MEdSim Magazine - Issue 1/2012

www.halldale.com The Journal for Healthcare Education, Simulation and Training

SURGICAL TRAINING

Surgical Education, Research, and Business Design MEDICAL SCHOOL EDUCATION AND TRAINING

Revolutionizing 21st Century Medical School Curriculum NURSE EDUCATION PROGRAMS

Learning Technology: Benefits and Challenges MEDICAL SIMULATION CENTERS

Medical Simulation Centers Work to Advance Medical Education

ISSN 2165-5367

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Issue 1/2012

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PUBLISHER’S STATEMENT

and communication skills are key abilities that must be taught and practiced, until deeply ingrained."

On the cover: Florida Hospital's da Vinci robotic surgical systems in the operating room.

Image credit: Florida Hospital.

population pyramid is top heavy and will become more so in the next twenty years providing many more ‘customers’.

In 1993 I was the subject of a laparoscopic procedure and already being involved in simulation I was curious to find out how training was performed using this new and different technique. I was not impressed by what I found and saw over later years at various conferences. Launching this magazine became a (long term) passion.

Thankfully there does now appear to be a real widespread desire and intent to transform healthcare education and training. It is much needed and there is no doubt that simulation will play a key role.

Surgical technologies, or ‘disruptive surgical technologies’ such as laparoscopy and robotics will also change the way in which care is given. Perhaps these practices will be a part of a technology contribution similar to that from which the airlines benefited. These ‘man machine interfaces’ in surgery readily lend themselves to simulation, in fact they demand it, as do the new breed of physicians who will deploy them.

I very much hope that you find this first edition of MEdSim a valuable read and I hope that we can help the healthcare industry transform its training as it strives to improve patient safety. We are not a simulation company though we are all convinced of its ability to improve training but as a simulation company colleague recently said, “it’s not the simulation, it’s the curriculum”.

Buying a simulator or two will not help you much unless it is fully integrated into a new curriculum. MEdSim, as its strap line states, will look at education, simulationand training. We hope to hear from you as we continue to develop the publication.

My editorial colleague on CAT magazine uses the salutation ‘safe travels!’.

Perhaps our salutation should be, Safe caring!

Andy Smith Publisher, MEdSim

andy@halldale.com

03 MEdSim Magazine

" ... leadership

In 1980 I attended an airline training symposium at which it was stated that if the current rate of accidents per thousand take offs was extrapolated in line with expected growth over the next twenty years, with no improvements to safety, the global industry could expect an accident a week by the early 2000’s.

What that would have done to the growth of the airline industry was easily understood and as we had just been approached by a group of airlines and existing clients to produce an airline training magazine (now CAT) I also ‘got it’. That scenario did not play out and in recent years the airline industry has been able to claim the lowest ever incident rates.

Broadly, the reasons for this major success were two fold, first massive improvements in aircraft and airline technologies. Second a transformation in training, specifically moving from training on the aircraft to training on devices like the full flight simulator. Today a pilot’s first flight in any commercial aircraft is with a full load of passengers aboard. The quality of flight simulation is hyper realistic.

Healthcare simulation and more specifically, surgical simulation is not yet at that happy state. It should be there in under a decade, at which point the surgeon’s first experience with a human patient should be as a fully trained ‘proficient or expert’ practitioner. The practice portion of the career will have been completed in training.

There are further similarities between the healthcare professions and the airlines.

Both face the same demographic problems, both face restrictions on work hours, both enjoy continually changing technologies, and sadly, both face a lack of interest in the job from the ‘brightest and best’ whose attention,up until now, they have enjoyed.Both are also driven by dedicated teams who must work together to achieve full success. Therefore leadership and communication skills are key abilities that must be taught and practiced, until deeply ingrained.

On the bright side, perhaps, both expect tremendous growth rates in the next twenty years, indeed for the healthcare sector that is unavoidable. The

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MEdSim Magazine and Training Transformation

Editorial Comment

Editor's Comment

" While the practice of medicine has changed tremendously over the past 100 years, medical education has remained

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relatively static."

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Medical education in the US and Canada has undergone major changes since 1910, when educator Abraham Flexner published his evaluation of 155 medical schools. His report, addressed primarily to the public, helped change the face of American medical education. It is sad to note that the number of medical schools in the US and Canada has not grown significantly since Flexner’s time while the population who need medical care has tripled.

While the practice of medicine has changed tremendously over the past 100 years, medical education has remained relatively static. Many medical schools still rely heavily on lectures and give tests that require the memorization of facts. Medical knowledge continues to grow and the successful practice of medicine is now more than ever a team effort. By failing to adjust to the advancing medical landscape, medical education – and medical care – have suffered. As a result, many international groups, including the World Health Organization (WHO), patient safety groups and others have sounded a call for healthcare transformation. At the annual Association of American Medical Colleges (AAMC) meeting held last November the theme was “the transformation of medicine.”

A report published by the AAMC’s Workforce Studies Group in August, 2011, shows state-by-state shortages and the states’ task force recommendations to lessen the problems. Even with these recommendations the U.S. faces a severe shortage of healthcare personnel over the next 20 years. In light of these shortages the AAMC has called for a 30 percent increase in enrollment or about 5,000 more doctors per year.

Since the Institute of Medicine released Crossing the Quality Chasm in 2001, and Elizabeth McGlynn and colleagues released the Rand quality care index in 2003, there has been a significant shift in our views of providing quality care. Medical associations, organizations and schools are addressing curriculum reform, students learning styles, the use of simulation, residency requirements and cost issues. They don’t believe that we can fix our quality or patient safety issues without addressing medical education reform.

Educating Doctors to Provide High Quality Care: A Vision for Medical Education in the United States released in 2004, was written by a committee comprised of 10 leading U.S. medical school deans and commissioned by the AAMC Institute for Improving Medical Education (IIME). They concluded that the quality of medical education will improve only if each of the components of the country’s medical education system – medical schools and teaching hospitals, accrediting bodies, certifying bodies, licensing authorities, and professional societies and organizations – is committed to making progress toward achieving an ideal medical education system that provides excellent medical education throughout a physician’s career. They recommended that graduation/promotion and accreditation, as well as licensure be based on evaluation and documentation of achieved learning objectives through early clinical exposure and interdisciplinary teamwork, integrating medical school content into pre-med programs and integrating some medical residency requirements into medical school curriculum to ensure acquisition of knowledge, skills, attitudes, values, and ability.

A number of medical schools have or are revising their curriculum to incorporate the recommended guidelines. In the last decade, medical schools increasingly have incorporated technology and expanded instruction through the use of medical simulation. Medical simulation is becoming commonplace in clinical education and teaching hospitals and will increasingly be used as an assessment tool to ensure that medical professionals have acquired and are proficient in the necessary skills.

MEdSim is designed to promote the most advanced education, simulation and training practices and highlight innovative curriculum, new training technologies, patient safety advances and healthcare strategies that address many of the above deficiencies and improve the practice of medicine.

As my colleague and publisher suggested: Safe Caring, or Good Health!

Judith Riess Editor in Chief, MEdSim judith@halldale.com

CONTENTS

MEdSim Magazine The Journal for Healthcare Education, Simulation and Training

Editorial

Editor in Chief Judith Riess, Ph.D. e. judith@halldale.com

Group Editor Marty Kauchak

e. marty@halldale.com US & Overseas Affairs Chuck Weirauch e. chuck@halldale.com US News Editor Lori Ponoroff e. lori@halldale.com RoW News Editor Fiona Greenyer e. fiona@halldale.com

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03 PUBLISHER’S STATEMENT Publisher & CEO Andy Smith states his vision to have MEdSim help the healthcare industry transform its training as it strives to improve patient safety.

04 Editorial Comment Editor in Chief Judith Riess discusses the rapidly evolving state of the art in medical education and introduces the community to MEdSim.

06 MEDICAL SCHOOL EDUCATION AND TRAINING Revolutionizing 21st Century Medical School Curriculum. Drs. Rosen, Geiling and Henderson discuss how information technology, especially simulation, can help develop new medical school curricula and revolutionize health care delivery.

10 MILITARY LEADERSHIP INSIGHTS An interview with Colonel Patrick R. Storms, M.D., United States Air Force, Chief of Medical Modernization, Air Education Training Command.

13 ACQUISITION AND ASSESSMENT STRATEGIES Optimal Acquisition and Asessment on Simulators In Surgery. Dimitrios Stefanidis, MD., describes how simulator curricula can optimize skill acquisition and learner readiness for success in the operating room.

16 COMMUNITY LEADER INTERVIEW An interview with Monica Reed, M.D., CEO Florida Hospital Celebration Health.

18 NURSE EDUCATION PROGRAMS

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise – especially translating into other languages – without prior written permission of the publisher. All rights also reserved for restitution in lectures, broadcasts, televisions, magnetic tape and methods of similar means. Each copy produced by a commercial enterprise serves a commercial purpose and is thus subject to remuneration.

MEdSim Magazine, printed January 2012, is published 4 times per annum by Halldale Media, Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA at a subscription rate of $25 per year.

MEdSim is distributed in the USA by SPP 75 Aberdeen Road, Emigsville PA 17318-0437. Periodicals postage paid at Emigsville PA. POSTMASTER: send address changes to: Halldale Media Inc., 115 Timberlachen Circle, Ste 2009, Lake Mary, FL 32746, USA.

Surgical Education, Research, and Business Design. The Nicholson Center is dedicated to the learning, science and business of medicine, reports Roger Smith, Ph.D. 26 MEDICAL SIMULATION CENTERS Chuck Weirauch examines medical simulation centers’ efforts to advance medical education.

29 CONFERENCE REPORT Surgicon – The 1st World Congress on Surgical Training.

30 MEDICAL SIMULATION CENTERS SiTEL, Our Newest Simulation Center: CSC DC. 32 NEWS Medical News. Updates from the medical community. Compiled and edited by the Halldale editorial staff.

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05 MEdSim Magazine

www.halldale.com/medsim

Learning Technology: Benefits and Challenges. Marty Kauchak looks at the nursing community’s efforts to use learning technologies in its education programs.

MEDICAL SCHOOL EDUCATION AND TRAINING

Revolutionizing 21st Century Medical School Curriculum Drs. Joseph Rosen, James Geiling and Joseph Henderson discuss how information technology, especially simulation can help develop new medical school curricula and revolutionize health care delivery.

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O

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ne hundred years ago Abraham Flexner introduced a radical new approach to medical education and prioritized the nature of medicine as a service to the public. At that time he used the introduction of the physical sciences in combination with a novel educational method to revolutionize medical education in America and ultimately raise the overall quality of care in the U.S. We are again at a similar time where the introduction of information technologies such as simulation can revolutionize medicine. However for this to work the basic paradigm, the educational process must mirror the changes coming in the delivery of care. One without the other will not work just as it was with the combination one hundred years ago. Flexner changed the methodology of education of physicians and clearly defined the goals of the contract between the physicians and society. The key element to success is a new kind of physician trained and educated with tools for the 21st century. This will not change the

fundamental contract between the physician and the patient. It will rather enable the physician to once again provide personal care in a direct manner to the patient as close to their home as possible in an economically feasible manner. We have clearly drifted in the past one hundred years from a system that held the contract to the service to the public as its cornerstone to a system that has fallen into disrepair.

We now have the opportunity to use technology to improve many parts of the system. We need to enable the physician to use evidence-based medicine to deliver the right care to the patient based on the best clinical research information available. Telemedicine, augmented by imaging technologies and robotics, can give the physician tools to enhance medicine. We need to use simulation to train the physician. Simulation in addition to the ability to revolutionize medical education can be used as a performance enhancer to interface between the physician and the patient to improve the quality of care. Other technologies

Above The new medical school at the University of Central Florida (UCF) will begin to transform medical education.

Image credit: UCF College of Medicine.

like the surgical robot can create “no fly zones� that prevent the surgeon from doing harm. But the same paradigm can be applied across medicine for the prescription of drugs to the delivery of basic care and information.

The seed for this paradigm shift must begin in medical school education as it did with Abraham Flexner. This unique contract between the patient and the provider that was clearly stated by Flexner remains today but is embattled by 21st century demands. These include increasing documentation, diminishing reimbursements; physicians need to do more in less time, an overwhelming flood of research to be accessed and limits on face time with the patient.

Each of the technologies that are required for this paradigm shift has been

Before trying to understand how technologies can revolutionize medical education, it is best to review briefly the present approach to medical education. Through this exercise we can then better look at how newer technologies like simulation will play a key role in revolutionizing both medical education and the practice of medicine. Present medical education can be seen as a process that includes lectures, labs and small groups, standardized patients and in some cases the use of mannequin simulators. Key studies have been done with respect to lectures and one on one teaching. In some cases lectures augmented by technology can come close to one on one teaching. Much of this work has been done at the Institute for Defense Analysis (IDA) and also exists in prior NASA studies.

The present system of medical education presents many challenges. These challenges limit our ability to provide a satisfactory education experience for medical students to become physicians.

The challenges are: • Emphasis on knowledge and skill over critical thinking, decision-making and teamwork; • Limited integration of the basic and clinical sciences; • Emphasis on lecture-based teaching methods; and • Not appealing to “digital natives” A physician has a complex task of diagnosis and treatment in a chaotic environment where information is often inadequate, not readily available, or inaccurate. The physician has to perform a task that is dependent on integrating many sources of information that span different disciplines, cross geographic areas, and stretch across time barriers.

There are tools to improve critical thinking and decision-making that have not been adequately applied to medicine.

There is little training done in teamwork or team building especially when collaborating across disciplines, organizations or continents to meet these challenges.

Future Solutions Today Using Information Technology Each of the technologies discussed needs to be woven into the fabric or tapestry of a new healthcare delivery system. Often these technologies will not have true value added in the present healthcare system. Their value added will have to wait to be fully assessed until we make the leap to a future system of care. Also many of the technologies listed below will be integrated into one platform for the provider and patient. The portal for this platform should be able to recognize the user and prepare the information for the user to be at the proper level for their understanding.

These technologies need to be part of an integrative curriculum (courtesy of University of Central Florida Medical School).

- Simulation and simulators for training to include: high fidelity, virtual real-

ity, mannequins, computer based system, interactive media; - Knowledge Based Systems for cognitive task analysis and-complex adversarial reasoning; - Telemedicine and network based care including robotics, home care systems and imaging systems; - Evidence Based Medicine such as information retrieval systems, medical library systems and hand held portals; and - Electronic Medical Records, electronic health records and computer patient records.

Each technological domain plays a role – no single technology is pre-eminent. However the technology that best bridges from education to delivery of care will be simulation. Simulation provides a number of advantages: • Accelerate development of expertise, self-confidence and motivation; • Create connection of knowing and doing; • Enable frequent practice and feedback; • Foster teamwork; and • Improve assessment.

Newer technologies like simulation will play a key role in revolutionizing both medical education and the practice of medicine. To look at simulation as only a method to educate will be a fatal flaw in the process needed to improve the delivery of care. Simulation should be seen as an environment in which the provider/s understand the overall disease process, the life cycle of the patient, and then specifically deals with incidents that arise in the life of the patient that interrupts the normal course of their health and affairs.

