Medical knowledge continues to expand rapidly, and surgeons are faced with increasing numbers of surgical procedures that must be learned and mastered. This revolution is occurring against a backdrop in which practitioners are required to become more efficient in patient care, with fewer hours available for teaching and learning. The added pressure of reduced work hours has led to limited options for responding to new disruptive technologies. When a new procedure such as laparoscopic cholecystectomy is introduced, how can large numbers of practicing surgeons and residents in training be trained to be safe and efficient without compromising patient care? The American College of Surgeons (ACS) has recognized this problem and has formulated an ad hoc committee to create a model for what will ultimately be ACS-approved regional skills centers that will offer surgeons, surgical residents, and medical students opportunities to acquire and maintain surgical skills, as well as learn new procedures and the use of emerging technologies.

Thomas Russell, the current executive director of the ACS, stated "The competitive surgeon of the next 10 to 20 years will need to possess a different set of skills than we have needed in the past" [1]. Dr. Russell has suggested that the use of simulation will provide early exposure to medical students, piquing their interest in a surgical career. Resident education will involve the use of simulators and experiences outside the operating room (OR) to enhance the core competencies and move the learning process away from the traditional approach of "see one, do one, teach one" to "see one, practice many, and do one" [1]. The surgeon of the future will be required to have periodic cognitive testing every few years as well as testing of their technological skills with the use of simulators as they progress in their careers. The acquisition of new surgical skills in practice will be much more structured in the future. The practice of industry-sponsored short courses with rapid introduction into clinical practice will no longer be acceptable. Surgeons will likely be required to undergo retraining in regional centers in which skills can be learned through validated multimodality curriculum.

A prime example of this is the carotid stenting procedure, which was recently approved by the US Food and Drug Administration (FDA). The new twist to this is that the FDA (for the first time) has mandated that all practitioners must train "to proficiency" on a simulator before they can perform the procedure on humans [2].

There is clearly an obvious need to develop skills centers to respond to the educational needs of new and potentially disruptive technologies. This chapter makes the case for the use of simulation to meet the educational needs of surgeons in the future, with a brief overview of the current state of simulation and simulators. In addition, a view of how centers should be organized in the future to meet these needs will be proposed, using an existing facility, the National Capital Area Medical Simulation Center, as an example of one institutions attempt to meet the challenge of responding to disruptive technologies.

6.1 Making the Case for Simulation for Medical Education

In 2000, the Institute of Medicine released its report "To Err is Human: Building a Safer Health System" [3]. This study noted that at least 44,000 Americans die from medical errors every year. As part of the plan for improvement, the authors stated in their recommendations that health care organizations should incorporate proven methods of training such as simulation. Though it may be too early to conclude that simulation in general is a "proven" method, this report certainly has placed the onus on the medical community to challenge the traditional medical education approach and address methods for reducing medical error.

The traditional surgical training method of see one, do one, teach one, in and out of the OR has recently undergone reappraisal. Studies have shown that for a variety of diagnostic and therapeutic procedures, clinicians doing this first few to several dozen cases are more likely to make a greater number of errors (the learning

* The opinions or assertions contained herein are the private views of the authors and are not to be construed as official, or as reflecting the views of the Department of the Army, Department of the Navy, the Advanced Research Projects Agency, or the Department of Defense.

curve) [4]. Some might argue that it has become unreasonable that patients be victims of medical invasive procedural training. On-the-job training with patients can result in prolonged invasive procedures, a potential for erroneous diagnoses, increased patient discomfort, and increased risk for procedure-related morbidity [5].

In many ways, the OR is a poor classroom for learning surgical skills. By necessity, there are several distractions, most having nothing to do with education, that take priority (patient issues) [6]. In general, the opportunity is underused [7]. The surgical mentor may not be a good teacher. In the OR, the teaching session cannot always be well designed or predicted. The case at hand may not be well suited for the learner. The progress or sequence of the operation cannot be altered to satisfy educational goals. Dissection and exposure cannot be performed for demonstration only. Steps may not be repeated, and the patient cannot be reassembled to start over if failure occurs [7]. In addition, fiscal constraints have resulted in pressure to achieve a high turnover in the OR, allowing less time for the attending staff to teach and trainees to practice skills [8]. Bridges and Diamond [8] have estimated that the annual cost of training chief residents in the OR amounts to more than $53 million per year, and suggest that adjunctive training environments that use traditional and virtual teachings aids may alleviate cost over time. In addition to time constraints, one cannot neglect the ethical issues of teaching and learning using patients [9].

