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PubMed2004

Simulation of minimally invasive vascular interventions for training purposes.

OBJECTIVE: To master the skills required to perform minimally invasive vascular interventions, proper training is essential. A computer simulation environment has been developed to provide such training. The simulation is based on an algorithm specifically developed to simulate the motion of a guide wire--the main instrument used during these interventions--in the human vasculature. In this paper, the design and model of the computer simulation environment is described and first results obtained with phantom and patient data are presented. MATERIALS AND METHODS: To simulate minimally invasive vascular interventions, a discrete representation of a guide wire is used which allows modeling of guide wires with different physical properties. An algorithm for simulating the propagation of a guide wire within a vascular system, on the basis of the principle of minimization of energy, has been developed. Both longitudinal translation and rotation are incorporated as possibilities for manipulating the guide wire. The simulation is based on quasi-static mechanics. Two types of energy are introduced: internal energy related to the bending of the guide wire, and external energy resulting from the elastic deformation of the vessel wall. RESULTS: A series of experiments were performed on phantom and patient data. Simulation results are qualitatively compared with 3D rotational angiography data. CONCLUSIONS: The results indicate plausible behavior of the simulation.

Algorithms↗

PubMed2003

A study comparing the effectiveness of conventional training and virtual reality simulation in the skills acquisition of junior dental students.

The use of virtual reality (VR) in the training of operative dentistry is a recent innovation and little research has been published on its efficacy compared to conventional training methods. Two groups of dental students, with no experience in operative dentistry, were trained solely by either VR or conventional training in the preparation of conventional class 1 cavities. The subjects all used the same operative armamentarium and phantom heads, and were allocated the same duration of practice periods. At the completion of these training periods, both groups produced two class 1 cavities on the lower left first molar, which were subsequently coded and blindly scored for the traditional assessment criteria of outline form, retention form, smoothness, cavity depth and cavity margin angulation. An ordinal score of 0-3 or 0-4 was assigned for each assessment criterion: the higher the score, the worse the evaluation. After initial independent scoring, the two examiners discussed any notable differences until an agreed score was reached. Once the codes were broken, non-parametric analyses were performed on the data. Wilcoxon Tests for the semiquantitative scores indicated significant differences between the VR and conventional training groups for outline form, depth and smoothness but not for retention or cavity margin angulation at P < 0.05 level, with the VR group receiving the higher, i.e. worse, scores. Cavity margin angulation approached significance with a P-value of 0.0536. The results indicated that VR-based skills acquisition is unsuitable for use as the sole method of feedback and evaluation for novice students.

Clinical Competence↗

PubMed2006

[Clinical and communication simulation workshop for fellows in gastroenterology: the trainees' perspective].

BACKGROUND: The continuing development in computer-based medical simulators provides an ideal platform for simulator-assisted training programs for medical trainees. Computer-based endoscopic simulators provide a virtual reality environment for training endoscopic procedures. This study illustrates the use of a comprehensive training model combining the use of endoscopic simulators with simulated (actor) patients (SP). AIM: To evaluate the effectiveness of a comprehensive simulation workshop from the trainee perspective. METHODS: Four case studies were developed with emphasis on communication skills. Three workshops with 10 fellows in each were conducted. During each workshop the trainees spent half of the time in SP case studies and the remaining half working with computerized endoscopic simulators with continuous guidance by an expert endoscopist. Questionnaires were completed by the fellows at the end of the workshop. RESULTS: Seventy percent of the fellows felt that the endoscopic simulator was close or very close to reality for gastroscopy and 63% for colonoscopy. Eighty eight percent thought the close guidance was important for the learning process with the simulator. Eighty percent felt that the case studies were an important learning experience for risk management. CONCLUSION: Further evaluation of multi-modality simulation workshops in gastroenterologist training is needed to identify how best to incorporate this form of instruction into training for gastroenterologists.

Computer-Assisted Instruction↗

PubMed2003

A pilot study comparing the effectiveness of conventional training and virtual reality simulation in the skills acquisition of junior dental students.