The following types of simulators can be used to improve medical education: animations, part-task trainers, gameand computer-based systems, individual and team scenarios using mannequins, standardized patients, computerized cases and virtual reality.

When considering this functionality of this integrated curriculum we should consider the two basic methods that we provide care to the patient. Understanding these two models of care is key to understanding the revolution in medical education that has to come into place in the 21st century. In one model we see the practice of medicine as lifecycle care. This is the long term care model. It best incorporates preventive medicine and lifestyle changes. The other model

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Present Medical Education and Training

There are several approaches to overcoming these challenges. The key is the limitation of the present curriculums and how they are organized. The present curriculum is not integrated around patient care. The present curriculum is rather Balkanized among various groups competing for time and space in the routine four years of medical education. Therefore the present curriculum is a clear barrier to major change. In the present curriculum most education is not patient centric but rather it is tissue centric in anatomy, or disease centric in pathology, or specialty centric in medicine. Among all of these competing demands for funding from the institution and time with the medical students there is a crisis. Within a medical school the medical students’ needs are often not prioritized at the top of the list but rather come after the faculty, the researchers, and many other stakeholders.

We need to connect the curriculum of medical school to the delivery of care.

The curriculum in a sense is a template for how a physician will provide care during his/her career. There should be a natural relationship between what is learned in medical school and the process of providing care. This is not present in today’s curriculum. The first step forward is to integrate the curriculum; use simulation and technology as a tool; use computerized cases and centralize knowledge management tools.

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developed over the past 50 years in their respective fields and domains. They now have to be put together into a new fabric of medical care and delivery that ensures patient safety through the use of simulation and other technologies.

MEDICAL SCHOOL EDUCATION AND TRAINING

that is generally used in practice is incident care or acute care episodic intervention. Incident care is the treatment of a particular problem as it interrupts the health of the individual. Both models are important and over time it is best to shift from an incident approach to a life cycle approach. However both methods will almost surely continue to play a critical role. And we need to always consider when we fund healthcare how we support each of these unique approaches.

UCF Medical School – an example of best practices As stated, it would be easier to start the revolution with a clean slate. There are a number of medical schools in the US beginning to do this. One of the best examples is the medical school at The University of Central Florida (UCF) under the direction of Debra German, M.D., Dean of the new medical school that will begin to transform medical education. As a template for change we can use her model to explain how medical education can be built on a new paradigm; how medical students trained in this new paradigm will be better prepared for a new healthcare system that will evolve in the 21st century. Dr. German provides three examples in her approach to medical education that are key components to her integrated curriculum: these include the use of web portals, immersive experiences and computerized cases.

The best way to explain what will be introduced in Orlando is to walk through the four years of medical education for a student at UCF and then map this onto patient care and see it through how it will enable the future physician to perform their social contract throughout their career.

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The Way Forward – Future after Next

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By using simulation in medical education we will lay the ground work for a fundamentally different approach to problem solving in medicine. This will not only include the practice of medicine but will also reach into research. The key piece as discussed above involves the nature of knowledge management. Ultimately medicine is about knowledge management. There are other fields that have moved ahead of medicine in knowledge management and it is important for us

to use the best practices of these fields in the practice of medicine and problem solving. The following series of key concepts will be integrated into the ultimate healthcare system of the 21st century and it is in this new system that we will deploy our new graduate of medical education prepared for the challenges of this new healthcare system.

• Network-based healthcare The first key concept in performance is the system of delivery of care itself. Therefore, we will propose a network based systems (net-centric). Key to this is the delivery of care from a distance through telemedicine. It will also include devices that provide the ability to touch the patient at a distance to deliver simple interventions and devices to see the patient to provide simple diagnostics – essentially a virtual house call. This overall system will be the beginning of a completely integrated virtual healthcare system that like a physical hospital provides all of the care that a patient needs in one place – in the future this one place will be virtual and will accommodate to wherever and whenever the patient needs care. Providing the right care, in the right place, at the right time to the patient as described by the former Director of the Institute of Surgical Research, John Holcomb regarding trauma care for the wounded warfighter.

Part of this network will be smart homes that enable the home in combination with the patient to provide some diagnostics, and therapeutics but

Above Present health-care system and its proposed change to a netcentric health-care system.

Credit: Krigg, Rosen & Koop, JEM, 2006.

almost more importantly the home will provide safety for the patient to prevent common problems like falls in the elderly.

• From simulation to performance machines The second key concept in performance is a performance machine.

This is the notion that a simulator is not only used for training and preparation but can be used real time or super real time to help in critical decision making.

The simulator helps to put all the critical information into a framework that allows the provider to make the right decision or is aided by the performance machine, the real time simulator to make the decision. We are already seeing these types of devices appear in medicine but they have been present in other critical fields for a longer period of time in aviation and the nuclear power fields. This was first developed in 1993 for a project for Baxter Healthcare to enhance arthroscopic knee surgery for ACL replacements.

• Future of evidence based medicine – patient specific predictive models The third concept in performance or knowledge management we generally look at the various repositories of information to be independent of behavior. We look at evidence based medicine with respect to what we know

Mimic’s dV-Trainer is designed to allow surgeons to practice the skills needed to operate Intuitive Surgical's da Vinci system.

Image credit: Jeff Berkley/Mimic Technologies, Inc.

include the standard past information about the patient but could include a model or simulation of the patient physical structure and a behavior model. The new electronic medical record would have a holomer (Satava) built into its data base that would help as a framework for following the patient through their life-cycle. The same approach taught in medical school using a virtual avatar of a hypothetical patient could now be a model for a real patient in a doctor’s practice. In this case the patient specific avatar could be used to help illustrate how certain behaviors such as over eating can lead to obesity and then how diabetes may develop and what are the secondary consequences that the patient and their family will face over the lifetime of the patient.

• New therapies in the 21st century – an explosion of new technologies for care The fifth concept deals with new therapies involving biology, robotics and virtual reality. We will see an ever rapidly changing introduction of possible treatments. The new provider will need to know about these, judge their value, and introduce and use them in a timely manner. This will require simulation and training on an ongoing manner. There will be challenges of choosing the right therapy and understanding the ethics for new treatments such as face transplants, tissue engineering of

parts and the use of stem cells for distributed diseases and focal events such as strokes and heart attacks. Robotics will be available in the form of exoskeletons that can support the disabled who are unable to walk, can help those with multiple amputations and polytrauma to walk again and return to independence, and to be used on the elderly to preserve their independence for as long as possible. Finally virtual reality is now being used to train people with cognitive impairments to return to independence, they can be used for stroke recovery and they can be used for soldiers with blast injuries. They can also be used to augment cognitive performance both for the patient and for the provider. Augmented reality can be used to superimpose a model of the patient onto the real patient to help with navigation to a tumor or to understand and explain a traumatic injury and loss of function to the patient and the family.

Summary The healthcare system will need to respond to the many demands of the 21st century and to provide universal care, improved safety, adequate patient/physician time in a seamless continuum of care. If we think carefully about this challenge we will see a clear opportunity that comes only once in a hundred years to re-engineer healthcare delivery through re-structuring medical education. medsim

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About the Authors Joseph Rosen, M.D., Joseph Henderson, M.D., and James Geiling, M.D. are faculty members at the Dartmouth Hitchcock Medical School.

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Above

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about some disease process in a population that has been studied in the past.

So in essence evidence based medicine is about the past not the future. Another way to look at simulation is to make a human body model that can predict what the effect of a new medication or combination of treatments will be on a specific individual. We have already begun to do this for the placement of AAA grafts. We can make patient specific models now of anatomical parts to help predict the performance of endovascular grafts. This can also be used to follow the history of grafts and predict failure in the future. In addition to physical models we can begin to include genetic markers to help predict the susceptibility of patients specifically to some disease from their individual genomes.

• Future of Electronic medical records – understanding the behavior of individuals The fourth concept has to do with behavior. One of the keys to successful medicine is to understand how the behavior of the patient impacts chronic and acute disease. This is a subtle talent that great practitioners develop over time. Essentially they need to understand the dynamics of their patient and the environment in which the patient exists. This includes their culture, their values and their family. It also includes the demands of both their vocations and avocations. It includes not only their physical demands but also their psychological demands. In the past we have not necessarily done well in educating the physician in how to understand this. As we have moved away from house calls and long term involvement with our patients and living in the same community we have lost some of these specialized skills seen in the general practitioner and now family medicine doctor.

We are presently involved in research in the field of adversarial understanding or reasoning. This enables us to better understand intent. Although this work is early in its maturation it will enable the physician to better understand and ultimately predict or constrain the behavior of their patient.

This is key to long-term control of obesity, smoking, exercise and other factors that contribute to chronic disease that is controllable to some extent. The electronic medical record can not only

INTERVIEW

Colonel Patrick R. Storms, M.D. Chief of Medical Modernization, Air Education Training Command Colonel Storms was interviewed by Group Editor Marty Kauchak. The interview addressed a wide range of simulation and training topics pertaining to the U.S. Air Force.

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MEdSim: Colonel, good afternoon and thanks for taking time to speak with MEdSim. Let’s first discuss your responsibilities at AETC. Colonel Storms: Our responsibilities are both for Air Education Training Command and in the medical modeling and simulation world. AETC actually has Air Force-wide responsibility for medical M&S activity. The Air Force medical M&S training program falls within the purview of the AETC Surgeon [Colonel Margaret B. Matarese] and I am her action officer for that.

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MEdSim: Describe how Air Force medical training has responded to lessons learned from the wars in Iraq and Afghanistan.

CS: There are two aspects to that.

First, are the overall changes in medical training at large. With the advent of our Tri-Care partners coming to offer some portion of the care previously provided in military treatment facilities (MTFs), what we have seen in the last two decades is a decline in the total

number of patients, particularly a decline in the number of acutely ill patients that are seen in our MTFs. Having a large number of very sick people is a remarkably effective training resource for a staff in training, be that medical residents, nurse training or medical technicians in training. A loss of some of that volume of extraordinarily sick people in the era of downsizing of some of our MTFs has left us with the opportunity to look for other training avenues to get that same intensity in level of training that we had previously seen based purely on patient volume.

Part two is when we turn to a war environment. I’ll be quite frank with you and say the nature of injuries and woundings we see in a wartime environment are unlike anything we see in the civilian or military treatment facilities.

MEdSim: As a follow-up, do even some inner city, civilian emergency facilities treat cases that approach the wartime level of injuries you and your colleagues have seen?

Above Colonel Patrick R. Storms, M.D., United Air Force, Chief of Medical Modernization, Air Education Training Command Image credit: U.S. Air Force.

CS: To some extent that is true. In terms of high caliber or highest projectile speeds of arms and armaments that is probably accurate. And certainly the Air Force utilizes civilian training platforms in our C-STARS [Center for Sustainment of Trauma and Readiness Skills] program that accomplish a lot of that familiarization and training.

Unfortunately, there’s another level of wounding that you don’t see in stateside medical facilities. IED injuries, for instance, really are not managed in even most of our high volume civilian trauma centers. So that’s an area where many of our folks can deploy without a tangible personal experience in that training.

I was the commander of a theater hospital in Southwest Asia and it was not unusual to see some of our new medics

MEdSim: As a follow-up what is needed to advance from the state-of-the-art in medical simulators to more effectively replicate more serious injuries, wounds and illnesses?

CS: There’s a tremendous (amount or body of) work being done on that front

now. First, what is needed is better synthetic tissue. While we can do extraordinarily effective cognitive mapping using the current generation of plastic mannequins, to get the real feel for a scalpel going into the skin, or the tissue planes that separates them, that is something the current technology is not quite there on yet.

We at AETC, have let some Small Business Innovative Research grants out specifically in the field of synthetic tissue research and development, as a model for that kind of hand skill training.

Mark Bowyer, a colonel (retired) M.D., mbowyer@usuhs.mil, the Director of Surgical Simulation at USUHS, would be a remarkable individual to talk to about what they are doing with synthetic tissue and tissue modeling.

MEdSim: Are there any other ways your service is using simulators in its medical training?

CS: Absolutely. We have a tiered system of simulator training. Our largest and most experienced sites are identified as Tier 1 training sites. They are responsible for curriculum implementation, oversight of subordinate facilities and aggressive

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MEdSim: Tell us how the Air Force is using simulations and other learning technologies in its classrooms and other facilities.

CS: The basis is that the curriculum drives the learning tool that you use – it’s a curriculum-focused effort. It’s been very interesting in that I recently had an opportunity to chat with some of my colleagues from the Uniformed Services University of Health Sciences and the VA medical centers. The commonality of approach is very striking – you identify a training need and then we look for the appropriate tool or technology to fill that need. Under some circumstances, training is best accomplished by live human actors. So if you are practicing the history of physical examination techniques, this practice is probably best done on a live human actor rather than any mannequin. If we are trying to look at cognitive mapping of a complex skill

set, then the plastic mannequins offer a remarkable opportunity because the advances in technology with the plastic mannequins have come a long way.

If you think back several decades ago you would do your cardiac life support training on something called the Resusci Annie. There was limited ability to perform mouth-to-mouth resuscitation and some model of thumping on the chest.

Current high-fidelity, patient simulators have physiological responsiveness, can accept medication administration, can respond appropriately to the administration of that medication, they will appear to breathe and have pupillary responses and they will respond appropriately to positive encounters and good medical choices, and to bad encounters and bad medical choices. It gives us the opportunity to repeatedly “crash” without damaging or harming a patient.

Visit us at IMSH

Booths 633 & 732

11 MEDSIM MAGAZINE

who had just arrived from their military bases and their common experience was, even if they had extensive training, they had never seen anything like the level of wounding that we encountered in those stations.

INTERVIEW ISSUE 1.2012 MEDSIM MAGAZINE

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training activities for their larger populations. They also are responsible for the larger view simulation curriculum development for themselves and their subordinate location.

The Tier 2 and 3 sites answer to their Tier 1 sites for both training and assistance in the day-by-day operations of their training laboratories. Those training opportunities focus on anything from readiness skills verification training, which is the wartime skills that every Air Force medic must be able to deploy and be utilized within his specialty, and the traditional training needs of a large facility because our graduate education sites have specific training requirements linked to their residency programs.

Almost all sites have needs for advanced cardiac life support training, specific nurse skills training, pediatric life support training and neonatal resuscitation training. A lot of our obstetrical sites utilize obstetrical simulators to go through obstetrical emergencies. Particularly at some our lower volume sites, that is a very important thing because they can practice, for example, a hemorrhage case again and again and again, where they might have a hemorrhaging patient except once every two months otherwise.

MEdSim: Can you discuss any other compelling reasons for the Air Force to invest in medical simulators and other learning technologies?

CS: The most compelling reason is that you can make a mistake and you can learn from the mistake without harming a patient. When I attended medical school in the late 1970s we learned on patients. And we still continue to practice our skills on patients, giving rise to the phrase “the practice of medicine”.