There are tremendous advantages to training outside the OR. The learning environment is more easily controlled and adjusted. The learning situation can be tailored for each student's needs and can be altered on a minute-by-minute basis to create the desired effect. Perhaps the most valuable part of this training is granting "permission to fail" in a safe environment where there is no risk to patients. Studies have uncovered significant problems with the current surgical education curriculum. These include lack of continuity from undergraduate to graduate surgical education, and the lack of supervision when acquiring physical examination skill, ultimately resulting in poor performance [10-12]. An innovative educational tool, the Objective Structured Clinical Examination (OSCE) has proven useful in the evaluation of the clinical competence of surgical residents [13].

Surgical simulators have, perhaps, the best potential to mitigate surgical risk related to the educational process. A surgeon will be able to practice new procedures repeatedly until he or she is judged proficient without endangering patients. The surgeon can also be presented with cases of increasing complexity as his or her skills progress during training. Computer-based surgical simulators offer the potential for including operative cases representing all known anatomic variations. The training program director can use the simulator and its student tracking software to ensure that each graduating resident has seen and dealt with all the pertinent anatomic variations for that surgical specialty [14]. Using simulation, mistakes would lose their consequences and become ways to learn. A master surgeon's trick of the trade or critical maneuver during an operation could be learned in situ by every simulation user. The opportunity to learn something new this way has never before been available to medicine [15].

Another potential justification of virtual reality (VR) training is reducing the length of a surgical residency program. Currently, these training programs require five or more years in order to permit adequate exposure to a variety of technical procedures and decision-making situations. Training programs are currently time limited and not proficiency based. VR training could potentially reduce 5-year residency programs, because residents would not have to wait for clinical cases to appear. Instead, he or she could call up a variety of cases and perform the procedure in VR several times before doing so on a human [16]. One of the added attractions of simulation is that training programs might be able to correct for case-mix inequalities, so that what one learns in residency no longer depends only on what comes through the door when on call [15]. Flexibility is important for mastery of skills. Simulation may well offer the additional flexibility required. Though currently costly to implement on a large-scale, simulation offers great promise in future reduction of errors (and malpractice suites), reducing (or eliminating) the use of animals, and helping to establish standards for certain procedures.

An additional, and perhaps increasingly crucial, role of simulation may well be the assessment of possible decline in the skills of older surgeons. Measuring technical competence through VR could also be applied to older surgeons. As surgeons age, manual dexterity can decline, but it has always been difficult to objectively assess these skills. There is currently no mechanism to determine when these skill levels have deteriorated to the point where the surgeon should not be allowed to operate [16]. This decline in skills and judgment has traditionally been assessed by individual surgeons or chiefs of services. A mature, validated system of simulation-based education could offer for the first time a lifelong log of performance on standardized techniques, allowing measurement of skills independent of age or other arbitrary milestones [15].

6.2 Simulation and Simulators for Medical Education: Past, Present, and Future

VR is a computer-based, simulated environment in which users interact with a high-performance computer, graphics, specialized software, and devices providing visual, tactile, and auditory feedback, thereby simulating a true-life environment. VR-simulated environments allow trainees to repeat procedural experiences at their own leisure. These exercises or procedures would otherwise require numerous real-life encounters and costly hours of supervision [17].

A commonly recognized type of VR experience is that of flight simulation. In the aerospace, aviation, and defense industries, flight simulation is mandatory before pilots assume flight responsibilities. In addition, flight simulation is regularly used to help commercial airline pilots maintain their skills, or to become familiar with problems they might one day encounter.

Haluck et al. in 2001 [18] noted that virtual environments and computer-based simulators, although well-established training tools in other fields, have not been widely incorporated into surgical education. Concerns over the lack of validation, the cost, and finding time for residents to participate were cited as concerns. There are four major areas in medicine where VR is beginning to emerge: (1) assistance before and during medical surgical procedures, (2) medical education and training, (3) medical database visualization, and (4) rehabilitation [19].

For the most part, the advantages of flight simulators hold equally true for surgical simulators [19]. Surgical simulators can provide a concentrated environment that lends itself to learning complex tactile maneuvers in a relatively quick and proficient manner. Moreover, simulation of infrequent but highly hazardous events provides experience in handling these scenarios that may not be available during a period of routine flight or surgical training [20]. The ideal surgical simulator should provide the following: it can be customized to the needs of the student, the variety of cases during training increases significantly, and the student can chose to train only the difficult part of the surgery and repeat it as often as necessary [20].

