➣ By Brenda K. Wiederhold & Mark D. Wiederhold
The advent of medical simulation technologies stemmed from a diverse array of fields, merging together to form a new way to not only practice medicine but teach, train and improve the lives of both patients and doctors. What once seemed like a far off fantasy has quickly emerged as a promising method of improving healthcare and is more a reality now than ever before, having been swiftly integrated into medicine and playing a much larger role in medical practice than predicted.
Early Mannequin Simulators
The creation of mannequins for medical purposes began in the early 1960s when a Norwegian plastic toy manufacturer, Asmund Laerdal, developed the Resusci Anne mannequin for CPR training. Life-size models of the body proved useful for practicing basic procedures like physical exams and mouthto- mouth, allowing students to train on a realistic figure before an actual human. Not long after medical mannequins were developed, engineers and physicians began improving on the inanimate patients with computer technology. The first high-fidelity computer- controlled human patient simulator, the SimOne, developed by Laerdal, was a lifelike model of a human patient used for anesthesia training that measured physiological and pharmacological changes in real time. Although SimOne was not widely used, its creation marked a turning point in computercontrolled mannequin simulation, and technologies thereafter replicated the essence of the SimOne.
Development of Surgical Simulators and VR
Simulators utilizing Virtual Reality (VR) emerged in the 1980s when the National Aeronautics and Space Administration (NASA) at the Ames Research Center in Palo Alto, California developed the first head mounted display (HMD) for displaying the data collected during planetary explorations. At the same time, the DataGlove was developed, making interaction with 3-D virtual scenes possible. The possibility of being immersed in a virtual environment while also being able to interact with the scene was what inspired the idea of immersive technologies for surgery, and thus the birth of surgical simulators.
Laparoscopic, or “keyhole” surgery, is a type of minimally invasive surgery (MIS). This type of procedure was introduced into general surgery in the late ‘80s and employs the use of a camera, a fiber-optic light and joystick-like instruments that perform the operation through tiny incisions. This new technique saw the addition of a new member to the surgical team, the robot, controlled by surgeons through video game-like controllers while looking at a computerized depiction of the actions occurring inside the body. The first robot- assisted surgical device used on humans, the RoboDoc, was developed in the early 1990s for orthopedic surgery. Computer-controlled robotic arms perform actions with a high degree of accuracy and precision, reducing pain, errors, and unnecessary damage leading to shorter hospital stays and accelerated recovery. More complex surgical robotic systems soon surfaced that possessed multiple applications throughout general surgery. The da Vinci system, developed by Intuitive Surgical and considered one of the top surgical robotic devices, ranges extensively in its abilities, and is able to perform MISs in various fields such as urology, gynecology, colorectal and cardiothoracic medicine, as well as procedures on almost every part of the body.
While this novel approach proved to be extremely beneficial to patients due to its minimal invasiveness, the procedures put enormous pressure on surgeons due to the loss of visualization it required, as well as a degraded sense of touch and impaired dexterity the instruments caused. High quality visualizations were needed to accurately perform the surgery as well as realistic haptic feedback, not to mention practice using the new video game-like controllers. Being able to feel present in the surgery through high quality, virtual depictions in real time was important for surgeons performing laparoscopic surgery. Improving VR technologies allowed this sort of seamless immersion into surgery, and without such technology, laparoscopic surgery would not have thrived.
Studies have also been conducted assessing the benefits of practicing in VR for improving performance in surgery. Draycott et al. showed that training on a simulator reduced neonatal injury by 7%. Dr. James “Butch” Rosser from the Beth Israel Medical Center has even developed a video game, Top Gun, for warming up and improving surgical trainees’ agility and accuracy before going into surgery. Hand-eye coordination has become increasingly important with the introduction of laparoscopic surgery, and its similarities to playing a video game, a joystick controller manipulating figures on-screen, has earned gaming a respectful place in today’s world of surgical training.
Training and Practice
Just like air flight simulators prove useful for training pilots, VR and mannequin simulators too have been shown to be extremely beneficial for training medical personnel. Combining mannequins and VR simulations for training allows for an extensive range of applications and different methods of training. While human actors, mannequins and videos have all been used in the past as teaching tools, full environment simulations (FESs) have recently grown in utility and popularity, along with simple screen-based computer simulations and partial task trainers for specific procedures. FESs include highfidelity mannequin simulators that replicate medical conditions in an accurate and detailed way, placed within a realistic environment that creates contextual factors that might be present in real situations, for example, a difficult patient, family members, and distractions, to gain experience responding to unusual or crisis situations more accurately. These types of simulations enhance the reality of training while also assessing performance more extensively and encompassing more competency skills than a mere checklist of tasks; not only is the medical procedure being measured, but professionalism, communication skills, and teamwork as well. This type of training is widely used among anesthesiology students, laparoscopic training, cartaroid stenting training, and dentistry procedures, and is used by nursing students and emergency medical technicians (EMTs).
Training using simulation technologies has been shown to improve accuracy and overall performance, thus explaining its widespread adoption. A 1999 survey conducted by Morgan and Cleave-Hogg showed that 71% of anesthesia and medical students were taught using some kind of mannequin or simulator, and a survey by Okuda et al. showed that 91% of emergency medicine residencies use simulation during training, 85% of which are mannequin-based.