But in a simulated environment you can present atypical or unusual presentations of crises, and you can drill the student or trainee again and again and again. In addition, a simulator environment allows a much greater use of teambased healthcare. That benefits us in terms of team building and expertise, and it strengthens our ability to communicate within the members of the medical team.

I can’t begin to overestimate the value of that team-based training. And that falls very naturally into a simulation environment.

MEdSim: Your forecast please on the new simulations and other learning technologies your medical community may see in its training programs in the next 24 months.

CS: Actually we are trying to remain engaged with our military partners in crafting that future for ourselves, particularly in the realm of trauma trainers. The current simulator models we use in most of our training arenas are built for general audiences at civilian or military hospitals.

They are very good for physiologic modeling but not ideal for trauma modeling. We are working aggressively with our Army partners, our other sister service partners and with civilian development agencies to come up with higher fidelity trauma trainers. In fact, our medics at Camp Bullis [San Antonio] are engaged in developing research projects to make those simulator products more life-like and realistic in a trauma environment. One of the technicians that works at Camp Bullis is developing “smell-o-vision” – in which he tries to incorporate the smells of a combat environment into their training scenarios. You don’t really think how much of a difference that makes until you have experienced that training with and without the smell-o-vision addition.

MEdSim: So in your assessment, how is industry progressing with regard to developing increased smell and some of the other attributes needed to increase fidelity in these simulators?

CS: All of our partners are fully engaged.

There are technological hurdles that have to be assessed – and I’ll tell you those technological hurdles are expensive. A Resusci Annie is a relatively cheap piece of plastic but it gives you very little in return. The higher fidelity patient simulators are quite expensive but in return you get much higher training fidelity and you escape the age old problem of having some trainer in the room tell you what is going on with the patient instead of visualizing that within the simulated patient sitting right in front of you. And it’s that suspension of disbelief that I think will mark the technological improvements in the future. The more we can step in and simply see the sim as the patient, the more effective that training will be.

MEdSim: So what is the Air Force’s commitment to investing in simulators and other learning technologies in the

classroom through the budget out years?

CS: I think you have seen a phenomenal investment on behalf of our own Air Force Surgeon General and the other services’ surgeons general in bringing simulation to the forefront – motivated by not only the desire to offer better training but the realization that with the development of these technologies we can make phenomenal strides that would not otherwise be available in the purely human dimension. And I don’t think we’re alone in the military in pursuing that strategy. My friends at the VA, in talking to them this past week, are very powerfully engaged in developing their own simulator presence and they are making tremendous strides in integrating curriculum into simulator training.

MEdSim: Anything else to add?

CS: One area of interest is the area of virtual simulation – creating a 3-D environment on the computer that will allow you to interact and to engage. We have seen some very promising demonstrations and we are investing in that future ourselves.

Here’s where I think that brings value. When I would greet a new group at the Theater Hospital, it would take those individuals a while to learn the lay of the land and to get to know their other deployed teammates. We deploy people from any of several MTFs into that deployed theater. The person standing across the stretcher from you may come from another Air Force Base.

Virtual reality offers the opportunity to these individuals to train together prior to deployment – meaning I can have a person at Wright Patterson AFB, Nellis AFB and Wilford Hall all engaged simultaneously in the care of a virtual patient in a virtual environment, and that give them the opportunity to learn their communications skills and handoffs.

Second, if I had an emergency room modeled after an ER at a deployed location, you could save a lot of time in just learning the lay of the land – you go down this hall and take a left to get to the blood bank. That is something someone has to learn by walking the floor space when they arrive. If you could do that in a virtual environment prior to deployment that would save a tremendous amount of orientation time. And I’ll tell you the bad guys tend not to take days off and tend not to respect our hand offs and transitions. medsim

ACQUISITION AND ASSESSMENT STRATEGIES

Optimal Acquisition and Assessment of Proficiency on Simulators in Surgery Dimitrios Stefanidis, M.D., Ph.D., FACS, FASMBS, examines issues supporting the use of simulators in medical training.

Motor Learning Theories

Above

According to Fitts and Posner, complex manual skills are acquired in three stages: the cognitive stage (the trainee reads about and watches demonstrations of the task), associative stage (the trainee translates knowledge to task performance by associating cognitive elements with musculoskeletal maneuvers), autonomous stage (the task completion requires minimal demands on attention resources).

Learning progresses sequentially, but the learning rate can vary substantially.

Specific to simulators, Gallagher et. al., described eight steps important to surgical skills curricula: 1. Didactic learning of relevant knowledge; 2. Information about the steps to task completion; 3. Illustration of common errors; 4.

Testing previous learning; 5. Technical skills training on simulator; 6. Immediate feedback about errors; 7. Summative feedback about errors; and 8. Repeated trainings and illustration of progress at the end of each and defined expected proficiency goals.

McClusky and Smith developed

The curriculum brings life to the simulator and ensures learning.

another sequential, progressive approach to curriculum development. The cognitive elements of the task are taught first, followed by the testing of the trainees’ innate abilities. Simulator-based training follows to translate cognitive skills into motor skills. Initial training with instructors providing feedback continues with independent practice until predefined proficiency criteria are reached. Skills increase in complexity until simulation training is complete. After performance benchmarks are achieved in the skills laboratory, trainees transition to the operating room.

Similarly, Aggarwal et. al., proposed a competency-based assessment system.

Acquisition of procedure-specific knowledge is followed by testing. The task is deconstructed to its key components to facilitate learning, a procedure video is

ISSUE 1.2012

Image credit: Author.

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T

he present paradigm shift from resident training using the Halstedian model, “see one, do one, teach one,” to training using surgical simulators results from concerns for patient safety, limited resident work hours, pressures on teaching faculty for more productivity, the cost of operating room training, and the need for objective assessment of trainees’ skill in an environment of constantly changing technology. The effectiveness of simulator-based training is mainly dependent on the quality of the curriculum, which brings life to the simulator and ensures learning. Designing optimal skills curricula requires an understanding of how manual skills are best acquired and the best ways to measure performance on simulators, which have a profound impact on learning. This article discusses the application of motor learning theory to simulator learning, important curricular elements for skill acquisition, and methods of simulator performance assessment that maximize learning and clinical skill transfer.

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provided, and tools for objective performance assessment are defined. Training models are developed and validated; proficiency-based training is acquired in the skills laboratory and transferred to the operating room.

Factors Affecting the Effectiveness of the Curriculum Although the above theories provide a framework for simulation curricular development, several factors should be considered to optimize skill acquisition and transfer.

• Deliberate Practice and Learner Motivation Deliberate practice, in which the learner monitors his/her performance and reacts to immediate feedback, is essential for skills acquisition. Internal and external motivations for deliberate practice are needed, and factors that positively affect motivation should be incorporated into skills training. Internal motivation, the most important force for learning, varies with learners and is difficult to modify. Effective external motivation includes dedicated, protected practice time away from other responsibilities, encouraging healthy competition among residents by setting performance goals, offering awards for accomplishments, or setting requirements on simulators that must be met before participation in the clinical environment is allowed. Mandatory participation in skills training may be the most effective motivator for surgical residents who have several negative external motivators.

• Performance Feedback For manual skills, feedback is performance-related information provided to the trainee.

Feedback can be intrinsic or extrinsic/ augmented.

Intrinsic feedback consists of performance-related information directed to the sensory system of the trainee (visual, auditory, or haptic perceptions during task performance). Research indicates that interventions that enhance the learner’s internal feedback may improve skill acquisition.

Extrinsic or augmented feedback is performance-related information provided to the performer by an external source that augments intrinsic feedback to improve performance. Augmented feedback motivates the learner to continue the effort needed to achieve the skill. In medical education, it is an informed, non-evaluative, performance

Above Dr. Dimitrios Stefanidis.

Image credit: Author.

appraisal by a teacher to reinforce strengths and foster improvement by providing information about actions and consequences and the differences between the intended and actual results.

Several authors have provided level 1 evidence that augmented feedback during simulator training results in improved skill acquisition and retention independent of the task. The quality, timing, and frequency of augmented feedback are very important. Augmented feedback can be provided in formative (during the performance of the task) or in summative (at the end of the task performance) form.

The frequency and duration of either type of feedback can vary and possibly influence performance. It is important that learners have practice time without feedback to develop learning strategies that can be enhanced by appropriately timed, good quality feedback. Although a reduced feedback frequency appears to benefit skill acquisition, the optimal frequency is unknown and task specific.

These areas need further study. Little is known about appropriate delivery methods of performance feedback and the optimal training methods for instructors who provide this feedback.

• Task Demonstration Effective task demonstration shows learners the intricacies of a task and assists them in forming a mental model for how to accomplish it. Video-based education is effective for the acquisition of surgical skills on simulators. Video tutorials provided before

and during training are superior to those provided before training only.

• Practice Distribution Practice distribution refers to learning a task in several training sessions with a period of rest between sessions and has been determined in several studies to be superior to massed practice where all training occurs in one session. However, the size of the effect is task dependent, is influenced by the interval between training sessions, and several studies have demonstrated opposing findings. Because the impact of practice distribution and inter-training interval on skill acquisition is task specific, additional study is needed to identify the optimal training sequence for various surgical skills. The optimal duration of each training session should be re-examined, because, at the present time, it is chosen arbitrarily.

• Task Difficulty and Practice Variability The literature suggests that skill acquisition is influenced by practice variability and training under increasing levels of difficulty. Using high fidelity medical simulators, learning was increased when trainees practiced with progressive levels of difficulty. Using a MIS virtual reality simulator, training on the medium level showed improved skill acquisition compared with training on the easy level. Progressively increasing difficulty has also been shown to be optimal for curricular design.

Contextual interference refers to the learning effectiveness of random versus blocked practice. Learning is increased when different tasks are practiced randomly rather than in a specific order and when training incorporates practice variability; however, the effect is not consistent and is dependant on task complexity and other factors.

• Proficiency-based Training Proficiency-based simulator training improves operative performance and is considered by many experts the ideal training paradigm on simulators. Proficiency-based curricula set training goals derived from experts and give learners a performance target to achieve. By providing targets and immediate feedback, learners can compare their performance to targets, which promotes deliberate practice, boosts motivation, and enhances skill acquisition. Proficiency-based training tailors training to the individual learner’s needs and produces uniform skills by meeting objective goals for all learners.

and during transition to the operating room. Because workload impacts performance, and this tool accurately provides performance information not otherwise available to learners and trainers, it should be incorporated into simulator training surgical skills assessment.

• Performance Anxiety and Physiologic Measures of Performance Mental stress is a possible factor for technical errors and inferior performance by surgeons, perhaps more so during minimally invasive than during open procedures. Because stress is difficult to evaluate subjectively, several studies have successfully used physiologic measures (heart rate) to objectively indicate stress.

Aviation studies have concluded that heart rate is the most useful psychophysical variable to assess pilot workload and mental strain. A recent study linked incomplete transfer of simulator acquired skills to the operating room with a significant increase in the surgical trainee’s heart rate in the operating room compared with the simulator. Because these metrics may provide additional information on learner performance, they should also be considered during simulator training.

Summary Many factors have been shown to optimize surgical skills curricula and the trainee’s learning so that learner proficiency can be achieved. Available studies regarding the best performanceassessment methods suggest that the incorporation of additional, more sensitive performance metrics may improve skill transfer. Simulator curricula that take into account all the factors discussed here can optimize skill acquisition and learner readiness for success in the operating room. medsim About the Author Dr. Dimitrios Stefanidis is Director, Carolinas Simulation Center, Carolinas HealthCare System, Charlotte, North Carolina. He may be contacted at email Dimitrios.Stefanidis@carolinashealthcare.org. Dr. Stefanidis attended Aristotelian University of Thessaloniki-Greece, completed a General Surgery Residency at the University of Texas, San Antonio and Fellowships at Tulane University in Minimally Invasive Surgery and the Carolinas Laparoscopic and Advanced Surgery Program.

ISSUE 1.2012

assessment relies on subjective ratings, the instruments must have proven reliability and validity before they are used for assessment. Global rating scales are superior to checklists for technical skill evaluation when completed by experts. validated rating scales for technical skill assessment and global operative assessment of laparoscopic skills should be incorporated into simulator training.

However, the relationship between this assessment type and other more objective performance metrics is not well studied.

• Automaticity Automaticity is the ability to perform motor acts automatically, leaving enough attentional capacity to engage in other activities. Automaticity is a characteristic of an expert performer and has been used in the literature to confirm learning by novices.

Novices practicing a new task often operate using maximum attentional capacity and cannot attend to other stimuli in their environment. To accurately measure automaticity and spare attentional capacity, a secondary task must compete for the same attentional resources as the primary task. Measuring the performance on the secondary task reflects how much attention can be spared for the primary task. Several previous studies show that the traditional metrics of time and errors are good performance measures during the early learning stages; however, more sensitive performance metrics such as a secondary-task are needed for complete assessment of performance.

• Workload Assessment Learner performance can be influenced by task workload, performance anxiety, and stress. Task workload, which can increase operator fatigue and frustration and compromise attention span, is higher during early learning and decreases with experience. With high workload, the ability to deal with unexpected demands can be impaired and performance errors may increase.

The National Aeronautics and Space Administration-Task Load Index (NASATLX) tool, first used in flight simulation, is a validated tool for workload self assessment, measures a task’s mental, physical, and temporal demands and the effort, frustration, and perceived performance of the trainee on a 20-point visual analog scale. Evidence suggests that the NASA-TLX tool provides a reliable measure of workload, task difficulty, and learner comfort during simulator training

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Traditional training paradigms such as time-based curricula (setting a specific training duration) and repetition-based curricula (setting a minimum number of repetitions) do not take into account individual learning differences and use arbitrary training endpoints. Given that learners have different baseline abilities, experiences and motivation, such curricula can lead to inadequate training or overtraining. Empiric evidence supports the superiority of proficiency-based training. The way goals are defined may also be important for skill acquisition.

• Performance Assessment Many questions regarding expertise in surgery need to be answered using high quality studies. How should expertise in surgery be defined and measured? How should proficiency levels based on expert performance be established? How should acquired expertise on simulators be detected in learners? Should expert levels be used as simulator-training endpoints or are less difficult performance levels more appropriate? Only with appropriate metrics to identify superior performance can these questions be answered.

Traditionally, skills curricula have used the easily obtainable metrics of task duration and errors for performance assessment; however, this provides no insight into the effort invested to achieve the performance goal or whether the learning has been completed and can produce a misleading picture of the trainee’s readiness to transition to the more stressful clinical environment. Several studies have shown that surgical trainees achieved expert-level performance based on time and error metrics on simulators, but their performance fell short of expert skill level in the stressful conditions of the operating room. This could be related to difficulties of assessing when simulator learning is complete.

More sensitive performance metrics such as limb kinematics, global rating scales, psychophysiologic measures, and measures of mental workload may provide complementary performance assessment to augment skill acquisition and transfer.

• Observer Ratings Surgical performance can be reliably assessed by an experienced observer using global rating scales, visual analog scales, checklists, or a combination of these. These instruments are versatile, and some can be used for similar tasks. However, since the

Left

INTERVIEW

Dr. Monica Reed, Chief Executive Officer (CEO) of Florida Hospital Celebration Health.

