The Benefits of Simulation Training for Fellows and Residents
Long used in aviation, simulation technology is emerging as a key component of graduate medical education programs.
As an endovascular surgeon in an academic practice, I am keenly interested in how to best train physicians to perform endovascular procedures. From my own professional involvement in aviation and aerospace medicine, I was aware of the value of simulation for complex technical training. More recent experience with new commercially available endovascular procedure simulators has demonstrated their value in the clinical training of fellows and residents.
After completing a fellowship in vascular surgery, I began service in the US Air Force (Figure 1). My military vascular surgery practice was fairly conventional at first, but I later became involved in planning and operational support for special teams that provided sophisticated medical care in remote settings. These teams were always seeking ways to improve training. The use of patient simulators for trauma and critical care training was introduced in the late 1990s, with positive results. Also, through my involvement in aerospace programs and participation as a flight crew member, I gained familiarity with aircraft simulators (Figure 2). Later, in a tour of duty with the National Aeronautics and Space Administration (NASA), I found myself in a culture that viewed simulation as an integral part of training. Simulation could be as simple as using a desktop teaching aid or as complex as a full-scale mission simulation, but it was incorporated every day.
When, as an experienced vascular surgeon, I sought training in endovascular procedures, I completed a 3-month “mini-fellowship” with an experienced endovascular surgeon. Despite the mentoring in angiography, peripheral intervention, and endovascular aortic aneurysm repair, I recognized some shortcomings of the traditional training model. For instance, I would have liked to practice a broader range of procedures and more complex cases. I wanted more, but had limited time to get it. From my previous experience, I knew the value of training through simulation, and I was convinced that it could play an important role in training specialists to perform endovascular procedures.
Medical simulation systems (Figures 3 and 4) allow physicians to gain experience and confidence in a realistic, safe environment, while providing the opportunity to practice a number of technical and problem-solving skills in a short period of time. For example, one can perform selective catheterization of a renal artery again and again, each time with a different type of catheter. Simulation also provides more opportunity to encounter and manage complications, such as stroke or other intraprocedural problems that are not commonly seen in clinical practice. Furthermore, simulation introduces layers of physiologic complexity—such as high blood pressure—that trainees need to monitor and treat medically. Even for experienced interventionists, simulation can be a tool to help refine techniques, practice on challenging anatomy, or to learn new tricks for managing specific situations. For the junior residents and students, simulation offers a chance to observe firsthand what happens during a procedure, thereby improving their situational awareness, and perhaps sparking a career interest.
TRAINING THE NEXT GENERATION OF
In conjunction with the Medical Simulation Corporation (Denver, CO), the University of California Davis Medical Center (UCDMC) Division of Vascular Surgery created a simulation-based training program to provide vascular surgery fellows with hands-on training on a variety of endovascular procedures, including diagnostic arteriography, angioplasty, and stenting. SimSuite® (Medical Simulation Corporation) at UC Davis Center for Virtual Care is a state-of-the-art simulated facility made up of a preprocedure room where patient selection, diagnostics, and preparation are provided with computer-based interactive presentations; a procedure room that features an interactive, high-fidelity patient simulator; and a postprocedure room where patient issues and case outcomes are debriefed.
The goal of our pilot program in 2004 was to determine if SimSuite® was an efficient method to train fellows and residents who are starting endovascular training, but have little experience. Thirteen physicians who were either in or entering vascular surgery residencies and two program directors participated in the training program. Intensive 1.5-day sessions with two to four participants each offered a highly focused experience. Upon completion, participants were asked to fill out detailed questionnaires evaluating their simulation training. According to their assessments, endovascular simulation was found to be a useful adjunct to traditional teaching methods and clinical experience. On the basis of the pilot program’s positive feedback, a training program for vascular surgery fellows in Western US programs was initiated in 2005.
In the endovascular operating room, a fellow or resident working on a case is very closely supervised. They benefit from the attending physician’s coaching and feedback, but may not have opportunities for independent decision-making and problem-solving. Simulation encourages learning by doing. During a simulation, learners are encouraged to independently plan and carry out each step of a procedure. They may encounter problems with catheter positioning, guidewire placement, or difficulties in selecting balloon size—challenges they may not have faced in the OR. Errors in case simulations highlight certain problems that the trainee may not have appreciated, such as the need to think about procedures in an organized way and the need to plan ahead. Simulation may also reveal bad habits, such as the excessive use of fluoroscopy.
Although simulation takes place in a risk-free environment, it is not a stress-free environment. Something as simple as having the mentoring physician stand quietly behind the trainee, observing the simulated procedure, can introduce a level of stress that helps the trainee accept the reality of the exercise (this is a concept known in the “simulation world” as “suspension of disbelief”). Learners engage seriously and act as they would in a clinical situation. Simulation gives residents and fellows an opportunity for an earlier transition into some of the critical-thinking paths that are necessary for safe and effective practice in the interventional suite or OR.
Simulation is quickly becoming a mainstream teaching tool in endovascular therapy. Carotid artery stenting (CAS) is the first medical procedure for which simulation training is an established prerequisite. When the FDA approved CAS, it specified that training programs had to accompany the marketing of the devices. All of the approved training programs have incorporated simulation because of its practicality and hands-on approach. Additionally, many CAS training programs are CME-accredited and may support hospital credentialing requirements.
Medical simulation has an exciting future. Years from now, there may be patient-specific simulations, in which surgeons will be able to train on simulated anatomy derived from an individual patient’s CT, MR, or angiographic data. Even more realistic simulators and more complex cases will likely be developed.
Although medical simulation will never replace clinical experience, it is becoming accepted as an educational tool with the potential to make physician training safer and more efficient.
David L. Dawson, MD, is Associate Professor, Division of Vascular Surgery, University of California Davis Medical Center in Sacramento, California. Dr. Dawson may be reached at email@example.com. SimSuite is a trademark of Medical Simulation Corporation.