Medical Simulation Training
A proven high-tech training method is earning its place in medicine.
Each time you board an airplane do you ever wonder what the pilots have done to earn their seats in the cockpit? If you automatically assume that they must have extensive training, you would be correct. Most pilots become licensed to fly only after logging nearly 70 hours of simulated training events designed to duplicate conditions on that particular type of aircraft. For decades, the aviation industry has used simulation training to prepare pilots for many routine as well as unexpected scenarios. Simulation technology (also called virtual reality training, or VR) is a proven training method in the field of flight. This high-tech approach to professional education is now earning its place in medicine.
FLATTENING THE LEARNING CURVE
Modern physicians face the ongoing challenge of learning the latest technologies and procedures, combined with the responsibility of delivering these new treatments safely during the care of their patients. Traditionally, a health care provider’s education begins with a textbook and, in most cases, progresses to hands-on learning in the form of animal testing or medical seminars. The gradual learning process then naturally and ultimately escalates when the physician begins delivering care to patients.
Today, however, as procedures and treatments become more technically demanding, the first time a physician may actually conduct a cutting-edge procedure or implement a new device could be on a patient in a clinical setting. The public—and the majority of physicians—would certainly feel more at ease if the steep learning curve required by most modern treatment methods could be flattened through the use of training scenarios. Medical simulation offers a training step at a level between textbook experience and the clinical case.
A recent study by Seymour et al provides a good example of the transfer of simulation to medicine.1 The findings highlight virtual reality training for gallbladder dissection performed by surgical residents. Results indicated that the VR-trained group performed this procedure 29% faster and made errors six times less frequently.
REALISM WITHOUT RISKS
Medical Simulation Corporation (Englewood, CO) is introducing a training system in a network of SimSuite Centers across the US. In these centers, complex cases can be practiced with realistic tools that sharpen the skills of nurses, medical residents, seasoned surgeons, and interventionalists, as well as other health care professionals. New techniques can be learned quickly and safely with no risk to patients. “You don’t want people practicing [for the first time] on patients. The medical profession—cardiology in particular—is extremely interested in measures that improve the quality of care,” says Spencer King, MD, Fuqua Chair of Interventional Cardiology at the Piedmont Hospital in Atlanta, Georgia.
In these state-of-the-art simulated clinical environments, hospital staff and the surrounding medical community can access a training system that includes three stages that take place in a preprocedure room, a procedure room that features a patient simulator, and a postprocedure room. The setting provides a realistic cath lab environment that features patented tactile force-feel technology and an artificial, interactive patient referred to as ?Simantha.? The simulated patient has a pulse and responds audibly, adding to the realism of the procedure.
DUPLICATION OF CARE FROM START TO FINISH
In addition to the interventional procedure, the complete process of caring for a patient is replicated. Cognitive decisions about the patient’s care are just as important as the procedure. The patient’s clinical presentation before the procedure includes a computerized display of symptoms, lab data, and other diagnostic test results. The practitioner then plans a workup for the patient and formulates a diagnosis. The training participants respond to author-driven questions intended to initiate critical thought processes that can affect the outcome of the procedure.
In the simulated case that I observed, the simulated patient complains of chest pain as her heart rate and blood pressure drop and she develops heart block. The physician treated the emergency situation with atropine and a pacemaker. He then manipulated the guide catheter, passed the wire into the patient’s right coronary, and deployed a stent to the target lesion. During the entire procedure, tactile and visual images added to the reality of the patient crisis. Finally, the simulated patient called out to the team that her chest pain was gone. The team sighed with relief and moved into the SimSuite Center postprocedure planning phase for this patient.
FACING DIFFICULT SCENARIOS SAFELY
This scenario, although simulated and relatively uncomplicated, was very realistic. However, not all cases go so well. Medical professionals are demanding that more difficult cases be made available by way of simulation training that educates physicians while posing no risk to patients. SimSuite training cases are based on actual patient cases authored by leading physicians, nurses, and technicians. The SimSuite courseware library offers cases that are diverse in disease state, anatomical variances, and other variables. During a case, the simulated patient’s unlimited reactions are dependent on the presenting illness, the actions taken by the medical team during the procedure, and author-scripted adverse events.
