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PubMed1985

Physician decision making over the telephone.

Physician decision-making behaviors were evaluated for 31 telephone encounters between trained patient simulators and 9 first-year residents, 11 third-year residents, and 8 practicing physicians on after-hours call. The following trends occur as physicians become more experienced: mean call length decreases, less time is spent on diagnosis, fewer diagnostic questions are asked, greater time is spent on management, and diagnostic reasoning becomes more intuitive. These findings suggest that previous models of good telephone decision making, which focused on empirical data collection, may not represent the process used by experienced physicians.

Decision Making↗
PubMed1994

Evaluation of a behavioral audiometry simulator for teaching visual reinforcement audiometry.

Eight audiology students with little or no visual reinforcement audiometry (VRA) experience each performed a VRA test on an infant. Four of the students received approximately 5 hours of behavioral audiometry simulator (BAS) training, and 1 week later, after the first VRA test, all eight students tested a second infant. Student performance was rated by three audiologists who were experienced in performing VRA with infants. The performance of the group that received BAS training improved significantly while the performance of the control group did not. Among the students who received BAS training, those who improved the most during stimulated testing also showed the greatest improvement in VRA with real infants.

Audiology↗
PubMed1993

Technology and the growth of anaesthesiology as a specialty.

Clinical monitoring techniques have affected patients, influenced other specialties; and changed the specialty of anaesthesia. Patients now fare better, the progress of surgery has been facilitated, and anaesthesiology itself has felt the impact of these developments. Technological advance stimulates our understanding of physiological processes, which is a foundation for progress yet to come. The complexity and abundance of equipment threatens to overwhelm the modern anaesthesiologist, a problem now being addressed without risk to patients by using simulators in training. By extrapolation from the last 30 years of progress, prospects in the specialty are breathtaking, though much needs to be done, particularly in countries struggling to advance anaesthesiology in the face of severe restrictions in personnel and resources.

Anesthesiology↗
PubMedDate not supplied

Noise-driven neuroplasticity in self-organizing feature maps: a neurocomputational model of phantom limbs.

The term "phantom limb" denotes the sensation that an extremity is present although it has been lost. A number of clinical features and recent findings of cortical map plasticity after destruction of afferent pathways (deafferentation) suggest that phantom limbs are caused by large-scale cortical reorganization processes. However, in paraplegics, who also suffer from cortical deafferentation, phantom sensations rarely develop, and if they do, they are weak, lacking in detail, and delayed, occurring after months. This has been taken to suggest a non-cortical genesis of phantom limbs. This article proposes a biologically plausible minimal neural network model to solve this apparent puzzle. Deafferentation was simulated in trained self-organizing feature maps. Reorganization was found to be directed by input noise. According to the model, the production of input noise by the deafferented primary sensory neuron promotes cortical reorganization in amputees. No such noise is generated or conducted to the cortex in paraplegics.

Amputation, Surgical↗
PubMed1997

Use of standardized patients to assess between-physician variations in resource utilization.

CONTEXT: As medical costs are increasingly being scrutinized, there is heightened interest in defining variations in physician behavior in clinical settings. OBJECTIVE: To evaluate if standardized patient (SP) technology is a reliable and feasible method of studying interphysician variations in test ordering, referral requests, prescribing behavior, and visit costs. DESIGN: The study was conducted with blinded SP visits to family medicine and internal medicine residents, university-affiliated family physicians, and community-based family physicians. Resource utilization and visit costs were assessed using test requisitions, consult requests, and prescriptions that were collected by the SPs. SETTING: Physicians' offices in ambulatory care, hospital-based clinics and in the community. PARTICIPANTS: Four persons (aged 57-77 years) trained to simulate having osteoarthritis of the hip. In one simulation, the patient had gastropathy due to nonsteroidal anti-inflammatory drug use, and in the other, the patient sought therapy for hip discomfort. MAIN OUTCOME MEASURES: Reliability of cost estimates of physician services, tests, consultations, prescriptions, and total visits and test-ordering behavior for nonsteroidal anti-inflammatory gastropathy. RESULTS: Overall, 112 (63%) of the physicians who were sent invitations to the study agreed to participate. Of 312 total SP visits conducted over a 1-year period, unblinding due to SP detection occurred on 36 occasions (11.5%). Reliable cost estimates of physician services, tests, and consultations, and moderately reliable estimates of total visit costs, were obtained with 4 visits per practicing physician and with 2 visits per resident. There were extreme variations in total visit costs generated by the study physicians. A small number of physicians had a major impact on this variability. CONCLUSION: Standardized patient technology provides a reliable, feasible method to assess variations in resource utilization between physicians.

