Simulation‐based surgical education in cardiothoracic training

Simulation has emerged as a feasible adjunct to surgical education and training for most specialties. It provides trainees with an immersive, realistic way to learn a variety of skills in a safe environment with the end goal of improving patient safety. There are three broad types of simulators: full mannequin simulators, part‐task trainers or bench models and virtual reality systems. This review aims to describe the current use of simulation in cardiothoracic surgical education and training. We identified multiple procedures that can be simulated in cardiothoracic surgery using a combination of the above simulators, three‐dimensional printing and computer‐based simulation. All studies that assessed the efficacy of simulators showed that simulation enhances learning and trainee performance allowing for repetitive training until the acquisition of competence but further research into how it translates into the operating theatre is required. In Australia, cardiac surgery simulation is not yet part of the training curricula, but simulators are available for certain tasks and procedures.     

Simulatortraining in der Anästhesie Möglichkeiten und Stellenwert

Simulation has gained an important role in medical education and continuing education in the field of anaesthesia and emergency medicine. This article gives background information on how full-scale simulators are applied in medical education as well as in continuing education for advanced anesthesia and scientific applications. Acceptance of training seems enhanced by inclusion of the human factor aspect, since this has proven to be a major source for the development of critical situations in our specialty. Furthermore, drawbacks of the simulators available and the current training availability in Germany is described.     

The current role of medical simulation in american urological residency training programs: an assessment by program directors

PURPOSE: Although medical simulation opportunities are increasingly available, resident training to date has involved primarily hands-on, subjective assessments. The role of simulation and computer based training for urology residents remains unknown. We evaluated the current status of medical simulation among urological training programs in the United States. MATERIALS AND METHODS: An anonymous questionnaire was developed and mailed to the program director at the 119 Accreditation Council for Graduate Medical Education accredited United States urology training programs, and consisted of 17 questions documenting the prior experience of the responder to medical simulation as well as the current status of simulation at their institution. An additional 14 questions sought the responders' opinion of medical simulation in urology training programs. RESULTS: The questionnaire was returned by 41 program directors (35%). Among respondents, access to a laparoscopy simulator was 76%. In comparison, reported access to cystoscopy, ureteroscopy, transurethral resection and percutaneous access simulators was 16%, 21%, 8% and 12%, respectively. Respondents indicated that these simulators were good educational tools, realistic and easy to use. Unanimous agreement was reported for simulation training in residency and that simulators allow practice in a controlled environment. Disagreement was reported about the cost effectiveness, validity and ability of simulators to replace hands-on instruction in the operating room. CONCLUSIONS: Among responders a high level of access to laparoscopic simulators for urology residents is coupled with low levels of access to other endoscopic trainers. Urology residency program directors unanimously recognize a role for simulation training in residency, although the extent to which they may be incorporated remains to be resolved.     

A comparison of the training value of two types of anesthesia simulators: computer screen-based and mannequin-based simulators

In this study, we compared two different training simulators (the computer screen-based simulator versus the full-scale simulator) with respect to training effectiveness in anesthesia residents. Participants were evaluated in the management of a simulated preprogrammed scenario of anaphylactic shock using two variables: treatment score and diagnosis time. Our results showed that simulators can contribute significantly to the improvement of performance but that learning in treating simulated crisis situations such as anaphylactic shock did not significantly vary between full-scale and computer screen-based simulators. Consequently, the initial decision on whether to use a full-scale or computer screen-based training simulator should be made on the basis of cost and learning objectives rather than on the basis of technical or fidelity criteria. Our results support the contention that screen-based simulators are good devices to acquire technical skills of crisis management. Mannequin-based simulators would probably provide better training for behavioral aspects of crisis management, such as communication, leadership, and interpersonal conflicts, but this was not tested in the current study. IMPLICATIONS: We compared two different training simulators (computer screen-based versus full-scale) for training anesthesia residents to better document the effectiveness of such devices as training tools. This is an important issue, given the extensive use and the high cost of mannequin-based simulators in anesthesiology.     