Satava [19] has described five components that contribute to the realism of a virtual surgical world: fidelity, organ properties, organ reaction, interactivity, and sensory feedback. He predicts that the future holds promise of a virtual cadaver nearly indistinguishable from a real person [19]. This concept is referred to as the Turing test, a standard test that means to determine if a computer could be created that responds the way a human would respond such that a human could not tell the difference between the computer and a human [21, 22]. The VR Turing test would be met if an interrogating human could not tell the virtual human apart from the real human by sight, hearing, or touch, even dissection [20].

Current simulators do not yet meet the criteria of the Turing test. It is conceivable that future improvement in computing power and decreased costs of such technology will allow for development of such realism in a virtual environment. That being said, the level of fidelity required to meet the Turing test is likely not necessary to develop useful simulators that will teach useful skills in a validated fashion. In fact, many simulators are currently being used to teach medicine and range from low tech (inexpensive) to increasingly high tech, with corresponding price tags. The future use and development of simulation will depend in large part on validation of their effectiveness as training tools and to a certain extent the adoption of simulation by the various medical and surgical boards and societies. As organizations and institutions realize the potential cost savings (in dollars and lives) of training with simulation, investment from both private and public sources should follow.

Surgical skills laboratories have been successfully used for decades [10]. They were first introduced with simple tie-and-suture boards and pigskin suturing models in the 1960s [23]. Multiple tools and materials have been used since [24]. All of these skills laboratories require a clear curriculum and constructive feedback in order to be effective [25]. As one begins to organize a surgical skills center, the focus must be on curriculum with the choice of simulation and simulators based on fulfilling that curriculum.

Numerous simulators and VR training devices are currently available for training surgeons. Some of these are simple and inexpensive, while others are complex and costly. Simulators encompass everything from simple skills trainers such as knot-tying boards to part-task trainers such as a chest tube trainer, up to full procedural trainers that allow for training a complete laparoscopic or endoscopic procedure. Though by no means comprehensive, the following represents some of the types simulators that are currently available for teaching surgeons with a brief discussion of their utility (where applicable) for training.

6.2.1 Bench Models

Animal laboratory animal facilities are not accessible to all. Using animals to practice surgical procedures is prohibited in the United Kingdom. Martin et al. [26] have compared their open surgical bench models with performance of similar tasks in live anesthetized animals. Their correlations between scores on bench and live examinations were high, validating their bench models.

6.2.2 Laparoscopic Skills

The teaching of laparoscopic skills to surgeons has been a fertile ground for simulator development. One of the major reasons for this is that it is much easier to suspend the trainees' disbelief, as the actual procedure is done using long instruments while viewing a two-dimensional image on a monitor. Additionally, most of the haptics required is a result of movement of instruments through trocars, which is relatively easy to duplicate.

Fried et al. [27] have shown that performance by postgraduate year (PGY)-3 residents in an in vitro laparoscopic simulator correlated significantly with performance in an in vivo animal model. Likewise, practice in the simulator resulted in improved performance in vivo.

Hytlander et al. [28] have shown that training novice surgeons on the LapSim (Surgical Science) laparo-scopic simulator translated to improved basic laparo-scopic skill performance in a porcine model, suggesting that skills learned on a simulator can be transferred to the OR.

Scott et al. [29] demonstrated that junior surgical residents who had formal laparoscopic skills training had improved operative performance with laparoscopic cholecystectomy more than did their nontrained peers.

In an important article in 2002, Seymour et al. [30] validated the transfer of training skills from VR to OR, by showing that residents who were pretrained to "expert criterion" on the Minimally Invasive Surgical Trainer - Virtual Reality (MIST-VR) performed better in the OR than did their non-VR-trained counterparts, with significantly less failure to progress, injury to gallbladder, burning of non-target tissue, and fewer errors. This was one of the first studies to demonstrate that individuals who train on a simulator can translate those skills into improved performance and outcome, a finding that should help further ignite enthusiasm (and funding) for skills training centers.

6.2.3 Gastrointestinal Endoscopy

Endoscopic procedures have also been fertile ground for development of high-fidelity simulators. As with laparoscopy, these procedures entail interaction with a patient through an instrument (the scope) with visualization on a monitor. For more than 30 years, different types of simulators, including mechanical [31], animal [32], animal-part [33], and computer-based models [34] have been used to teach and learn endoscopic procedures. The goals of simulator-based teaching methods should be the acceleration and improvement of training in endoscopy for beginners, the maintenance of competency with endoscopic procedures, and testing of new procedures prior to performance on a patient [35].

One such virtual endoscopy simulator (GI-Mentor, Simbionix, Tel Hashomer, Israel) has been shown to be capable of identifying differences between beginners and experts in gastrointestinal endoscopy. Training on this simulator for 3 weeks improved performance of beginners significantly in a study conducted by Fer-

litsch et al. in 2002 [35]. In a separate study, Ritter et al. [36] have shown that the GI Mentor simulator can distinguish between novice and intermediate endoscopists. They concluded that the simulator assesses skills with levels of consistency and reliability required for high-stakes assessment.

