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Simulation-Based Training: The NextRevolution in Radiology Education?

Terry S. Desser, MD

Simulation-based training methods have been widely adopted in hazardous professions such as aviation, nuclearpower, and the military. Their use in medicine has been accelerating lately, fueled by the public’s concerns overmedical errors as well as new Accreditation Council for Graduate Medical Education requirements for out-come-based and proficiency-based assessment methods. This article reviews the rationale for simulator-basedtraining, types of simulators, their historical development and validity testing, and some results to date inlaparoscopic surgery and endoscopic procedures. A number of companies have developed endovascular simu-lators for interventional radiologic procedures; although they cannot as yet replicate the experience of perform-ing cases in real patients, they promise to play an increasingly important role in procedural training in thefuture.

Key Words: Simulation, education, endovascular simulation

J Am Coll Radiol 2007;4:816-824. Copyright © 2007 American College of Radiology

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NTRODUCTION

In surgery, as in anything else, skill, judgment, and confidence arelearned through experience, haltingly and humiliatingly. Like thetennis player and the oboist and the guy who fixes hard drives, weneed practice to get good at what we do. There is one difference inmedicine, though: we practice on people. [1]

The intrinsic ethical tension between patients’ bestnterests and trainees’ need for experience came into pub-ic focus with the publication of the Institute of Medicineeport To Err Is Human [2]. The staggering number ofupposedly preventable medical errors cited in thatublication—more than the number of annual vehic-lar fatalities— garnered headlines nationwide and ledo demands for increased scrutiny of medical educa-ion practices from both politicians and the general pub-ic. And although much has been learned in recent de-ades about what constitutes effective adult education,urrent medical training paradigms remain virtuallydentical to those originally outlined by Flexner and Hal-ted a century ago [3].

Simulation, as defined by anesthesiologist and simula-ion pioneer David Gaba [4], “is a technique—not aechnology—to replace or amplify real experiences withuided experiences that evoke or replicate substantial

epartment of Radiology, Stanford University School of Medicine, Stanford,alifornia.

Corresponding author and reprints: Terry S. Desser, MD, Stanford Uni-ersity School of Medicine, Department of Radiology, 300 Pasteur Drive,

cail Code 5621, Stanford, CA 94305; e-mail: [email protected].

16

spects of the real world in a fully interactive manner.”imulation-based education methods have been widelysed in industries such as commercial aviation, nuclearower, and the military, in which training in real-lifeituations would be hazardous and mistakes disastrous.s is often the case, however, real-life catastrophes oc-urred before simulation methods gained acceptance andcritical mass of support. In the case of commercial

viation, for example, a flight simulator had been devel-ped in 1929, but it took high pilot death rates duringorld War II before flight simulation was embraced by

he Air Force as a training tool [3].Medical education may now be at a similar tipping

oint. Simulation-based training methods are being usedith increasing frequency in medical school and resi-ency training programs [5]. The 2007 Internationaleeting for Simulation in Healthcare sponsored by the

ociety for Simulation in Healthcare (http://www.ssih.rg) drew more than 1,200 attendees, double the numberrom the previous year. Radiologists have taken note: theadiological Society of North America (RSNA), the So-iety of Interventional Radiology, and the Cardiovascu-ar and Interventional Radiological Society of Europeave all established individual task forces and have joinedogether to set strategy and issue recommendations forimulation training [6]. In this article, I review the his-orical development, types, and evaluation methods ofimulation-based training techniques in medicine in gen-ral and radiology in particular. The potential role ofimulation in assessment and credentialing is also dis-
ussed.
© 2007 American College of Radiology0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.07.013

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Desser/Simulation-Based Training 817

ISTORICAL DEVELOPMENT

he modern history of medical simulation began in theate 1950s with the pioneering work in cardiopulmonaryesuscitation of anesthesiologist Peter Safar [7-9]. Stim-lated by research showing that expired air ventilationdministered to patients by face mask or endotrachealube was capable of maintaining normal blood gases inatients, Safar began a series of studies that culminatedn his paper on mouth-to-mouth ventilation, publishedn JAMA in 1958 [10]. Safar presented his findings atonferences worldwide, including a Scandinavian Soci-ty of Anesthetists meeting in Norway later that year. Inttendance was anesthesiologist Bjorn Lind, who intro-uced Safar to Norwegian toymaker Asmund Laerdal.he 3 collaborated to produce the resuscitation trainingannequin known as Resusci Anne in 1960, adding a

hest compression component after the discovery by in-estigators at Johns Hopkins University that externalompression of the chest could generate a blood pressureulse in animals. Laerdal Medical’s Resusci Anne enabledhe training of both medical professionals and laypersonsn techniques of cardiopulmonary resuscitation and hasaved countless lives since its initial development. In theid-1990s, two anesthesiologist colleagues of Safar’s at

he University of Pittsburgh developed a more anatomi-ally correct airway and simulator and contracted withhe Medical Plastics Corporation of Texas for its manu-acture. Laerdal then acquired Medical Plastics and mar-eted the simulator under the name SimMan [7,8].

