VR to OR
By David Raths

Can online learning and virtual reality simulators revolutionize medical training?

Using screen avatars dressed in medical scrubs to represent them, a team of residents and senior medical students wearing headsets logs onto a network and enters a 3D virtual emergency department created at Stanford University.

During six trauma scenarios, each person takes a role—nurse, x-ray technician, or emergency room physician. By selecting buttons from a menu, they control their avatar’s actions, such as clearing a patient’s airway. The onscreen patient’s vital signs respond appropriately. An instructor debriefs the participants about the choices they made using an audio–video replay of the scenario.

Is this the future of medical training?

Its creators in the Stanford University Medical Media and Instructional Technology (SUMMIT) group believe this web-based learning technology has the potential to improve leadership, cooperation, and communication skills that can be transferred from the virtual reality environment to the operating room. The web sessions could have participants working together from London, California, and Ottawa, said Dr. David Gaba, a professor of anesthesiology and associate dean for immersive and simulation-based learning at Stanford.

“These virtual worlds will become one of several modalities in refresher training that during the course of your medical career you will cycle through,” he said. Another potential use for virtual reality simulation will be for surgeons to practice the operation they are about to perform with data simulating the exact patient they’re going to be operating on, Gaba added. “That will be done on unusually complex cases such as separating conjoined twins.”

The use of virtual reality environments is just one part of a larger shift toward simulation in medical education that also includes mannequins, online learning modules and task trainers that provide haptic or tactile feedback. Simulations have long been standard in other high-hazard industries, such as aviation, maritime, transportation, and nuclear energy. But their use has not yet become commonplace in medicine, which is still taught largely using the age-old apprenticeship model of “see one, do one, teach one.”

But with patient safety an increasing concern and with more sophisticated simulations available, a growing number of educators are pushing for simulations to play a larger role in medical and nursing school curriculum and internship training.

Simulations can be used to teach minimally invasive procedures and assess competency before physicians in training even enter an operating room. This represents a paradigm shift in medical training, argues Dr. Christopher Cates, director of vascular intervention at Emory University in Atlanta. “Until they perform well enough on a simulation in a virtual world, they aren’t going into the operating room.”

But before simulation plays a wider role, many questions must be answered about standardization and measurement. First, not all simulations are equally sophisticated, so who will validate which are ready for prime time? A more basic issue is that medicine has never established specific standards of proficiency at performing procedures. If medical schools are going to assess whether simulators are improving technical proficiency, they must first set standards for acceptable levels of performance.

The use of simulators in medical training also raises questions about the importance of lifelong training for clinicians. “Right now experienced personnel get very little recurrent training,” said Gaba. “And what they do get is variable and haphazard.” However, simulators offer the possibility to improve continuing education on new techniques and to regularly test competency if the cultural and financial issues around continuing medical education can be worked out.

“We are seeing simulation being used for advanced practitioners to learn new skills or brush up on certain skills,” said Dr. Ajit Sachdeva, director of the education division of the American College of Surgeons in Chicago. “But I don’t think we’ll see physicians go to simulation for a high-stakes certification like pilots do anytime soon.”

Some studies have identified improvements in residents’ technical skills after they’ve worked on simulators, but more research needs to be done to validate the use of specific simulations. Finding the funding for that research and getting the medical industry to make fundamental changes to training methods are huge challenges for simulation advocates. But Gaba sees some encouraging signs, including more liability insurers offering discounts to physicians who’ve done training on simulators. “More professional societies and certifying boards in medicine are getting involved, too, but the jury’s still out on whether this is a groundswell or just some isolated progress,” he said. “Ultimately, the public will be the big driving force, but they have yet to be seriously engaged. They’re more concerned with the cost of care and access, not quality and safety.”

Perfect storm

The development of a new procedure to deal with carotid artery disease provided the “perfect storm” for proving the value of simulation training, according to Dr. Cates. Carotid artery stenting is a minimally invasive alternative to surgery that each year is expected to benefit 200,000 patients who otherwise would not be candidates for stroke-prevention treatment. Although it’s less invasive and reduces risk for patients, any errors during the procedure could have serious repercussions such as stroke, Cates said, so the tradition of training on patients during an actual clinical procedure is problematic. Therefore, for the first time, the U.S. Food and Drug Administration has required physicians to practice on a virtual reality simulator and achieve a level of proficiency before they perform this procedure.

Using the Procedicus VIST (Vascular Intervention System Trainer) simulator from Swedish company Mentice AB, Emory’s NeuroAnatomy Carotid Training program measures the technical performance of endovascular surgeons. Cates said the device does a great job of simulating a catheter inside the body and gives accurate feedback on things such as vessel wall interactions. It can distinguish between expert and novice in minute catheter movements, he said.

“We’re actually measuring the difference between operators as well as the learning curve of an individual operator,” Cates said. “We can objectively track individual operator performance skill improvements.”

The Society for Cardiovascular Angiography and Interventions has made a day and a half of training at a regional simulation center part of a three-step training course on carotid stenting that also includes online learning and classroom instruction. “This is as close as a medical society gets to credentialing,” said Cates.

As more simulations are validated as offering skills training that is transferable to the operating room and objectively measuring an operator’s ability, the carotid stenting model could be extended to such fields as anesthesiology, surgery, urology, neurology, and orthopedics.

