Medical Modeling and Simulation Database

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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.