Diagnosis-Related Groups↗
PubMed1987

Training children in road crossing skills using a roadside simulation.

Five-year-old children were trained in road-crossing skill using a new method which allows them to act safely in relation to vehicles on a normal road. The children learned to time their crossings of a "pretend road" as if the vehicles were on this, rather than on the adjacent road. A previous study, using a single lane of traffic, showed that many children performed well in this simulation with minimal instruction, but that five-year-olds were generally less proficient than older children. In the present study, the method was extended to the more realistic case of two-way traffic, and training programmes for five-year-olds were assessed. (In addition, the performances of adults in the two-way pretend task and in actually crossing the road were compared; the results confirmed the validity of the simulation. After a few sessions of guided practice, the children's efficiency in making use of gaps by setting off promptly after a vehicle had passed improved markedly; in single-lane crossing they reached almost adult standard. In both single-lane and two-way crossing they became as successful as adults in completing their crossings before a second vehicle passed and they took account of the duration of the gap by crossing more quickly when time was short. They remained very cautious, rejecting many adequate gaps. The standard of performance after a few sessions of two-way crossing was maintained over a three week break in training. Practice with one-way traffic did not help them with two-way crossing. In sum, after practice in the simulation, five year olds develop a degree of competence normally shown by older children, whose experience on the roads puts them at lower risk. This suggests that the simulation, which allows children to safely explore and develop their capabilities more fully than when actually crossing the road, would be a valuable addition to road safety programmes.

Accident Prevention↗
PubMed2002

An evaluation of a virtual reality airway simulator.

UNLABELLED: In this research, we sought to test the hypothesis that the AccuTouch Flexible Bronchoscopy Simulator (Simulator) is an effective way to teach clinicians the psychomotor skills necessary to use the fiberoptic bronchoscope as an instrument for intubating the trachea of a pediatric patient. Pediatric residents with no prior experience in fiberoptic bronchoscopy were studied. Residents performed fiberoptic intubation on children undergoing general anesthesia. Tapes of these intubations were analyzed for: time to visualization of the carina, and number and time that the bronchoscope tip hit the mucosa. Residents were then trained on the Simulator. Performance of fiberoptic intubation on a subsequent child was compared. Training on the Simulator was the only instruction that the residents received between the two cases. A control group of residents performed two consecutive intubations without training on the Simulator between cases. Residents studied an average of 17 cases, and spent 39 min on the Simulator. Performance was markedly improved after the Simulator. Time to completion of successful intubation with a bronchoscope was reduced from 5.15 to 0.88 min (P < 0.001). The number of times that the tip of the bronchoscope hit the mucosa was reduced from 21.4 to 3.0 (P < 0.001). The amount of time that the resident spent viewing the mucosa decreased from 2.24 to 0.19 min (P < 0.001). The percent of time viewing the channel of the airway increased from 58.5% to 80.4% (P = 0.004). This bronchoscopy simulator was very effective in teaching residents the psychomotor skills necessary for fiberoptic intubation. Significant improvement was seen in time to completion of endotracheal intubation, as well as other performance indicators. IMPLICATIONS: This research showed that the AccuTouch Bronchoscopy Simulator is an effective way to teach the psychomotor skills necessary to intubate the trachea of patients using a fiberoptic bronchoscope. The residents that practiced on the Simulator dramatically improved their skills compared with a control group of residents.