Image credit: Florida Hospital.

model for many of our destination services. Our Institute for Lifestyle Medicine and Healthy 100 program is focused on the prevention and performance enhancement model of care for patients, employees, physicians, corporations and our general community and incorporates the use of our 50,000 square foot fitness facility.

Living Laboratory: Celebration Health is focused on educating a global community of physicians and allied health professionals in the latest advances in healthcare. Our innovation unit and Nicholson Center allow us to partner with corporations, and venture philanthropists to create an environment for research and innovation.

Dr. Monica Reed, CEO Florida Hospital Celebration Health

ISSUE 1.2012

Interview with Dr. Monica Reed, CEO, Florida Hospital Celebration Health at World Robotics Conference in Miami, Fl

by Judith Riess, Editor, MEdSim.

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MEdSim: Please give me some background on the Florida Hospital System.

Dr. Reed: The Florida Hospital system is made up of eight different hospital campuses in Central Florida under one license. Celebration Health opened its door in 1997 and was created to be a unique clinical environment that focused on health, healing and innovation. This cultural DNA allows an open platform to grow and to provide for the needs of our patients and to help shape healthcare as medicine advances. We have an excellent foundation that supports our quest for medical excellence.

We have four key strategic pillars that focus our goals as an excellent Community Hospital: First and foremost we are here to serve our community. Our definition of community is truly global:

45 percent of our patients come from outside of our local community and almost 20 percent from either outside of Florida or the United States. We continually focus on providing evidence based care in an innovative clinical environment that meets the need of a diverse population.

Destination Services: realizing that we serve a global community and want to continue to do so we meet these needs by providing comprehensive and the most advanced minimally invasive surgical services.

Wholistic Health: believe in a holistic approach to medicine for our patients and our employees and that patient care and safety requires a holistic view (treating the whole patient not just the illness).

This is incorporated into the patient care

MEdSim: When you recruit new doctors what do you look for?

Dr. Reed: We are looking for physicians that believe in excellent clinical care, are highly skilled leaders in their area of expertise, are willing to try different approaches to problem solving, are interested in technologies that improve medical care and are willing to conduct and be part of new training initiatives.

MEdSim: What do you feel is key for hospitals to provide better patient care and safety?

Dr. Reed: As mentioned before, providing excellent care and treatment, having an interest in training whether through simulation, robotics or other new technologies to ensure medical competency. It is also important to being open to forming relationships with industry.

Let’s partner to make instruments better in terms of patient care. We need to hold clinical conferences together, like this (Robotic Conference) that will allow us to have and you to develop better instruments, better simulations, better training that meets the needs of the doctor and the patient. In order to develop new instruments, simulations or models that assure they meet our needs requires open communication.

We have to communicate to tell you

MEdSim: What can be done to enhance medical simulations and how can industry help?

Dr. Reed: The simulations must be reproducible and as close to what actually occurs in surgery or in treatment as is possible. For example, the haptic response. It has to be realistic enough to make doctors feel that they are in the actual environment. The only way to ensure competency is through education, training and practice. Practicing in a safe environment where we can “do no harm” leads to competent care.

Having said that, it has to be affordable for hospitals, medical and nursing schools and medical simulation centers. Research has shown that physicians have less errors if they “warm up” through practice with video games, simulations, etc. Athletes “warm up”, lecturers practice before presentation, actors “rehearse” - we can do the same for the operating theatre.

We have to build a robust system to track physicians, not as a punitive measure but for skills attainment.

They would begin with basic skill – then progress to advanced procedure – and finally refresher. Being able to time themselves on the procedures, their accuracy, their choices, leads to competency. The tool would allow the physician an administrator, professor, attending to know what skill needed refreshing, etc.

Editor's Note As a physician, speaker, author, and CEO of Florida Hospital Celebration Health, Dr. Reed has dedicated her professional career to promoting health, healing, and wellness. Additional to her executive responsibilities for Celebration Health, Reed was recently promoted to Senior Executive Officer for Florida Hospital East and Florida Hospital Kissimee in 2009. In recognition of her accomplishments she has been recognized as one of the nation’s Top 25 Minority Executives in Healthcare by Modern Healthcare.

A graduate of Loma Linda University School of Medicine, who specialized in obstetrics and gynecology, Dr. Reed has also served as Florida Hospital’s chief medical officer, the associate director of Florida Hospital's Family Practice Residency program, and on the national stage as a medical news reporter for NBC and ABC affiliates in Alabama and Florida. Dr. Reed is the author of the recently released The Creation Health BREAKTHROUGH, a book focused on eight Principles of healthy lifestyles.

Already subscribed to MEdSim? Congratulations, you now have all the healthcare education, simulation and training information you need, when you need it.

If not, sign up today for FREE! Deadline extended for a year’s free digital subscription until February 29 2012 Register online today: www.halldale.com/medsim

ISSUE 1.2012

MEdSim: How do you feel about using simulation to train?

Dr. Reed: Using simulation to train medical professionals is no longer a niche environment but a responsibility of hospitals. We owe it to ourselves as healthcare providers and to our patients to be as competent and skilled as possible. All doctors would like to assure their patients of the outcome of a surgery or an illness. We cannot but we can assure them that we are highly competent and well trained. The variation that we see in healthcare today can be substantially reduced by effective use of simulation training modules.

MEdSim: Where would you begin using simulation to train?

Dr. Reed: Simulation training should start in medical schools. Deborah Didactic course work is important and students also need to practice what is preached. Using simulation or a game based educational approach would help to acquire the needed skills. Simulation training allows us to advance in medicine from the old adage of “see one, do one, teach one”, to seeing and doing many, many times, and removes variation in teaching. Team training is needed and enhances our ability to offer safe reliable care and should include the different members of the health care team. Through a simulated environment you would be able to troubleshoot and solve problems. Team dynamics and training are so important to efficiency in the OR and on the floor.

We know simulation expands medical competency in a safe environment.

Now we must develop the appropriate training and design tools that accurately measure levels of proficiency. If we are confident that the knowledge acquired transfers to the real world environment we will improve patient care and safety and reduce medical cost. medsim

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what we need and you have to answer responsibly, not just for profit but to insure that whatever is produced/developed meets,/advances care and creates value for the patient and our healthcare delivery model.

Nurse Education Programs

Learning Technology: Benefits and Challenges As the nursing community increases its use of learning technologies in education programs, community leadership is also concerned about faculty development, returns on investment and other issues in the life cycle of a training system, reports Group Editor Marty Kauchak.

A

confluence of events is creating a demand to insert more technology into the continuum of learning for nurses.

Simulations, simulators, distance learning and other training enablers allow prospective nurses to learn and refresh many of their skills more efficiently and more effectively. At the same time, the community’s leadership is grappling with returns on investment on these devices and support issues, including how faculty is prepared to use these instructional media.

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Education Overview

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New accessions into the U.S. nursing community complete different lengths of study commensurate with the levels of practice at which they will be employed.

Learning technology has become a foundation of many of these programs.

Typically, practical/vocational nurses (LPN/LVN) complete a course of study over a year to 15 months. Registered nurses complete a course of study either through a diploma program (three

years), associate degree program (two years), or a bachelor degree program (four years).

Beyond entry-level education, graduate degrees increase a community member’s intellectual prowess across a range of specialties, from research to specific academic subjects.

In November 2011, MEdSim had the opportunity to gain one in-depth insight on community education during a visit to the School of Nursing at the LSU Health Sciences Center. The center offers four degrees: a B.S. in Nursing, the Master of Nursing, an M.S. in Nursing and a Doctor of Nursing Science (DNS).

The school has tailored its’ degree programs to the dynamics of the workforce, the contemporary student and the profession.

There are three pathways to earn the baccalaureate degree in nursing at the New Orleans-based school. Aside from the traditional way of earning the B.S. in Nursing degree in four years following graduation from high school, previous awardees of a baccalaureate degree

Above A 2010 survey reported that 87 percent of schools offer some form of simulation with either high or moderate fidelity manikins.

Image credit: Laerdal Medical.

in any discipline may earn their nursing degree in less than a two-year timeframe of study through the Career Alternative RN Education option. Demetrius Porche, DNS, Ph.D., Dean and Professor at the School of Nursing, also pointed out that a third program, the RN to BSN Program, is a specialized program of study designed specifically for the RN with an Associate Degree or diploma in Nursing.

“They are coming in to complete their BSN degree.”

Aspiring master’s degree candidates may specialize in administration, anesthesia, clinical nurse specialties (adult health), community health, nursing education and nurse practitioner (family and neonatal).

The Doctorate of Nursing Science is a research-focused academic endeavor.

Technology Insertion For its part, the LSU nursing program is ambitiously integrating simulation and other learning technologies into its baccalaureate and masters programs.

The school of nursing’s undergraduate and masters courses are based on a hybrid model of instruction – with residence instruction supplemented by a blend of learning technologies. “Even with our undergraduates who predominately come to class and sit in a lecture, courses have supplemental content that’s online. Some courses may supplement their lectures with podcasts and online discussion modules – discussion boards. Some may use online chat. And at the graduate level we do the same thing,” Porche said.

To help understand the amount of technology-enabled instruction at the school, the senior administrator pointed out that the LSU undergraduate clinical nursing programs have three foundations to clinical courses: a theory course, a clinical practicum course and a simulation course. “The simulation course is where they are completely going through simulation activity. And the amount of time spent in each respective

Above Demetrius Porche, DNS, Ph.D., Dean and Professor at the School of Nursing, LSU. Image credit: LSU.

activity depends on the course credit.”

The LSU School of Nursing uses an array of simulators and simulations to develop learning skills. Some representative devices include high-fidelity manikins, the NOELLE birthing simulator and soft-tissue replication products to build suturing skills. “We are simulating at all educational levels, from the clinical

skills with low fidelity to the high fidelity – manikins – which are in a patient scenario. There the students have to learn to react, know to respond and also watch the patient’s response,” Porche explained.

LSU’s use of learning technologies mirrors instructional strategies across the community.

Janet Willhaus, the National League for Nursing’s simulation scholar-in-residence, observed the use of learning practices involving simulations and simulators is rapidly increasing in nursing education.

Willhaus, a doctoral student from Washington State University studying the science of using simulation technologies in nursing education, is able to quantify these developments. She noted that in 2007, with funding from Laerdal Medical Corporation, the NLN conducted the first national, multi-site, multi-method study to build the science related to the use of simulation in nursing education. “A 2010 survey of all nursing programs from the National Council of State Boards of Nursing reported that of the 1,060 schools that responded, 87 percent offer some kind of simulation experience with either high or moderate fidelity manikins. “Technology has spurred the development of

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include almost any piece of equipment

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and feedback can now be extended to

Nurse Education Programs ISSUE 1.2012 MEDSIM MAGAZINE

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several techniques for learning outside the clinical environment.” Willhaus continued, “Although full-body static manikins used for practicing nursing skills have been around for years, it is only in the last 10 years or so that computerized versions which have heart, lung, and vocal sounds have become affordable for health care professional education.

These manikins can be programmed to respond to student actions and their use provides a safe alternative to beginning practice on real patients. Many schools of nursing are purchasing simulators for student practice and learning.”

ROI and Other Challenges

Above

During an interview with MEdSim in his downtown New Orleans office, Porche noted the state of medical and learning technologies are moving so quickly, that it is often difficult for industry to offer cost-effective learning devices with adequate degrees of fidelity for wide use.

And the senior administrator pointed out another intriguing limit to the wider use of learning technologies. “It is the faculty development that also must occur.

The faculty no longer must stay clinically competent only in their respective area. They have to also remain clinically competent in educating – how to use this technology to educate. And the other piece is you have to know how to use the technology. You have faculty with various levels of sophistication with everything from computers to other technologies. So, it’s the faculty development and the costs – which are unbelievable.”

Faculty competency in learning technologies was also of interest to Willhaus, who noted that schools that purchase equipment without investing in their staff and faculty are not really helping the students. “Owning an expensive tool does not improve learning when it never gets out of the box and into the hands of students”.

Help may be on the way, in part, with the NLN’s creation of initiatives such as the Simulation Innovation Resource Center (SIRC) website (http://sirc.nln. org) with courses and resources for faculty and a year-long Leadership Development Program for Simulation Educators, now in its second year. The efforts designed for those interested in assuming a leadership role in the field of simulation in nursing education.

Porche, as a senior administrator

How much simulation is enough in a nursing education program?

Image credit: Laerdal Medical.

with budget oversight of state of Louisiana education funds, also expressed his attention to returns on investment in learning technologies. He noted that when 600 to 700 students participate in simulation activities there is tremendous wear-and-tear on the devices. “It’s expensive – not to mention the faculty resources. If you are going to do simulation there is a common misunderstanding that you take less faculty. That’s not true because you need more faculty because you want to simulate in small groups and so you can debrief in small groups.”

And beyond the investment in simulation devices, are the related costs of simulation support infrastructure.

Indeed, when MEdSim visited the LSU School of Nursing, two new simulation labs were being built with debriefing rooms and other facilities.

Yet, Porche was upbeat on the school’s ROI in learning technologies and other aspects of instruction. “We are getting a very good return. Our employers of our nurses are satisfied and the students’ pass rates on their certification and licensure exams are very high.”

Asked for a “help wanted” list to provide to the health care learning technologies community, Porche placed faculty development on the top of his list. Noting that while industry’s technology offerings are good, he noted the challenges of keeping up with technology trends, learning how to teach with those technology devices and maintaining desired outcomes.

The school of nursing dean also noted his staff’s efforts to bolster interprofessional simulation – team building in clinical settings. Projects that integrate medical, respiratory therapy, nurse anesthetists and undergraduate nursing students into the same virtual domain are being developed. “We’re trying to look at team competencies – and to really understand each other’s role. That’s where we need to go – in the area of inter-professional simulation while they are here.”

Other Downstream Developments The NLN and at least one national governance body are examining other challenges and opportunities in using learning technologies in community programs.

Funded by a three-year grant from Laerdal Medical, a subgroup of the NLN Presidential Task Force on High Stakes Testing, is laying the groundwork for the use of simulation for high stakes testing in nursing education, identifying program outcomes that can be evaluated using simulation, and developing and piloting test simulation scenarios and evaluation tools at schools of nursing across the country.

Willhaus noted there is currently a national research study of simulation in nursing education being conducted by the National Council of State Boards of Nursing. “Ten schools of nursing and hundreds of students are participating in an investigation of how much simulation is enough in a nursing education program. The study will last three years and will follow the students through the nursing education part of their education. Some of the students will be followed after graduation as they move into the work setting.” medsim

SURGICAL TRAINING

Surgical Education, Research, and Business Design There is a constant and growing need for education in new medical procedures and the use of new devices, Roger Smith, Ph.D., Florida Hospital, Nicholson Center reports.

Nicholson Center courses in medical practice are guided by the six core competencies established by the American College of Graduate Medical Education (ACGME): • Competency in patient care - compassionate, appropriate, effective;

Above In October 2011, the Nicholson Center opened a new free-standing $35 million education facility.

