Letter from the Secretary General and Editor-in-Chief

➣ Professor Dr. Brenda K. Wiederhold

Dear Reader,

“Virtual worlds, both immersive and Web-based, are at the frontier of innovation in medical education,” wrote an anesthesiologist in 2008. As Richard Satava wrote 10 years ago, “The greatest power of Virtual Reality (VR) is the ability to try and fail without consequence to animal or patient. It is only through failure – and learning the cause of failure – that the true pathway to success lies.”

Only recently, however, has the VR cost barrier been broken by the establishment of large, collaborative simulation centers, as these partnerships anticipate the influx of practitioners demanding VR training for certification. For example, the Israel Center for Medical Simulation is part of the licensing and accreditation process for various health professionals, including paramedics and anesthesiology residents. The Uniformed Services University National Capital Area Medical Simulation Center, which provides 346,000 hours of simulations per year, partners with the National Board of Medical Examiners, the American College of Surgeons (ACS), and the American Council of Obstetrics and Gynecology. The American Board of Internal Medicine adopted medical simulation (med sim) for use in its certification program for interventional cardiologists. Med sim reaches as far as Accra Ghana, West Africa, where a partnership with ACS created the Medical and Surgical Simulation Institute.

A growing number of health professionals – physicians, nurses, dentists, EMTs, and others – have embraced VR med sim because of its ability to:

• Reduce serendipity in education and training – VR can even out the variability in training should a particular situation not present itself during the surgical residency.
• Facilitate practice and rehearsal without patient consequence – The resident can practice on a 3-D, haptically-enhanced simulator that matches the patient’s anatomy as many times as it takes to feel comfortable with the procedure.
• Reduce medical errors – Interdisciplinary teams can train to reduce errors caused by team member communication gaps or unfamiliarity with new equipment.
• Reduce reliance on animal models – Increasing pressure by PETA and scarcity of cadavers has accelerated the adoption of VR simulation.
• Reduce healthcare costs – Med sim offers the potential to decrease time spent and consequent costs.

Before the advent of mainstream VR med sim, anesthesiologists enjoyed 10% premium reductions beginning in 2001 based on malpractice claims data collected after anesthesiologist errors were reduced based on their work with mannequins. Today, there is a 20% malpractice insurance rate differential between anesthesiologists training with simulators and those not trained with simulators, and the members of this latter group are in steady decline.

In addition to anesthesiology, the use of VR med sim in endoscopic and laparoscopic surgery is producing promising results in terms of effectiveness and cost-effectiveness. One study of laparoscopic surgery found that trainees who studied on their own using a laparoscopic and endoscopic VR simulator achieved proficiency just as well as trainees who were proctored. The independent-study approach was less time consuming for trainees, and certainly minimized instructor time.

There are significant benefits to simulation training, as one study focusing on endovascular procedures found. After nine residents trained for three days on the simulation, performance improved significantly from early on day one in three categories:

• Total procedure time decreased 54%
• Volume of contrast decreased 44%
• Fluoroscopy time decreased 48%

Endovascular simulation training is up to 16 times less expensive than similar training with animals, as found by researchers in another study. The economic analysis compared the rental of an animal laboratory to the purchase or rental of the simulator Procedicus VIST (Mentice). According to the researchers, consumption of stents for each procedure is the largest cost in the animal lab, as the stents cannot be retrieved from the animal.

Most recently, a meta-analysis of more than 600 studies involving technology-enhanced simulation training showed consistently large effect sizes for knowledge, skill, and behavior outcomes, and moderate effects for patient-related outcomes. The authors of this JAMA study are currently researching how to use simulation-based teaching most cost-effectively, and we look forward to reviewing the results of that research.

Create your own reality!
Brenda Wiederhold