6.2.4 Endonasal Surgery

Edmond [37] reported that training residents on an endoscopic sinus surgical simulator had a positive impact on OR performance among junior otolaryngology residents. In contrast, Caversaccio and colleagues [38] reported that an endonasal surgery simulator allowed junior surgical trainees to better understand the anatomy, but failed to make an impact on OR performance. They cited some of the limitations of the particular simulator, including absence of force feedback and considerable time consumption.

6.2.5 Urology

Matsumoto [39] demonstrated a positive effect of training at the surgical skills laboratory on endourological skills. Jacomedies et al. have suggested that virtual ureterscopy simulator training may allow beginning urology residents to shorten the initial learning curve associated with ureteroscopy training [40].

6.2.6 Bronchoscopy

Bronchoscopy training on a simulator readily includes deliberate action, reaction, opportunities for repetition, correction of errors, and ability for individualized learning, all key components to the educational process [5]. Rowe and Cohen [41] demonstrated that training on a bronchoscopy simulator translated into improved performance on subsequent fiber optic intubation in children.

6.2.7 Anesthesiology

No other specialty to date has embraced simulation as actively as has anesthesiology. The emphasis has been on team training and crisis management more than on specific skills.

Chopra et al. [42] demonstrated that anesthesiologists trained on a high-fidelity anesthesia simulator responded more quickly and appropriately when han dling a crisis on a simulator. Controlled studies involving humans to validate this finding would present an unacceptable risk, however. Further development of the simulation concept evolved out of the recognition that two thirds of all accidents or incidents in anesthesia can be attributed to human error. To counter this, Howard and colleagues [43] developed a training program entitled Anesthesia Crisis Resource Management in order to optimize anesthesiologist and team performance during stressful incidents. Success in this arena has led to the use of mannequin-based simulators in surgical training as an alternative to "real" trauma resuscitations for teaching teamwork and crisis-management skills [10, 44].

Several other simulators are currently available or under development for a variety of medical specialties. It is beyond the scope of this chapter to present these in detail. Suffice it to say that more of these will become available with increasing realism and sophistication in the very near future. Perhaps the greatest lesson to be learned as we utilize these new technologies is that although VR enhances training, it does not replace existing methodology. A considered synthesis of the two, however, inevitably requires that we redefine the idea of what constitutes a complete medical education.

VR systems introduce the alluring possibility of a completely objective measurement and assessment of the trainee's ability. As the cost of simulators is still quite high, very few institutions can afford to obtain and maintain a large inventory that may be necessary to meet the needs of all surgical learners. As such, the idea of regional centers makes sense. The exact makeup of such a center will depend in large part on the needs of the learners and the resources available. The most logical approach to developing such a skills center is to identify the population to be trained, the skills that they need, and then develop robust curriculum to meet those needs. Only then should consideration be given to what simulators to purchase to meet those needs.

In other words, the curriculum should dictate the simulators and not vice versa. The remainder of this chapter is devoted to looking at a case study of how one institution has responded to the challenge of training for disruptive technologies by constructing a comprehensive simulation center. This example is by no means meant to be prescriptive, but will hopefully serve as an example of things that must be considered when organizing such a center.

6.2.8 Case Study: The National Capital Area Medical Simulation Center

The National Capital Area Medical Simulation Center (NCAMSC) is part of the Uniformed Services Uni versity of the Health Sciences (the United States' only military medical school) located in Bethesda, Maryland. Officially opened in April of 2000, the Center uses a variety of medical simulation approaches and technologies to teach and evaluate clinical and surgical skills. Its target population consists of medical and nursing students, interns and residents, and practicing physicians. The NCAMSC is the first single location to integrate the use of VR technology, computer-controlled mannequins, and human-simulated patients under one roof. The Center is contained in roughly 11,000 contiguous square feet and is divided into four functional areas. The floor plan of the center is shown in Figure 6.1.

The Center is divided into four functional areas. These are the Administrative Area, the Clinical Assessment Laboratory, the Computer Laboratory, and the Surgical Simulation Laboratory. Each distinct area can sustain educational activities on its own, and when necessary integrate the operations of the entire Center for a more comprehensive approach. All of the functional areas have been designed to maximize students' access to clinical experience in a state-of-the-art learning environment. The Administrative Area

The administrative area of NCAMSC is the hub of the Center. It incorporates the administrative offices as well as the video teleconference room or VTC Room.