Image credit: Florida Hospital.

years of planning and investment. The first courses were coordinated through industry sponsorships from Karl Storz Endoscopy-America, Johnson & Johnson Ethicon Endo-Surgery, GE Healthcare, and Getinge USA. The initial focus was on Women’s Health and Urology, but has expanded far beyond this in 10 years.

The Institute provided fully equipped teaching laboratories, didactic education spaces, and experienced surgeoninstructors who were able to share their knowledge and techniques with younger or less experienced colleagues. In the first five years of operation this institute trained over 17,000 surgeons in a large number of specialty programs.

In October 2006, Tony and Sonja Nicholson, prominent real estate developers in Central Florida, pledged $5 million to expand the institute and it was

ISSUE 1.2012

The Learning of Medicine

• Competency in medical knowledge biomedical, clinical, cognate sciences and their application; • Competency in practice-based learning and improvement - investigation and evaluation, appraisal and assimilation of evidence; • Competency in interpersonal and communication skills - effective information exchange, teaming with patients and families; • Competency in professionalism - carrying out professional responsibilities, ethics, sensitivity; and • Competency in systems-based practice - awareness and responsiveness to the larger context and system of healthcare and the use of system resources.

Specialized courses for surgeons, physicians, allied health personnel, students, residents, fellows, and healthcare executives apply these criteria to the curricula and the laboratory events that are offered.

In 2001, Florida Hospital opened the Surgical Learning Institute, the original name of the Nicholson Center, after two

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his is especially true for surgeons who are constantly being equipped with better methods and tools for dealing with the challenging job of repairing the inside and outside of the human body. To meet this need, there are a number of institutes for graduate medical education around the country. Florida Hospital joined these ranks with a focus on educating surgeons and an emphasis on emerging new techniques in robotic, laparoscopic, and orthopedic surgery. Serving as a living laboratory for healthcare advancement and innovation, the Nicholson Center is dedicated to three major goals: the learning of medicine, the science of medicine, and the business of medicine.

SURGICAL TRAINING

formally renamed the Nicholson Center for Surgical Advancement (NCSA) in recognition of their generosity. In February 2008, the center expanded into Robotic Surgery training through a partnership with Intuitive Surgical Inc. With the simultaneous addition of a number of world-class robotic surgeons to the Florida Hospital system, this new emphasis led to world-wide recognition of the Nicholson Center as one of the leading surgical education institutes for robotic and laparoscopic training.

In October 2011, the Nicholson Center opened a new free-standing $35 million education facility. The 54,000 square foot building contains a 500 seat didactic center, 25 surgical stations, two fully equipped operating rooms, and dedicated space for at least six surgical robots.

This new facility will allow the inhouse training of 20,000-plus surgeons per year, and the ability to extend its services globally through advanced video production and teleconferencing.

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The Science of Medicine

MEDSIM MAGAZINE

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In 2010, then-Congressman Alan Grayson (D-FL) directed a federal grant for $4.2 million to the NCSA to further expand robotic and telesurgery research. This grant is currently supporting three distinct projects. First, NCSA is leading the development of a national Fundamentals of Robotic Surgery (FRS) curriculum for certifying all surgeons in these leading edge procedures. The core knowledge, skills, and curriculum that should be mastered by any aspiring robotic surgeon are being identified through meetings of leading robotic surgeons from around the world.

The products of this work will become the basis for future national certification programs in robotic surgery, and will be managed by an authoritative and unbiased national medical society just as the Fundamentals of Laparoscopic Surgery (FLS) is today.

Second, NCSA is investigating the effectiveness of simulators in developing and maintaining surgical skills in robotic specialties. It has been shown that surgeons who perform hand-eye coordination exercises prior to robotic surgery improve their performance during the procedure.

Working together with Mimic Technologies, Inc. we are creating a simula-

Above The Nicholson Center will allow the in-house training of 20,000-plus surgeons per year.

Image credit: Florida Hospital.

tion system that will allow a surgeon to perform an operation in a simulator that contains a digital model of the patient’s actual anatomy. The data file from an MRI of the real patient will be converted into a digital model that can be operated upon in the simulator. The surgeon will rehearse on digital physiology that exactly matches that of the patient. This kind of patient-specific surgical rehearsal may improve the performance of the surgeon even more than the generic warmup exercises that have been used in the past.

Finally, the grant is supporting advanced experiments in telesurgery using robots. We believe that surgical procedures that are performed at a distance will have some fundamental differences from those performed in a local setting. The communication lag that exists between two facilities will always impose a limitation on the ability to perform delicate surgeries. We accept these limits in the technology and are focusing on modifying surgical procedures so that they are tolerant of this lag and safe to the patient. We are identifying the communication lag that exists between key pairs of cities and facilities where telesurgery will be performed in the future. Then we are measuring the level of latency that can be tolerated by the small atomic movements that make up an entire surgical procedure. Some of these movements will be safe under

the levels of lag found between city pairs, but others will be so delicate and precise that they cannot tolerate the lag that is created in the robotic, computer, and communication infrastructure. Our experiments will call upon the expertise of robotic surgeons to redesign these key movements and actions so that they can tolerate longer latency in communication between the surgeon and the patient. In doing so, we are seeking to invent new procedures that will define how surgery will be performed safely when the technical, regulatory, legal, and medical delivery systems are ready to allow telesurgery.

The military is a major proponent of this concept because it will eventually allow an expert surgeon anywhere in the world to apply his skills to save the life of a soldier in a remote military hospital. But before telesurgery can reach around the world, it must reach across a city. Short-distance telesurgery across a metropolitan area will be very valuable in its own right. It will allow expert surgeons to provide their services to multiple regional hospitals without physically commuting between facilities, converting wasted commute time into productive surgical time.

Finally, near the end of our research calendar we will combine the results of the surgical rehearsal experiments with those from telesurgery to explore the concept of automatic surgery. When a surgeon performs an operation on a digital model of a patient in a simulator, all of the movement and action commands will be recorded to a computer file. In essence, this file is a detailed instruction set on exactly how to perform the

surgery. We will then prepare a physical model or real tissue under a real robot in exactly the same position that existed in the simulator. We will then inject the surgical movement command file into the real robot and allow it to repeat the surgery on the tissue, without the intervention of a human surgeon. The robot will be running on auto-pilot. These experiments will allow us to determine how many variables in this environment can be controlled and how many are still beyond the reach of the current tools.

The long-term goal of this capstone project is to contribute to a system that can perform surgery in extreme environments where the communication link is so unreliable or so delayed that no other technique for telesurgery will work. This could be the means through which surgeons on the earth operate on astronauts in moon colonies or Mars missions. It would allow surgical instructions to be sent to a submarine in the depths of the ocean or to scientific outposts on the polar cap of Antarctica. It could also allow medical missionaries to bring surgical specialties into the most remote and primitive places on earth.

The research enabled by this grant is far-reaching. Some of it will impact the practice of robotic surgery in the next few years, while other pieces will plant the seeds of surgical change that will require decades to mature.

to making these methods financially viable. Florida Hospital employs classic techniques in operations research and optimization to design its robotic surgical practices. These are supported by changes within the administrative structure of the system, as well as a very robust marketing strategy to educate the public on the benefits of new techniques and effective surgeons.

The Nicholson Center is the conduit through which the Florida Hospital System provides all of these valuable services in the learning, the science, and the business of medicine. medsim About the Author Dr. Roger Smith is the Chief Technology

Officer for Florida Hospital's Nicholson Center for Surgical Advancement where he is leading a team of researchers in applying simulation devices to the process of surgical education. He was previously the CTO for the U.S. Army Program Executive Office for Simulation, Training and Instrumentation (PEO STRI) and a Research Scientist for Texas A&M University. He is a Graduate Faculty Scholar at the University of Central Florida. He has published over 150 technical and management papers and several books. Dr. Smith holds a Ph.D. in Computer Science, Doctorate and Master's in Business Administration, M.S. in Statistics, and a B.S. in Applied Mathematics.

www.MimicSimulation.com

The Business of Medicine

VALUE

Reduces need for training robot; does not require expensive training instruments and materials; saves operating room time

EFFICIENCY

Encourages surgeon adoption of da Vinci 速 system; frees up clinical robot for generating procedures

FLEXIBILITY

Quickly moves new surgeons up the learning curve on both S and Si platforms with customizable training options

SAFETY

Extensive, validated training prior to da Vinci 速 assisted surgery can improve patient outcomes

ACCESS

Increases training access for residents, fellows and novice surgeons; minimizes proctor supervision

Mimic, dV-Trainer, MSim, and Mscore, are trademarks of Mimic Technologies, Inc. Intuitive Surgical and da Vinci are registered trademarks of Intuitive Surgical, Inc. dV-Trainer is not a product manufactured, sold or distributed by Intuitive Surgical, Inc.

ISSUE 1.2012

Proven, Highly Realistic Simulation Training for the da Vinci速 Surgical System

23 MEDSIM MAGAZINE

The Florida Hospital System is one of the largest by patient volume in the country. It is also one of the leaders in adopting and practicing robotic surgery with business methods that recoup the huge investments required for this type of practice. The tools and techniques that make this possible are shared with hospitals and surgeons in a number of consulting services and conferences offered by the hospital. Each of the sponsored medical conferences from Florida Hospital includes a track on successfully designing, staffing, operating, and marketing a robotic surgery practice.

Acquiring advanced equipment is never a guaranteed path to business success. There are many variables from local demographic of the population, to the selection of surgeons, to the design of the operating rooms that contribute

Medical Technology, Training and Treatment Conference May 9 - 12, 2012 • Renaissance Hotel at SeaWorld • Orlando Florida

Why MT3?

MT3 helps the community answer questions on how to achieve transformation in training, how to asses competency rather than hours in training, and how to integrate the hard won knowledge of the military medics into the civil domain.

• A featured session of leading military medical procurement execs will discuss opportunities for Medical Simulation suppliers.

• Sessions on: How to design a Simulation Center & Program

The Impact of Surgical Technology on Training

Risk management for Patient Safety

Medical College Curriculum Design

How to Impact Resident Training/Competency through Simulation • The need for radical change in healthcare education and training is now accepted – American Association of Medical Colleges – we need a transformation in healthcare training, not a reformation. Dr L D Britt Chair of the American College of Surgeons – we cannot make it to the next level without simulation.

• Ongoing changes to medical/surgical technologies readily lend themselves to a simulation training solution eg robotics, laparascopy, endoscopy etc.

• The rapid adoption of this technology offers great scope for simulation and simulator providers. As an example, over 80% of all prostatectomies in the US are now done using the DaVinci Robot - only ten years after its market introduction!

Cardiac, OB/Gyn, Pediatric, Gastro-intestinal surgeons are rapidly developing new robotic techniques for their specialties.

• Demographics, or the need to rapidly recruit and train a new healthcare workforce to replace the retiring baby boomers and service up to 30m new patients under the Affordable Healthcare Act plus another 78m baby boomers over the next 20 years are unavoidable drivers.

2012 MT3 Invited Speakers John Armstrong, MD University of

Troy E. Reihsen University of Minnesota

South Florida

Medical School

Stephen Barnes, MD Missouri

Richard Resnick, MD Orthopedic

University School of Medicine

Surgery

Mark Bowyer, MD Uniformed Services

Joseph Rosen, MD Dartmouth

University of the Health Sciences

Hitchcock Medical School and Thayer

Howard Champion, MD

School of Engineering

Daniel M. Clinchot, MD Ohio State

James “Butch” Rosser, Jr. MD Beth

University Medical Center

Israel Medical Hospital

C. Donald Combs, PHD Eastern Virginia

Robert Rush, MD Madigan Army

Medical School

Medical Center

Thomas J. Doyle CAE Healthcare

Ajit Sachdeva, MD ACS

James Geiling, MD Dartmouth

Richard Satava, MD University of

Hitchcock Medical Center

Washington, Florida Hospital, Celebration

Faculty, MD University of Miami

Health

Annette Hilldabrand, COL. USA, DVM

John Schaefer, III, MD Medical

OTSG/DoDVSA

University of South Carolina

Pamela Leonard, RN Kaiser Permanente

Steven W. Swann, MD, COL USSOCOM

Jeff Levy, MD Case Network,

Angela D. Tenbroeck Duval County

Al Moloff, D.O. MPH, COL (RET) U.S.

High School

Army

Sterling Williams, MD American

Monica Reed, MD Florida Hospital

College of Obstetrics and Gynecology

Celebration Health For information on Booths please contact: Andy Smith - 407 474 4760 or andy@halldale.com Justin Grooms - justin@halldale.com Mary Trier - 407 620 3357 or marytrier@gmail.com General inquiries - mt3conference@gmail.com

www.mt3conference.com

Medical Simulation Centers

Medical Simulation Centers Work to Advance Medical Education Medical simulation centers are emerging around the world to advance medical education to the next level by developing curricula that employs the technology to improve skills and assess performance.

The centers are also conducting research that provides evidence to simulation's effectiveness as a learning tool, reports Chuck Weirauch.

P

rivate sector and government medical simulation centers are using simulation to take medical education to the next level of innovation. Surgical and other skills that heretofore could only be learned and refreshed in a live venue can be developed in a virtual environment. One of the more subtle but dramatic uses of medical simulation is in robotic surgery.

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Robotic Surgery Curricula

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Just as the American College of Surgeons, worked to develop the Fundamentals of Laparoscopic Surgery curriculum to improve surgeons' skills and as a tool to measure proficiency, efforts are now underway to develop a Fundamentals of Robotic Laparoscopic Surgery curriculum.

One such effort to advance surgical medical simulation and the development of the Fundamentals of Robotic Laparoscopic Surgery curriculum is a $4.2 million Telemedicine and Advanced Technology Center (TATRC) grant awarded to Florida Hospital’s Nicholson Center

for Surgical Advancement. The grant is for the development of a Center of Excellence (COE) in Medical Robotics and Simulation Research. TATRC is a division of the U.S. Army Medical Research and Material Command.

The Nicholson Center, co-located at Florida Hospital Celebration Health in Orlando, now hosts the largest multispecialty medical robotics training program in the world. According to Nicholson Center Administrator Rick Wassel, the Center currently has six da Vinci robotic surgical systems that are dedicated exclusively to training physicians from around the world in more than six medical specialties. “While the primary use of the da Vinci system has been for laparoscopic prostate cancer surgery (and in fact more than 85 percent of such surgeries in the U.S. are now done with the da Vinci), advances in robotics research have shown applications for its use in cardiovascular, thoracic, gynecological, urology and general surgery, as well as in oncology,” Wassel said.

Above The Nicholson Center will house the Center of Excellence in Medical Robotics and Simulation Research.

Image credit: Florida Hospital.

Robotics and Simulation Research In October 2011 the Nicholson Center opened its new 54,000 square-foot Global Training and Education Institute, which will house the COE in Medical Robotics and Simulation Research. The six da Vinci robotic systems will be located in this building and be equipped with the da Vinci Skills Simulator provided by system manufacturer Intuitive Surgical. Along with the 25-station wet lab for simulation robotics and learning for new procedures and techniques will be a Simulation and Robotics Lab for medical modeling and simulation and robotics, virtual, mixed and augmented reality, telesurgery and mobile surgery. The Institute also features a 500-seat conference center.