Medical simulation training allows health care professionals with varying levels of experience to prepare for crisis situations and also master new devices and procedures as they are introduced into the marketplace. In addition, the SimSuite training program encourages cohesive teamwork through its group approach to training. SimSuite Center participants can assess their performance with metrics captured by the system that can be compared to both local and national averages. These metrics can include procedure completion time, door-to-balloon time, radiation exposure, and contrast and equipment used.
TRAINING BEYOND REALISM
I recently watched a series of live interventional cardiology cases that were broadcast to more than 4,000 physicians attending the Transcatheter Cardiovascular Therapeutics (TCT) scientific session in Washington, DC. From the George Washington University Hospital, Gregg Stone, MD, Roy Leiboff, MD, and Jon Reiner, MD, announced that a patient had been urgently delivered to the cath lab for primary angioplasty for acute MI and that they would jointly perform a live intervention. The audience in the Washington Convention Center was captivated by the intensity of the procedure due to the high-risk nature of the patient’s deteriorating condition. The patient was apparently uncomfortable and suffering from chest pain, and there were sudden drops in blood pressure during the intervention. The moment of highest drama occurred when the patient developed ventricular fibrillation after reperfusion from balloon angioplasty. After successful defibrillation, Dr. Stone turned to the video camera and described the case he had just performed as the first live transmission of a simulated angioplasty case of acute MI at a TCT scientific session. The audience was stunned by the realism of the simulated complex angioplasty for a right coronary occlusion (Figure 1).
After the simulated case, my colleague Jon Reiner, MD, Director of the Cardiac Catheterization Laboratory at George Washington University Hospital commented, “The times that I’ve used the system, I noticed that my heart rate started to rise a bit as things happen in the cath lab. I had to remind myself that I was doing a simulation and not a procedure on a real patient.” The GW Medical Center plans to open a SimSuite Center in 2003. Other simulation centers are currently located at the Swedish Heart Institute in Seattle, Washington, (Figure 2) and at the Geisinger Medical Center in Danville, Pennsylvania. Up to 15 additional SimSuite Centers are expected to open during the next year according to Medical Simulation Corporation.
Nearly one thousand physicians and other health care professionals nationwide have evaluated the SimSuite Training System. The system has also played a key role in the completion of a number of landmark studies, including The Foundation for Advanced Medical Education (FAME) grant to create a model program for advanced training procedures; the Agency for Healthcare Research and Quality (AHRQ) grant to enhance the knowledge of innovative training procedures that contribute to patient safety; and the National Board of Medical Examiners (NBME) grant, which is a pilot study to develop a methodology for the assessment of professional skills using simulation training.
In this era of medical accountability and revelation of medical errors, simulation technology promises to enhance the training experience and help physicians reduce their mistakes. The expansion of training opportunities for peripheral vascular intervention is an important application. The societies most involved in peripheral vascular procedures, including vascular surgery, radiology, and cardiology, are exploring ways to use the simulation training experience as a bridge from didactic experience and textbook learning to the catheterization laboratory. Focused training experiences using simulation have been created and are under production for interventional procedures in the renovascular and iliofemoral vascular beds, as well as for carotid interventional procedures.
Simulation technology is poised to become the primary training platform of the future. According to the Institute of Medicine, as many as 98,000 people die each year from medical errors that occur in hospitals; simulation training could reduce this tragic complication rate. My colleague David Holmes, Jr., MD, Professor of Medicine at the Mayo Clinic in Rochester, Minnesota, put the value of simulation training this way, ?What needs to be realized is that the cost of a single tragic complication can far exceed the cost of the simulation training that may have prevented it.?
Daniel J. McCormick, DO, FACC, is Director of the Cardiac Catheterization Laboratory at Hahnemann University Hospital in Philadelphia, Pennsylvania, and author of an iliac artery stenting case for the SimSuite Training System’s courseware. Dr. McCormick may be reached at (215) 762-7776; firstname.lastname@example.org.
Gina Marone, MSN, RN-CS, is a Nurse Practitioner and former Clinical Manager of Cardiovascular Diseases at Hahnemann University Hospital in Philadelphia, Pennsylvania.
1. Seymour et al. Virtual reality training improves OR performance. Ann Surg. 2002:236:4(458).