Simulator Training: The Future?

Mike Larvin

RCS Director of Education

Professor of Surgery

University of Nottingham at Derby

Imitation of reality for research, testing,

training or education

Requires:

• valid source information

• simplifying approximations and assumptions

• validity, reliability, fidelity

Simulation

Technological triggers: Cold war

“Tennis for Two” (1957) Higinbotham (Brookhaven)

used missile trajectories

Sputnik 1 (1957)Launched atop a modified

ballistic missile

• UG: less practical surgery

• PG1-2: foundation years

• PGY3-4: core MRCS

• PGY5-8+: specialty FRCS

• Less experience, WTD

• New technologies to learn

• Patients and trainees have changed

Surgical training has changed

• medical errors kill 98,000 people annually

• $37 to $50 billion for adverse events

• resident 80h week, less direct interaction

• bioterrorism threats and crisis management

Public drivers US IOM 2004

Generation ‘X’ = most of you

• Followed ‘baby boomer’ generation

• Born 1961 to 1981, ‘13th US generation’ - premarital sex, atheistic, republican, less respect for parents and authority - greater formal education

Generation X: Tales for an Accelerated CultureDouglas Coupland, 1991

• Followed ‘Generation X’

• Born early 1980s to mid-1990s - rapid communication, peer orientation, instant gratification, stimulating work - family breakdown, tech-savvy, ‘open’

Hunter-Gatherers of the Knowledge EconomyDavid Berreby, 1999

Generation ‘Y’ = junior trainees

• Followed ‘Generation Y’

• Born early mid-1990s to 2000s - baby boomlet - highly connected, lifelong use of comms and media technologies such as WWW - “digital natives”: instant messaging, texting, MP3, mobile phones, YouTube

Grown Up Digital: How the Net Generation is Changing Your WorldDon Tapscott 2009

Generation ‘Z’ = coming soon

Trainees still require:

• Knowledge

they prefer e-learning• Skills

technical, decisions, comms: like simulation• Structure

curriculum and assessment: online is fine

STEP® Foundation and Core

• MMC and ISCP competences

• MRCS preparation

• 8 A4 printed modules

• e-learning, video, web simulation

• e-community and college days

Courses and programmesMedical School F1/F2 ST1/2 ST3/4 ST5/6 Consultant Plus

• Anatomy• ATLS® • BSS, FSS, SSS• CCrISP®• Communication• STEP® Core• STEP® Foundation• Core Specialty Skills• Core Surgical Sciences• e-Surgery (DoH)

• Aesthetics• Plastics • Breast• Cardiothoracics • Coloproctology• Emergency & Trauma• OMFS• Orthopaedics• Otorhinolaryngology• Urology• MIS• Neurosurgery• Paediatrics• Vascular Surgery

• Professional Practice - Training the Trainers - Training and Assessment in Practice

• Executive Leadership • SAS Leadership • Professional Forum • Research Network• International Network• Operating Theatre Team Project• Military Operations Surgical Training (MOST - MoD)

College courses

Regional College Total

Courses Participants Courses Participants

2005 - 6 457 7806 117 2165574

9971

2006 - 7 441 7373 95 1894536

9267

2007 - 8 449 7368 135 2084584

9452

• anatomy, physiology, history, behaviour,

physical findings

• cadavers, prosections, plastinates

• plastics

• animal tissue

Active simulation

‘Human in the loop’ simulation

Ideal when:

• real environment too expensive or risky

• need to learn in "safe" environment

• test mistakes in safety-critical systems

• ‘type change’ after basic pilot training

Interactive simulation

• ‘live’: real people, simulated kit, real world

hi-fidelity, samples likely performance

• ‘virtual’: real people, simulated kit and world

VR training

• ‘constructive’: sim people, kit and world

behavioural training and assessment

Training simulation types

• Sim Man 3g (Laerdel)

• life-sized mannequin

• responds to injected drugs

• programmed for life

threatening emergencies

• can be changed ‘on the fly’

High-fidelity live simulation

• 1985, K Semm’s

‘pelvi-trainer’

for laparoscopy

• Haptics included

ἅπτεσθαι - to “contact” or “touch”

Laparoscopy

• visual components by computer graphics

• touch components by haptic feedback

• input/output: force feedback

could be widely distributed via standard

web browsers with standard game joysticks

Virtual simulators

• 2010: Symbionix

‘Laparotrainer’

for laparoscopy

• Haptics not included

Laparoscopy

• Largest capital project since post-war rebuilding

Eagle project

Wolfson Surgical Skills Centre

anatomy teaching

procedural simulation

Simulation Centre

skills laboratory minimal access,critical care

operating theatre

Synthetics and animal tissue

Minimal access and critical care

Operating theatre

Teaching suite

Lower cost simulation

• improved health outcomes, reduced errors

• reduced health care costs, enhanced quality

• better skills, lower malpractice rates

• more flexible training at correct pace

• allows practice and mistakes, improves skills

without consequence to the patient

Benefits

• Despite their

proven effectiveness,

junior surgeons usually

have to pay to attend courses

from their own pocket

Donaldson, 2009

Costs

Simulator training: the future?

• More simulation, improved models

• Expensive, collaboration makes sense

• Preparation for work-based training

• NOT a substitute for the ‘real thing’

• More versatile than patient-based training

• Useful in standardising assessment

mlarvin@rcseng.ac.uk