The purpose of the Institute is to

Vipul Patel, M.D., is the world leader in robotic prostatectomies, having performed more than 5,000. He is also the Director of Florida Hospital's Global Research Institute. In summarizing what is needed for the advancement of robotic surgery, Patel said that the next critical step in robotics is probably in simulation.

"The reason, there is still a very steep learning curve for the da Vinci procedure," Patel explained. "And what we know is that this is a continuous learning curve. You continue to learn no matter how many you do. Simulation is probably the safest and most ethical way to practice surgery before you first do it on humans. One of the most critical areas is developing a fundamental knowledge for robotic surgery, and to do it we need to have simulation."

Other Simulation Research Research on how to improve robotic surgery education through simulation will also be conducted at other medical

Performance Assessment

Above Florida Hospital's Dr. Vipul Patel with a da Vinci robotic surgery system.

Image credit: Florida Hospital.

education institutions, including the University of South Florida (USF)'s Center for Advanced Medical Learning and Simulation (CAMLS). CAMLS will feature a Surgical Simulation Center that will house two da Vinci robotics suites that will include the Skills Simulator and a number of simulated operating rooms that will have an extensive array of medical simulation devices. As at Florida Hospital's COE, the USF Simulation Center will be employed to develop and provide courses for surgeons in the latest robotic laparoscopic and other minimally invasive techniques, as well as for OR teamwork training and medical simulation research.

Closing Training Gaps "We are interested in looking at the comparative effectiveness of robotics technology to traditional surgical approaches," said CAMLS Director John Armstrong, M.D. "This is a real opportunity to define how robotics can enhance the outcomes for patients. We are also looking at how to close training gaps in robotic surgery. The primary education gap for the learner is simply understanding the efficiency of the robot and the tissue handling relative to the traditional instrument, which is the surgeon's hand.

This is the first gap that needs to be filled.

Defining the means to assess surgeons' performance skills in robotic surgery through simulation is also the goal of a study that will be conducted this summer at the Surgical Simulation Center at the Carolinas Medical Center in Charlotte, N.C., according to Dimitrios Stefanidis, M.D. and Ph.D., Director for Carolinas Medical Center. The goal of the study is the establishment of criteria for proficiency-based training that incorporates simulation into the curriculum.

"Our main focus or research area is identifying the metrics of performance and optimizing the curricula, or in other words, studying peoples optimal learning styles and provide them with the educational environment which enhances skills development so that they can learn faster and better," Stefanidis pointed out. "The best training paradigm is proficiency-based, using criteria-based on training goals."

"One way to assess performance is to track surgical motion in simulators," Stefanidis continued. "Our study, which is funded by several medical associations, is to assess current surgical proficiency levels. We need to identify those lagging behind and bring them up to speed. Also, we know that there is a transfer of skills from the simulator to the clinical environment. However, this transfer in not a hundred percent complete, so we are looking at ways to improve it."

VA Medical Simulation Center Recognizing the value of simulation technology for medical training and education, the U.S. Department of Veterans Affairs (VA) has begun to implement its Simulation Learning, Education and Research Network (SimLEARN) throughout its system of more than 170 Veterans Health Administration (VHA) medical centers around the country. Work has also begun for the establishment of the SimLEARN National Center in Orlando.

ISSUE 1.2012

Tough Learning Curve

Then we need to define just how many simulated procedures are actually necessary before someone becomes competent and all of the levels beyond competency to proficiency, and ultimately expert performance. The over arching goal is to define learner outcomes, ensure competency at each level until expert performance is achieved."

27 MEDSIM MAGAZINE

advance medical simulation and robotics and be a leader in those fields, Wassel explained. He cited partnerships with the Orlando military modeling and simulation community, along with the area's new Medical City and Veteran's Administration Hospital with its Medical Simulation Center, as catalysts for that goal.

"The old medical model of see one, do one, teach one is no longer applicable in today's environment," Wassel said.

"The new model is see many, do many, teach many, and we can accomplish that through simulation, much of it translated from military M&S. Medical simulation allows us to change the way we train physicians and impact their interaction with patients, through avatars or not."

According to Florida Hospital Chief Technology Officer, Roger Smith, what makes the Nicholson Center's effort to develop the Fundamentals of Robotic Laparoscopic Surgery curriculum unique is that it will be created to be shared; with all civilian and military medical education organizations, institutions, and hospitals. The ‘Robotic Surgery 101’ course will incorporate medical simulation technologies and become a part of the process to allow medical education organizations to certify surgeons to perform da Vinci robotic surgery, he explained.

Medical Simulation Centers

VHA’s SimLEARN is a national program established to develop and manage a strategic operating plan for the provision of simulation education, training, and research across the VHA. The SimLEARN program proposal was approved by the US Under Secretary for Health in July 2009.

The SimLEARN National Center will be located at the new Orlando VHA medical center currently under construction.

The Center is scheduled to open in June 2012. Once in operation, the Orlando facility will feature new simulation modalities in inpatient and outpatient research areas. The National Center staff will be responsible for the development of simulation-based curricula to address high-priority clinical needs and the distribution of this training and education material via the national SimLEARN network.

Top administrative staff for the SimLEARN National Center have been hired, and are in place in leased space in Orlando until the Center opens in 2012. After a nationwide search, the VA selected Orlando because of the concentration of modeling and simulation expertise and resources in the area, said

Above The Orlando VHA medical center is scheduled to open in June 2012.

Image credit: U.S. Dept. of Veterans Affairs.

Louise Van Diepen, VA Deputy Chief Learning Officer.

"We felt that Orlando provided a lot of synergies as it relates to simulation," Van Diepen said. "We are working with a lot of our Department of Defense partners located in Orlando, such as the Army's Program Executive Office for Simulation,

Training and Instrumentation, and the University of Central Florida's Institute for Simulation and Training. The National Center and the Orlando VHA medical center will be located at the Lake Nona Medical city, The SimLEARN National Center will initially focus on developing hands-on curricula for several medical simulation applications, including mannequin-based simulation, virtual patients, standardized patients, virtual environments, and haptic and non-haptic task trainers. medsim

Why should your company advertise in the next issue?

ISSUE 1.2012

Advertise in MEdSim and put your products and services in front of 35,000 Healthcare Professionals including Risk Managers, Patient Care Managers, Quality Managers, Medical/Surgical Educators, Nursing Managers/Senior Nurses, Finance Managers, Purchasing Managers, and Hospital/Health Center Administrators, from all of the Universities, Medical Schools, Nursing Schools, Hospitals and Simulation Centers across America.

Interested in advertising? Then please contact: Justin Grooms [Eastern USA & Canada] t. 407 322 5605 e. justin@halldale.com Pat Walker [Western USA] t. 415 387 7593 e. pat@halldale.com Jeremy Humphreys [Europe/RoW] t. +44 (0)1252 532009 e. jeremy@halldale.com

MEDSIM MAGAZINE

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www.halldale.com/medsim

Left

Conference Report

200 delegates attended the 1st World Congress on Surgical Training.

Publisher Andy Smith shares his insights after attending the September 2011 conference on surgical training.

A

lthough this event took place in early September 2011 its topic, content and the international audience from 31 countries that it attracted, make it an event that should be of interest to the surgical training community.

Surgicon was created by Margareta Berg, M.D., Consultant Orthopedic Surgeon of the Sahlgrenska Institute in Gothenburg, Sweden. As the Introduction to the Congress Handbook stated Sweden is often associated with terms like ‘quality’ and ‘safety’ and was the first country to create a national register of surgical results back in 1979. It is a superb setting for an innovative and much needed event.

The conference was opened by Lena Furmark, R.N., Political Advisor, Ministry of Health and Social Affairs, Sweden, with a review of the avoidable errors within the Swedish healthcare system which serves a population of just over 9 million. Approximately 100,000 patients are affected by avoidable injuries while

undergoing treatment resulting in around 3,000 deaths and 630,000 additional care days and a direct cost of Eu 6 million [$(US) 7.67 million].

These numbers were put into global context by Prof. Gerry O’Sullivan, the immediate past President of the Royal College of Surgeons in Ireland and of the European Surgical Association.

O’Sullivan added global statistics of 30 percent of all admissions leading to surgery or 247 million procedures per year resulting in 7 million complications and approximately 1 million deaths. The underlying assumption of the meeting that something would be done and was being done to combat this situation and improve patient safety was highlighted

by Ms. Furmark whose government has adopted a zero tolerance stance on avoidable medical error similar to that which it took with regard to road traffic accidents. That resulted in an all- timelow rate of traffic related deaths in 2010.

The Swedish approach is based on a system oriented concept, not specific

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Surgicon – The 1st World Congress On Surgical Training

to an individual error but looking at both individual and systemic preventable errors and adopting a zero tolerance policy toward patient harm. To participate in funding designed to help improve patient safety the healthcare provider is required to: • Establish an annual patient safety report including measures implemented and the results; • Participate in work against resistant bacteria; • Contribute to a national patient survey; and • Assist in developing national standards of care.

Adoption of WHO Checklists and a safe surgery scheme run by the association and supported by Insurers were also mentioned.

After that context setting the conference proceeded to look at contentious subjects such as the ‘selection’ of suitable future surgeons to ensure that a minimum of the training resource is wasted and the need for a radical change to training itself such that student surgeons spend their time specifically in training and less in providing general service. Irish, Australian and New Zealand speakers outlined recent developments in training in their own countries whilst anatomical training, team training and training delivery were all given their due and the event also exposed the different experiences of English, Italian and Swedish doctors in training to the new EU rules on limits to working hours. The experience is needless to say dramatically different. A final session on the role of industry in providing and supporting training pointed out the need for this to be done and the effectiveness of this type of training. An acceptable and transparent working relationship between physicians and industry they agreed was needed. Also, industry support must be free of commercialism. Throughout the event digital voting technology was used to poll the attendee’s views and the results were shared after each session.

All in all, a strong start and a worthwhile first event which will be followed by the second iteration in 2013. Details can be viewed at www.surgicon.org. medsim

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Image credit: Surgicon Congress.

Left

Medical Simulation Centers

CSC DC is one of the nation’s most advanced Clinical Simulation Centers.

Image credit: SiTEL.

interior space of CSC DC is easily tailored so it is a more effective use of space for our faculty, students, and technologists.

This allows for multiple uses through the lifetime of CSC DC.

Learning Lounge

SiTEL, Our Newest Simulation Center: CSC DC Yuri Millo, M.D. and Pamela Leonard describe the advancements in their latest simulation center to better meet learner needs.

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his past June (2011), we at Simulation and Training Environment Lab (SiTEL) of Medstar Health opened our newest Clinical Simulation Center, CSC DC, located at 4000 Connecticut Avenue N.W., Washington, D.C. 20008. This center is a state-of-the-art facility built in partnership with Herman Miller. CSC DC serves both MedStar’s hospitals and the healthcare community in the national capital region. During the first ten weeks of operations, CSC DC saw 1,524 participants during the peak on boarding time for new nurses and physicians entering MedStar’s healthcare system.

The need for new learning environments in healthcare is met through simulation training centers like CSC DC. Clinical Simulation Centers in general are emerging as free-standing learning environments, supporting all areas in healthcare education and training. Our CSC DC in particular is one of the nation’s most advanced Clinical Simulation Centers, because our design approach for CSC DC included elements that can be easily moved or adjusted. This design concept was modular, and like a stage in a

theater, our faculty and technologists can re-stage the learning environment for any type of training, as many times as needed.

When it comes to learning, the user experience is everything. The physical environment impacts how students learn. Thus, the challenge we at SiTEL faced with designing our new simulation training environment was to create a space that can be rapidly transformed, allowing frequent transitions across diverse training needs. Our CSC DC accomplishes this. Adaptability is the most desired form of flexibility from an operational viewpoint. This refers to the capability of making operational changes without construction. CSC DC’s modular design supports multiple technologies that combine to create an exceptionally realistic environment. The space is designed to train healthcare professionals and students in the domains of skills acquisition, clinical reasoning, communication, and team training. To meet these needs, we’ve used technology to define the spaces in CSC DC, rather than have permanent, immovable walls define our space. With this movable structure, the

CSC DC includes a new concept for learning spaces known as a Learning Lounge.

Our Learning Lounge is a place where personalized learning can occur and where each encounter is different from the learner’s point of view. In essence, the Learning Lounge is a protected time and space for reflection, research, or exploration. Our Learning Lounge concept was inspired by the desire to shift healthcare organizations toward becoming learning organizations. Much like our center’s overall structure, CSC DC’s Learning Lounge is an adaptable space designed to meet the needs of students and faculty.

Our CSCs: Mission and Courses In addition to our new center, we also operate several other centers in the Baltimore and D.C area. The mission of our Clinical Simulation Centers (CSCs) is to improve patient safety and clinical outcomes by integrating clinical simulation-based teaching methodologies into the training curriculum for all healthcare professionals. All of our CSCs craft a particular learning environment that creates experiential education. We integrate medical simulation and traditional medical training to reinforce best practices and patient safety mental models and strive to keep medical errors at an absolute minimum. Continued changes in technology also create an arena where patient safety concerns become even more critical. At our CSCs, we respond to patient safety concerns by teaching medical procedures using real life, immersive simulations.

In immersive and interactive learning environments, medical professional gain valuable experience in a realistic environment, learning with patient simulators instead of real patients. Last

Above With a movable structure, the interior space through the lifetime of CSC DC.

Accreditations gram teaches residents and surgeons the physiology, instrumentation, and technical skills involved in performing basic laparoscopic surgery. In addition, the FLS assessment component measures a candidate’s cognitive knowledge, case/ problem management skills, and physical dexterity.

We are also an authorized American Heart Association (AHA) Training Center providing emergency life support classes at our Clinical Simulation Centers. All of our resuscitation courses incorporate AHA outcome data, resulting in expanded code blue curricula.

Finally, in June 2009, we also received Level 1 Accreditation I from the American College of Surgeons Accredited Education Institutes (ACS AEI). The vision of the ACS AEI is to create a network of ACS-approved regional Education Institutes that offer practicing surgeons, surgical residents, medical students, and members of the surgical team a spectrum of educational opportunities, including those that address acquisition and maintenance of skills and focus on new procedures and emerging technologies. The ACS AEI also seeks to focus on competencies and to specifically address the teaching, learning, and assessment of technical skills using state-of-the-art

About the Authors Yuri Millo, M.D., Director, Simulation and Training Environment Lab (SiTEL). Dr. Millo is the Director of The Simulation and Training Environment Lab (SiTEL), part of MedStar Health in Washington D.C. Dr. Millo’s main focus is education and training for healthcare force using innovative technologies and pedagogical approach for adult learners. He developed serious games as Code Orange Simulator for emergency preparedness and Treatment of Burn Patient Simulator “Burn 101”, motion capture tools for surgical skill trainers on Xbox console, development of procedure simulators, shell games for online and mobile healthcare education, and HDLS courses (highly interactive hands on courses for low frequencies high impact hospital events).