A second simulation effort in the mid-1960s by Uni-ersity of Southern California engineer Stephen Abraha-son and physician Judson Denson introduced com-

uter control to mannequin simulators. Their Sim Oneannequin was built in collaboration with the aerospace

ompany Aerojet, which needed to develop peacetimepplications of its technologies in the military fundingull before the escalation of the Vietnam War [8]. Givenhe computer technology available at the time, Sim Oneas remarkably lifelike, with, for example, pupils thatilated and constricted and a chest that moved withespiration. However, the simulator was never commer-ially viable because of the limited availability of com-uter technology and lack of demand for simulation-ased training from medical educators steeped in thepprenticeship training paradigm [8,11]. A third simula-ion effort, a cardiology physical examination trainingannequin called Harvey, was developed at the Univer-

ity of Miami in 1968. Harvey could reproduce a varietyf physical findings, including blood pressure, respira-ory rate, pulses, heart sounds, and murmurs. Studentsho trained with Harvey were shown to perform better

n their cardiology electives than peers who trained only
ith patients [8,12]. q
The development of sophisticated mathematical mod-ls of physiology and pharmacology together with inno-ations in computer technology permitted more realisticannequin simulators to be developed, beginning in the

980s. Stanford anesthesiologist David Gaba and col-eagues created the Comprehensive Anesthesia Simulationnvironment, which combined a simulated “patient” (aannequin whose vital signs could be manipulated by com-

uter) and a real operating room equipped with actual an-sthesia machines. This “high-fidelity simulation” used aealistic simulated environment and focused on team-ased training, following models of crew training devel-ped in the aviation industry. Using the Comprehensivenesthesia Simulation Environment system, Gaba andis colleagues could train residents and entire medicaleams to manage rare but dire critical care events. Theystem was also used to test the importance of humanactors such as fatigue on trainee performance, and theiresults were used as evidence in development of the Ac-reditation Council for Graduate Medical Education’suty hours limitations for residents. At approximatelyhe same time, a group at the University of Florida de-eloped the Gainesville Anesthesia Simulator, which re-reated physiologic changes in response to the adminis-ration of drugs and anesthetic gases. Both systems wereater commercialized, the Comprehensive Anesthesiaimulation Environment as MedSim Advanced Med-cal Simulations, Ltd., and the Gainesville Anesthesiaimulator system as Medical Education Technologies,nc. [8].

As computer technologies became cheaper and moreowerful, virtual environments with visual, auditory,nd tactile (haptic) components were created that sim-lated a number of surgical and interventional proce-ures. These “procedural simulators” were developedor a wide range of clinical domains, including bron-hoscopy, endoscopy, endoscopic retrograde cholan-iopancreatography, colonoscopy, ophthalmic sur-ery, surgical suturing, and endovascular proceduresescribed in more detail below [13-20].

HY SIMULATORS? LIMITATIONS OFURRENT TRAINING METHODS

he current medical education framework dates to thearly 20th century and is based on the premise that train-es will obtain the necessary expertise by observing andorking closely with expert practitioners [6,21,22]. After

n initial period of close oversight by attending physi-ians, trainees are given progressively more independencen working with patients until the requisite training pe-iod has elapsed. This “master-apprentice” model is thustime-based system: trainees are assumed to have ac-

uired the necessary skills and knowledge by virtue of

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818 Journal of the American College of Radiology/Vol. 4 No. 11 November 2007

aving trained for the set period of time. And althoughhe system has historically worked well, there is muchoom for improvement.

First, it is obvious that young physicians have differentntrinsic aptitudes and acquire skills at different rates. Aystem to measure true proficiency would be preferable tostablishing a fixed time period for training. Because theength of time physicians train is one of the main factorsn training cost, residents who become proficient quicklyould see the ultimate cost of their training reduced.

Second, attending physicians’ evaluations of trainees’erformance is subjective, and they invariably exhibit theommon biases prevalent in performance assessment,uch as the “halo effect” (the tendency to rate all perfor-ance categories high or low on the basis of a single

rait), leniency bias, recency bias, and so on [6,23]. Sim-lators, which capture and record performance metricsuch as time to complete a task and the accuracy of theesult, can provide objective assessment of proficiency.

Third, studies of learning have shown that adults learnest when they participate actively in the learning processnd are provided with timely and appropriate feedback24]. Simulation-based training is “hands on” and capa-le of providing immediate cues to trainees.Fourth, as duty hours are limited and procedures mi-

rate to the outpatient setting, trainees’ exposure to aide variety of cases diminishes. Simulators can poten-

ially fill this gap. Finally, it is clear that the public’solerance for being the “guinea pigs” while trainees gainlinical experience is rapidly disappearing. Simulation-ased training methods potentially provide ample oppor-unities for trainees to practice complex procedures andrisis management without putting patients at risk. In-eed, some educators argue that simulation-based medi-al education is now an ethical imperative [25].

