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Virtual reality and medicine--from the cockpit to the operating room: are we there yet?

Teaching medicine to medical students, physicians in training and nurses is a challenging task that has remained unchanged for decades. The airline industry has achieved a great deal of safety and quality in a technically challenging environment. Many believe that their outstanding achievement is due to team training and crew resource management using simulators and dedicated training programs. Many experts in the medical profession believe that adopting the same strategies in teaching medical students and trainees could achieve significant reductions in medical errors and improve the quality of patient care. This article explores the role of teaching medicine using virtual reality in a multitude of medical specialties and outlines the use of simulation training at Saint Louis University.

Education, Medical↗
PubMed2003

The response of trained athletes to six weeks of endurance training in hypoxia or normoxia.

This study was performed to investigate the effect of training under simulated hypoxic conditions. Hypoxia training was integrated into the normal training schedule of 12 endurance trained cyclists. Athletes were randomly assigned to two groups and performed three additional training bouts per week for six weeks on a bicycle ergometer. One group (HG) trained at the anaerobic threshold under hypoxic conditions (corresponding to an altitude of 3200 m) while the control group (NG) trained at the same relative intensity at 560 m. Preceding and following the six training weeks, performance tests were performed under normoxic and hypoxic conditions. Normoxic and hypoxic .VO2max, maximal power output as well as hypoxic work-capacity were not improved after the training period. Testing under hypoxic conditions revealed a significant increase in oxygen saturation (SpO 2, from 67.1 +/- 2.3 % to 70.0 +/- 1.7 %) and in maximal blood lactate concentration (from 7.0 to 9.1 mM) in HG only. Ferritin levels were decreased from 67.4 +/- 16.3 to 42.2 +/- 9.5 microg/l (p < 0.05) in the HG and from 54.3 +/- 6.9 to 31.4+/- 8.0 microg/l (p = 0.17) in the NG. Reticulocytes were significantly increased in both groups by a factor of two. In conclusion, the integration of six weeks of high intensity endurance training did not lead to improved performance in endurance trained athletes whether this training was carried out in hypoxic or normoxic conditions.

Adult↗
PubMed2004

A preliminary study in using virtual reality to train dental students.

This study compared virtual reality simulator-enhanced training with laboratory-only practice on the development of dental technical skills. Sixty-eight students were randomly assigned to practice their skills in either a traditional preclinical dentistry laboratory or in combination with a virtual reality simulator. The results indicate that students who trained with the virtual reality simulator between six and ten hours improved significantly more than did the students in the control group from the first examination of the year to the final examination of the year. These results indicate that the use of virtual reality simulators holds promise for the training of future dentists. Additional research is necessary to determine the ideal implementation of virtual reality simulators into traditional dentistry curricula.

Clinical Competence↗
PubMed1995

Physiological correlates of simulated wheelchair racing in trained quadriplegics.

This study examined the physiological responses during a 7.5-km simulated wheelchair race (SR) performed on rollers by 8 male quadriplegic marathon racers and analyzed the factors associated with SR time. Cardiac output (Q) was estimated during the SR using carbon dioxide rebreathing, from which stroke volume (SV) and (alpha-v)O2 diff were calculated. Subjects raced at 90 and 93% of peak oxygen uptake (VO2) and peak heart rate, respectively. SR time was inversely related (p < 0.05) to peak VO2, and VO2, Q, and SV during the SR, but not (alpha-v)O2 diff, age, and lesion level. Multiple regression analysis included only absolute SR VO2 in the equation to predict SR time: Y = -29.7X + 65.9; SE = 5.8. SR VO2 was significantly (p < 0.05) related to Q and SV but not to (alpha-v)O2 diff. These descriptive data suggest that SR performance in trained male quadriplegics might be limited by central, as opposed to peripheral, factors that determine VO2.

Adult↗
PubMed1993

An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC.