The Administrative Area serves as the hub for daily operational concerns such as personnel, budgeting, and resource allocation. This area houses the offices of the Center to include the medical director, the director of clinical skills/standardized patient training, and the administrative director.

The VTC is the Center's audio/video entry and exit point to the outside world (Fig. 6.2) Equipped with state-of-the art video teleconferencing equipment, any of the video signals from around the center can be routed through this room and sent to all connected sites anywhere in the world. This allows remote sites to participate and review many of the exercises that take place in the center.

This room is also equipped with a "telecommuting" conference table, which allows up to 12 students, faculty, or visitors to connect their laptops to any of the 12 local area network ports for high-speed Internet access. The table is also outfitted with 16 headphone ports, allowing various audio exercises that permit instructors and students to sample the same audio files simultaneously for review and discussion. As a standard conference room, it is also equipped with slide-to-video converter, document camera, and VCR.

Fig. 6.1 The floor plan of the National Capital Area Medical lab, a virtual operating room (OR), a 16-station computer lab, Simulation Center. The Center contains a video teleconferenc- and a 12-room standardized patient exam area with a central ing suite (VTC), an administrative area, a virtual reality (VR) control/monitoring area

Fig. 6.1 The floor plan of the National Capital Area Medical lab, a virtual operating room (OR), a 16-station computer lab, Simulation Center. The Center contains a video teleconferenc- and a 12-room standardized patient exam area with a central ing suite (VTC), an administrative area, a virtual reality (VR) control/monitoring area Clinical Assessment Laboratory

The clinical assessment laboratory is designed for teaching and evaluating students in the basic clinical skills of history taking, physical examination, communication, and interpersonal skills. Here simulated patient encounters provide an ideal transition from the classroom to real patient contact. The clinical assessment laboratory also prepares students for the US Medical Licensure Examination. An additional three standardized patient trainers are employed to ensure the smooth operation of this area. This area consists of four sub sections.

The Orientation Room is used to brief students. Ceiling-mounted, drop-screen and LCD projectors are used to display PowerPoint and/or video presentations for orientation, registration, and briefing the students on specific event protocols. Here students are registered for clinical events through a login process that tracks them throughout their activities.

The Clinical Exam Room Area consists of 12 exam rooms that serve as the simulated clinical environment. There are ten regular (120 NSF) exam rooms and two large (220 NSF) rooms with hospital beds that can be used for inpatient and/or critical care simulation. The large rooms are also suited for trauma simulation and small-group teaching events.

In the Clinical Exam Room Area, students have the opportunity for live patient encounters that simulate specific challenges in outpatient, inpatient, or critical care settings (Fig. 6.3). Specifically, individuals (referred to as standardized patients) are hired and trained

Fig. 6.2 The Video Teleconferencing Room (VTC) of the National Capital Area Medical Simulation Center

Fig. 6.3 Clinical Exam Rooms in the National Capital Area Medical Simulation Center. Here "standardized" patients are being examined by medical students

Fig. 6.3 Clinical Exam Rooms in the National Capital Area Medical Simulation Center. Here "standardized" patients are being examined by medical students to simulate scripted clinical cases. These clinical cases may be simulated using performance, make-up, or real conditions and sometimes a combination of all three.

Each exam room is equipped with two video cameras and microphones that permit encounters to be recorded for subsequent analysis. Each room also contains a computer for each patient and a wall-mounted computer located outside of the room for each student to use for pre- and post-encounter documentation.

Typically, clinical exams are designed following a directive to achieve specific educational goals. The standardized patient trainers and the medical director collaborate with faculty members to create projects that meet stated educational goals.

The Monitoring Area is at the center of the Clinical Exam Room Area and allows the standardized patient trainer and faculty instructors to monitor the progress of clinical exams. A specialized video router controls

Examination Positions For Patients
Fig. 6.4 a The control panel that allows for optimal positioning of the camera's in the patient exam room. b The central monitoring area allows faculty to view single or multiple rooms from one location

24 videotape decks that track students as they move from room to room. A touch-screen control panel permits cameras to be positioned for optimal imaging (Fig. 6.4). Faculty and students are able to view the encounter through one-way mirrors outside each room or from central monitors that allow monitoring of multiple rooms simultaneously (Fig. 6.4). Faculty and students may also review and learn from recorded tapes as if they were in the room, allowing for more detailed observation and dynamic feedback. The monitoring area is also used for training simulated patients.

The Standardized Patient Lounge is a staging area for simulated and standardized patients to prepare and relax. This area is required as patients often use theatrical makeup to simulate traumatic injuries or other conditions. Computer Laboratory

The Computer Laboratory has two sections, the Computer Laboratory itself and an adjacent Control Room.