Pamela Leonard, RN, MS, Director, Clinical Simulation Centers, SiTEL (Simulation and Training Environment Lab) MedStar Health. Pam started the Wall of Honor at the Washington Hospital Center CVRR. She was inspired by the original Wall of Honor developed by Charlotte Farris and her group at Baylor University Medical Center. Pam stated, "This display is not just a great way to recognize the nurses for their professional commitment, but also encourages others to pursue advanced certification.”

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is easily tailored to allow for multiple uses Image credit: SiTEL.

In addition to the flexible functionality of our simulation spaces and the studentcentered focus of our courses, our simulation centers are highly-accredited teaching facilities that meet the rigorous educational standards of many of the top medical education groups in the nation. In 2009, we became a member of the American College of Obstetricians and Gynecologist Simulation Consortium. The American College of Obstetricians and Gynecologists (ACOG) Simulations Consortium was initiated to offer simulations-based obstetric and surgical skills training to obstetricians and gynecologists. Its mission is to develop and implement unique simulationbased curricula to augment traditional procedure-oriented education in obstetrics and gynecology.

In March 2009, we also received testing status from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The mission of Fundamentals of Laparoscopic Surgery (FLS) is to provide surgical residents and practicing surgeons with an opportunity to learn the fundamentals of laparoscopic surgery in a consistent, scientifically accepted format and to provide a tool to test cognitive, clinical, and technical skills, with the overarching goal of improving the quality of patient care. The FLS pro-

educational methods and cutting-edge technology. medsim

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year, our CSCs completed training for 186 different courses, increasing our volume of participants to 11,517. These courses encompassed over 46,000 hours of training. We will continue to gear our training courses toward procedural skills acquisition, clinical reasoning, communication skills, and team training. We design courses for all those who provide essential care in the healthcare environment. This includes disciplines such as hospital security, spiritual care, students, nurses, residents, physicians, advanced practice providers, and prehospital and allied health professionals.

One of our nation’s greatest unsolved challenges is training for healthcare, and we at SiTEL have assembled one of the most unique teams in the nation to address this need. In addition to training the healthcare community, our CSCs also participate with local high schools to immerse students interested in becoming healthcare providers in the healthcare environment.

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Medical News Updates from the medical community. Compiled and edited by the Halldale editorial staff. For the latest breaking news and in-depth reports go to www.halldale.com.

Medical Students at NYU School of Medicine Use Interactive Virtual 3D Cadaver – First-year students at NYU School of Medicine were introduced to a pioneering online 3D interactive virtual human body called the BioDigital HumanTM. This unique educational experience supplements the traditional use of human cadavers in anatomy instruction by allowing students to both view and interact with realistically simulated 3D organs and other anatomical structures. This technology is just one way NYU School of Medicine provides its students cutting-edge, web-based learning environments to break the lockstep of traditional medical education.

Anatomy students view the life-size digital content displayed on a projector screen in NYU School of Medicine’s anatomy lab using sophisticated consumer-grade 3D glasses. They also use laboratory iPads to magnify and explore the models in great detail. Similar to experiencing a 3D film, viewing the graphics stereoscopically provides the illusion of depth and greater appreciation for the 3D models and their relationship to each other. This immersive, virtual reality set-up is an unprecedented 3D anatomy installation at NYU School of Medicine and is now available to its students and faculty. The 3D models of human anatomy were developed by NYU School of Medicine’s Division of Educational Informatics and BioDigital Systems LLC, then packaged and deployed in the BioDigital Human platform.

Virtual liver developed to improve diagnoses and surgery – Scientists and surgeons from France, Germany, United Kingdom and Switzerland have developed a “virtual liver” that will

Above Online 3D interactive virtual human body – BioDigital Human.

Image Credit: BioDigital Systems LLC.

help surgeons better plan and carry out tumor operations and ensure quicker patient recovery.

The European Union-funded PASSPORT research project (Patient-Specific Simulation and Pre-Operative Realistic Training) makes a uniquely accurate “virtual liver” available to physicians based on medical images sent by the radiologist to a PASSPORT online service, which helps surgeons decide whether they should or not operate.

Surgeons can now see more precisely where a tumor is and where they will have to operate to safely remove it, the European Commission said in a statement.

Commission Vice-President Neelie Kroes said that “the technology devel-

oped in the project is a breakthrough that will improve diagnosis and surgery, and help to save lives,” as liver cancer claims hundreds of thousands of lives in Europe and the world.

The liver performs more than 100 vital functions in the human body. Liver diseases, including cancer and sclerosis of the liver, kill thousands of people every year. Liver transplants are only an option for a very small proportion of patients with liver disease. Another option is to remove the infected part of the organ and allow the liver to regenerate. To do so, surgeons need to know the tumor’s precise location, the volume of the functional liver which would remain, and the patient’s overall health in order to accurately assess the chance of a successful intervention.

Under current practices, less than 50 percent of patients undergo surgery.

PASSPORT’s virtual liver could considerably increase this percentage, the Commission hopes.

effectiveness of technology-enhanced medical simulation in clinical training— and the study’s lead author, David A. Cook, MD, a medical-education specialist at Mayo Clinic in Rochester, Minn., suggested in an interview that the time has come to stop proving the obvious.

The analysis was recently published in the Journal of the American Medical Association (JAMA).

The authors searched the literature and found that clinicians and medical students trained with simulation devices show markedly better knowledge, skills and behaviors at the bedside than their peers who do not receive such training.

Cook led the review and metaanalysis to quantitatively summarize the outcomes of studies looking at technology-enhanced simulation training for “health professions learners in comparison with no intervention,” according to JAMA. Cook and colleagues identified 609 eligible studies enrolling more than 35,000 physicians, medical students, nurses, dentists and other healthcare professionals.

Of the examined studies, 137 were randomized, 67 were non-randomized studies with two or more groups and 405 used a single-group, pretest-posttest design.

“You would think it’s self-evident that simulation would improve skills and behaviors,” Cook told Healthcare Technology Management. “Practice

makes perfect; why would you even need to study the question? So the [proliferation] of studies looking at this question sort of makes you wonder whether people are either asking selfevident questions or just looking to see what other people have done. I can’t answer that question; it would just be speculation. But it does seem a bit surprising to me that it would take 609 research studies to answer this question. It’s time for the field to move on to other questions. Rather than asking whether or not this type of training works, we need to start looking at what makes it work and how can we make it work better.”

Tripler Medical Simulation Center achieves SSH accreditation – Tripler Army Medical Center’s Medical Simulation Center in Honolulu recently achieved the Society for Simulation in Healthcare accreditation. TAMC is the second simulation center in the Department of Defense to achieve this accreditation and the only one in Hawaii and Pacific region.

Ruth Andrews, the simulation center’s administrator, said the center’s main focus is graduate medical education programs, but they support all graduate professional health programs such as nursing, physicians assistant, and even staff training. The center has a variety of simulators from simple task trainers all the way through the highfidelity simulators that allow training on many skills The old paradigm used to be ‘See one; Do one; Teach one,’ and now it’s moving toward ‘Simulate one; Do one; Teach one,’” said Maj. Taylor Sawyer,

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Above TAMC’s Medical Simulation Center.

Image Credit: Stephanie Bryant/Tripler Army Medical Center.

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William Tennent High School students use CyberSurgeons simulation – Pressed for time and juggling several patients at once, the Alpha case manager stood before her chief medical officer updating the status of patients. For one, the problem appeared to be mononucleosis. Among other symptoms, though, this patient had an enlarged spleen, which could lead to further complications.“Because she has an enlarged spleen, she should avoid physical contact and physical activity. If there’s a puncture, the spleen could burst. So she should take it easy until all symptoms are relieved.

It could take up to two weeks,” said Brigitte Goudz, the case manager. She prescribed pain relievers, plenty of water and rest.

Via video conference, the medical officer acknowledged her report, but corrected Brigitte on one point.“It could actually take two to three months for all symptoms to abate. Otherwise, everything’s looking good with your treatment plan and trial, so we can discharge this patient,” said the medical officer. Brigitte, a junior at William Tennent High School, quickly walked back to her teammates hovering over Apple laptops on a round table studying patient case histories. Similar teams dotted the room.

The juniors and seniors studying anatomy got the chance to play medical detectives for a day.Through CyberSurgeons, a simulation program that uses the Web and videoconferencing technology, students connected with an educator at Wheeling Jesuit University in West Virginia. She was their chief medical officer and directed their mission on a fictitious mercy ship handling trauma patient care along the Amazon River in South America.Run by the Challenger Learning Center at the Center for Educational Technologies at West Virginia, the curriculum is based on national and state science standards related to human body systems and the disease process, according to the CyberSurgeons website. Each student was assigned a role within their team: Case manager, medical and surgical specialist, diagnostic specialist or clerical specialist.

JAMA: Medical technology simulation training has proven its worth – A new meta-analysis has confirmed the

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medical simulation director. “This (evolution) is very important (to medical training).” Sawyer explained that right out of medical school a lot of the residents haven’t experienced or performed any procedures. Andrews said this is why simulation is so important now in medical training facilities.

“In simulation, you can practice as often as you want without risk of injuring anyone,” said Andrews. “You use it to build your skills and your knowledge.”

The accreditation validates education that the people who are doing the simulations provide,” he said. “The data that the residents who use the program accumulated assisted us in getting the accreditation. It validates the training that they are doing. It shows that (the center) is of a high level and been reviewed by people outside of Tripler and found to be good.”

Pilot project trains Army reservists at Mayo Clinic Simulation Center – Military medical personnel have been visiting the Mayo Clinic Multidisciplinary Simulation Center in Rochester, MN to hone their skills before an expected deployment to Afghanistan.

Army Reserve Col. Walter Franz III, commands the 945th Forward Surgical Team, which includes more than a dozen medical military specialists, about half from Minnesota and half from other states. He is also a family physician at Mayo in Rochester. To prepare for the Afghanistan deployment, Franz selected the “Sim Center,” as it’s known to Mayo staff, because he wanted his personnel to get some hands-on experience with pediatric trauma. A U.S. Army Reserves colonel has begun a pilot project to see if all Army medical reservists should get Mayo Clinic Multidisciplinary Simulation Center training. His medical team has served previously in Iraq.

According to Franz, the pilot project’s purpose is to determine if simulation training should become a standard part of Army Reserve medical training and makes sense to do at Mayo. Col. Joaquin Cortiella said the purpose of his own presence during the pilot study in Rochester was to gather information and report back to Brig. Gen. Bryan R. Kelly for a decision about the possibility of having combat support hospital personnel “come here and do some trauma training.”

New Medical Simulation Centers Indian university to establish teaching labs with simulation – The NTR University of Health Sciences in Hyderabad, India has written to the state government asking for funds of Rs 20 lakh each to all 10 government medical colleges, for setting up skill development labs for teaching emergency care.

University registrar T. Venugopal Rao said setting up of the labs may materialize by the next academic year as the state government has responded positively to their proposal. He said they decided to set up the skill labs after the Andhra Pradesh Medical Graduates Association in the US gave a demonstration to students and professionals on using the mannequins during a program conducted at the Gandhi Medical College recently.

The mannequins, or life-sized dolls, have simulated airways which are used in teaching first aid, CPR (cardiopulmonary resuscitation) and airway management skills, along with computer simulation, to model the behavior of the human body. At present, no medical college in the state, except a few corporate hospitals, use mannequins, said Venugopal Rao. The cost of each mannequin ranges from Rs 1 lakh to Rs 65 lakh.

The principal of Gandhi Medical College, Dr K. Venkatesh has said the mannequins would help the faculty in teaching emergency care to students in a proper way. He also said they have written to the Medical Council of India asking permission to set up a MD course in Emergency Care.

“MCI officials are going to visit the college soon and there would be no hurdles in getting permission to start the course, as we have all the required facilities and infrastructure,” Dr Venkatesh said.

New nursing education center focuses on simulation – Providence Health & Services, with more than 3,500 nurses in its Los Angeles-area hospitals and other healthcare centers, is creating a Nursing Institute to advance quality patient care through professional development, education, technology and research.

The Providence Southern California Nursing Institute will serve as a training

ground for nursing graduate residents, established nurses and other clinicians at Providence medical centers and ancillary services. And it will promote nurse-led research to further improve patient care.

The program is the vision of Katherine Bullard, R.N., regional chief nursing officer for Providence in Southern California. A core team of nurses, under program director Kathleen Harren, R.N., is laying the foundation for the institute and expects to begin operations in the spring.

“Our goal is to have uniform evidence-based practices across all our ministries in Southern California to ensure the best care for our patients,” Harren said. “One of our first steps is to identify our successes. If something works well at our hospital in San Pedro, we will adapt that practice at our hospital in Tarzana. It’s about applying best practices to advance the science of nursing, which will improve outcomes for patients.”

Harren is the former chief nursing officer at Providence Little Company of Mary Medical Center Torrance where she obtained grants for education and training programs that utilize simulations to help nurses and other team members practice and develop skills, decision-making processes and critical thinking abilities without risk to actual patients. “We hope to establish a regular simulation center where we can expand our technology-based learning capabilities,” Harren said. “We envision team-based, inter-professional and inter-disciplinary learning to broaden our approach to training and actual patient care.”

Nurse Educator/Coordinator Julie Vance said if you can dream it she can make it happen through proper programming of the new patient simulators.

She said simulation allows for a safe non-threatening environment to refine skills that can be utilized later at the bedside.

New Products New Hansen Medical Robotic Catheter System – Hansen Medical’s new Sensei X Robotic Catheter System is a flexible robotic platform that integrates advanced catheter control with 3D visualization, designed to provide catheter

other simulation technology on the market is its patient-specific nature, said president and cofounder Moty Avisar.

That is, images of a particular patient — such as MRIs or CTs — can be loaded into the simulator, allowing the surgeon to see a near-exact replica of what she’d see when operating on that particular patient.

When using the simulator, a doctor grasps and manipulates the same type of tool used during the operation, but in this case, the tool is a model that enables interaction with the medical images the doctor is seeing on the simulator’s screen. “To achieve the level of immersion we want to achieve, we need the same exact tools,” Avisar said.

Another differentiator is that Surgical Theater plans to focus on simulating higher-risk, open surgeries as opposed to endoscopic procedures, for example — meaning its simulators should have a higher value to experienced surgeons.

Its first product will train physicians on how to perform brain aneurysm surgeries, which Selman describes as “one of the most technically complex procedures a neurosurgeon does.”

A Visual Boost for Immersive Simulation Center – Barco has installed two 3-D stereoscopic CADWalls and an I-Space system at the University of Toledo’s new Interprofessional Immersive Simulation Center.

The CADWall is a wide field-of-view,

ultra-high resolution 3-D stereoscopic display wall featuring Barco’s proprietary projection system. “It creates a very large (about 16 ft. wide) flat-screen image, through a single, rear projector so people can walk right up to the screen,” Ken Hunter, the company’s Director of Sales and Marketing for Virtual and Augmented Reality, told MEdSim. As CADWall is a 3-D stereoscopic system, the learner wears 3-D glasses to visualize an object in three dimensions, so that the object “sits” in front of the individual.