The use of virtual reality (VR) in the training of operative dentistry is a recent innovation and little research has been published on its efficacy compared to conventional training methods. To evaluate possible benefits, junior undergraduate dental students were randomly assigned to one of three groups: group 1 as taught by conventional means only; group 2 as trained by conventional means combined with VR repetition and reinforcement (with access to a human instructor for operative advice); and group 3 as trained by conventional means combined with VR repetition and reinforcement, but without instructor evaluation/advice, which was only supplied via the VR-associated software. At the end of the research period, all groups executed two class 1 preparations that were evaluated blindly by 'expert' trainers, under traditional criteria (outline, retention, smoothness, depth, wall angulation and cavity margin index). Analyses of resulting scores indicated a lack of significant differences between the three groups except for scores for the category of 'outline form', for group 2, which produced significantly lower (i.e. better) scores than the conventionally trained group. A statistical comparison between scores from two 'expert' examiners indicated lack of agreement, despite identical written and visual criteria being used for evaluation by both. Both examiners, however, generally showed similar trends in evaluation. An anonymous questionnaire suggested that students recognized the benefits of VR training (e.g. ready access to assessment, error identification and how they can be corrected), but the majority felt that it would not replace conventional training methods (95%), although participants recognized the potential for development of VR systems in dentistry. The most common reasons cited for the preference of conventional training were excessive critical feedback (55%), lack of personal contact (50%) and technical hardware difficulties (20%) associated with VR-based training.

Competency-Based Education↗

PubMed1990

The Anesthesia Simulator-Recorder: a device to train and evaluate anesthesiologists' responses to critical incidents.

The Anesthesia Simulator-Recorder is a computer program that trains and evaluates anesthesiologists' management of critical incidents. The program executes on IBM compatible personal computers, combining a graphic display of the operating room with mouse-driven input and using an integrated set of physiological and pharmacological models to predict patient responses. The program records the simulated patient's vital signs and all management decisions, and produces a printed case summary. The Anesthesia Simulator-Recorder was evaluated by 44 resident and attending anesthesiologists at seven different anesthesia training centers. These anesthesiologists found the simulator easy to use with clear presentation of the case and management options. The physiological and pharmacological models produced clinically realistic predictions of patient behavior (mean score = 8.5, where 10 is highly realistic and 1 is unrealistic). The Anesthesia Simulator-Recorder was appraised as an excellent training device (mean score = 8.5, where 10 is outstanding and 1 is poor) because it provides the ability to repeatedly practice the management of critical incidents. The simulator was judged to be a good evaluation device (mean score = 6.6, where 10 is outstanding and 1 is poor). No significant differences were found in evaluations between the institution where the program was developed and other institutions, or between residents and attendings.

Anesthesiology↗

PubMed1994

A computer model of amplitude-modulation sensitivity of single units in the inferior colliculus.

A computer model is presented of a neural circuit that replicates amplitude-modulation (AM) sensitivity of cells in the central nucleus of the inferior colliculus (ICC). The ICC cell is modeled as a point neuron whose input consists of spike trains from a number of simulated ventral cochlear nucleus (VCN) chopper cells. Input to the VCN chopper cells is provided by simulated spike trains from a model of the auditory periphery [Hewitt et al., J. Acoust. Soc. Am. 91, 2096-2109 (1992)]. The performance of the model at the output of the auditory nerve, the cochlear nucleus and ICC simulations in response to amplitude-modulated stimuli is described. The results are presented in terms of both temporal and rate modulation transfer functions (MTFs) and compared with data from physiological studies in the literature. Qualitative matches were obtained to the following main empirical findings: (a) Auditory nerve temporal-MTFs are low pass, (b) VCN chopper temporal-MTFs are low pass at low signal levels and bandpass at moderate and high signal levels, (c) ICC unit temporal-MTFs are low pass at low signal levels and broadly tuned bandpass at moderate and high signal levels, and (d) ICC unit rate-MTFs are sharply tuned bandpass at low and moderate signal levels and flat at high levels. VCN and ICC units preferentially sensitive to different rates of modulation are presented. The model supports the hypothesis that cells in the ICC decode temporal information into a rate code [Langner and Schreiner, J. Neurophysiol. 60, 1799-1822 (1988)], and provides a candidate wiring diagram of how this may be achieved.

Animals↗

PubMed2006

Simulators in catheter-based interventional radiology: training or computer games?

Training in interventional radiology (IR) relies on a traditional apprenticeship; to protect patients, expert supervision is mandatory until knowledge, attitudes and practical skills have been certified as satisfactory. However, the current quality of IR training is threatened by reduced time for trainees to learn, as well as a loss of basic diagnostic, training cases to non-invasive imaging. At the same time, IR techniques are becoming a focus of interest to a range of other clinical specialities. To address this training shortfall there is a need to develop novel training alternatives such as simulator models. Few simulator models in any medical field have been successfully validated to show improved clinical skills in treating patients. To date no endovascular simulator has met this standard. A good simulator must be based around key performance measures (metrics) derived from careful analysis of the procedure to be replicated. Metrics can be determined by trained psychologists from a direct analysis of the content of the job or task to be tested. The identification of these critical measures of performance is a complex process which must be tailored to a training curriculum to be effective. Simulators based on flawed metrics will invariably lead to unsatisfactory assessment. It follows that simulator development must involve the statutory licensing authorities. Equally it is essential that we do not assume that training on a particular simulator will correlate with the ability to perform the task in the real world. This "transfer of training" must be rigorously proven by validation studies.