The Computer Laboratory has two primary functions. The first is to identify, develop, and/or use medical education software that contributes toward clinical or medical readiness skills. The second is to provide an environment in which computer-based, interactive clinical examinations can be administered (Fig. 6.5).

The Computer Laboratory consists of 16 Internet-accessible workstations that run a variety of medical educational CD ROMs. Eight overhead cameras and a one-way mirror between the Lab and the Computer Control room ensure that examinations can be properly monitored when the Lab is used for testing. Students use the computer laboratory to work with interactive software programs that may be linked to activities occurring in other functional areas of the Center.

Additionally, students can prepare for the NMBE (National Board of Medical Examiners) exam by practicing test questions from several test prep software packages available in the center. Currently, the computer lab meets or exceeds the requirements to be a NBME testing site. Students and faculty can also use the computers to conduct independent studies or view university mail or class schedules.

The Computer Control Room is adjacent to the Computer Laboratory. It is the nerve center of the Center. All data, voice, and video signals are fed through the Control Room and can be routed to other areas accordingly. The Control Room also houses several departmental servers that handle the current needs of the center.

During testing, the Control Room operates as a monitoring station for instructors, allowing overall viewing of the Computer Laboratory through the oneway mirrored window or any of the workstations individually from the overhead camera. A high-speed fiber optic link between the Center and the National Library of Medicine also exists. This link provides the Center with access to Internet II, which is still in the development stage. This link will be used to test and develop streaming video and other high-bandwidth/high-reliability applications as they are developed to augment medical training. Surgical Simulation Laboratory

The Surgical Simulation Laboratory uses VR and a full-scale OR mock-up to provide highly realistic scenarios for surgical training. This area was the

Fig. 6.5 The Computer Lab of the National Capital Area Simulation Center. The Lab consists of 16 PC workstations

first site approved to investigate teaching the surgical skills practicum of the Advanced Trauma Life Support course, using computer-based simulators and plastic models rather than anesthetized animals or cadavers.

The Operating Room (O.R.) is furnished to look and feel like a typical OR. In addition to the typical O.R. equipment, the room holds intravenous catheterization, endoscopy, and diagnostic ultrasound simulators. The O.R. can be configured to match the conditions of a standard O.R., an emergency room or an intensive care unit. Here, three human-patient simulators that respond to various drugs and interventions are used for teaching medical and surgical interventions and teamwork to a variety of health care providers (Fig. 6.6).

Fig. 6.6 The Operating Room of the National Capital Area Medical Simulation Center, showing three high-fidelity human-patient simulators (foreground) and an ultrasound simulator in the back right corner

Driven by computers, the human-patient simulators can be preprogrammed with patient characteristics or variables such as age, anatomy, and physiology factors, depending on the training event. Students are faced with real-life situations as they interact with the human simulator, depending on the scripted clinical procedure. The simulators have palpable pulse areas and will exhibit the appropriate physiologic reactions in response to various intravenous or inhaled agents. The simulators can be moulaged to represent wounds and clinical conditions (Fig. 6.7). Presently, one of the simulators has the capability for 80 different drugs to be "virtually" administered by various computer microchips. The simulator responds to the type and amount of these drugs according to instructor-determined, preprogrammed patient variables. The simulators provide a very powerful tool teaching a variety of clinical scenarios. The O.R. is staffed by a full time coordinator and a physician surgical director, whose offices are also found in this area.

In the O.R. Control Room, overhead microphones, four overhead video cameras, and a one-way mirror into the O.R. allow instructors to communicate with the O.R. coordinator. In the Control Room, the coordinator can change patient variables on the computer and even speak into a hidden microphone feed on the simulated patients in order to bring more realism to the scene. An additional feature in the control room is a button that will turn off the power in the O.R., allowing for the simulation of what to do during a real power outage (Fig. 6.8).

The Virtual Reality (VR) Laboratory develops and tests computer-based surgical simulators to meet the educational objectives of the Center. Research that advances simulation procedures is also a fundamental directive as is harnessing the capabilities of existing technologies. This area is also run by the surgical director with a staff that includes a Ph.D. computer scientist, software developers, and a graphic artist. In the VR Laboratory, state-of-the-art computer-based equipment enables students to view medical objects in two or three dimensions. A haptic interface allows the computers to recreate the tactile sense that permits users to touch, feel, manipulate, create, and alter simulated three-dimensional anatomic structures in a virtual environment. Here students can teach themselves at their own pace and can feel comfortable about making mistakes as well as repeating an exercise. The VR Laboratory is equipped with simulators for vascular anastomosis, laparoscopic surgery, bronchoscopy, peri-cardiocentesis, a diagnostic peritoneal lavage unit, and a hand-immersive environment for on-going research (Fig. 6.9). Both the pericardiocentesis and diagnostic peritoneal lavage simulators were developed in the VR Laboratory. These two simulators are the first of their kind and are unique to the Center. The VR Laboratory

