Medical Modeling and Simulation Database
American College of Surgeons

White Paper on Surgical Simulation

Why should a practicing surgeon, surgical faculty member/educator, surgical resident, surgical assistant, or indeed any medical student contemplating a career in surgery have an interest in the use of "simulation" in surgery?

As used here the term "simulation" covers the gamut of educational tools in medicine in which one item substitutes for another - everything from standardized patients where actors portray patients to inanimate models with which suturing and other motor skills can be practiced to mannequins that can portray signs and symptoms and have realistic physiology to computer-based procedural simulators on which laparoscopic procedures can be rehearsed to immersive virtual environments such as "The Virtual OR" in which multiple types of simulation are employed.

There are seven imperatives or driving forces that will ultimately require such interest in simulation. This web portal has been designed to provide essential information on simulation for the surgical community. Excerpts from seminal articles in the fields of medical and surgical education and simulation have been attached that succinctly capture both the challenges and opportunities presented to the ‘House of Surgery’ by the availability of this educational tool.

Reducing Serendipity in Education and Training First, there are an ever-increasing number of surgical procedures to be mastered by surgical residents in the finite timeframe that a residency constitutes; a timeframe that has been further constrained by the 80-hour work week limitation for residents and by an increasingly ambulatory patient population. The reason residencies are so lengthy is because the variability in training experiences is reduced the more time one spends in a residency training situation. For example, the likelihood a surgical resident will be faced with a particular surgical situation "x" increases as the time "t" spent in a residency is increased. Residency accrediting bodies increasingly want to ensure that each resident has had a specific portfolio of experiences during their training. Simulation affords the opportunity to provide a simulated experience for the resident should the genuine experience not happen to present itself during the time that the particular resident is on-duty. The result is that simulation provides a more uniform educational experience for the resident.

Practice and Rehearsal Without Patient Consequences Second, the use of simulation allows the individual to practice their procedures or skills in a non-threatening environment and multiple times under varying conditions thereby fulfilling the key tenet of the Hippocratic Oath which is to "first, do no harm". New visualization technology will make it possible for an individual to practice the particular operation or procedure they will perform multiple times on a volume-rendered three-dimensional, haptically-enhanced simulator that exactly matches the anatomy of the patient undergoing the procedure. Practice can continue until the individual feels comfortable with their skill level performing the procedure or until some pre-defined objective metric is achieved. In addition, simulation allows the introduction of team-based training opportunities and allows one to introduce such rare but challenging conditions as an electrical power outage during the simulated procedure.

Reducing Medical Errors Third, Institute of Medicine reports on patient safety, now several years old, have increased awareness that a significant number of medical errors occur each year by otherwise well-meaning practitioners and that of this number there are a large number of deaths that result from such errors. Simulation allows the deliberate practice of procedural skills to achieve a defined level of competency to reduce procedural errors and is increasingly allowing for the training of interdisciplinary teams to reduce errors related to the breakdown of communications among group members. Simulation also has the potential to identify and reduce errors that can occur within health care systems when, for example, a particular health system purchases two different models of patient care equipment, monitors for example, each of which operates somewhat differently, which can contribute to errors by users of the equipment.

Reducing Reliance on Animal Models Fourth, there has been an increasing ethical imperative in recent years to curb the use of animal models for medical training purposes as well as the use of human patients as "guinea pigs" as it were for the purposes of medical education. Publicity in recent years concerning medical device sales personnel performing medical procedures in the operating room, the increasing visibility of organizations such as the People for the Ethical Treatment of Animals and the patient advocacy and patient rights movements have all played roles in this area, as has the ever-increasing difficulty in obtaining a sufficient number of cadavers and other necessary body parts to support education and training. Simulation offers the potential for decreasing reliance on animal models and "practicing" on human patients in the medical education process.

Reducing Healthcare Costs Fifth, the percentage of the U.S. gross domestic product spent on health care services continues to grow and simulation can help temper this cost growth. Simulation offers the potential to improve utilization of operating rooms and a consequent reduction of costs by reducing the time it takes practitioners to perform procedures in the operating theatres. These time reductions will be the result of the efficiencies to be gained by rehearsing the procedures in advance utilizing simulation as discussed above. In addition, the field of anesthesia has already demonstrated that the use of simulation can reduce errors and subsequent malpractice liability. The use of simulation has been credited with a reduction in the cost of malpractice insurance for anesthesiologists.

Easing Introduction of New Surgical Procedures Sixth, simulation can speed the introduction of new surgical procedures, especially among those practitioners who no longer are in an active training environment. When new surgical procedures are introduced, such as was the case with laparoscopic cholecystectomy, it is often difficult for community practitioners to gain these new skills. Simulation could substantially shorten the learning curve for acquiring these new skills and reduce reliance on animal models.

Ensuring Career-long Procedural Competence Seventh, simulation offers the opportunity to incorporate a ‘hands-on’ component to recertification examinations that currently are paper and pencil based. The addition of simulation to the recertification process can provide added safety for the public and assurance that there has not been a degradation of the surgeon’s skills since they were initially trained.