One challenge is the expense: sophisticated simulators can cost up to $500,000. According to Cates, though, partnerships between medical societies and vendors could help. “It is very expensive,” he said, “but for vascular medicine the hardware is already in place.” He said a cooperative regional approach is necessary. “Some people get simulators just to say they have a simulator and it sits in the corner and people stack boxes on top of it,” Cates said. “It has to be tied into a real training need and it has to be part of the curriculum.”

Tiger by the tail

Embedding simulation deeper into the curriculum is Professor Pamela Andreatta’s challenge at the University of Michigan Medical School in Ann Arbor. As director of the school’s Clinical Simulation Center, which opened in July 2004, Andreatta is working with faculty in several departments to develop standards for use of its endoscopic, endovascular, and arthroscopic simulators, and she said the pace of change is rapid.

“I feel like I’ve got a tiger by the tail,” she said. “Between the increasing interest level, the rapid development of new simulators, and the development of curriculum, it’s an exciting time.”

One of the missions of her center is to research the effectiveness of simulation in medical training. “Every hour spent in simulation is an hour not spent in an applied setting,” she said, “so we have to make sure it’s valuable. There seem to be obvious patient safety benefits to training outside the patient setting, but we need to prove it.”

Andreatta added that more research must be done to definitively prove the value of simulators. “We can’t make a general conclusion that simulation has a significant impact on clinical applications, because we don’t have enough data yet,” she said. “The preliminary data does suggest that in the early learning phases of clinical skills, it does make a difference and will likely improve patient safety.”

One obvious benefit of simulation is the ability to present new physicians with situations they may not see in their normal rotations. “In smaller residency programs, there are things you should be competent to handle that you may not get the exposure to in the hospital,” Andreatta said. “With simulation, we can control the setting.”

At Michigan, acceptance of simulation varies by department and by faculty members themselves. Certain specialties already have an abundance of simulation products on the market geared toward surgical interventions. Andreatta’s goal is to find a champion in each department. “The residents need it to be part of the curriculum to use it,” she said. “They see the advantage of it, but if they’ve been on for 32 hours straight, they are not going to say to themselves, ‘I think I’ll go over to the sim center and practice.’”  If it has been part of their coursework, however, the senior residents often go to the simulation center to “warm up” before a procedure.

The University of Michigan Medical School has decided to plunge ahead on setting its own proficiency standards. “If they become national standards, fine. If not, we’ll evolve or figure out what to do then,” said Andreatta. “But we’re not going to wait.” For instance, the school is creating its own standards of technical proficiency for such skills as laproscopic suturing. “And there have to be different standards for medical students, interns, junior residents, senior residents, and faculty,” she said. “That’s very time-consuming because they have to come in and use the simulators, and we have 24 clinical departments to work through.”

Web simulations

Elaborate virtual reality programs that cost hundreds of thousands of dollars are not the only simulations having an impact on medical training.

“There have been clear advances in simulation on the web, with offerings that make it easy to earn CME (continuing medical education) credits,” said Sachdeva. “They can be made more interactive and use more multimedia features, but they are already pretty mature.”

Private-sector companies such as Anesoft Corp. of Issaquah, Washington, offer online simulations of anesthesia and critical care emergencies to respond to. Users can earn CME credits for passing online exams.

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The Virtual Anesthesia Machine (VAM), created by researchers at the University of Florida, is available for free on the web at www.anest.ufl.edu/vam.
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VAM simulates the inner workings of an anesthesia machine and ventilator. “The machine itself is designed to protect fragile internal components, but that makes it difficult for students to visualize what’s happening inside,” explained Dr. Sem Lampotang, an associate professor of anesthesiology and one of VAM’s creators. “We made a conscious decision to create a simulation that makes no attempt to simulate the external appearance,” he said. “The external appearance is the problem. We focus on the functional.”

The simulation helps those studying to become anesthetists understand the flow of gasses within the equipment and the results of malfunctions or user error. It is now translated into 22 languages and has had 25,000 registered users. Hundreds of residency, nursing and veterinary programs use VAM. Professors build it into their curriculum and students can earn CME credits for taking the course and passing an online exam.

Moving forward

Proving a correlation between the use of simulation and overall patient safety will be very difficult because there are so many confounding variables. Academic research on simulation should continue, Sachdeva said, “but the lack of data should not slow us down. When airlines started using simulation as standard operating procedure, they didn’t have controlled studies that proved its effectiveness. Some things you just have to refer to expert judgment even if you can’t have conclusive proof.”

Medical educators agree that besides the technical issues around validating the measurement of simulators, getting physicians to accept the idea of testing proficiency is perhaps an even bigger roadblock. “You do get pushback,” Cates said, especially from the old guard of physicians who have not traditionally embraced having their performance measured. “That has caused us problems,” he added. “We have to be involved in defining what quality is. If physicians don’t do it, somebody else will do it for us.”

The driving force for change could be the specialty boards requiring maintenance of qualifications, said Gaba, adding that the young clinicians training now will be less resistant to simulation because they’re getting familiar with it. “If it’s part of how they were trained initially,” he said, “they’ll expect to use it in the future.” 

Published: June 2006