Clinical Competence↗

PubMed1997

Magnetic resonance imaging of children without sedation: preparation with simulation.

OBJECTIVE: It was hypothesized that a scanner simulator that replicates the magnetic resonance imaging (MRI) environment could be used to prepare pediatric subjects for successful completion of a diagnostic-quality MRI examination without pharmacological sedation. METHOD: Sixteen healthy children, 6 to 17 years of age, were matched for age and sex with 16 psychotropic medication-naive children with obsessive-compulsive disorder. Distress was measured throughout simulation and scanning procedures using heart rate and a self-report distress scale. Ten healthy children, 6 to 17 years of age, also underwent the same actual MRI scanning procedure but did not undergo the simulation scanning procedure. RESULTS: Significant decreases in heart rate and self-reported distress level were observed in all subjects during the simulator session that were maintained to the end of the actual scanner experience. All subjects successfully completed MRI examinations without chemical restraint. Subjects who were not trained in the simulator had higher heart rates and self-reported distress levels in the actual scanner than did simulation-trained subjects. CONCLUSIONS: Simulation without pharmacological sedation successfully prepared pediatric subjects in this pilot study for high-quality MRI studies. Subject preparation may be an alternative procedure to sedation for routine MRI examination in healthy and anxious children 6 years of age and older.

Adolescent↗

PubMed2002

Incorporation of a computerized human patient simulator in critical care training: a preliminary report.

BACKGROUND: The intent of the study was to document initial experience with human patient simulation, using a full-scale computerized mannequin, in evaluating cognitive performance among junior surgery residents. METHODS: This was an observational study of eight postgraduate year-2 surgery residents during initial critical care rotation that assessed their responses to three unknown scenarios using a human patient simulator. RESULTS: No resident successfully completed the first scenario. Of note was a reluctance to call for help until the scenario reached a critical stage. Subsequent performance improved in areas previously neglected. Resident acceptance of simulation scenarios as a teaching tool was excellent. CONCLUSION: The human patient simulator is a valuable tool in critical care education, identifying weaknesses both in individual student performance and in program content.

Adult↗

PubMed2002

Human simulation in emergency medicine training: a model curriculum.

The authors propose a three-year curriculum for emergency medicine residents using human simulation both to teach and to assess the Accreditation Council for Graduate Medical Education (ACGME) core competencies. Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism into a three-year emergency medicine residency. The core competencies are incorporated into each case, focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. Because of the limitations of current assessment tools, the demonstration of resident competence is used only for formative evaluations. Limitations of this proposal and difficulties in implementation are discussed, along with a description of the organization and initiation of the simulation program.

Clinical Competence↗

PubMed1988

Medical simulation for disaster casualty management training.

A required, role-intensive leadership simulation in emergency and disaster medicine management for fourth-year medical students is described, and the value of an extended role-playing experience discussed. The week-long (120 hours) simulation exercise is designed to provide an opportunity for Federal medical students to experience a realistic combat or disaster environment similar to environments in which they may be required to operate medical support systems. Students function in a variety of roles and have the opportunity to place into practice all emergency medical knowledge and skills acquired throughout medical school. As a prerequisite to the exercise, students successfully complete a 3-week didactic course in Operational and Emergency Medicine which includes Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) Provider Courses. By means of disaster simulation they refine medical skills, leadership style, substantially improve clinical judgment, and deal with the complexities of problems associated with their future roles as medical officers.

Disaster Planning↗

PubMed2005

Do workshops improved the technical skill of vascular surgical trainees?

AIMS: Adjuncts to conventional surgical training are needed in order to address the reduction in working hours. This purpose of this study was to objectively assess the efficacy of workshop training on simulators. METHODS: Fifteen consecutive participants of the European Vascular Workshop in 2003 and 2004 were recruited to this study. Participants performed a proximal anastomosis on a commercially available abdominal aortic aneurysm simulator, were then given intensive training on sophisticated models for 3 days and re-assessed. Pre- and post-course procedures were videotaped and independently reviewed by three assessors (tapes were blinded and in random order). The operative end product was similarly assessed. Four measures of technical skill were used: generic skill, procedural skill; a five point technical rating of the anastomosis (assessed using validated rating scales) and procedure time. Non-parametric tests were used in the statistical analysis. RESULTS: The video assessment scores for aneurysm repair increased significantly following completion of the course (p=0.006 and p=0.004 for generic and procedural skill, respectively). End product assessment scores increased significantly post-course (p=0.001) and participants performed aneurysm repair faster following the course (p<0.05). Inter-observer reliability ranged from alpha=0.84-0.98 for the three rating scales pre- and post-course. CONCLUSION: Objective improvements in technical performance follow intensive workshop training. Participants' perform better, faster, and with an improved end product following the course. Such adjuncts to training play an important part in a focused integrated programme that addresses reduced work hours.

