctors to improve their visual recognition skills while using  robotic surgical instruments. A basic skills module offers a series of virtual in vivo scenarios where users perform virtual operative steps with various levels of complexity. Add-on modules for specific procedures, such as radical prostatectomy, hysterectomy, and cystectomy, present haptically enabled virtual in vivo practice scenarios. 
Institutions such as Roswell Park perform nearly 100% of prostate and bladder surgeries with robotic systems. RoSS offers a way for medical schools and surgical practices to train their staff until they master the touch and feel of using the da Vinci in a given procedure, while keeping their da Vinci fully available for surgery.

MedaPhor—Gynecological and Obstetrics Ultrasound Training

Ultrasound technicians also must gain competency without causing discomfort or injury to patients, particularly in sensitive procedures such as gynecological and obstetrics ultrasound. This training is resource intensive, requiring the use of in-demand equipment,  prolonged and repeated patient contact in the clinical setting, and supervision by experienced clinicians with limited time.

MedaPhor (Cardiff, Wales, UK) recently began global distribution of ScanTrainer, a new haptically enabled transvaginal ultrasound simulator. Its gynecological and obstetrics ultrasound training modules replicate the experience of examining a normal and retroverted uterus and teach core ultrasound examination skills.

ScanTrainer’s haptically enabled computer training modules allow trainees to efficiently develop the complex mix of cognitive skills and hand-eye coordination without the need for an ultrasound machine, a patient, or direct supervision by an expert. Using Sensable’s Phantom Omni haptic device, ScanTrainer provides a realistic, touch-enabled training experience, allowing sonography trainees to literally feel what they see on the computer screen in order to gain lifelike scanning experience in a more cost-effective way. The system measures performance against a gold standard, enabling the trainees to learn by trial and error at their own pace and gain unlimited opportunities to practice prior to contact with patients. This ensures greater competency when final interactive training with patients begins, significantly reducing the amount of direct supervision required.

A range of ScanTrainer systems with associated pathologies and learning modules are planned for early 2012, including a transabdominal system for teaching obstetric, general, and accident- and emergency-based medical examination.

Conclusion

Even though hands-on training will always be a part of medical education, advanced simulators can provide clinicians with the repeated experiences they need in a wider variety and number of cases than they may find in any given training rotation or program. Simulators are already delivering basic skills training as well as training for specialized procedures that require clinicians to rely on their sense of touch and not just what their eyes see. It is also democratizing access to medical skills training by offering learning experiences to clinicians who don’t have access to resource-rich teaching hospitals or expensive cadavers. At a time of global reassessment of what’s working and not working in healthcare, medical device manufacturers will likely see demand for simulators grow.

References
1. Jeremy Laurance, “Surgeons Should Train on Simulators, Like Pilots,” The Independent [online]16 March 2009 [cited 5 July 2011]; available from Internet: www.independent.co.uk/life-style/health-and-families/health-news/surgeons-should-train-on-simulators-like-pilots-1645737.html.
2. J.D. Mabrey, K.D. Reinig, and W.D. Cannon, “Virtual Reality in Orthopedics: Is it a Reality?” Clinical Orthopaedics and Related Research 468, no. 10 (2010): 2586–2591.

Venkat Gourishankar is senior haptics engineer at Sensable (Wilmington, MA). Laura Wallace is director of marketing at Sensable.

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