Medical simulation centers are emerging around the world to advance medical education to the next level by developing curricula that employs the technology to improve skills and assess performance. The centers are also conducting research that provides evidence to simulation's effectiveness as a learning tool, reports Chuck Weirauch.     

Private sector and government medical simulation centers are using simulation to take medical education to the next level of innovation. Surgical and other skills that heretofore could only be learned and refreshed in a live venue can be developed in a virtual environment. One of the more subtle but dramatic uses of medical simulation is in robotic surgery.

Robotic surgery curricula

Just as the American College of Surgeons, worked to develop the Fundamentals of Laparoscopic Surgery curriculum to improve surgeons' skills and as a tool to measure proficiency, efforts are now underway to develop a Fundamentals of Robotic Laparoscopic Surgery curriculum.

One such effort to advance surgical medical simulation and the development of the Fundamentals of Robotic Laparoscopic Surgery curriculum is a $4.2 million Telemedicine and Advanced Technology Center (TATRC) grant awarded to Florida Hospital’s Nicholson Center for Surgical Advancement. The grant is for the development of a Center of Excellence (COE) in Medical Robotics and Simulation Research. TATRC is a division of the U.S. Army Medical Research and Material Command.

The Nicholson Center, co-located at Florida Hospital Celebration Health in Orlando, now hosts the largest multispecialty medical robotics training program in the world. According to Nicholson Center Administrator Rick Wassel, the Center currently has six da Vinci robotic surgical systems that are dedicated exclusively to training physicians from around the world in more than six medical specialties. “While the primary use of the da Vinci system has been for laparoscopic prostate cancer surgery (and in fact more than 85 percent of such surgeries in the U.S. are now done with the da Vinci), advances in robotics research have shown applications for its use in cardiovascular, thoracic, gynecological, urology and general surgery, as well as in oncology,” Wassel said.

Robotics and simulation research

In October 2011 the Nicholson Center opened its new 54,000 square-foot Global Training and Education Institute, which will house the COE in Medical Robotics and Simulation Research. The six da Vinci robotic systems will be located in this building and be equipped with the da Vinci Skills Simulator provided by system manufacturer Intuitive Surgical. Along with the 25-station wet lab for simulation robotics and learning for new procedures and techniques will be a Simulation and Robotics Lab for medical modeling and simulation and robotics, virtual, mixed and augmented reality, telesurgery and mobile surgery. The Institute also features a 500-seat conference center.

The purpose of the Institute is to advance medical simulation and robotics and be a leader in those fields, Wassel explained. He cited partnerships with the Orlando military modeling and simulation community, along with the area's new Medical City and Veteran's Administration Hospital with its Medical Simulation Center, as catalysts for that goal.

"The old medical model of see one, do one, teach one is no longer applicable in today's environment," Wassel said. "The new model is see many, do many, teach many, and we can accomplish that through simulation, much of it translated from military M&S. Medical simulation allows us to change the way we train physicians and impact their interaction with patients, through avatars or not."

According to Florida Hospital Chief Technology Officer Roger Smith, what makes the Nicholson Center's effort to develop the Fundamentals of Robotic Laparoscopic Surgery curriculum unique is that it will be created to be shared; with all civilian and military medical education organizations, institutions, and hospitals. The ‘Robotic Surgery 101’ course will incorporate medical simulation technologies and become a part of the process to allow medical education organizations to certify surgeons to perform da Vinci robotic surgery, he explained.

Tough learning curve

Vipul Patel, M.D., is the world leader in robotic prostatectomies, having performed more than 5,000. He is also the Director of Florida Hospital's Global Research Institute. In summarizing what is needed for the advancement of robotic surgery, Patel said that the next critical step in robotics is probably in simulation.

"The reason, there is still a very steep learning curve for the da Vinci procedure," Patel explained. "And what we know is that this is a continuous learning curve. You continue to learn no matter how many you do. Simulation is probably the safest and most ethical way to practice surgery before you first do it on humans. One of the most critical areas is developing a fundamental knowledge for robotic surgery, and to do it we need to have simulation."