YPES OF SIMULATORS: TERMINOLOGY

imulation devices that reproduce only a limited portionf reality, such as a model of a body part, are often calledpart-task trainers.” These are most often used for tech-ical or psychomotor skills training, such as venipunc-ure. Part-task trainers range in sophistication fromome-grown devices fabricated from familiar householdbjects (think of the “olive in a turkey breast” phantomsed to train radiologists in ultrasound-guided breastiopsies), to high-tech systems such as the Harvey man-equin, described above, which trains students in cardiacndings on auscultation.Another way to classify simulators is by the technology

hey use. “Simulated or standardized patients” are actorsrained to act as patients to train medical students innterviewing techniques, physical examinations, and

ore general communication skills. Standardized pa- n

ients have become a common part of the curriculum inedical schools and of objective-structured clinical ex-

minations. Mannequins with purely mechanical com-onents are termed “physical model simulators.” Onexample is the CPR mannequin Resusci Anne, describedbove. “Computer-based” systems may be designed likeomputer games in which the user interacts with a virtualnvironment via devices that control the scene. ER-sim,n online simulation game (Legacy Interactive, Holly-ood, California; http://www.ersim.com) is one such

xample. Tactile (haptic) feedback is now technologi-ally feasible and is an essential component of surgical,ndoscopic, and endovascular simulators. “Hybridimulators” combine a physical model or mannequinith a computer that modifies simulated physiologicarameters. “Immersive simulators” create a complete-D world in which users are made to feel as if they areperating entirely within the simulated environment.sers move their bodies in space and are able to interactith computer-created scenes. One often cited example

s the US Marine Corps combat simulator [26], in whichvirtual locomotion control enables the user to move

hrough the scene by walking in place. This technologyas recently been incorporated into the latest generationideo games, though as yet it has not been developed intomedical simulation tool.

ALIDATION AND ASSESSMENT OFIMULATORS

he simulation literature has adopted specific terminol-gy from the domain of educational testing to evaluateimulation systems [3,27,28]. Face validity describeshether the system looks like what it is designed to

epresent, in other words, if it is sufficiently realistic forhe user to suspend disbelief while performing the simu-ated task. Assessment should also include a subjectivevaluation of the ease of use of the interface and whetherubjects enjoy using the simulator (usability testing).ontent validity, a psychometric concept, describes the

xtent to which a simulation exercise reproduces all as-ects of the real-world experience. Content validity de-cribes whether a simulator accurately reproduces therocess it is supposed to model and must be tested byxpert practitioners. Concurrent validity describes howlosely subjects’ performance on a simulator correlatesith their performance on a gold standard measure ofroficiency. So for example, surgeons with recognizedxpertise should perform significantly better on a simu-ator than novices. Predictive validity describes the extento which good performance on the simulator predictsood performance on real patients.

With current software, it is possible to design any
umber of virtual environments to simulate a variety of
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asks. The difference between a useful simulation and aere computer game based on a medical scenario is the

egree to which the exercise meets the validity criteriabove. Evaluations of simulator technology should haverofessional educators or psychologists as coauthors toefine the tasks to be modeled and to prove rigorouslyhat learning has taken place [29]. In addition, therehould be a set of performance metrics integrated into theimulator to record trainees’ correct and incorrect ac-ions. And these metrics should be meaningful, not sim-ly easy or convenient to measure. For example, currentndovascular simulators track metrics such as the overallime required to perform a procedure, the volume ofontrast used, C-arm handling, and so on. But as yet,hey cannot capture information on detailed catheteranipulation skills or errors in judgment [6]. Finally,

ctions on a simulator should follow the laws of physics3]. When a trainee makes an error, its true physiologiconsequences should be reflected in the system. There isontroversy about whether it is psychologically harmfulo allow trainees to “kill” their patients via their actions inimulators. Nevertheless, errors must be allowed to occurn simulators so that trainees can see potential conse-uences and hopefully limit them to the virtual worldather than the real one.

imulators for Laparoscopic Surgery

hen laparoscopic surgery was introduced in the 1980s,urgeons needed new visuospatial and psychomotor skillshat were difficult to acquire on the job in the operatingoom. Centers specializing in teaching laparoscopic tech-iques used either animal models or inanimate objects

nside boxes (“box trainers”) to allow surgeons to gainacility in the method. Ultimately, virtual reality simula-ors with immersive visual environments and tactile feed-ack were developed [21]. Although simulator-basedraining seems intuitively to be useful, to date there haveeen few randomized, double-blind, controlled trialsroving that simulators are effective. One such study,onducted by Seymour et al [30], showed that residentsrained to perform laparoscopic cholecystectomies with aimulator used correct dissection technique, made 6imes fewer intraoperative errors, and had shorter oper-ting times than those who did not. Residents not trainedsing virtual reality were 5 times more likely to injure theallbladder or burn nontarget tissue. Another study fromeymour’s group [31] showed that virtual reality trainingn the use of an angled laparoscope significantly im-roved the operative performance of novices. Recogniz-ng the potential of simulation, the American College ofurgeons has established a formal accreditation processor education programs that meet standards and criteria
evised for simulation-based training. To date, 7 institu- t
ions have been designated as level I American College ofurgeons–accredited education institutes [32].