Anesthesia↗
PubMed1999

Measuring and developing suturing technique with a virtual reality surgical simulator.

BACKGROUND: We have developed an interactive virtual reality (VR) surgical simulator for the training and assessment of suturing technique. The surgical simulator is comprised of surgical tools with force feedback, a 3-dimensional graphics visual display of the simulated surgical field, physics-based computer simulations of the tissues and tools, and software to measure and evaluate the trainee's performance. STUDY DESIGN: This study uses the simulator to measure and compare the skills of 8 experienced vascular surgeons versus 12 medical students when performing a virtual reality suturing task. Eight parameters of the suturing task were measured: total tissue damage, accuracy of needle puncture, peak tissue tearing force, time to complete the task, damage to the surface of the tissue, angular error in needle technique, total distance traveled by the tool tip, and a measure of overall error. Three test conditions (dominant hand, nondominant hand, and 3-dimensional needle guide) were tested. Statistical significance was defined as a univariate two-sided p value < or = 0.05. RESULTS: The surgeons' average performance was significantly better than the students' average performance for three of the measured parameters (total tissue damage, time to complete the task, and total distance traveled by the tool tip) for each of the test conditions. For the test condition most similar to surgery (using the dominant hand to suture) one additional parameter was also significantly different (the measure of overall error). The medical students showed improvements for 6 of the 7 parameters for which the users received feedback during the training process. The surgeons also had significant improvement for 4 of the 7 parameters. The students had a larger improvement than the surgeons for 6 of the parameters, but these differences were not statistically significant. CONCLUSIONS: Data indicate differences between surgeon and nonsurgeon performance and in improvement in performance with training. One possible explanation for the superior performance of the surgeons is that their suturing skills applied well to the simulated suturing task. Additional research is required to confirm or deny the similarity between actual and simulated surgical tasks and the relevance of virtual reality surgical simulation to surgical skill assessment and training.

Computer Simulation↗
PubMed1988

Learning fibreoptic intubation: use of simulators v. traditional teaching.

This study compared a graduated training programme with that of a traditional teaching method to facilitate the learning of the technique of fibreoptic nasotracheal intubation. Thirty-two anaesthesia trainees were randomly assigned to two groups. The graduated programme involved: practice on a bronchoscopy teaching model; exposure of the epiglottis and vocal cords in patients recovering from general anaesthesia; performance of fibreoptic nasotracheal intubation in awake sedated patients. The traditional programme involved: demonstration (on a patient) of one fibreoptic nasotracheal intubation by the instructor; performance of fibreoptic nasotracheal intubation (by the trainee) in awake sedated patients. Nasotracheal intubation was accomplished significantly more often by the trainees in the graduated programme (86 out of 96 (89.6%) v. 64 out of 96 (66.5%) (P less than 0.01). The results demonstrate that trainees who undergo a graduated training programme using simulators are initially more successful at awake fibreoptic nasotracheal intubation than those who have learned in the traditional manner, and that the conditions of the investigation were acceptable to the trainees and patients.

Anesthesiology↗
PubMed2005

A simulation-based acute skills performance assessment for anesthesia training.

UNLABELLED: In an earlier study, trained raters provided reliable scores for a simulation-based anesthesia acute care skill assessment. In this study, we used this acute care skill evaluation to measure the performance of student nurse anesthetists and resident physician trainees. The performance of these trainees was analyzed to provide data about acute care skill acquisition during training. Group comparisons provided information about the validity of the simulated exercises. A set of six simulation-based acute care exercises was used to evaluate 43 anesthesia trainees (28 residents [12 junior and 16 senior] and 15 student nurse anesthetists). Six raters scored the participants on each exercise using either a detailed checklist, key-action items, or a global rating. Trainees with the most education and clinical experience (i.e., senior residents) received higher scores on the simulation scenarios, providing some evidence to support the validity of the multi-scenario assessment. Trainees varied markedly in ability depending on the content of the exercise. In general, anesthesia providers demonstrated similar aptitude in managing each of the six simulated events. Most participants effectively managed ventricular tachycardia, but postoperative events such as anaphylaxis and stroke were more difficult for all trainees to promptly recognize and treat. Training programs could use a simulation-based multiple encounter evaluation to measure provider skill in acute care. IMPLICATIONS: A trainee's skill in managing critical events can be assessed using a multiple scenario simulation-based performance evaluation.