The author defines the term standardized patient (SP), the umbrella term for both a simulated patient (a well person trained to simulate a patient's illness in a standardized way) and an actual patient (who is trained to present his or her own illness in a standardized way). He first discusses the many values of simulated patients over actual patients as teaching and assessment tools in the classroom and refutes a few myths about the use of SPs. Then he recounts the origin and development of SPs over a three-decade period, beginning with his work as a neurologist at the Los Angeles County Hospital, where he trained a model from the art department to simulate a neurological patient and assist in the assessment of clinical clerks. He then describes additional roles of SPs that have developed, including: (1) their use in the Clinical Practice Examination created at Southern Illinois University School of Medicine and (2) the major use that has come into being over the last 10-15 years; facilitating the comprehensive assessment of clinical competence using multiple stations in examinations such as the objective structured clinical examination. He concludes with information about recent and current work on SPs, who are becoming more and more accepted in the assessment process, and urges skeptics not to make judgments about the value of SPs until they have experienced the technique firsthand and reviewed the literature concerning the extensive and often high-quality research about this assessment tool.

Clinical Competence↗
PubMed2000

PreOp endoscopy simulator: from bronchoscopy to ureteroscopy.

The high cost of virtual reality simulators has posed a major obstacle to the widespread adoption of simulators for medical training. HT Medical broke through this cost barrier by developing the PreOp Flexible Bronchoscopy simulator, a realistic training simulation system that integrates force feedback, multimedia, and 3D graphics on a PC. We are currently extending the PreOp platform so that it can simulate other endoscopic procedures. This paper discusses our efforts to extend the platform to simulate flexible sigmoidoscopy and ureteroscopy.

Bronchoscopy↗
PubMed2004

Computer-based simulator for catheter insertion training.

Minimally invasive surgery procedures are getting common in surgical practice; however the new interventional procedure requires different skills compared to the conventional surgical techniques. The need for training process is very important in order to successfully and safely execute a surgical procedure. Computer-based simulators, with appropriate tactile feedback device, can be an efficient method for facilitating the education and training process. In addition, virtual reality surgical simulators can reduce costs of education and provide realism with regard to tissues behaviour and real-time interaction. This work take into account the results of the HERMES Project (HEmatology Research virtual MEdical System), conceived and managed by Consorzio CETMA-Research Centre; the aim of this project is to build an integrate system in order to simulate a coronary angioplasty intervention.

Catheters, Indwelling↗
PubMed1990

A computerized simulator for critical-care training: new technology for medical education.

A patient simulator has been developed for training, certification, modeling, and demonstrating problems in the management of critical-care patients. The Critical Care & Hemodynamic Monitoring Training System consists of a personal computer, software, and a replica of a human torso designed to enable students to practice critical-care medicine. The computer displays patient histories, laboratory results, treatment options, patient responses, and a real-time cardiac monitor. The torso apparatus is used to practice insertion of a hemodynamic monitoring catheter; the cardiac monitor displays catheter pressure readings as the catheter is advanced into the heart and also pulmonary artery and wedge position. Special screen calculators in the program may be used to determine hemodynamic, respiratory, ventilatory, and renal function indices. In contrast to previously described simulators and computer oriented instructional programs, this system contains no inherent data base. Instead, authors build a library of informative cases by using the hardware and software tools provided. Individual "modules" of patient information are authored, and these are transparently linked as a student undertakes management of a patient. Although this system is a technologic achievement, determination of its usefulness as an instructional tool or certification aid must come from broader use and controlled studies.

Clinical Competence↗
PubMed2004

Teaching economics in the graduate health administration curriculum: a mini-case simulation approach.