Anastomosis, Surgical↗

PubMed2002

Using the AIDA--www.2aida.org--diabetes simulator. Part 2: recommended training requirements for health-carers planning to teach with the software.

The purpose of this article is to document some recommended training requirements for health-carers planning to teach using the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 200,000 visits have been logged at the AIDA Website--www.2aida.org--and over 40,000 copies of the AIDA program have been downloaded free-of-charge. This report describes various training requirements that are recommended for health-care professionals who are interested in teaching with the software. Intended goals of this article are to answer possible questions from teachers using the program, highlight some minimum recommended training requirements for the software, suggest some "hints and tips" for teaching ideas, explain the importance of performing more studies/trials with the program, overview randomised controlled trial usage of the software, and highlight the importance of obtaining feedback from lesson participants. The recommendations seem to be straightforward and should help in formalising training with the program, as well as in the development of a network of teachers "accredited" to give lessons using the software. This report, together with the previous article (Part 1, Diabetes Technol Ther 2002;4:401-414), highlights the utility of providing guidelines and suggesting recommended training requirements for health-carers planning to make use of educational medical/diabetes software.

Blood Glucose↗

PubMed2006

Counselling on lifestyle factors in hypertension care after training on the stages of change model.

BACKGROUND: In assisting the nurse's counselling on lifestyle changes in hypertension care a behaviour model can be used. AIM: To analyse the effects of nurses' training on the use of the stages of change model when counselling hypertensive patients to perform lifestyle changes. METHODS: As part of a randomised, controlled trial, 19 nurses belonging to the intervention group took part in video-recorded consultation training with simulated patients. To evaluate the training, the nurses audio-recorded their consultations with two patients before and after the intervention. Analysis focused on the areas of non-pharmacological treatment and the nurses' attention to the patients' readiness for change. RESULTS: Patient participation in the consultations increased after the training. The importance of non-pharmacological treatment was mentioned more frequently for all areas of lifestyle behaviour, exercise, smoking, alcohol consumption, food and stress, and the nurses acquired a more distinct structure for their consultations. The mean length of the recorded consultations increased from 18 min to 20.5 min. All the criteria for fulfillment of attention to patient's readiness to change were met in nine consultations before the training and in seven after it. After the training, attention was paid to support more frequently than before in the action and maintenance stages and a great deal of information was provided.

Counseling↗

PubMed2004

Bronchoscopy simulator effectively prepares junior residents to competently perform basic clinical bronchoscopy.

BACKGROUND: Teaching procedural skills in a clinical setting is becoming increasingly difficult. Simulators can provide safe and inexpensive skills training. This randomized study was conducted to evaluate the effectiveness of a bronchoscopy simulator in teaching clinical bronchoscopy. METHODS: Three groups of surgical residents were evaluated while performing an intraoperative flexible bronchoscopy. First year (PGY1) residents were randomly assigned to perform bronchoscopy either with (n = 5) or without (n = 5) preprocedural bronchoscopic simulator training (PreOp flexible bronchoscopic simulator, Immersion Medical, Gaithersburg, MD). Residents PGY2 to 3 (n = 3) with prior bronchoscopic experience (> or = 10 bronchoscopies) underwent evaluation without simulator training. Subjects were required to complete a systematic airway examination through a laryngeal mask airway with patients under general anesthesia. Evaluation criteria included procedure time, number of verbal and physical interventions by evaluator, and a rating of exam thoroughness, proficiency, and confidence. RESULTS: The PGY1 subjects who trained on the simulator required significantly fewer verbal (6.2 +/- 1.6 vs 3.2 +/- 0.8) and physical (1.6 +/- 0.2 vs 0.2 +/- 0.4) cues and performed more systematic examinations (2.6 +/- 0.5 vs 4.4 +/- 0.9 on scale 1 to 5) than those who did not use the trainer. The skill level of PGY1 subjects who worked with the simulator was similar to that of PGY2 to 3 residents experienced in bronchoscopy. Procedural times were not different between groups as the evaluator maintained the pace of the examination using verbal and physical assistance. CONCLUSIONS: One hour of training with the bronchoscopic simulator effectively taught residents basic bronchoscopy and familiarity with airway anatomy. Residents using the trainer performed first-time bronchoscopy nearly as competently as residents experienced with bronchoscopy.