Anesthesiology↗
PubMed2001

Assessment of a bronchoscopy simulator.

The study objective was to validate a flexible bronchoscopy simulator by determining if it could differentiate between expert and novice bronchoscopists. A subsequent evaluation phase was then done to determine whether use of the simulator would improve the rate of bronchoscopy skill acquisition for new pulmonary fellows. A multicenter prospective cohort study was performed using a bronchoscopy simulator. Three cohorts were evaluated based on the number of bronchoscopies previously performed: "experts" (> 500, n = 9), "intermediates" (25 to 500, n = 8), and "novices" (none, n = 11). Each participant performed two simulated cases with performance measures being recorded by the simulator. Performance measures that distinguished between groups were then used to evaluate the learning curve for new fellows training on the simulator. A randomized-controlled trial was then conducted comparing the quality of bronchoscopy performance for new pulmonary fellows who were trained either with conventional methods or with the simulator. Expert bronchoscopists performed better on the simulator than intermediates who performed better than novices in terms of procedure time, percentage of segments visualized, time in red-out, and wall collisions. Training of new fellows demonstrated that after performing 20 bronchoscopic simulations, the skill level acquired with the simulator significantly improved in terms of speed, percentage of segments visualized, time in red-out, and collisions. Fellows trained on the simulator performed better than fellows trained using conventional methods during their first actual bronchoscopies as assessed by procedure time (815 versus 1,168 s, p = 0.001), a bronchoscopy nurse's subjective quality assessment score (7.7 +/- 0.3 versus 3.7 +/- 2.5, p = 0.05), and by a quantitative bronchoscopy quality score (percentage of segments correctly identified/procedure time, 0.119 +/- 0.015 versus 0.046 +/- 034, p = 0.03). In conclusion, the bronchoscopy simulator was able to accurately assess bronchoscopy experience level. Training new fellows on the bronchoscopy simulator leads to more rapid acquisition of bronchoscopy expertise compared with conventional training methods. This technology has the potential to facilitate bronchoscopy training and to improve objective evaluations of bronchoscopy skills.

Adult↗
PubMed2003

Bedside cardiology skills training for the osteopathic internist using simulation technology.

Medical practice changes that limit patient availability, instructor time, and advances in technology have led to a greater use of simulators and multimedia computers in medical education. These systems address the problem of inadequate bedside skills training and poor proficiency among all health care providers. While studies have shown their effectiveness among medical students, residents, and practicing physicians, none has focused on the osteopathic internist population--one that is becoming more responsible for conducting initial and follow-up physical examinations. This report describes the use of "Harvey," the cardiology patient simulator, and the UMedic Multimedia Computer System at a workshop conducted at the American College of Osteopathic Internists' 61st Annual Convention and Scientific Sessions. Participants in this study significantly improved their ability to identify common cardiac auscultatory events, as indicated by pretest-to-posttest scores. Workshop participants were nearly unanimous in their belief that they would like to use these tools for learning and assessment.

Cardiology↗
PubMed2005

Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training.

SUMMARY BACKGROUND DATA: To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision METHODS: A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. RESULTS: VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. CONCLUSIONS: VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.

Attention↗
PubMedDate not supplied

Conceptual framework for laparoscopic VR simulators.

Availability of YR laparoscopic simulation for surgical training has increased significantly. Nevertheless, few studies have explored such simulators' requirements and the degree of fidelity necessary to provide effective educational tools. The authors aim to identify which didactic resources available in YR simulation technologies are most important for laparoscopic training.

