Dr. Paul A. Wetter stresses the importance of team training and simulation exercises and looking to new innovations in education and training.

Dr. Paul A. Wetter, Chairman, Society of Laparoendoscopic Surgeons (SLS), discusses how technology is changing medical education and training and highlights surgical breakthroughs and the importance of simulation.

We live in one of the most challenging periods in the history of medical practice, with physician stress at an all-time high, yet technological breakthroughs and medical education continue to fascinate and encourage us. As the SLS site points out, we are doing amazing things.

The new mini-laparoscopic surgery uses a needle-sized trocar that achieves greater visibility, improved dexterity, and more angles, resulting in an easier surgery. Image Credit: Jay Redan, M.D.

At SLS we have advocated an emphasized team training and the use of simulation exercises, which are also recommended by many academic medical centers. Since healthcare reform emphasizes patient-centered care, technology will both inform and create opportunities and advantages to use both. We are getting more sophisticated, creating efficiency and a level of quality that wasn’t possible a decade ago.

Multi-Disciplinary Teams

If we look at what was rare just a decade ago - high-tech simulation centers from coast to coast, from Florida Hospital to Stanford University Medical Center - we see that surgical education has been transformed, propelled by institutions and medical societies, to make sure surgical teams are updated on the latest skill set. Part of what will improve surgery in the future is simulation training for teams, allowing new surgeons, their colleagues and their nurses to practice working well together, so that they will really understand what it will be like to provide care for patients alongside anesthesiologists, radiologists, general surgeons and other specialties.

Focusing on the Leaders

At MIS WEEK 2015 in New York City (SLS’ minimally invasive surgical conference), we will honor, both on stage and in our programs, leaders in MIS education technology, many of whom work together to create some of the best teaching departments in the world. Some of them will teach our attendees via TED-like talks; others will meet privately with Fellows and younger members who dare to dream and are driven to create the next big “new thing”.

One of our themes is how past technology has influenced the future. We are putting together an actual MIS museum, which will house old prototypes, press coverage, old photographs and videos that show new medical students and the rest of the attendees how MIS has progressed. At the end of the exhibits we will go into the future of minimally invasive surgery, the technology and brains behind the future of medicine, and this future includes developments in simulation technology.

What’s New?

Each week we learn of another new center using updated simulation and team training to teach new things. I’ve just learned of the new iEXCEL at the University of Nebraska Medical Center, where teams will be able to step inside a virtual heart and interact with robots that breathe, bleed, and react like patients. Why is this new center so important? First, it is bringing needed training and new physicians to a top medical center in the heartland - and rural medicine is the new frontier. Second, as an opinion piece in the Omaha World-Herald points out, we are complementing book learning with actual hands-on training.

Back when we used real patients almost exclusively as test subjects, we did so at a calculated risk, with our minds distracted by that important patient. Today's technology, from the dVTrainer to Wi-Fi enabled mannequins, allows us a great deal of reality and is consistently being developed to improve the way we learn.

The School of Nursing at Baylor University in Dallas has added the industry’s most advanced birthing simulator. This new tool aids teams in clinical scenarios, including shoulder dystocia and postpartum hemorrhage. Baylor points out that a July 2014 study (published in the Journal of Nursing Regulation) provided strong support for the use of patient simulators in nursing education, and showed that “substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates who are ready for clinical practice.”

According to the American Medical Association, 86 out of 90 medical schools and all 64 teaching hospitals that responded to a recent survey by the Association of American Medical Colleges reported that they now use simulation to train medical students. Technology keeps the learning surgeon’s mind on the process with fewer distractions. Such training is well worth the investment - which is why we will continue to offer a variety of SLS fellowships in simulation technology training.

We are making excellent progress using simulation in other areas. In the military, for example, new technology has been designed to train both military and civilian emergency medical personnel in trauma situations, such as hemorrhage control. It allows them to perform simulation-based training in any location, from the classroom to the battlefield. Also new are several simulation centers initiating simulation-based preparations to optimize their own readiness for Ebola patients, and to more rigorously address issues regarding essential training, protocol development, personal protective equipment, and facilities. Brand new supported research is exploring the means for robots to exhibit realistic, clinically relevant facial expressions and to respond automatically to clinicians in real time.

