Both Robert Miller, MD, MBA, Executive Director of the American Board of Otolaryngology, and Gerald Healy, MD, the first otolaryngologist-head and neck surgeon to be President of the American College of Surgeons, agree that medical simulation is becoming a critical part of medicine’s present and a cornerstone of its future. They appreciate simulation’s growing role in educating physicians and in continuing medical education, and its potential contribution to better and safer patient care.
Medical simulation-whether it’s a low-tech version using tubing for students to practice clearing an airway or a temporal bone dissection simulator being designed and tested at the level required for board certification-is an essential educational tool, said Dr. Miller, who is also the chair of ENT Today‘s editorial board. He added that although American physicians, computer scientists, and engineers are making significant progress in developing medical simulations and incorporating them into medical education, progress is slow in taking simulation to the highest levels because adequate public and private funding opportunities have not yet materialized.
Dr. Healy’s view of medical simulation from the 30,000 feet perspective starts with a mandate for changing medical education and maintaining skills for senior physicians that by necessity includes simulation. The old days where we sent medical students to doctors’ offices or had them follow senior physicians around the hospital to observe their interactions with patients and then discuss it are over, for the most part. Today, how practicing physicians are reimbursed resembles how other pieceworkers are compensated. They get paid by how much they produce, so their [unpaid] time with students has been curtailed as they attempt to maintain their revenue streams and keep their practices afloat, he explained.
The physician-in-training’s lack of opportunity to follow medicine’s traditional learning path of See one, do one, teach one only heightens the need for a variety of simulations of varying complexity. The changes in staffing at academic medical centers, which restrict residents’ hours on duty, makes them less likely to hone their skills at the bedside. Only the sickest patients are in hospitals now, and they tend to be discharged as quickly as possible, leaving little time for medical students to interact with them. If the resident just happens to be at the right place at the right time, he or she might be lucky enough to learn something important, commented Dr. Healy.
Ironically, the patient safety movement has significantly decreased medical students’ access to live patients and the opportunity to interact and learn from them. Medical simulation is helping to fill that gap.
One form of simulation, virtual reality (VR), has slowly been incorporated into curricula by medical schools across the country in recent years, in reaction to changes in training. As traditional methods of animal and cadaver dissection and working with live patients have become problematic, VR is picking up the slack. Using VR helps medical schools overcome the ethical, cost, and practical barriers to effective learning that decreased access to traditional training modalities presents. And incorporation of medical simulation into board certification in internal medicine, family practice, and some surgical specialties such as gastroenterology has left medical schools rushing to acquire the equipment and support staff necessary to implement VR properly.
What Is Medical Simulation?
Medical simulation is an all-purpose term covering everything from using a block of resin or wood for would-be surgeons to get the feel of handling a drill to a surgical simulation so sophisticated that it reproduces an individual patient’s anatomy perfectly, so that the surgeon can practice a delicate procedure tailored to that patient before undertaking the actual surgery. In between these extremes lie mannequins-either body parts such as an arm to practice starting an IV, or a specially designed unit such as Martin, a head and neck mannequin developed by military contractor Lockheed Martin for teaching endoscopic sinus surgery. Medical simulation also includes actors playing the part of patients, sometimes using simulated body parts to enhance the learning experience.
Computer-based medical simulations, or VR, enhance learning by using visual, auditory, and haptic feedback to help physicians feel that they are making decisions and performing procedures in real life. VR also allows participants to repeat the simulation as many times as necessary to attain a level of comfort with the task. It incorporates a variety of resources, including CT and MRI data, computer-generated images, video cameras, models, and sensors for learners to practice in lifelike environments.
A rapidly growing type of medical simulation, far removed from the meticulous virtual otolaryngology-head and neck surgery world, is emerging from collaborations among medical schools, the videogame industry, and the US military. These simulations closely resemble video games and throw the learner into the adrenaline-pumping fast pace of the emergency department or battlefield. Although they may enhance clinical skills, their main purpose is for practicing teamwork and rapid-fire decision-making. For example, Pulse!!, a user-friendly VR platform developed at Texas A&M University-Corpus Christi with $12 million from the Office of Naval Research and support from BreakAway, a Maryland-based video game developer, is used to train doctors, nurses, physician’s assistants, and other emergency personnel. Another popular option, for computer savvy professors and physicians, is Second Life. This inexpensive open-source platform is used to host medical simulations that students can access online. Second Life users can create their own avatars to walk through VR hospitals, emergency departments, patient rooms, and surgical suites.
Medical Simulation and Otolaryngology
Medical simulation has already revolutionized medical education in primary care disciplines and some surgical specialties, but faces a tougher road in otolaryngology. The pioneers in otolyarngology-head and neck surgery, whom you will meet in Part 2 of this series on medical simulation, have done extraordinary work with surgical simulations but have also encountered serious funding obstacles. Even joining forces among themselves and forming alliances with neurosurgeons, computer scientists, and engineers, they have not found the approximately $15 million in funding required to validate simulation results at the level required to be incorporated in board certification.
Some otolyarngology medical educators are exploring partnerships with private industry and the military, trying to demonstrate that there will be a large enough market to make otolyarngology simulations commercially viable. It may take several years for these efforts to bear fruit but the potential is there. According to Dr. Miller, funding, particularly for crucial validation studies, is lacking now and may take several years to come through. Right now, medical simulation is a very good tool for education, but it still has a long way to go before it can be used to test a physician’s skills. That will take a huge commitment of time and money to accomplish, he said.
Part 2 of this series will discuss current developments in medical simulation.
©2008 The Triological Society