Training in the discipline of economics has long been recognized as an important component of the curriculum in graduate health administration (GHA) education. Yet economics is a subject that is often considered hard to teach and difficult for students to learn. What is missing is a body of literature that identifies methods that are most appropriate for teaching economics to graduate students aspiring to be health care managers. Moreover, given the keen interest in developing competency-based curricula today, what is also needed is empirical evidence, which systematically links the key skills, knowledge, and abilities economics courses try to develop with the teaching approaches best suited to do so. This paper helps fill this gap in the literature by describing and evaluating the author's "Top of the News" (TOTN) mini-case simulation series piloted in her Health Care Economics course in the Master of Health Administration (MHA) curriculum at Saint Louis University during the spring semester of 2002. This approach combines elements of the case study and simulation methods used by others, but adds several innovations. Although the TOTN method was designed specifically for a course in health care economics, it is one that can be readily adapted for courses across the GHA curriculum. The article concludes that although the TOTN exercises proved to be fairly successful, GHA faculty and practitioners concerned about preparing today's students to meet tomorrow's health care leadership challenges need to not only identify effective teaching methods, but also have a lot more to discover about the learning styles of the students they teach.

Education, Graduate↗
PubMed2005

Radiofrequency ablation of hepatic tumors: simulation, planning, and contribution of virtual reality and haptics.

For radiofrequency ablation (RFA) of liver tumors, evaluation of vascular architecture, post-RFA necrosis prediction, and the choice of a suitable needle placement strategy using conventional radiological techniques remain difficult. In an attempt to enhance the safety of RFA, a 3D simulator, treatment planning, and training tool, that simulates the insertion of the needle, the necrosis of the treated area, and proposes an optimal needle placement, has been developed. The 3D scenes are automatically reconstructed from enhanced spiral CT scans. The simulator takes into account the cooling effect of local vessels greater than 3 mm in diameter, making necrosis shapes more realistic. Optimal needle positioning can be automatically generated by the software to produce complete destruction of the tumor, with maximum respect of the healthy liver and of all major structures to avoid. We also studied how the use of virtual reality and haptic devices are valuable to make simulation and training realistic and effective.

Catheter Ablation↗
PubMed2004

Phantom-based interactive simulation system for dental treatment training.

In this paper, we propose a new interactive simulation system for dental treatment training. The system comprises a virtual reality environment and a force-torque measuring device to enhance the capabilities of a passive phantom of tooth anatomy in dental treatment training processes. The measuring device is connected to the phantom, and provides essential input data for generating the graphic animations of physical behaviors such as drilling and bleeding. The animation methods of those physical behaviors are also presented. This system is not only able to enhance interactivity and accessibility of the training system compared to conventional methods but it also provides possibilities of recording, evaluating, and verifying the training results.

Computer Simulation↗
PubMed2003

[Advanced patient simulators in pre-hospital trauma management training--the trainees' perspective].

BACKGROUND: Computerized Human Patient Simulators (HPS's) have been increasingly utilized to improve and assess medical performance during critical scenarios. AIMS: To evaluate the utilization of advanced HPS's for trauma management training in pre-hospital setting. METHODS: Four scenarios representing frequent critical events in the pre-hospital trauma treatment were developed using the METI (Medical Education Technologies Inc, Gainesville, Florida) and SimMan (Laerdal, Stavanger, Norway) HPS's. Reserve and regular army medical teams encountered the scenarios, which were all fully videotaped. The A-V recording of the training sessions was used in the debriefing session conducted by experts in trauma care immediately after the encounters. At the end of the workshop, all participants filled in a personal feedback questionnaire. RESULTS: Sixty-six physicians and 16 emergency medical technicians participated in the study. Seventy-eight members (95%) of this group had participated in a previous Advanced Trauma Life Support course, 63 (77%) during the two years before the study. Only 6 (7.3%) of the participants treat trauma cases daily, and 7 (8.5%) more treat such cases at least once in two weeks. Seventy-two (82.8%) of the participants pointed out that the scenarios represent true trauma cases, and the same number reported that the video-based debriefing was excellent or very good. Sixty-four participants (78%) reported that the simulator training improved their decision-making, 54 (65.8%) claimed that it improved their manual skills, and only 47 (57.5%) believed they gained new knowledge. Eighty participants (97.5%) recommended simulator-based training as part of future training and performance assessment. CONCLUSIONS: According to this preliminary subjective study, simulator-based training may be used as a tool in improving the competency of medical teams in treating trauma victims in pre-hospital settings.