Diagnostic Peritoneal Lavage

Fig. 6.7 Moulaged high-fidelity human-patient simulators. a A blunt trauma scenario with a "seatbelt sign," b a mangled extremity, c a patient with gunshot wounds across face and the chest receiving a surgical airway, d the same patient being elec-trocardioverted for an arrhythmia

Fig. 6.7 Moulaged high-fidelity human-patient simulators. a A blunt trauma scenario with a "seatbelt sign," b a mangled extremity, c a patient with gunshot wounds across face and the chest receiving a surgical airway, d the same patient being elec-trocardioverted for an arrhythmia

Fig. 6.8 A view of the Operating Room from the Control Room through the one-way mirror. The red button on the wall turns off the power in the Operating Room to allow for team training under such circumstances

is actively involved in ongoing validation research of existing and newly developed simulators, and continues to take the lead in developing new simulators and simulation technology.

6.3 Conclusion

For reasons of educational quality, safety, and cost, VR and simulation can enhance surgical training and learning now, and their role will almost certainly expand as computer power and availability increase. Clearly, the introduction of simulation into medical education is a disruptive force that challenges the status quo. However, it is likely that societal pressure to reduce errors in the face of decreased time and availability of clinical teaching material will result in mandates to provide training and maintenance of skills using simulation. Forward-thinking institutions should embrace the

Vascular Anastomosis Simulation
Fig. 6.9 Examples of virtual reality simulators found in the simulator, c bronchoscopy simulator, and d diagnostic perito-VR lab at the National Capital Area Medical Simulation Cen- neal lavage simulator ter. a Laparoscopic surgery simulator, b vascular anastomosis

adoption of simulation in well-thought out curriculum that will meet the educational needs of the learners that they support. Careful thought should be given to how resources should be spent and centers organized to respond to the present and future challenges. It is essential that centers should be built with flexibility in mind and should be staffed with a full complement of educators, clinicians, and administrative and support personnel. Ideally, centers will also engage in validation research and development of simulators and curricula that will continue to push this exciting and rapidly growing field ever forward to respond to future disruptive technologies as they occur.


1. Russell T (2003) From my perspective. Bull Am Coll Surg 88:3-4

2. Sternberg S (2004) Science clearing the way for shift in fighting stroke. USA Today. http://www.usatoday. com/tech/news/techinovations/2004-04-26-stents-strokes.

3. Kohn LT, Corrigan JM, Donaldson MS (eds.) (2000) To err is human: building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. National Academy Press, Washington, D.C.

4. Kaufman DM, Bell W (1997) Teaching and assessing clinical skills using virtual reality. Medicine meets virtual reality. Morgan KS et al (eds.) IOS, Amsterdam, pp 467-472

5. Colt HG, Crawford SW, Galbraith O (2001) Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest 120:1333-1339

6. Haluck RS, Krummel TM (2000) Computers and virtual reality for surgical education in the 21st century. Arch Surg 135:786-792

7. Scallon SE, Fairholm DJ, Cochrane DD, Taylor DC (2001) Evaluation of the operating room as a teaching venue. Can J Surg 35:173-176

8. Bridges M, Diamond DL (1999) The financial impact of teaching surgical residents in the operating room. Am J Surg 177:28-32

9. Gates EA (1997) New surgical procedures: can our patients benefit while we learn? Am J Obstet Gynecol 176:1293-1297

10. Gorman PJ, Meier AH, Krummel TM (2000) Computerassisted training and learning in surgery. Comp Aid Surg 5:120-130

11. Chalabian J, Garman K, Wallace P, Dunnington G (1996) Clinical breast evaluation skills of house officers and students. Am Surg 62:840-845

12. Endean ED, Sloan DA, Veldenz HC, Donnelly MB, Schwarcz TH (1994) Performance of the vascular physical examination by residents and medical students. J Vasc Surg 19:149-156

13. Sloan DA, Donnelly MB, Schwartz RW, Strodel WE (1995) The objective structured clinical examination. The new gold standard for evaluating postgraduate clinical performance. Ann Surg 222:735-742