Excerpts from the Literature

Medical Modeling and Simulation: The Problem

The apprentice model used to train physicians and healthcare providers has remained virtually unchanged for centuries.

--William F. Dunn, Simulators in Critical Care Education and Beyond, The Society of Critical Care Medicine; 2004:1-2.

The decision about how we learn is at a crossroads: we can continue to use the same methods we’ve used for centuries, or we can keep the best of the traditional methods and simultaneously leverage new technologies that we derive from the revolutions in computing and information technologies that are occurring in parallel with our own revolutions. We can invest in the science that will create revolutionary ways to learn, making our mistakes in realistic, but not real, situations where patients are not put at risk.

--Steven L. Dawson, A Critical Approach to Medical Simulation, Bulletin of the American College of Surgeons, 2002:87(11):12-18.

For many decades we have employed a model of educating physicians that emerged in the nineteenth century. We assume we know, and can impart during medical school, a finite body of facts that all medical students must know. Following medical school, we rely on an apprenticeship method, in which each succeeding cohort of residents is taught primarily by the one just ahead of it. We rely on "master clinicians" – the teaching attending physicians – to impart their clinical wisdom patient by patient, as the young physicians-in-training gather closely around.

--Mark R. Chassin "Is Health Care Ready for Six Sigma Quality?" The Milbank Quarterly, 1998;76:565-591.

However, the apprenticeship model is becoming increasingly difficult to sustain. As insurers reduce reimbursements to hospitals, senior doctors are under pressure to focus on revenue-generating work – treating sick people and conducting procedures – rather than on teaching. Moreover, in order to cut costs, operations and therapies that once took place over several days are now performed in a few hours, or in outpatient settings. As a result, students are spending less time with individual patients and have fewer opportunities to observe a case from diagnosis to resolution. Some life-threatening conditions, such as anaphylactic shock or a ruptured aortic aneurysm, occur infrequently enough that a trainee may become a licensed physician without encountering such disorders or mastering the skills to treat them. Health care may be unique among high-risk fields in that learning takes place largely on human beings.

--Jerome Groopman, A Model Patient, The New Yorker, May 2, 2005.

The skills required for the practice of modern procedure-based medicine are frequently so difficult to learn that traditional training is no longer acceptable, and learning on patients is increasingly suboptimal. Eleven years after Satava reported his vision of virtual reality for training procedural skills in minimally invasive surgery, this technology and proficiency-based training method are beginning to change the training paradigm in all of procedural-based medicine. Hereafter, physicians performing the procedure on patients for the first time will have a more homogeneous skill set, which will lead to safer, objectively assessed intraoperative performance. The ultimate goal is for this shift in procedural skills training to result in improved quality of care for patients.

--Anthony G. Gallagher and Christopher U. Cates, Approval of Virtual Reality Training for Carotid Stenting, JAMA. 2004;292(24):3024-3026.

The real world of patient care is one of scarce resources, enormous time pressure, increasingly complicated clinical problems, and high expectations for both the patients and the professionals. The best way to reduce the bite is to become more specific about what the standards of performance for the technologies should be, about the process of validating compliance with the standards, and about the effectiveness of applications, both in improved training and skills and in improved outcomes for the patient.

--C. Donald Combs, Analyzing the MMVR Research Space, Past Emphases, Future Directions, Medicine Meets Virtual Reality, 2003, IOS Press:36-41.

Traditional training methods for new [medical and surgical] procedures include performing the procedure on animals, cadavers, or mechanical models or supervised performance of the procedure on patients. Inherent problems with these traditional training strategies include the ethical and anatomical problems of training on animals, risks posed with repeated exposure to radiation, and the expense of consuming real medical devices.

--Anthony G. Gallagher and Christopher U. Cates, Approval of Virtual Reality Training for Carotid Stenting, JAMA. 2004;292(24):3024-3026.

Excerpts from the Literature

Medical Modeling and Simulation: The Potential

As computing power expands and the cost of simulation equipment falls, it is likely that most, if not all, surgical training programs will be devoting substantial curricular time to simulator-based training. Increasing evidence of the efficacy of ex vivo training, coupled with societal pressure, will probably mean that future residents will need to demonstrate proficiency in basic techniques before being allowed to operate on patients.

--Richard K. Reznick and Helen MacRae, Teaching Surgical Skills-Changes in the Wind, The New England Journal of Medicine, 2006:355(25):2664-2669.

For the first time in the history of medicine, they [simulators] offer the opportunity for the objective assessment of performance with standardized metrics in a safe and controlled manner.

--Mark W. Scerbo, The Future of Medical Training and the Need for Human Factors, Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting-2005.

The Committee believes that health care organizations should establish team training programs for personnel in critical care areas (e.g., the emergency department, intensive care unit, operating room) using proven methods such as the crew resource management techniques employed in aviation, including simulation.

--To Err is Human: Building a Safer Health System, Institute of Medicine, 1999.

While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.

--S. Barry Issenberg, et al, Features and Uses of High-Fidelity Medical Simulations That Lead to Effective Learning: A BEME Systemic Review, Medical Teacher, 2005:27(1):10-28.