Audiovisual Aids↗

PubMed1994

Does training on an anaesthesia simulator lead to improvement in performance?

We have used the Leiden anaesthesia simulator, which makes use of a standard anaesthesia machine and monitors, and realistically simulates the anaesthesia work place. After obtaining informed consent, 28 anaesthetists and anaesthesia trainees in one hospital took part in the study. All participants were exposed to a pre-scripted simulated "control" scenario of anaphylactic shock (phase 1). The sessions were videotaped and the performances of individual participants were evaluated using a standardized scoring scheme. During phase 2, the participants were allocated randomly to undergo training in the management of either anaphylactic shock (group A, n = 13) or malignant hyperthermia (group B, n = 15) on the simulator. After 4 months, each participant underwent a blinded evaluation session with a pre-scripted "test" scenario of malignant hyperthermia (phase 3). These sessions were also videotaped and evaluated as for phase 1. The participants in group B responded more quickly, treated better and deviated less from the accepted procedure during phase 3 than those in group A. The total performance of participants in group B during phase 3 was significantly better than those in group A. We conclude that training on an anaesthesia simulator does improve the performance of anaesthetists in dealing with emergencies during anaesthesia.

Anaphylaxis↗

PubMed1999

PreOp endoscopic simulator: a PC-based immersive training system for bronchoscopy.

The high cost of simulators that offer adequate realism for training has been a major challenge for the simulation community. The cost of the computers alone has been too high for most training institutions to afford. We have met this challenge by developing the PreOp Endoscopic Simulator, our second generation of low-cost medical simulators. The PreOp system integrates multimedia, 3D graphics simulation, and force feedback technology on a PC. This paper discusses the challenges of this project and the trade-offs and solutions that we developed to overcome them. We discuss our process of analyzing and prioritizing the medical tasks necessary to correctly perform flexible bronchoscopy. In addition, we illustrate how we blended together simulation and multimedia technology to ensure adequate immersion and training efficacy, while keeping the system cost to a minimum.

Biopsy↗

PubMed2004

Learning curves and impact of psychomotor training on performance in simulated colonoscopy: a randomized trial using a virtual reality endoscopy trainer.

BACKGROUND: The aim of this study was to analyze the learning curve for the GI Mentor II endoscope trainer and to determine whether psychomotor training can contribute to an improvement in the performance of virtual colonoscopy. METHODS: To analyze the learning curve, 28 subjects were divided into three groups on the basis of their experience with gastrointestinal (GI) endoscopy: experienced surgeons (group 1, performed > 200 endoscopic procedures, (n = 8)) residents (group 2, performed < 50 endoscopic procedures, (n = 10)); and medical students (group 3, never performed GI endoscopy, (n = 10)). The participants were tested on the GI Mentor II virtual reality simulator 10 consecutive times. Assessment of the learning curve was based on the following three parameters: time used, number of punctured balloons, and number of wall collisions. In the second part of the study, 20 subjects who had never performed GI endoscopy were included. After performing a virtual colonoscopy, they were randomized to a group that received psychomotor training and a control group. Finally, all subjects performed a virtual colonoscopy. Assessment of endoscopic skills during the colonoscopy was based on nine parameters dealing with psychomotor skills. RESULTS: The learning curve for time expended reached a plateau after the second repetition for group 1 (Friedman's test, p < 0.05), after the fifth repetition for group 2 (p < 0.05), and after the seventh repetition for group 3 (p < 0.05). Experienced surgeons did not improve their scores for regarding number of balloons punctured or number of wall collisions (p > 0.05), indicating the absence of a learning curve for these parameters. Group 2 improved their scores up to the fourth and fifth repetitions, respectively (p < 0.05), and group 3 up to the fifth and seventh repetitions, respectively (p < 0.05). Experienced surgeons achieved the best performance, followed by group 2 and then group 3. The surgeons who had received psychomotor training performed the second virtual colonoscopy significantly faster than the control group (Mann-Whitney test, p < 0.001) and made significantly greater improvement in all other parameters as well. CONCLUSIONS: There were different learning curves for surgeons depending on their endoscopic background. The familiarization rate on the simulator was proportional to the endoscopic experience of the surgeons. Psychomotor training had a significant effect on the performance of a simulated colonoscopy.

Clinical Competence↗