CyberSurgeon

Advanced simulation technologies for surgical education

by Col. Richard M. Satava, Jr., MD, FACS, Washington, DC

There is a unique opportunity to take a bold step forward in enhancing surgical education through the incorporation of surgical simulators into the surgical curriculum. The educational process involves many levels and should include the residency program directors, the surgical specialty societies, the residency review committees, the member boards of the American Board of Medical Specialties, and the American College of Surgeons (ACS). Each of these groups has an important role in the educational process, and together they should demonstrate responsible yet visionary guidance by supporting the concept of implementing technical skills assessment through simulation within a decade. Should the medical profession abdicate these responsibilities, the managed health care and insurance industries may seize upon these technologies and use them to restrict privileges granted to surgeons or perhaps deny payment.

Background
Recent innovations in advanced technologies in computing, graphics visualization, simulation, and virtual reality have progressed to a point where serious consideration must be given to the role of advanced simulation for surgical education. The precedent for simulation for training has been proven with over 40 years of successful utilization of flight simulators. These simulators have reached a level of visual photorealism, multisensory input, and complex motion platform technology that permits not only applicant screening, training, and evaluation, but also licensing and annual recertification for military and commercial pilots. Although still in their infancy, medical and surgical simulators are emerging that promise to bring to the medical field a fidelity of surgical simulation comparable to that of flight simulators. The important recent accomplishments include:

1. The Visible Human Dataset by the National Library of Medicine, which provides a high-fidelity three-dimensional virtual model of a human cadaver that was derived from patient-specific data.
2. Rapid advancement in application-specific computational engines and software, such as the Silicon Graphics Reality Engine and Sun Microsystems Java, which begin to provide the computer power and software sophistication necessary to render the images with the high fidelity and in real time.
3. The emergence of corporations specializing in medical modeling, simulation, and education, such as High Techsplanations, Ethicon Endosurgical, Medical Media, Inc., CinéMed and Engineering Animation, Inc., which have produced first and second generation medical and surgical simulators.
4. Introduction of simple yet effective haptic input devices (adding the sense of touch) by Immersion, Inc., Exos, Inc., and Sensable Devices, Inc.
5. Publication of results of constructive models and task analysis of surgical procedures for education and training in virtual environments by Johnston, Loftin, and others, based upon their decades of experience in psychometric validation of astronaut and pilot training using modeling and simulation.

The ingredients to launch a successful effort for virtual reality surgical simulators exists and requires encouragement, advice, and oversight by authoritative medical and surgical organizations. Physicians have the opportunity to seize the initiative and provide the leadership and guidance that could usher in a revolutionary improvement in surgical education. The impact would be felt across the board and would enhance the quality of education in basic scientific (anatomic) knowledge, the teaching of basic and advanced technical skills, the testing and evaluation of surgical skills, and the development of preoperative planning tools. Ultimately, the use of simulators would provide an objective certification/recertification tool to determine and maintain technical surgical abilities. Because this science is in its medical infancy, sage and stringent guidance is required to ensure that it matures properly.

Components of the educational process
There are various components of the educational process upon which a surgical simulator would have an impact. The device is simply the tool; it is the content of the educational experience that requires careful crafting to ensure that added value is provided.

In general, a curriculum is usually developed and always implemented at the individual training program level, under the responsibility of the residency program director. Many surgical societies provide guidance or generic curricula to assist the program director.

The residency review committees have responsibility to monitor the residency programs and determine compliance for education and training. Their most effective contribution would be to determine when surgical simulators are ready to be considered a required component of the educational process. The effect would be to make it essential that every surgical training program acquire and train surgical residents on a surgical simulator. In addition, their perspective of the entire training landscape could provide an overview of the impact on a national scale. The member boards of the American Board of Medical Specialties have authority for certification, and it is here that the largest impact can be made. Over the next five years, it should be possible to demonstrate that surgical simulators are a valuable assessment tool that can be used to assess a resident's surgical technical skill. If this demonstration does occur, it is a reasonable, responsible, and reputable position to consider incorporation of a requirement that residents be tested on a surgical simulator as part of the certification/recertification process, either by the residency training program or by the member boards. This requirement would put the control of the process in the hands of surgeons who sit on the member boards, not third-party payors, employers, or regulators. Regardless of the ultimate determination regarding the use of simulation for certification, there now exists a clear opportunity to significantly enhance the education and training of surgeons through the use of surgical simulators.

Since the residency program directors will be the ultimate users, it is at this level that the curricula must be developed and the effectiveness assessed. As surgical simulators improve, innovative program directors will take the initiative and will incorporate surgical simulators into their curricula and assess the advantages of those curricula. The various surgical societies must monitor the progress of the improvements through their respective surgical education committees and provide guidance and possibly draft generic curricula to take advantage of the new technology. While individual programs could publish outcomes analysis of the effectiveness of surgical simulators for their training programs, the surgical societies could sponsor multi-institutional studies on effectiveness.

The ACS could provide the overall leadership role for the evaluation of the technology and curricula, coordinate efforts across the surgical specialties, and disseminate the full spectrum of information to the membership. The evaluation should include information provided by the individual program directors and surgical societies and give a high-level assessment of the role of surgical simulators in the surgical education process (whereas the surgical societies would assess the value of the simulators to their specific specialty).