imulators in Critical Care

s described above, a great deal of simulation technologyas developed initially by anesthesiologists. A detailed

eview of simulator training in clinical care is beyond thecope of this article, but many studies have been per-ormed to show that high-fidelity simulation improveshe performance of anesthesia and emergency medicineeams in managing crises [11,13, 33-37].

ndoscopy

omputer-based simulators have been developed for aariety of endoscopic procedures [14]. Unlike the lapa-oscopic simulators, to date, no rigorous prospectivetudies have been performed on the effectiveness of en-oscopy simulators. One pilot concurrent validationtudy of an upper endoscopy simulator suggested thatxperts performed better than trainees and novices [14],ut another study found no benefit to simulator training18]. For flexible sigmoidoscopy, one study found thatedside training resulted in better scope insertion, nego-iation of the rectosigmoid region, and other endoscopicasks compared with simulator training. Another studyhowed an advantage with simulator training for the veryarly stages of learning colonoscopy that disappearednce 30 procedures had been performed by the non-imulator-trained group [20]. Overall, recent work sug-ests that simulation may be useful during the early stagesf endoscopic procedural training, but it cannot replaceraditional bedside instruction [14].

IMULATORS IN RADIOLOGY

n a sense, radiology educators have long made use ofimulation-based training in the form of “hot seat” con-erences. Providing residents with examples of unusualases in an unknown case-discussion format is a criticalomponent of training, because the full scope of clinicalntities they will likely see during decades of practiceight not be predictably encountered during the train-

ng period. In recent years, there have been efforts such ashe RSNA’s Medical Imaging Resource Center, the ACR’sase-in-Point series, AuntMinnie.com’s “Case of the Day,”

nd others to enable multimedia, case-based learning on aarge scale. In addition, radiology educators in certain sub-pecialties have begun to create online teaching modules toxploit the ease of disseminating information in digitalorm. The Cleveland Clinic Pediatric Radiology moduleavailable at https://www.cchs.net/pediatricradiology/)s one particularly successful example.

True immersive simulations in the radiology domain,
hough, are much newer. As volumetric data sets have
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ecome available and computer technology has im-roved, simulators that enable physicians to interact withigh-fidelity reproductions of human anatomy have be-ome feasible. Monsky et al [38] used a sonographicimulation system (UltraSim; MedSim Advanced Medi-al Simulations, Ltd., Fort Lauderdale, Florida; http://ww.medsim.com/products/products.html) to teach

nd evaluate the performance of two consecutive classesf 8 first-year residents in scanning and interpreting 10est ultrasound cases in the abdomen and pelvis. TheltraSim system consists of a full-size mannequin with

ealistic body contours and a soft torso surface, an ultra-ound “probe,” and an ultrasound scanner console andonitor. The probe is actually a 3-D position sensor that

nteracts with the mannequin and stored commerciallyvailable 3-D teaching data sets that have been createdrom sonograms performed on real patients. Study re-ults showed that the simulator improved residents’ ab-ominal and pelvic scanning technique, as well as theirelf-assessment scores. The investigators concluded thathe simulator was useful for both training and the evalu-tion of residents’ performance.

At the 2006 annual meeting of the RSNA, preliminaryork on a radiographic simulator for training technolo-ists in the positioning of cervical spine radiographs wasresented. A high-resolution, computed tomographicata set of the head and spine is used to create a virtualatient, and students manipulate a computer animationf an x-ray tube to project the virtual beam through thepine. The resultant x-ray projection is calculated fromay projection algorithms and displayed on a secondonitor. Students can practice positioning the standard

iews of the cervical spine initially with “fluoroscopic”eedback, and later without feedback, all without expos-ng patients to radiation [39].