Simulation-based education for cardiac, thoracic, and vascular anesthesiology

Simulation has been used for medical teaching and testing for at least four decades in some form, such as that used for cardiopulmonary resuscitation training; however, new technology applied to medical and procedural training has recently led to a marked increase in the use of simulation-based instruction. Educational theory has further supported simulation for medical education and procedural training. Simulation-based testing to demonstrate competence with new procedures is already required by the US Food and Drug Administration for one angiographically-placed device, and it is likely that simulation-based credentialing for procedures will be increasingly prevalent. Anesthesiologists, like other physicians, may be credentialed or certified based on their performance in a simulated environment in the future. This review describes some of the current simulation-based education techniques related to cardiovascular and thoracic anesthesiology. Additional discussion covers some of the applicable educational theory and the expected future uses of simulation modalities in healthcare education, testing, and practice.     

The use of patient simulators in podiatric medical/surgical education

Patient simulators have made their mark in medical education, and will be a permanent, integral part in the training of medical specialties. Their scope will always be increasing and changing as technology keeps improving the quality and the sophistication of the simulators. Studies have shown that patient care and treatment has improved with the use of simulators, allowing true mental and physical confidence of the practioners before and during patient care. The role of patient simulators has increased in podiatric education, and will now become an integral part during podiatric college, podiatric residency, and most likely as postgraduate continuing medical education credits.     

Lehrveranstaltung Notfallmedizin am Universitätsklinikum Freiburg

Efforts to improve the quality of undergraduate medical education are commonly hampered by limited human and financial resources. This deficiency may be offset by the development of well structured and innovative teaching concepts, which optimize available assets. The newly conceived modular course "Emergency Medicine" at the University Medical Center Freiburg was conducted for the first time in the winter semester 2006/2007. The core of the course is a 3-day practical training period. It provides the possibility to teach a maximum number of medical students with only four lecturers using patient simulators, interactive case scenarios (simulation software MicroSim), and case scenarios with standardized patients. Evaluation of the course revealed standardized patients to be the best of all teaching methods with an overall average grade of 1.1 (patient simulators 1.2, computer simulation 1.4). Of the students, 88% stated that the practical training encouraged their interest in the speciality emergency medicine. The excellent student evaluation results show that the new course "Emergency Medicine" for medical students constitutes a successful balance between the constraint of resource limitation and the goal of excellent medical education.     

Computer-based endoscopy simulation: emerging roles in teaching and professional skills assessment

Advances in endoscopy simulation are reviewed with emphasis on applications in teaching and skills assessment. Endoscopy simulation has only been realized recently in a computer-based fashion because of advances in technology, but several studies have been performed both to validate computer-based endoscopy simulators and to assess their potential role in training. Multiple studies have shown that simulators can distinguish between clinicians at different skill levels and also have shown improvement in clinician skill, particularly at the early stages of training. This article summarizes those studies. The cost versus benefit of endoscopic simulators is also discussed, as well as the upcoming role of simulators in judging competence and as a tool in the credentialing process.     

Simulation in cardiothoracic and vascular anesthesia education: tool or toy?

The use of simulators in cardiothoracic and vascular anesthesia runs the gamut from standardized patients and part-task trainers to full-scale high-fidelity human patient simulators. The use of simulation to teach medical students, anesthesiology residents, board-certified anesthesiologists with subspecialty interests, hospital administrators, attorneys, and the lay public is still evolving as educational research evaluates the use of simulation and health professional educators struggle to define its role and value. This article provides a general overview of the field and attempts to critically evaluate what is and what is not scientifically determined about simulation and simulators.     

The training and careers of regional anesthesia fellows--1983-2002

BACKGROUND AND OBJECTIVES: The education and subsequent careers of regional anesthesia fellows have not been examined but may provide insight into improving future fellowship training and/or the future of the subspecialty. METHODS: Regional anesthesia fellows educated during a 20-year period (1983-2002) were asked to complete a comprehensive survey that detailed their training, current professional setting, and use of regional anesthesia, and how they foresee the future of regional anesthesia. A separate survey of academic anesthesiology chairs assessed the role of and need for regional anesthesiologists in teaching departments. RESULTS: Twelve regional anesthesia fellowship programs in the United States and Canada provided contact information on 176 former fellows. The survey response rate from those practicing in North America was 49% (77/156). Two of the 12 responding institutions have trained 68% of regional anesthesia fellows. Of respondents, 61% are or have been in academic practice. Regional anesthesia remains an integral part of most respondents' current practice, as evidenced by significant use of regional techniques, active involvement in subspecialty societies, and participation in continuing medical education programs. Academic chairs indicate that fellowship-trained regional anesthesiologists play important roles in resident education and are in demand by academic departments. CONCLUSIONS: This report details how regional anesthesia fellows from 1983 to 2002 were trained and how they currently practice and examines their insights regarding the strengths and weaknesses of past and future regional anesthesia education.     