In addition, advancements and improvements should be provided to all of the surgical societies to ensure equivalency and concurrence across the surgical disciplines. Through its annual meeting, official publications, and other communication channels, the College could make available to the membership at large the full spectrum of information regarding the state of the art, the progress, and the future role of surgical simulation within the context of the surgical education process. There is no specific new or additional mechanism required to perform these tasks; rather, surgical simulation should become just one further tool to be evaluated, monitored, assessed, and reported upon through the various committees that are responsible for surgical education and new technology assessment.

Whether we choose to acknowledge or ignore the facts, our young physicians are a generation to whom information technologies (including video games and simulations) are a "natural" part of their daily lives. Since computer simulations are now accepted as a powerful (if not integral) part of the overall general educational process, their implementation into surgical education is only a matter of time. It is this emerging generation's perception (whether right or wrong) that the medial profession will be either a visionary force to dramatically improve their educational experience, or an obstructive barrier that frustrates and impedes them.

The technology is maturing at such a rapid rate that leadership must take the initiative by providing realistic goals. Within five years, the technology and curricula (many of which are being developed in innovative surgical residency training programs today) will be mature enough to begin formal inauguration into training programs, with the long-term goal of having a "technical skills" assessment on a surgical simulator by the end of a decade. Such milestones provide ample time for technology incorporation (five years) and validation in training programs (five years) before the first testing would occur.

The companies that would build and sell the simulators and provide test delivery are expectantly "waiting in the wings" for a sign that their investments in developing simulators and testing centers would be fulfilled by the need. Now is the time to "place a stake in the ground" for a decade hence, with the flag declaring that testing through simulation will be required—provided the curricula and technological promise materialize. If such a stand is not taken, there will be very little incentive for commercial development, and the implementation may take two to three decades.

It is recognized that the technology is mature enough for only some initial, simple surgical tasks; however, the rate of advances in the development of technology is so great that within a decade the requisite quality of performance will exist. This is not a call to dash madly forward, but an acknowledgment to assume responsible guidance before the technology rushes past and establishes random implementation without restraint (not unlike laparoscopic surgery). An even worse scenario would be the seizure of this opportunity by managed care organizations or insurance companies as a method of restricting practice or denying reimbursement. It must be emphasized that although simulation will become an enhancement (as well as a reduction on reliance on live animal models) to current education and certification processes, it categorically will not replace any of the traditional methodology.

Conclusion
The time is right to assess advanced surgical simulation technologies and to begin to incorporate them into the surgical education process. Incorporation must occur at all levels, and it must involve the surgical residency program directors, the surgical specialty societies, the residency review committees, the member boards of the American Board of Medical Specialties, and the American College of Surgeons. Physicians must assume the role of leadership by coordinating the activities of the various participants, communicating with their members, and supporting the concept of implementing technical skills assessment through simulation within a decade.

Dr. Satava is clinical associate professor of surgery, Uniformed Services University of Health Sciences, General Surgery Service, Walter Reed Army Medical Center, Washington, DC. Send us your e-mail address

The Committee on Informatics is interested in compiling a list of e-mail addresses of Fellows of the College. If you have an e-mail address, please send it to: postmaster@facs.org
To check out the College's website and home page, use the address: http://www.facs.org

Learning with new tools

The process of educating a surgeon is far different today than it was a few years ago or than it surely will be in the future. Changes in how a surgical resident learns basic surgical skills, for instance, are being driven by the evolving demographics of hospitalized patients, strict fiscal management of our hospitals and operating rooms, and the large-scale movement of surgical procedures into ambulatory settings. These days, junior surgical residents spend less time in the operating room, perform fewer procedures, and spend much more time on the wards and critical care units caring for patients who have increasingly complex illnesses. How will they learn to tie knots, dissect tissues, place sutures, and other basic skills?

With the aid of simulation technologies, suggests Dr. Richard Satava in the accompanying piece. Although he focuses on the exciting possibilities of advanced computerized simulation technology, many more simple mechanical devices are already available. With more than 1,000 surgical residency programs serving as the developmental laboratories, in a few years the relatively primitive simulations of today will be sufficiently developed to provide realistic surgical fields with the look, touch, and feel of "the real thing."

With careful planning and intelligent, systematic introduction of these new tools for learning and evaluation of proficiency into our graduate surgical curricula, junior residents can develop mastery of basic skills on simulators—rather than on patients—and use the operating room efficiently to learn procedures and develop surgical judgment. It is the role of surgical societies, program directors and surgical educators, residency review committees, and certifying boards to develop specified objectives for this exciting technology, and proceed to integrate it into educational programs that will maximize its capabilities.

C. James Carrico, MD, FACS
Chairman, Committee on Emerging Surgical Technology and Education

____________________________________

Reprinted from the Bulletin of the American College of Surgeons
Vol. 81, Number 7: 77
July 1996

Cybersurgeon articles

Committee on Informatics

This page and all contents are Copyright © 1996-2000
by the American College of Surgeons, Chicago, IL 60611-3211