Crisis management in radiology is another area suit-ble for simulation training. Medina et al [17] developedcomputer simulation of pediatric and adult patients

ndergoing sedation, analgesia, and contrast media com-

Table 1. Some common commercial endovascularTrade Name Manufacturer

Procedicus VISTendovascularsimulator (Figure 1)

Mentice, Göteborg, Swed

Angio Mentor (Figure 2) Simbionix USA CorporatiCleveland, Ohio

Simsuite Medical SimulationCorporation, Denver,Colorado

CathLabVR system Immersion MedicalCorporation, San Jose,
California
lications during radiologic procedures, but to date haveot published studies of its effectiveness. More recently,ainiero et al [40] conducted a high-fidelity medical

imulation exercise with an interactive anesthesia man-equin in whom the physiologic scenario of a life-threat-ning contrast reaction was simulated. Six first-year radi-logy residents were tested on their ability to perform 16ritical actions necessary to stabilize the patient. Thexercise exposed several areas of weakness, and 5 of the 6esidents agreed that the training was a valuable educa-ional experience.

imulators in Interventional Radiology

nterventional radiology promises to be the radiologicubspecialty in which simulators will have the biggestmpact on training and credentialing. The spectacularmages now achievable with noninvasive imaging modal-ties such as computed tomographic angiography haveeduced the number of purely diagnostic angiograms,hereby minimizing the opportunities for trainees to ac-uire the basic catheter manipulation skills necessary forore advanced interventions such as angioplasty and

mbolization [28,41,42]. In addition, competitor spe-ialties outside radiology have long been interested incquiring the skills necessary to perform catheter-basednterventions. A number of endovascular simulators haveeen developed that allow practice with the manipula-ion of catheters and guidewires, contrast media injec-ion, and real-time fluoroscopy (Table 1, Figures 1 and). The recent US Food and Drug Administration deci-ion to approve one manufacturer’s carotid stent, contin-ent on the company’s devising a training system that didot put patients at risk, set a precedent and provided aajor impetus for the development of endovascular sim-

lators [3,43]. A number of validation studies are nowngoing. Nicholson et al [44] conducted a face and con-ent validity study of the Procedicus VIST simulatorMentice, Göteborg, Sweden; Table 1) with 100 practic-

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ng interventionalists averaging 12.4 years of endovascu-ar experience. Specialties represented included 71 inter-entional cardiologists, 21 vascular surgeons, and 1nterventional radiologist. The users attended a 1.5-dayourse in which they received training on the simulatornd then were asked to perform 1 right carotid arterio-ram, 1 left carotid arteriogram, and 1 total right and leftarotid angiogram on the system. After the 3 cases wereompleted, the realism of the Procedicus VIST simulatorxperience was evaluated on a 5-point, Likert-type scale.ubjects were asked about the appearance of the anat-my, the realism of the physical behavior of the proce-ure tools, and the overall assessment of the technicalasks in the procedure. The results showed good simula-ion of aortic arch and carotid vascular anatomy, excel-ent realism in catheter and guidewire movements, andverall excellent realism in the procedure.

Using a different endovascular simulator (Simsuite;edical Simulation Corporation, Denver, Colorado; Table

), Dawson et al [45] offered a series of 2-day endovas-ular skills training workshops for vascular surgery resi-ents in the first year of vascular specialty training. Aascular surgeon familiar with the simulator supervised 9esidents one on one in catheter, sheath, and wire han-ling; angioplasty balloon inflation; and stent deploy-ent in the domains of aortoiliac, renal, and carotid

rtery disease. Performance metrics recorded automati-ally by the simulator software included total procedureime, fluoroscopy time, the volume of contrast mediumsed, time to treat complications, and the total number

ig 1. The Procedicus VIST endovascular simulatorMentice, Göteborg, Sweden). The operator selectsires, catheters, balloons, and so on, on the controlcreen (left) and manipulates them via an introducert the “groin” of the plastic model. A fluoroscopic

mage of the virtual procedure is shown in the rightcreen. The simulator provides haptic feedback to theser on the basis of the devices chosen and theessel being studied and simulates contrast flow andesultant hemodynamics. The system also keepsrack of the user’s performance for use in assess-ent. (Courtesy of Mentice.)

f balloons, stents, and wires used. Faculty members also t

rovided subjective feedback to trainees on their perfor-ance. Results on the index aortoiliac case showed that

ompared with performance on day 1, simulation train-ng enabled trainees to perform the case 54% faster with48% decrease in fluoroscopy time and a 44% decrease

n the volume of contrast material administered. Post-raining questionnaires indicated that the trainees foundhe experience sufficiently realistic to be useful in trainingnd felt that there would be benefit from practicing on aimulator during their fellowships. The direct cost of therogram was $2,146 per resident, including the cost ofhe simulator but not including loss of the trainee’s ser-ices during the 2-day period of the course.

One randomized controlled study of 20 general surgeryesidents learning catheter-based interventions showed thathe group receiving simulator training performed betterhan the control group in 2 consecutive lower extremityndovascular cases [46]. A number of other endovascularimulation studies have been performed, but to date,irtually all have involved vascular surgeons or vascularurgery residents [45, 47-50]. Recently, the Society ofnterventional Radiology created the Task Force on

edical Simulation, chaired by Aalpen Patel, MD, of theniversity of Pennsylvania. Together with the Cardio-

ascular and Interventional Radiological Society of Eu-ope, they have created a strategic plan in which they notehe limitations of the current master-apprentice trainingodels and outline plans for creating, validating, and

romoting medical simulation in interventional radiol-gy training [6,42,51]. Their mission is to identify theroper role of current simulation technologies in training

ig 2. The Simbionix ANGIO Mentor (Simbionix USAorporation, Cleveland, Ohio). The user operatesires, catheters, syringes, and other devices at the

oot of the simulator. A simulated fluoroscopic images displayed on the right-hand screen. The left-handcreen shows a simulated image of the C-arm fluo-oscopy procedure. The simulator device providesaptic feedback to the user on the basis of the de-ices chosen and the vascular environment. (Cour-
esy of Simbionix USA Corporation.)