Computer Simulation↗
PubMed1987

Training and evaluating teams of simulated patients.

The purpose of this study was to train and evaluate teams of standardized (simulated) patients as part of a required course in family medicine for second-year medical students. During three hours of training, six women were trained to play the same person. These standardized teams played four roles during the 12-week course. Each simulator was interviewed by three student interviewers who were part of six groups of ten to 12 students, each group led by a physician. All sessions were audiotaped, and a coding system was developed. The completeness of response, new unscripted items, and accuracy of information provided by the simulators were measured using the audiotape sessions as sources of data. In addition, the degree of accuracy of the affect of each simulator was assessed by faculty and students in written case histories. The results of the study show that multiple simulators are an effective way of promoting active learning and of teaching basic clinical concepts and skills. Teams of standardized patients give students a consistent learning experience when there are constraints of student group size, time, and scheduling simulations within a traditional curriculum.

Clinical Competence↗
PubMed1989

Flight simulator platform motion and air transport pilot training.

The influence of flight simulator platform motion on pilot training and performance was examined in two studies utilizing a B-727-200 aircraft simulator. The simulator, located at Ames Research Center, is certified by the FAA for upgrade and transition training in air carrier operations. Subjective ratings and objective performance of experienced B-727 pilots did not reveal any reliable effects of wide variations in platform motion design. Motion platform variations did, however, affect the acquisition of control skill by pilots with no prior heavy aircraft flying experience. The effect was limited to pitch attitude control inputs during the early phase of landing training. Implications for the definition of platform motion requirements in air transport pilot training are discussed.

Adult↗
PubMed2005

Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone.

BACKGROUND: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods. METHODS: Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed. RESULTS: Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone. CONCLUSIONS: compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.

Animals↗
PubMed1989

The use of a simulated patient to assess clinical practice in the management of a high risk asthmatic.

Actors were trained to simulate a young asthmatic woman in the high risk category. Sixty-four of the 195 general practitioners and family medicine registrars in Christchurch city agreed to take part in the study in which they would be consulted by a simulated patient remaining blind to identification of the patient, the time and the medical problem. The simulators were trained to record information from the consultation and rate doctor behaviour when presenting, as a new patient on transfer, for a repeat prescription of asthma medication. Forty-nine doctors had one consultation and of these 25 had a second. Consultation time averaged 15.6 minutes and waiting time 17.4 minutes. Practice nurses and physiotherapists were rarely utilised. There were no specialist referrals. Serum theophylline levels were estimated in 4%. The chest was examined in 39% of consultations, the peak flow in 59%, both in 30% and neither in 32%. Drug prophylaxis was encouraged in 62%, home peak flow meter monitoring was encouraged in 49%, smoking was discouraged in 41%, aerosol technique was checked in 1%, a crisis plan was provided in 57% and asthma education in 42%. Doctor behaviour and communication skills were rated highly except that clear instruction on follow up appointments was given in only 24%. The second consultation appeared to be a briefer rerun of the first, indicating episodic care rather than planned long term management. A number of issues were identified for further study and education.

Adult↗
PubMed2004

Virtual-reality-based laparoscopic surgical training: the role of simulation fidelity in haptic feedback.

Although there have been significant advances in the development of virtual-reality-based surgical simulations, there remain fundamental questions concerning the fidelity required for effective surgical training. A dual-station experimental platform was built for the purpose of investigating these fidelity requirements. Analogous laparoscopic surgical tasks were implemented on a virtual station and a real station, with the virtual station modeling the real environment with various degrees of fidelity. After measuring the subjects' initial performance on the real station, different groups of subjects were trained on the virtual station under a variety of conditions and finally tested on the real station. Experiments involved bimanual pushing and cutting tasks on a nonlinear elastic object. The results showed that force feedback results in significantly improved training transfer as compared to training without force feedback. The training effectiveness of a linear approximation model was approximately the same as that of a more accurate nonlinear model.

Analysis of Variance↗