Computer Graphics↗
PubMed2006

Objective assessment of gynecologic laparoscopic skills using the LapSimGyn virtual reality simulator.

BACKGROUND: Safe realistic training and unbiased quantitative assessment of technical skills are required for laparoscopy. Virtual reality (VR) simulators may be useful tools for training and assessing basic and advanced surgical skills and procedures. This study aimed to investigate the construct validity of the LapSimGyn VR simulator, and to determine the learning curves of gynecologists with different levels of experience. METHODS: For this study, 32 gynecologic trainees and consultants (juniors or seniors) were allocated into three groups: novices (0 advanced laparoscopic procedures), intermediate level (>20 and <60 procedures), and experts (>100 procedures). All performed 10 sets of simulations consisting of three basic skill tasks and an ectopic pregnancy program. The simulations were carried out on 3 days within a maximum period of 2 weeks. Assessment of skills was based on time, economy of movement, and error parameters measured by the simulator. RESULTS: The data showed that expert gynecologists performed significantly and consistently better than intermediate and novice gynecologists. The learning curves differed significantly between the groups, showing that experts start at a higher level and more rapidly reach the plateau of their learning curve than do intermediate and novice groups of surgeons. CONCLUSION: The LapSimGyn VR simulator package demonstrates construct validity on both the basic skills module and the procedural gynecologic module for ectopic pregnancy. Learning curves can be obtained, but to reach the maximum performance for the more complex tasks, 10 repetitions do not seem sufficient at the given task level and settings. LapSimGyn also seems to be flexible and widely accepted by the users.

Clinical Competence↗
PubMed1997

Disorientation and postural ataxia following flight simulation.

BACKGROUND: Motion sickness-like symptoms can afflict pilots training in military simulators. This simulator sickness involves symptoms of gastrointestinal distress, eyestrain and disorientation. A simulator sickness Questionnaire (SSQ) with subscales available for each of these dimensions has been developed to assess the problem. HYPOTHESIS: This study examined the hypothesis that there is a strong correlation between the SSQ subscale which summarized self report of disorientation symptoms and an objective measure of post-simulation postural instability. METHODS: Data from two Navy simulators were analyzed: Device 2F114, a Weapon System Trainer for the A-6E Intruder, and Device 2F143, an Operational Flight Trainer for the EA-6B. Tests of standing and walking unsteadiness were administered along with the Simulator Sickness Questionnaire (SSQ). RESULTS: Significant correlations were found between scores on postural stability tests and the SSQ disorientation subscale scores, but correlations between scores on postural stability tests and the SSQ nausea and oculomotor subscale scores were much weaker and not statistically significant. CONCLUSIONS: These results provide some evidence for the validity of the disorientation subscale of the SSQ and suggest that the postural instability observed after simulator exposure may, in fact, result from disorientation.

Aerospace Medicine↗
PubMed2002

Algorithmic tools for real-time microsurgery simulation.

Today, there is growing interest in computer surgical simulation to enhance surgeons' training. This paper presents a simulation system based on novel algorithms for animating instruments interacting with deformable tissue in real-time. The focus is on computing the deformation of a tissue subject to external forces, and detecting collisions among deformable and rigid objects. To achieve real-time performance, the algorithms take advantage of several characteristics of surgical training: (1) visual realism is more important than accurate, patient-specific simulation; (2) most tissue deformations are local; (3) human-body tissues are well damped; and (4) surgical instruments have relatively slow motions. Each key algorithm is described in detail and quantitative performance-evaluation results are given. The specific application considered in this paper is microsurgery, in which the user repairs a virtual severed blood vessel using forceps and a suture (micro-anastomosis). Microsurgery makes it possible to demonstrate several facets of the simulation algorithms, including the deformations of the blood vessel and the suture, and the collisions and interactions between the vessel, the forceps, and the suture. Validation of the overall microsurgery system is based on subjective analysis of the simulation's visual realism by different users.

Algorithms↗