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nd to guide the evolution of simulation methodologies.hey note that at present, simulators have not been

hown to be adequate for training novices in catheteranipulation skills and cannot substitute for actual pa-

ient experience. Furthermore, as in the aviation indus-ry, simulators should be used only in the context of anverall curriculum in interventional procedures and withhe oversight of professional societies and regulatory au-horities [6,28,41,42,51]. In the future, they argue, stan-ard measures for testing and validating simulatorshould be developed. As with the Digital Imaging andommunications in Medicine standard, simulator man-facturers should work together to ensure cross-platformompatibility among simulator devices so that, for exam-le, an anesthesia simulator could interface with an en-ovascular procedure simulator to model the physiologichanges expected if a catastrophic event such as vesselupture occurs. The joint task force envisions that in theear future, there will be numerous interventional radi-logy simulation training modules proven to transferkills, reduce errors, deliver clinical benefit, integratednto training curricula and validated for certifying andredentialing examinations [6].

IMULATION: THE FUTURE

s noted previously, powerful forces are converging torive the future of medical simulation. The current mas-er-apprentice model of resident education is “an expen-ive anachronism” [28] that sorely needs updating. Edu-ation researchers have shown that adults learn best byoing, not by listening and observing [24]. Simulationxercises provide medical trainees with hands-on experi-nce and have the potential to accelerate learning dramat-cally, particularly early in training, without exposingatients to any risk. Second, and in part fueled by theccreditation Council for Graduate Medical Educa-

ion, the medical culture is changing from the passivecceptance of time-based training to a proficiency-basedodel in which core competencies must be documented.

imulation-based methods have the potential for bothraining and assessment and could prove hugely benefi-ial in credentialing efforts. Third, societal acceptance ofrainees’ need to learn at the potential expense of patientare has vanished, necessitating the development of newraining models that do not put patients at risk. In anes-hesiology, a culture change to zero tolerance for operat-ng room errors, rather than the acceptance of extremelyow error rates, was needed to catalyze high-fidelity sim-lator development. A similar systems-based approach toinimizing and ultimately eliminating individual error

s beginning to take hold in other subspecialties as well.Nevertheless, the wholesale adoption of computer

imulators before validation would be irresponsible. Sim- d

lation devices must be designed carefully, with inputrom psychologists who have analyzed the factors thatonstitute expert performance and need validation byomain experts to show proof of effectiveness. This wille time consuming and expensive. Some of the expenseay ultimately be offset by decreased liability in the form

f lower malpractice costs. But with health care dollarsimited, it is unclear whether forces mobilizing for uni-ersal access to medical care will trump those advocatingmproving patient safety with simulator training. Andith doctors’ motivations increasingly suspect in the layress, simulator deployment must be integrated into ahoughtfully structured subspecialty curriculum, withpproval and oversight of regulatory authorities, or riskeing viewed simply as a means to quickly credentialompetitor specialists to perform lucrative procedures.

The Interventional Radiology Joint Simulation Taskorce has outlined 1-year, 3-year, and 5-year to 10-yearlans for the development of training standards, profes-ional education methods, practice building, and simulatoresearch and the dissemination of information about simu-ator training to the public [51]. Other radiology subspecial-ies, such as gastrointestinal fluoroscopy, could also benefitrom the development of simulators. Although the numberf diagnostic upper and lower gastrointestinal studies hasecreased dramatically since endoscopy was developed,racticing radiologists still perform these procedures, andesidents now encounter many fewer opportunities for prac-ice during training. Unlike interventional radiology, how-ver, there are no device manufacturers with a financialnterest in catalyzing development of gastrointestinal proce-ural simulators, so radiology societies, such as the RSNA,he American Roentgen Ray Society, and the Association ofniversity Radiologists, will likely need to play a role. In the

uture, a tiered training paradigm may emerge in procedure-ased specialties, one in which inexpensive lower fidelityimulation devices substitute for patients during the steephase of trainees’ learning curve, followed by higher fidelityimulation supplementing procedural experience with pa-ients as skills mature. Once proven effective, simulators willikely find a role alongside conventional oral and writtenxaminations to document technical proficiency for creden-ialing and recertification examinations.