The role of medical simulation: an overview

Robotic surgery and medical simulation have much in common: both use a mechanized interface that provides visual "patient" reactions in response to the actions of the health care professional (although simulation also includes touch feedback); both use monitors to visualize the progression of the procedure; and both use computer software applications through which the health care professional interacts. Both technologies are experiencing rapid adoption and are viewed as modalities that allow physicians to perform increasingly complex minimally invasive procedures while enhancing patient safety. A review of the literature and industry developments concludes that medical simulators can be useful tools in determining a physician's understanding and use of best practices, management of patient complications, appropriate use of instruments and tools, and overall competence in performing procedures. Future use of these systems depends on their impact on patient safety, procedure completion time and cost efficiency. The sooner simulation training can be used to support developing technologies and procedures, the earlier, and typically the better, the results. Continued studies are needed to identify and ensure the ongoing applicability of these systems for both training and certification.     

Simulation

Simulation is an established instrument for medical training and further education covering technical and non-technical skills. It provides a platform for training psychomotor skills and professional behavior. Various simulators have been developed for cardiac, thoracic, and vascular surgery. Skill trainers are described for heart valve surgery and coronary anastomoses. Even beating artificial hearts are commercially available for surgical training, besides classical animal models. Virtual reality provides an additional dimension for training in thoracoscopic and interventional surgery. Every simulator has to be embedded in a defined curriculum to achieve the optimal effect. Curricula in the form of courses may be more effective in teaching basic surgical skills than learning solely during patient treatment in the operating room. One popular method to facilitate simulators for education is scenario training in real time. International associations recommend the implementation of scenario simulation for emergency training and evaluation of surgical skills in various disciplines. Issues, such as communication, team leadership and decision making can be effectively trained by simulation scenarios. There are only a few but fundamental publications providing evidence that simulation has a positive effect on patient care during cardiac surgery and on intensive care units; however, simulation can never replace experience in real patient care. Especially inexperienced healthcare providers have a tendency to overestimate their competence after training by simulation. Simulation is therefore a valuable adjunct but not a substitute for medical training and further education.     

Lehre und Simulation

Since 1st October 2003 the new German "Approbationsordnung für Arzte" (Medical Licensing Regulations) requires an increasing amount of small group teaching sessions and encourages a multidisciplinary and more practical approach to the related topics. In 2004 the German Society of Anaesthesiology and Intensive Care Medicine has provided almost all anaesthesia faculties of German Universities with equipment for full-scale simulation. This article describes methods for a simulation-based medical education training program. Basic requirements for a successful training program using full scale simulators are the provision of an adequate logistical and material infrastructure, teacher attendance of train-the-trainer courses, implementation in the medical curriculum and an instructor-student ratio of 1:3, equivalent to that for bedside teaching. If these requirements were fulfilled, medical students scored the simulation scenarios "induction of anaesthesia", "acute pulmonary embolism", "acute management of a multiple trauma patient" and "postoperative hypotension" as 1.5, 1.6, 1.5 and 1.5, respectively, on a scale of 1-6. These scores were better than those given for other segments of the curriculum.     

Anaesthesia and education

A literature review was undertaken to document the status of anaesthetic education in both the peer-reviewed anaesthesia and medical education literature. A search was performed using Silver Platter for the period 1983-91, and the most widely circulated medical education and anaesthesia journals in North America were reviewed in detail. Although anaesthetists are involved in many educational activities, the literature is oriented towards postgraduate training. Common issues include the assessment and selection of residents. Newer methods of evaluation, for example, daily assessment by preceptors, have been described, but work continues to be needed on these and older methods, such as oral examinations. Selection processes may be improved by incorporating psychological and psychomotor measures in the assessment process. A limited number of teaching methods, especially simulators, have been the focus of much interest, while other methods, such as bedside teaching, have received little attention. Programs of recertification or maintenance of competence, which have been announced by certifying bodies, may place new emphasis on the study of the design, effectiveness, and outcome of continuing medical education. In conclusion, the review revealed that there are many opportunities for anaesthetists to conduct educational research into many traditional and new areas of medical education.     