Other Simulation Research 

Research on how to improve robotic surgery education through simulation will also be conducted at other medical education institutions, including the University of South Florida (USF)'s Center for Advanced Medical Learning and Simulation (CAMLS). CAMLS will feature a Surgical Simulation Center that will house two da Vinci robotics suites that will include the Skills Simulator and a number of simulated operating rooms that will have an extensive array of medical simulation devices. As at Florida Hospital's COE, the USF Simulation Center will be employed to develop and provide courses for surgeons in the latest robotic laparoscopic and other minimally invasive techniques, as well as for OR teamwork training and medical simulation research.

Closing training gaps

"We are interested in looking at the comparative effectiveness of robotics technology to traditional surgical approaches," said CAMLS Director John Armstrong, M.D. "This is a real opportunity to define how robotics can enhance the outcomes for patients. We are also looking at how to close training gaps in robotic surgery. The primary education gap for the learner is simply understanding the efficiency of the robot and the tissue handling relative to the traditional instrument, which is the surgeon's hand. This is the first gap that needs to be filled. Then we need to define just how many simulated procedures are actually necessary before someone becomes competent and all of the levels beyond competency to proficiency, and ultimately expert performance. The overarching goal is to define , learner outcomes as a way to define learner competence, their confidence and then on to expert performance."

Performance Assessment

Defining the means to assess surgeons' performance skills in robotic surgery through simulation is also the goal of a study that will be conducted this summer at the Surgical Simulation Center at the Carolinas Medical Center in Charlotte, N.C., according to Dimitrios Stefanidis, M.D. and Ph.D., Director for Carolinas Medical Center. The goal of the study is the establishment of criteria for proficiency-based training that incorporates simulation into the curriculum.

"Our main focus or research area is identifying the metrics of performance and optimizing the curricula, or in other words, studying peoples optimal learning styles and provide them with the educational environment which enhances skills development” so that they can learn faster and better," Stefanidis pointed out. "The best training paradigm is proficiency-based, using criteria-based on training goals."

"One way to assess performance is to track surgical motion in simulators," Stefanidis continued.  "Our study, which is funded by several medical associations, is to assess current surgical proficiency levels. We need to identify those lagging behind and bring them up to speed. Also, we know that there is a transfer of skills from the simulator to the clinical environment. However, this transfer in not a hundred percent complete, so we are looking at ways to improve it."

VA Medical Simulation Center

Recognizing the value of simulation technology for medical training and education, the U.S. Department of Veterans Affairs (VA) has begun to implement its Simulation Learning, Education and Research Network (SimLEARN) throughout its system of more than 170 Veterans Health Administration (VHA) medical centers around the country. Work has also begun for the establishment of the SimLEARN National Center in Orlando.

The Orlando VHA medical center is scheduled to open in June 2012. Image Credit: U.S. Dept. of Veterans Affairs
The Orlando VHA medical center is scheduled to open in June 2012. Image Credit: U.S. Dept. of Veterans Affairs

VHA’s SimLEARN is a national program established to develop and manage a strategic operating plan for the provision of simulation education, training, and research across the VHA. The SimLEARN program proposal was approved by the US Under Secretary for Health in July 2009.

The SimLEARN National Center will be located at the new Orlando VHA medical center  currently under construction. The Center is scheduled to open in June 2012. Once in operation, the Orlando facility will feature new simulation modalities in inpatient and outpatient research areas. The National Center staff will be responsible for the development of simulation-based curricula to address high-priority clinical needs and the distribution of this training and education material via the national SimLEARN network.

Top administrative staff for the SimLEARN National Center have been hired, and are in place in leased space in Orlando until the Center opens in 2012. After a nationwide search, the VA selected Orlando because of the concentration of modeling and simulation expertise and resources in the area, said Louise Van Diepen, VA Deputy Chief Learning Officer.

"We felt that Orlando provided a lot of synergies as it relates to simulation," Van Diepen said. "We are working with a lot of our Department of Defense partners located in Orlando, such as the Army's Program Executive Office for Simulation, Training and Instrumentation, and the University of Central Florida's Institute for Simulation and Training. The National Center and the Orlando VHA medical center will be located at the Lake Nona Medical city,

The SimLEARN National Center will initially focus on developing hands-on curricula for several medical simulation applications, including mannequin-based simulation, virtual patients, standardized patients, virtual environments, and haptic and non-haptic task trainers.