High-fidelity simulators are also optimal tools for assessing the performance of physicians and surgeons throughout their career, and are useful for practicing new techniques or procedures before performing on real patients. In addition, with improving VR and modeling technology, physicians are hoping that in the near future they will be able to download a patient’s specific data and test solutions and different procedures on the virtual patient before the real person to ensure the best practice will be used.
MMVR and TATRC
While many organizations are promoting medical simulation research and development, Medicine Meets Virtual Reality (MMVR) and the Telemedicine and Advanced Technology Research Center (TATRC) have played large roles in improving medical simulation technologies and optimizing their applications in both the medical and military arenas. While both MMVR and TATRC separately support advancements in telemedicine, they have recently teamed up, holding dual events focused on improving clinical competency using medical simulation for training and practice, with an emphasis on maintaining the skills of anesthesiologists, surgeons, and other medical personnel. The events bring together leading researchers and doctors alike to assess current practices, areas in which programs are lacking, and to produce fresh ideas on how to improve and expand on these practices. These events and conferences encourage the creative development of new technologies to discover best practices and new uses, and it is because of organizations like these that medical simulation has been integrated on multiple platforms, such as crisis management training, improving clinical competency and patient safety, and medical trauma training for military troops performing in battle.
Adoption and Incorporation –
Certification to Financial Benefits:
The themes of improving patient safety and clinical competency through the use of simulation technologies have increasingly become a priority for many prominent medical organizations as well. The American Surgical Association’s Blue Ribbon Panel recommends that medical simulators be adopted into surgery as a tool for education, teaching and verifying competence, and The American Board of Internal Medicine has shown their support for incorporating medical simulation into board exams by giving grants to companies developing simulators. The promising results of medical simulation technologies have even inspired a bipartisan effort to further research, with Rep. Randy Forbes (RVA) and Patrick Kennedy acting as instrumental leaders in the movement. HR 4321, the Enhancing SIMULATION (Safety in Medicine Utilizing Leading Advanced Simulation Technologies to Improve Outcomes Now) Act of 2007, is a bill supporting medical simulation research and training to reduce healthcare costs, improve safety and create more simulation centers.
Many organizations have already adopted medical simulation techniques into formal assessments of performance, certification programs, and board exams. The first organization to integrate computer-based case simulation into testing was The United States Medical Licensing Examination (USMLE). The American Board of Family Practice has also incorporated computer- based case simulations for each individual examinee into their family practice board certification exam. International organizations have also expanded their exams to include medical simulation. The Royal College of Physicians and Surgeons of Canada use video simulations during their internal medicine exam, and The Israeli Board of Anesthesiologists Examination Committee has adopted one of the most extensive simulation-based portions of their board exam, developing five standardized scenarios to assess competency in a range of practices from administration of anesthesia to trauma and operating room management. Continuing medical education (CME) programs have also found simulation techniques to be sufficient for ensuring physicians’ skills remain fresh; simulator-based education is required by The American Board of Anesthesiology to fulfill the maintenance of certification requirements, and many other CME credits are now fulfilled using simulation programs.
Studies have been conducted showing that practicing and training with simulator technologies lowers the number of errors performed during procedures, thus reducing malpractice. According to a press release by Randy Forbes in 2007, the cost of medical errors in the U.S. can be as much as $79 billion dollars a year. However, hospitals funded by a trial program utilizing simulations and established by the U.S. DOD saw the rate of clinical errors decrease from 30.9% to 4.4%. In 2001, The Consolidated Risk Insurance Company (CRICO), a malpractice carrier for the Harvard community, started offering insurance premium incentives to anesthesiologists who were trained in crisis resource management at the Center for Medical Simulation, as well as grants to cover costs. Reduced malpractice due to incentive programs like CRICO’s has led to other similar arrangements for other specialties, such as obstetrics and gynecology.
Resistance May Be Futile
Some physicians resist these new forms of teaching and training, saying that a virtual reenactment can never replace hands-on practice, and while it is undeniable that real-life experience will yield the best results, what simulation technologies offer is a chance to make early learning more effective and provide new ways of exploring techniques. In addition, with companies readily incorporating simulation into their medical practices the laparoscopic device market has already become a multibillion dollar endeavor and according to iData Research, anticipated advancements project that by 2018 sales will reach approximately $7.5 billion, with major corporations like Ethicon and Allergan vying for control. Clinical, as well as financial benefits, make a slow in growth unlikely, and for the time being medical simulation is here to stay.
Brenda K. Wiederhold, Ph.D., MBA, BCIA
Virtual Reality Medical Institute
Mark D. Wiederhold, M.D., Ph.D., FACP
Virtual Reality Medical Center
San Diego, California
President of Virtual Reality Medical Institute (VRMI) in Brussels, Belgium. Executive VP Virtual Reality Medical Center (VRMC), based in San Diego and Los Angeles, California. CEO of Interactive Media Institute a 501c3 non-profit Clinical Instructor in Department of Psychiatry at UCSD Founder of CyberPsychology, CyberTherapy, & Social Networking Conference Visiting Professor at Catholic University Milan.