Computer-based simulator for training in gastrointestinal endoscopy

The concept of a simulator as a training tool is well established, notably in aviation. Skills in gastrointestinal endoscopy mainly depend on experience and are routinely acquired by practicing on patients, initially under supervision of a senior endoscopist. Increased public's attention to medical errors, the legal and ethical issues, the progress in computer technology, the continuous introduction of new endoscopic techniques, and the changes in medical practice that limit patient availability,--all are forcing us as educators to rethink previously established principles and to use endoscopy simulators with the aim to teach fundamental endoscopic skills in a risk-free setting, away from the patient. This article reviews currently available endoscopy computer-based simulators and their potentially role in digestive endoscopic training.     

Medical simulation: Overview, and application to wound modelling and management

Simulation in medical education is progressing in leaps and bounds. The need for simulation in medical education and training is increasing because of a) overall increase in the number of medical students vis-à-vis the availability of patients; b) increasing awareness among patients of their rights and consequent increase in litigations and c) tremendous improvement in simulation technology which makes simulation more and more realistic. Simulation in wound care can be divided into use of simulation in wound modelling (to test the effect of projectiles on the body) and simulation for training in wound management. Though this science is still in its infancy, more and more researchers are now devising both low-technology and high-technology (virtual reality) simulators in this field. It is believed that simulator training will eventually translate into better wound care in real patients, though this will be the subject of further research.KEY WORDS: Simulation, wound management, wound modelling     

Standardized patients and mechanical simulators in teaching and assessment at colleges of osteopathic medicine

CONTEXT: A 2001 survey of 19 colleges of osteopathic medicine (COMs) revealed that standardized patient programs (SPPs) are increasingly used in osteopathic medical education. However, no new data have been published since. OBJECTIVES: To evaluate current SPP and mechanical simulator use at COMs compared with previous survey results. METHODS: In 2005, an electronic survey regarding the use of SPPs (eg, staffing, facilities) and mechanical simulators in the teaching and assessment of students' clinical skills was sent to the deans of the 23 fully accredited COMs and branch campuses. RESULTS: Responses were received from all 23 COMs for a 100% response rate. According to survey results, 19 COMs (87%) had active SPPs, 2 COMs (9%) reported that SPPs were in development, and the remaining 2 COMs (9%) used students as patients. In comparison, only 12 COMs (63%) in 2001 had active SPPs. Results indicated an increased use of standardized patients for assessment, particularly in physician-patient communication, osteopathic manipulative medicine, and osteopathic manipulative treatment. In addition, 12 COMs (52%) reported using mechanical simulators in the teaching or assessment of clinical skills. CONCLUSION: From 2001 to 2005, the use of SPPs and mechanical simulators at COMs increased substantially.     

Are surgery training programs ready for virtual reality? a survey of program directors in general surgery

BACKGROUND:

The use of advanced technology, such as virtual environments and computer-based simulators (VR/CBS), in training has been well established by both industry and the military. In contrast the medical profession, including surgery, has been slow to incorporate such technology in its training. In an attempt to identify factors limiting the regular incorporation of this technology into surgical training programs, a survey was developed and distributed to all general surgery program directors in the United States.

STUDY DESIGN:

A 22-question survey was sent to 254 general surgery program directors. The survey was designed to reflect attitudes of the program directors regarding the use of computer-based simulation in surgical training. Questions were scaled from 1 to 5 with 1 = strongly disagree and 5=strongly agree.

RESULTS:

A total of 139 responses (55%) were returned. The majority of respondents (58%) had seen VR/CBS, but only 19% had “hands-on” experience with these systems. Respondents strongly agreed that there is a need for learning opportunities outside of the operating room and a role for VR/CBS in surgical training. Respondents believed both staff and residents would support this type of training. Concerns included VR/CBS’ lack of validation and potential requirements for frequent system upgrades.

CONCLUSIONS:

Virtual environments and computer-based simulators, although well established training tools in other fields, have not been widely incorporated into surgical education. Our results suggest that program directors believe this type of technology would be beneficial in surgical education, but they lack adequate information regarding VR/CBS. Developers of this technology may need to focus on educating potential users and addressing their concerns.     

Surgical Robotics in Urology: Robotic Assisted Radical Prostatectomy

Although the applications of robotics in urologic surgery are believed to be great, robotic surgery is presently in its infancy. Experience from our institution and others are increasingly showing the benefits of robotic assistance for not only feasibility, but in cancer, functional and quality of life outcomes. Increased use and training will further the frequency of robotic surgery. Moreover, application to teaching with simulators as well as emerging technology will undoubtedly increase utilization of this technology.⁷