ONCLUSION

imulation-based training methods, which have savedountless lives in the fields of aviation, nuclear power,nd the military, are beginning to gain a foothold inedicine. The old, time-based, “see one, do one, teach

ne” apprenticeship model for training residents is beingupplanted by an outcome-based model in which tech-ical proficiency and a core knowledge base must be
ocumented. Simulation techniques can be used for

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oth training and assessment and are poised to meethe needs of residency and fellowship program direc-ors and accreditation and credentialing bodies thatncreasingly require documentation of proficiency.he costs of acquiring simulation equipment and ofesigning and conducting simulation exercises may ul-imately be offset by more efficient training and reducediability costs, but only time will tell.

EFERENCES

1. Gawande A. The learning curve: like everyone else, surgeons need practice.That’s where you come in. The New Yorker. January 28, 2002:52-61.

2. Kohn JT, Corrigan JM, Donaldson MS, eds. To err is human: building asafer healthcare system. Washington, DC: National Academy Press;1999.

3. Dawson S. Procedural simulation: a primer. Radiology 2006;241:17-25.

4. Gaba DM. The future vision of simulation in health care. Qual Saf HealthCare 2004;13(suppl):i2-10.

5. Issenberg SB. The scope of simulation-based healthcare education. SimulHealthcare 2006;1:203-8.

6. Patel AA, Gould DA. Simulators in interventional radiology training andevaluation: a paradigm shift is on the horizon. J Vasc Interv Radiol2006;17:S163-73.

7. Acierno LJ, Worrell LT. Peter Safar: father of modern cardiopulmonaryresuscitation. Clin Cardiol 2007;30:52-4.

8. Cooper JB, Taqueti VR. A brief history of the development of mannequinsimulators for clinical education and training. Qual Saf Health Care2004;13:11-8.

9. Grenvik A, Schaefer J. From Resusci-Anne to Sim-Man: the evolution ofsimulators in medicine. Crit Care Med 2004;32(suppl):S56-7.

0. Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration;airway obstruction during manual and mouth-to-mouth artificial respira-tion. JAMA 1958;167:335-41.

1. Bradley P. The history of simulation in medical education and possiblefuture directions. Med Educ 2006;40:254-62.

2. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology forhealth care professional skills training and assessment. JAMA 1999;282:861-6.

3. Binstadt ES, Walls RM, White BA, Nadel ES, Takayesu JK, Barker TD,et al. A comprehensive medical simulation education curriculum foremergency medicine residents. Ann Emerg Med 2007;49:495-504.

4. Gerson LB, Van Dam J. Technology review: the use of simulators fortraining in GI endoscopy. Gastrointest Endosc 2004;60:992-1001.

5. Anderson JH, Raghavan R. A vascular catheterization simulator for train-ing and treatment planning. J Digit Imaging 1998;11(suppl):120-3.

6. Dawson SL, Cotin S, Meglan D, Shaffer DW, Ferrell MA. Designing acomputer-based simulator for interventional cardiology training. Cathe-ter Cardiovasc Interv 2000;51:522-7.

7. Medina LS, Racadio JM, Schwid HA. Computers in radiology. Thesedation, analgesia, and contrast media computerized simulator: a newapproach to train and evaluate radiologists’ responses to critical incidents.Pediatr Radiol 2000;30:299-305.

8. Sedlack RE. Validation of computer simulation training for esophagogas-troduodenoscopy: pilot study. J Gastroenterol Hepatol 2007;22:1214-9.

9. Sedlack RE, Baron TH, Downing SM, Schwartz AJ. Validation of acolonoscopy simulation model for skills assessment. Am J Gastroenterol
2007;102:64-74.
0. Sedlack RE, Kolars JC. Computer simulator training enhances the com-petency of gastroenterology fellows at colonoscopy: results of a pilotstudy. Am J Gastroenterol 2004;99:33-7.

1. Dutta S, Krummel TM. Simulation: a new frontier in surgical education.Adv Surg 2006;40:249-63.

2. Riles TS. Surgical training: the past, the present, and the future. Ann VascSurg 2005;19:140-1.

3. Bacal R. A performance management bias and error glossary. Available at:http://www.work911.com/performance/particles/bias.htm. Accessed April2, 2007.

4. Collins J. Education techniques for lifelong learning: principles of adultlearning. RadioGraphics 2004;24:1483-9.

5. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical educa-tion: an ethical imperative. Acad Med 2003;78:783-8.

6. US Naval Research Laboratory. Immersive simulation. Available at:http://www.nrl.navy.mil/aic/ims/. Accessed October 1, 2007.

7. Reznek MA, Rawn CL, Krummel TM. Evaluation of the educationaleffectiveness of a virtual reality intravenous insertion simulator. AcadEmerg Med 2002;9:1319-25.

8. Gould DA, Kessel DO, Healey AE, Johnson SJ, Lewandowski WE. Sim-ulators in catheter-based interventional radiology: training or computergames? Clin Radiol 2006;61:556-61.

9. Johnson S, Healey A, Evans J, Murphy M, Crawshaw M, Gould D.Physical and cognitive task analysis in interventional radiology. Clin Ra-diol 2006;61:97-103.

0. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality trainingimproves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002;236:458-63.

1. Ganai S, Donroe JA, St Louis MR, Lewis GM, Seymour NE. Virtual-reality training improves angled telescope skills in novice laparoscopists.Am J Surg 2007;193:260-5.

2. American College of Surgeons. Listing of ACS accredited education insti-tutes. Available at: http://www.facs.org/education/accreditationprogram/list.html. Accessed April 10, 2007.

3. Overly FL, Sudikoff SN, Shapiro MJ. High-fidelity medical simulation asan assessment tool for pediatric residents’ airway management skills. Pe-diatr Emerg Care 2007;23:11-5.

4. Gaba DM. Improving anesthesiologists’ performance by simulating real-ity. Anesthesiology 1992;76:491-4.

5. Gaba DM, DeAnda A. The response of anesthesia trainees to simulatedcritical incidents. Anesth Analg 1989;68:444-51.

6. Grenvik A, Schaefer JJ III. Medical simulation training coming of age.Crit Care Med 2004;32:2549-50.

7. Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm inpediatric medical education: teaching neonatal resuscitation in a simu-lated delivery room environment. Pediatrics 2000;106:E45.

8. Monsky WL, Levine D, Mehta TS, et al. Using a sonographic simulator toassess residents before overnight call. AJR Am J Roentgenol 2002;178:35-9.

9. Desser TS, Ahlqvist J, Dev P, Hedman L, Nilsson T, Gold GE. Learningradiology in simulated environments: development of a simulator for teach-ing cervical spine radiography [abstract]. Available at: http://rsna2006.rsna.org/rsna2006/V2006/conference/event_display.cfm?em_id�4428655.Accessed March 28, 2007.

0. Mainiero MB, Shapiro M, Murphy B. Use of high-fidelity medical sim-ulation in the education of radiology residents in contrast reaction man-agement. Presented at: 54th Annual Meeting of the Association of Uni-
versity Radiologists; Austin, Tex; 2006.
http://www.work911.com/performance/particles/bias.htm

http://www.nrl.navy.mil/aic/ims/

http://www.facs.org/education/accreditationprogram/list.html

http://www.facs.org/education/accreditationprogram/list.html

http://rsna2006.rsna.org/rsna2006/V2006/conference/event_display.cfm?em_id=4428655



4

4

4

4

4

4

4

4

4

5

5


1. Gould DA. Interventional radiology simulation: prepare for a virtualrevolution in training. J Vasc Interv Radiol 2007;18:483-90.

2. Gould DA, Reekers JA, Kessel DO, et al. Simulation devices in interven-tional radiology: validation pending. J Vasc Interv Radiol 2006;17:215-6.

3. Gallagher AG, Cates CU. Approval of virtual reality training for carotidstenting: what this means for procedural-based medicine. JAMA 2004;292:3024-6.

4. Nicholson WJ, Cates CU, Patel AD, et al. Face and content validation ofvirtual reality simulation for carotid angiography: results from the first100 physicians attending the Emory Neuroanatomy Carotid Training(ENACT) program. Simul Healthcare 2006;1:147-50.

5. Dawson DL, Meyer J, Lee ES, Pevec WC. Training with simulation improvesresidents’ endovascular procedure skills. J Vasc Surg 2007;45:149-54.

6. Chaer RA, Derubertis BG, Lin SC, et al. Simulation improves residentperformance in catheter-based intervention: results of a randomized, con-
trolled study. Ann Surg 2006;244:343-52.
7. Aggarwal R, Black SA, Hance JR, Darzi A, Cheshire NJ. Virtual realitysimulation training can improve inexperienced surgeons’ endovascularskills. Eur J Vasc Endovasc Surg 2006;31:588-93.

8. Dayal R, Faries PL, Lin SC, et al. Computer simulation as a component ofcatheter-based training. J Vasc Surg 2004;40:1112-7.

9. Hsu JH, Younan D, Pandalai S, et al. Use of computer simulation fordetermining endovascular skill levels in a carotid stenting model. J VascSurg 2004;40:1118-25.

0. Patel AD, Gallagher AG, Nicholson WJ, Cates CU. Learning curvesand reliability measures for virtual reality simulation in the perfor-mance assessment of carotid angiography. J Am Coll Cardiol 2006;47:1796-802.

1. Becker GJ, Connors B, Cardella J, et al. SIR and CIRSE joint medicalsimulation task force strategic plan. Available at: http://www.sirweb.org/clinical/cpg/CIRSE_SIR_Joint_Strategy_7-14-06.pdf. Accessed March
27, 2007.
http://www.sirweb.org/clinical/cpg/CIRSE_SIR_Joint_Strategy_7-14-06.pdf

http://www.sirweb.org/clinical/cpg/CIRSE_SIR_Joint_Strategy_7-14-06.pdf