14. Kaufmann CR (2001) Computers in surgical education and the operating room. Ann Chir Gynaecol 90:141-143

15. Dawson SL (2002) A critical approach to medical simulation. Bull Am Coll Surg 87:12-18

16. Ota D, Loftin B, Saito T, Lea R, Keller J (1995) Virtual reality in surgical education. Comput Biol Med 25:127-137

17. Issenberg SB, McGeghie WC, Hart IR et al (1999) Simulation technology for health care professional skills training and assessment. JAMA 282:861-867

18. Haluck RS, Marshall RL, Krummel TM, Melkonian MG (2001) Are surgery training programs ready for virtual reality? A survey of program directors in general surgery. J Am Coll Surg 193:660-665

19. Satava RM (1995) Medical applications of virtual reality. J Med Syst 19:275-280

20. Lange T, Indelicato DJ, Rosen JM (2000) Virtual reality in surgical training. Surg Oncol Clin N Am 9:61-79

21. Bleich HL, Turing A (1995) The machine, the enigma, and the test. MD Comput 12:330-334

22. Heiser JF, Colby KM, Faught WS et al (1979) Can psychiatrists distinguish a computer simulation of paranoia from the real thing? The limitations of Turing-like test measures of the adequacy of simulation. J Psychiatr Res 15:149-162

23. Boyle DE, Gius JA (1968) Tie and suture training board. Surgery 63:434-436

24. Gorman PJ, Meier AH, Krummel TM (1999) Simulation and virtual reality in surgical education: real or unreal? Arch Surg 134:1203-1208

25. Barnes RW, Lange NP, Whiteside MF (1989) Halstedian technique revisited. Innovations in teaching surgical skills. Ann Surg 210:1187-1121

26. Martin JA, Regehr G, Reznick R, Macrae H, Murnahan J, Hutchinson C, Brown M (1997) Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:273-278

27. Fried GM, Derossis AM, Bothwell J, Sigman HH (1999) Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator. Surg Endosc 13:1077-1081

28. Hyltander A, Liljegren E, Rhondin PH, Lönroth H (2002) The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc 16:1324-1328

29. Scott DJ, Bergen PC, Rege RV, Laycock R, Tesfay ST, Valentine RJ, Euhus DM, Jeyarajah DR, Thompson WM, Jones DB (2000) Laparoscopic training on bench models: better and more cost effective than operating room experience. J Am Coll Surg 191:272-283

30. Seymour NE, Gallagher AG, Roman SA, O'Brien MK, Bansal VK, Anderson DK, Satava RM (2002) Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 236:458-464

31. Markman HD (1969) A new system for teaching proctosig-moidoscopic morphology. Am J Gastroenterol 52:65-69

32. Noar MD (1995) An established porcine model for animate training in diagnostic and therapeutic ERCP. Endos-copy 27:77-80

33. Freys SM, Heimbucher J, Fuchs KH (1995) Teaching upper gastrointestinal endoscopy: the pig stomach. Endoscopy 27:73-76

34. Bar-Meir S (2000) A new endoscopic simulator. Endoscopy 32:898-900

35. Ferlitsch A, Glauninger P, Gupper A, Schillinger M, Haef-ner M, Gangl A, Schoefl R (2002) Evaluation of a virtual endoscopy simulator for training in gastrointestinal endos-copy. Endoscopy 34:698-702

36. Ritter EM, McClusky DA, Lederman AB, Gallagher AG, Smith CD (2003) Objective psychomotor skills assessment of experienced and novice flexible endoscopists with a virtual reality simulator. J Gastrointest Surg 7:871-878

37. Edmond CV (2002) Impact of the endoscopic sinus surgical simulator on operating room performance. Laryngoscope 112:1148-1158

38. Caversaccio M, Eichenberger A, Häusler R (2003) Virtual simulator as a training tool for endonasal surgery. Am J Rhinology 17:283-290

39. Matsumoto ED, Hamstra SJ, Radomski SB, Cusimano MD (2001) A novel approach to endosurgical training: training at the Surgical Skills Center. J Urology 166:1261-1266

40. Jacomides L, Ogan K, Cadeddu JA, Pearle MS (2004) Use of a virtual reality simulator for ureteroscopy training. J Urology 171:320-323

41. Rowe R, Cohen RA (2002) An evaluation of a virtual reality airway simulator. Anesth Analg 95:62-66

42. Chopra V, Gesink BJ, de Jong J, Bovill JG, Spierdijk J, Brand R (1994) Does training on an anesthesia simulator lead to improvement in performance? Br J Anaest 73:293-297

43. Howard S, Gaba D, Fish K, Yang G, Sarnquist F (1992) Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63:763-770

44. McLellan BA (1999) Early experience with simulated trauma resuscitation. Can J Surg 42:205-210

Was this article helpful?

0 0

Post a comment