 Team Sharing & Education

As with all new technologies, it is critical that these important developments allow for team sharing and education. This is another topic that will be discussed at MIS WEEK this year. The vast amount of knowledge we’ve accumulated over the past thirty years has resulted in a fragmented health care system in which specialization is increasing. As a consequence, medical students have a difficult time navigating all of the information and are left to find specialists in many different areas. That is a great challenge for our medical students, and it can be remedied by having them learn from multidisciplinary teams. We know that the best way for new doctors to train is through experienced teams of surgeons who enjoy working together and passing on what they know. Schools of medicine are catching on, and are both pairing students with teams and assessing students for their ability to work with groups of surgeons in other specialties.

At our Euro-American Multi-Specialty Summit in February, brand new technology was introduced that will allow us to make even smaller incisions, familiarly called “mini-laparoscopic surgery.” This is not the mini-lap surgery that was invented in 1987. Brand new instrumentation now enables the surgeon to avoid scarring completely, and this time as a therapeutic tool, not just for diagnostics. Last month we completed the very first course in this technology, with surgeons from 27 countries from different specialties participating.

The new mini-laparoscopic surgery uses a needle-sized trocar that achieves greater visibility, improved dexterity, and more angles, resulting in an easier surgery. The pinpoint incisions are much smaller as well, using only two-to-three millimeter instruments, which decrease patient pain and allow faster healing. Because there is less equipment to be re-used, costs are significantly lower. The courses at the Summit went over the new technique, which evolved from a diagnostic technology only into a new surgical treatment.

Technology & the Need for Training

With new exciting technology comes the need for appropriate training. Google’s deal with Ethicon to develop surgical robots using artificial intelligence, via surgical platform, will help us achieve greater control and accuracy than is possible with traditional surgery, minimizing the risk of trauma and damage to the patient. It will enable surgeons to remotely control devices inside the patient’s body to help minimize entry wounds and reduce blood loss and scarring. (It is Google’s self-driving car research that led to this modern advancement in the operating room.)

The research is now focused on advanced imaging and sensors that will enhance the physician’s ability to discern smaller details in patient tissue. This imaging will be coupled with augmented reality, displayed on monitors, and will include patient information that doctors will need. Training for these advancements is crucial for persuading surgeons to accept and use the technology.

Individual Training

And let’s not forget that, away from the classroom, there is an opportunity to continue individual learning as well. Training on cell phones allows us to learn and discover even more. As of summer 2014, more than 75 billion apps were downloaded from the Apple App store alone. A little over two percent are medical applications - and considering the billions of apps created, that is quite a few. This technology is propelling us forward, forcing us to become more creative and innovative as progress comes more quickly. This is still no replacement for the multi-disciplinary team that can guide each surgeon in real time.

Since Apple announced its new Watch there has been much discussion about what wearable technologies can do for new surgeons - and it turns out, a lot. We now know that the first model will check a patient’s pulse, for example. The introduction of this new technology will usher in a change that will happen within a few short years. Expect medical innovation to happen quickly and translate into new products in hospitals.

The Cost Issue

There is speculation that the increasing attention to cost will slow down innovation. That is not happening in all instances. Concerns about cost are an issue thanks to changes in the last few years, including the Affordable Care Act and Medicare funding changes. It’s the efficiencies of modern technology that are taking center stage. A new JAMA study, led by Marty Makary (April 9, 2015) at the Hopkins School of Medicine, studied the cost savings and number of postoperative complications avoided by performing minimally invasive surgery versus open surgery. Makary reported that minimally invasive surgery is an often-overlooked opportunity to make surgery safer and less costly: “The investigators found that there was a marked decrease in surgical costs, postoperative complications and hospital stays in both simulations. If hospitals increased their rate of MIS to that of the 83rd percentile, patients could have 169,819 fewer days in the hospital and 4,306 fewer postoperative complications. In total, this would mean a $377 million reduction in annual cost.” This kind of lesson needs to be built into our discussion at medical schools around the world. It confirms what we already know but needs to be passed on to the next generation of medical professionals.

Looking to the future, as patients demand less and less pain and scarring, we will move in the direction of “non-surgery,” using molecular energy technology adopted originally from the aviation industry. In twenty to thirty years this kind of non-surgery will allow us to heal patients at the level of the individual cell. So while the business of practicing medicine can be stressful at times, and keeping up with the latest technology has its challenges, today’s surgical medicine is increasingly exciting.

We have a lot to look forward to and a lot to learn, with new technology providing the enjoyment.

About the Author

Dr. Paul Alan Wetter is Chairman of The Society of Laparoendoscopic Surgeons (SLS), the medical society for minimally invasive surgeons for all medical disciplines.