Medical training must at some point use live patients to hone the skills of health professionals. At the same time there is an obligation to provide optimal treatment to insure patient safety and well-being…The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as a convenience of training.

--Amatai Ziv et al, Simulation-based Medical Education: An Ethical Imperative Academic Medicine, 2003 Aug;78(8):783-8.

The paradigm of medical education at each level of training and practice is shifting, causing the need to use alternative instructional methodologies. Simulation training is a viable alternative that allows the learner to obtain experience and skill prior to interacting with students in vivo. This training minimizes the risk to patients and limits the time and resources that are frequently expended through traditional training methodologies.

--Kathryn Mendoza and L.D. Britt, Minimally Invasive Surgical Simulation Training Center: Executive Summary, 2002.

Medical schools are redesigning their curricula and rethinking the nature of medical education. This transformation includes a greater emphasis on bioethics, patient-focused care, and the incorporation of the fruits of the medical-technological revolution. Although overreliance on technological medicine may sometimes be a threat to humanistic care, the proper use of simulation technology has the potential to enhance humanistic training in medicine. To optimize the use of SBME [simulation-based medical education] and overcome resistance by health professionals SBME trainers should be skillful in creating a receptive atmosphere, providing constructive feedback, and using video feedback and debriefing. Skillful use of SBME can use the intensity of simulated experience to nourish culture changes and support recognition of fallibility and areas of weakness.

--Amatai Ziv et al, Simulation-based Medical Education: An Ethical Imperative Academic Medicine, 2003 Aug;78(8):783-8.

High-fidelity simulation provides a promising opportunity for risk-free training in procedures and management of potential complications. While it does not replace clinical training, it does offer a means for mentored instruction in a realistic way, allows the interventionist to make procedural errors and then experience the consequences, and completely avoids the risks of patient injury and medico-legal liability associated with ‘hands-on’ training in a patient care setting. Our data support the contention that simulation is a valid tool for instructing surgical residents and fellows in basic endovascular techniques and should be incorporated into surgical training programs.

--Rabih A. Chaer, et al, Simulation Improves Resident Performance in Catheter-Based Intervention, Annals of Surgery, 2006:244(3):343-352.

Excerpts from the Literature

Medical Modeling and Simulation: The Reality

The paradigm has shifted. The robots are coming and simulation and objective assessment are here to stay. Information systems, robots, and simulators are being incorporated into the daily practice of surgery and perhaps the inevitable direction will be that every surgical procedure will automatically and continuously include rehearsal, training, recording, and assessment.

--Richard M. Satava, The Future of Surgical Simulation and Surgical Robots, Bulletin of the American College of Surgeons, March 2007:92(3)13-19.

At a public meeting in April 2004, an FDA panel voted to accept a proposal that virtual reality simulation would be an important component of a training package for carotid stenting…Trainees would learn catheter and wire handling skills on a high-fidelity virtual reality simulator until the trainees achieved a level of proficiency in didactic and technical skills.

--Anthony G. Gallagher and Christopher U. Cates, Approval of Virtual Reality Training for Carotid Stenting, JAMA. 2004; 292:3024-3026.

Dr. David Gaba recently persuaded Stanford to make simulation training – both scripted scenarios and mannequin practice – a requirement for medical students…

--Jerome Groopman, A Model Patient, The New Yorker, May 2, 2005

According to Dr. Daniel Jones, the chief of minimally invasive surgery at Beth Israel Deaconess, his hospital is the only one in the country to require surgical residents to demonstrate proficiency in simulated procedures in order to advance to the next year. The policy was instituted last year, after a campaign by Jones, who recently established a skills lab at the hospital which includes ten laparoscopic video trainers, a urological simulator, a gastrointestinal simulator, and two mannequins…one for use in anesthesia procedures, the other for trauma cases.

--Jerome Groopman, A Model Patient, The New Yorker, May 2, 2005

Anesthesiologists pay less for malpractice insurance today, in constant dollars, than they did 20 years ago…over the past two decades, patient deaths due to anesthesia have declined…one advance was the development of high-tech mannequins that allow anesthesiologists to practice responses to allergic reactions and other life-threatening situations. Anesthesiologists say the mannequins have also allowed them to become more proficient at performing an emergency procedure akin to a tracheotomy that involves slitting open a clogged airway – something a doctor can’t practice on live patients.

--Joseph T. Hallinan, The Wall Street Journal, June 21, 2005.

The Center for Medical Education and Innovation ™ is a 20,000 square foot state-of-the-art medical education and training facility located on the fourth floor of the McConnell Heart Hospital at Riverside [Methodist Hospital, Columbus, Ohio]. It replicates a hospital environment, from the scrub sinks to the equipment to the collaboration among healthcare professionals. The Center incorporates the most advanced, innovative medical simulation and education technologies available today and allows multidisciplinary training of medical professionals along the full continuum of care, from paramedics and emergency technicians to residents, nurses and attending physicians.

--HealthNet Newsletter, FITNE, Inc., Fall 2005.

Eastern Virginia Medical School