Learning content displayed with CADWall includes CT scans, MRIs and other material. Teachers, researchers, students and others are thus able to “see parts of the human body floating in space and are able to rotate them, slice them and look at the various biological structures,” Hunter said.

The company’s I-Space is a multisided, cubic immersive environment that completely surrounds the learner with virtual imagery, immersing him or her in a virtual environment through the support of a rear-projection system.

The environment is built around three, 90-degree screens, one in the center and one each, to the left and the right, as well as an image on the floor. “When you walk in, everywhere you see, including your peripheral vision is a projected image.”

Hunter added that the contract with the university resulted following a successful demonstration project using a Barco virtual reality system in a learning environment. “After using the system for five months, everyone within the facility was impressed and wanted to

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Above 3-D stereoscopic CADWalls and I-Space system.

Image Credit: Barco.

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stability with force sensing, instinctive and precise catheter placement, as well as reduced radiation for both physician and patient. At the conference, physicians will be able to experience the ability to perform true 3D catheter mapping and driving with a functional Sensei X Robotic Catheter System, fully integrated to a St. Jude Medical EnSiteTM 3D Mapping System. There will also be two additional Demo Kiosks where physicians can practice catheter mapping and driving in virtual simulation.

“When physicians experience the truly instinctive nature of the 3D catheter control and visualization offered by the Sensei X Robotic Catheter System, they will see the great potential of this robotic catheter system in patient care,” said Bruce Barclay, Hansen Medical’s president and CEO. “We continue to see increasing momentum in the adoption of the Sensei X Robotic Catheter System by a new generation of electrophysiologists, who are embracing new and innovative solutions in order to provide improved care for their patients and to grow their practices.”

“We continue to improve our world class education and training program which is designed to provide physicians and their staff with the ability to use the system with confidence and precision in a shorter period of time. Physicians will be able to see and experience the training we offer at the Boston Atrial Fibrillation Symposium,” Barclay concluded.

New Surgical Theater surgery simulation software for rehearsal – Startup Surgical Theater is developing personalized surgery simulation software that loads medical images of patients to help doctors rehearse tomorrow’s surgery today.

The Cleveland-area company was started by two former Israeli Air Force officers with extensive experience developing flight-simulation technology, as well as a surgeon with University Hospitals Case Medical Center (UH).

“What’s unique about these guys is that they understand the importance of rehearsing exactly what you’re going to do the next day,” Warren Selman, chairman of UH’s neurological surgery department, said of the Surgical Theater’s founders. Selman is helping the company develop its simulators.

One of the key differences between Surgical Theater’s simulator and some

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have more and bigger systems – they were so impressed the technology worked for them.”

Barco, as an integrator for this project, added third-party hardware and software at the simulation center to create a unified solution. Ken Hunter: ken. hunter@barco.com Medical textbooks now available on iPad – A new kind of textbook is popping up in the classrooms of innovative medical schools across the country – like Weill Cornell, UC Irvine, Warren Alpert of Brown and the University of Central Florida. These schools, and others like them, have partnered with Inkling, a San Francisco start-up that rebuilds medical textbooks from the ground up for iPad. On Inkling, the textbooks of major publishers such as Lippincott and Elsevier become Smartbooks that are more flexible, engaging, and effective than their print versions.

One of Inkling’s newest releases is the classic reference, Harrison’s Principles of Internal Medicine. Built to leverage Inkling’s robust search, sharing and annotating platform, the Smartbook version of Harrison’s features more than 100 instructional videos, numerous interactive diagrams, slideshows and guided tours, as well as 57 formerly online-only chapters. With Inkling, medical students and doctors have their favorite textbooks and most trusted medical resources right at their fingertips. By this fall, a full curriculum of medical titles will be offered on this platform.

An Integrated Training Approach – SAIC is on the cusp of delivering an integrated virtual and live training solution that promises to be a game changer for medical simulation training. The foundation of SAIC’s learning strategy is the web-based On-Line Interactive Virtual Environment (OLIVE) 3.0 platform and a new medical simulation engine that leverages a third party physiology model for patient response and treatment.

This latest version of OLIVE bolsters the state-of-the-art for enterprise-grade virtual world platforms by working in a web browser, having enhanced security attributes and DIACAP certification underway, running in the cloud, and featuring enhanced photo-realistic avatars.

SAIC plans to take advantage of its competencies as one of the largest health IT providers to the U.S. DoD to

Above The new iExaminer system.

Image Credit: Intuitive Medical Technologies.

further enhance this OLIVE capability.

The company’s integrated medical simulation training vision also relies on mannequins and other part task trainers to allow learners to be placed in scenarios through the continuum of learning – up through situations where infrequent occurrences have to be handled perfectly or a person’s life will be on the line.

As in other simulation and training endeavors, SAIC is remaining true to its role as an integrator of best-of-breed solutions. In one instance the company does not manufacture, but rather uses high fidelity mannequins and other parttask trainers supplied by specialized vendors and other industry teammates.

Dr. Paul Miller, a Chief Scientist at the company’s Health Solutions Business Unit, explained the value of these devices during a recent industry trade show. In one instance, Miller pointed out that one mannequin at his exhibit booth allows the aspiring medical professional to learn how to use a tourniquet within five minutes. “It took me a long, long time to develop this skill, working in emergency rooms and waiting for patients to arrive for treatment. When we have good technology that enables learning how to do a procedure and learning many procedures in one day instead of waiting for patients to come

through the door, that really accelerates the training process.”

Miller added that SAIC is seeking to raise the level of training offered through these very capable, standalone devices to a higher level through a system integration strategy using a medical simulation engine to deliver training inside and outside of OLIVE. “What’s missing is an umbrella to integrate those into a system where there are mannequins and part-task trainers, but they are being consistently monitored and integrated into a learning system.”

SAIC’s medical training strategy will support individual as well as team skills.

Enhancing Eye Care Skills – Intuitive Medical Technologies’ new iExaminer system allows fundus photography with the practitioner’s iPhone (4 and 4S).

The iExaminer system has two components – hardware and software app.

The hardware adapts the iPhone (4 or 4S only) to the Welch Allyn PanOptic. The software app (available via iTunes or the App Store) includes a walk-through of a full eye exam and it enables the iPhone camera to capture the images from the PanOptic.

Jennifer Lawrence, the company’s Chief Operating Officer, told MEdSim that the company’s app (iExaminer) optimizes the iPhone camera and takes simultaneous low resolution video broken down into approximately 40 frames and high resolution photographs.

“Therefore, in one imaging session (it records for 5 sec) you can choose the best images from approximately 50 frames.”

Above MARC’s TruSkin.

Image Credit: Medical Accessories and Research Corporation.

The Ventriloscope’s cost is reported to be only one-tenth the cost of a high fidelity mannequin, the company said Lecat’s office recently released its heart trigger which enables any sound to be synchronized with the actual pulse of a human or mannequin with a large number of sounds to go with it. “Our lung trigger will be released shortly and enable any breath sound to be portrayed anywhere on a mannequin, not limited to the usual speaker locations. The survival skills package as above is new and has been well received as well,” he added.

Over 300 units are in place at over 100 schools in the U.S., Canada, UK, Korea, Australia, and in the near future, Malaysia and the Dominican Republic. It is priced to allow almost any school to have very high quality simulation exercises. The company’s beta test sites include Stanford, the Imperial College of London, University of California San Diego, and University of California Davis.Paul Lecat, M.D.: plecat@agmc.org New Incident Response Trainer – The Complex Incident Response Training System (CIRTS) is a family of game-based systems designed to train high-priority individuals and small teams who work embedded in larger

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The system has two components: the stethoscope and a handheld transmitter. Realistic heart, lung, bowel and other bodily sounds are stored on a standard SD card in MP3 format. The transmitter can play up to 12 sounds from each SD card and send them wirelessly to the stethoscope for the purpose of simulation and testing.

The device is said to be the only device that allows the authentic integration of getting a patient’s history with a realistic exam. Dr. Lecat, the Medical Director at the William G. Masson, M.D., Center for Clinical Skills Training, Assessment and Scholarship at Northeastern Ohio Universities Colleges of Medicine and Pharmacy, said “This is what health care providers do all the time. We need to teach our students how to recognize serious illnesses before they encounter them! Many use ‘real’ patients, but they obviously can’t be too sick, or they can’t come to the center for an exercise.”

The Ventriloscope enhances the many mannequins in the community, including the broken ones. “A major advantage is the ability to place ‘any sound, anywhere’ on a live patient or mannequin. If you want to simulate a carotid bruit, we can do that, though I’m not aware of a mannequin other than Harvey, who can do that. But why not simulate a thyroid bruit in grave’s disease, or renal artery stenosis in a refractory hypertensive? These are findings we want our trainees to recognize and act upon,” Lecat emphasized

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The system is not intended to take the place of an in-office fundus camera, however, in a non-traditional clinical or rural setting or in a teaching atmosphere, the company believes the product is a cost-effective alternative that provides good images of the back of the eye – with or without dilation.

“Specifically, in a teaching atmosphere, instructors can use the system to instruct students on getting a good image of the back of the eye as well as test students on their ability to take and analyze a picture of the back of the eye,” Lawrence said, and added, “We believe that for some, this may be the only way students will get a true look at the back of the eye. This will close the gap for students who may try to simply memorize the view of the back of the eye rather than trying to achieve a quality image of their own.”

For more information and to see photos taken with the iExaminer, visit www.iexam.com. Under the “support” tab, Dr. Wyche Coleman, the iExaminer’s inventor, has several videos outlining best practices to get quality images from the iPhone. Jennifer Lawrence: jhl. imt@gmail.com Realistic Soft Tissue Developments – Zeeland, Michigan-Based Medical Accessories and Research Corporation (MARC) specializes in the development and production of realistic soft tissue replication to meet the learning audience’s specific need. MARC also provides workshop bones, clear display models, soft tissue trainers, and implant replications. All manufacturing, research, and development is located on site in Michigan and all the materials are purchased from companies within the U.S. MARC’s TruSkin was developed in collaboration with Wayne State Medical School and was introduced to the marketplace in the Spring of 2011.

Designed to be a “hands on” teaching aid for suturing, stapling, and suture removal, it has been found to work great with injection training, biopsies, T.B. testing, wound packing, cyst removal, postpartum fundal massage, and trocar/ tube insertion training.

Ventriloscope Update – Dr. Paul Lecat’s Ventriloscope has proven to be an extremely reliable and realistic system for the wireless transmission of any sound into a realistic stethoscope.

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teams-of-teams. The first examples of this audience are military medical specialists who work within tactical units. “What CIRTS allows the individual medic trainees to do based on navigation through a training matrix is to develop their abilities to do realistic and extensively more challenging medical and operational situations,” Phil Jones, MYMIC’s Vice President of Human Solutions, said during a system demonstration at an industry trade show attended

by MEdSim. MYMIC is developing CIRTS’ Combat Medic (CM) variant under a Small Business Innovative Research Phase II contract with the U.S. Army’s Telemedicine and Advanced Technology Research Center. In addition to CIRTS-CM, MYMIC has also developed Combat Life Saver, Emergency Medical Technician and MEDEVAC prototypes of the system.

The CIRTS-CM product demonstrated for the community elevates the trainee beyond basic medical skillset training – into decision-making scenarios within stressful tactical environments.

CIRTS utilizes the VBS2 gaming platform to help the learning audience achieve its learning outcomes. VBS2 is the U.S. Army and Marine Corps’ choice of gaming platform for first-person training. MYMIC is also developing a plug-in CIRTS capability that brings realistic medical operations into small unit, game-based training.

MYMIC is creating an after action review module to support the trainee’s continuum of learning. Comtact: Phil Jones: phillip.jones@mymic.net STAT! Prototype Described – Vcom3D reported progress on developing its STAT! prototype serious game for medical training. The product is presently in Phase I development and is expected to cross the threshold to Phase II this March.

When MEdSim spoke with Carol Wideman, the company’s president and CEO in mid-December, the scenario was configured with four patients and an attending trauma medical staff.

Vcom3D is pursuing a learning strategy that has been identified as a requirement by medical system integrators, and civilian and medical learning institutions – the need for medical team training. “It’s an interactive game

that has gameplay at a level that is very effective. Participants are able to train as a team. The key thing is that you can always add procedures,” Wideman added.

The product’s Phase I effort supports a U.S. Air Force medical simulation project. The company is also in discussions with the U.S. Army and at least one civilian medical institution on efforts to further enhance the product and completing an evaluation at the end of Phase I. Indeed, while the current scenario has a military venue and describes a response to an IED detonation, Wideman emphasized the product development team and its military and industry counterparts are examining ways to insert trauma-type scenarios in the civilian sector into the game.

DRE offers customized medical simulation suites – DRE, Inc. now offers customizable medical simulation suites that are economically priced to fit the budgets of teaching institutions of nearly any size. According to the company, both its new and refurbished medical equipment provide valuable hands-on experience to students training for careers in hospitals, physicians’ offices, rest care facilities, and surgery centers. Possible suites include birthing labs, patient rooms and operating room environments.

DRE provides an array of simulationsuitable equipment, including monitors, tables, lights, incubators, ventilators and much more. Teaching institutions can choose the level of refurbishment to fit their needs as a low cost-option. medsim

Calendar 27 January - 1 February 2012 IMSH San Diego, CA www.ssih.org 9-11 February 2012 MMVR Newport Beach, CA www.mmvr.com 28 February - 1 March 2012 HPSN 2012 Tampa, FL www.hpsn.org 7-9 March 2012 CREOG & AGPO Orlando, FL www.agpo.org 16-17 March 2012 ACS AEI Consortium Chicago, IL www.facs.org/education/ accreditationprogram/index.html 23-25 March 2012 ASiT Cardiff, UK www.asit.org 26-27 / 29-39 March 2012 WRGC IV & ISGE Orlando, FL www.wrgcus.com 9-12 May 2012 MT3 Orlando, FL www.mt3.bz 3-6 June 2012 ASPE San Diego, CA www.aspe.org 12-14 June 2012 Games for Health Boston, MA www.gamesforhealth.org

Index of Ads B-Line Medical www.blinemedical.com 19 CAE Healthcare www.caehealthcare.com OBC iSys Global Solutions www.isysglobal.com 11 MEdSim Magazine www.halldale.com/medsim

17 & 28

Mimic Technologies www.mimicsimulation.com 23 MT3 Conference www.mt3conference.com

IBC & 24-25

Simbionix www.simbionix.com IFC

Advertising contacts Director of Sales & Marketing: Jeremy Humphreys [t] +44 (0)1252 532009 [e] jeremy@halldale.com Sales Representative, USA (West): Pat Walker [t] 415 387 7593 [e] pat@halldale.com Sales Representative, USA (East) & Canada: Justin Grooms [t] 407 322 5605 [e] justin@halldale.com

Medical Technology, Training and Treatment Conference May 9 - 12, 2012 Renaissance Hotel at SeaWorld • Orlando Florida

Benchmarking Quality Care and Enhancing Patient Safety through Better Education and Training! www.mt3conference.com

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