Why is Simulation So Slow in Gaining Acceptance in Medical Education?

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Dr. Howard Champion and Dr. Jan Cannon Bowers look at issues to be addressed to make simulation an integral part of experiential medical training.

Howard Champion MD, FRCS (Edin), FRCS (Eng), DMCC, FACS and Jan Cannon-Bowers PhD highlight and discuss the business model, medical education and simulator issues that need to be addressed to make simulation an integral part of medical education.

There are huge pressures to reform medical education at this time. The shorter work week for resident training reduces the scope and volume of patient exposure. Increasing demands to reduce patient risk associated with the traditional mentored development of clinical and technical proficiencies are mounting, as is public demand for increasing objectivity and transparency of competence before trainees practice on their own. Many residents qualifying from training programs do not feel adequately prepared for autonomous practice. This, among other factors, accounts for the fact that 80% of surgeons graduating from general surgical training programs go on to fellowship training. The escalating costs of training - both direct costs and also those due to extending time in the operating room (and other clinical environments) - are of great concern to hospital and clinic administrators. They are also of concern to the federal government, which provides huge support for medical training through Medicare reimbursement to hospitals and Veterans Administration support of faculty.

Given these pressures, it is somewhat surprising that medical educators and administrators have not more fully embraced simulation as at least a partial solution. Not only have simulators been shown to enhance performance in the operating room (OR) and improve patient outcome, they reduce the need for mentorship and OR time during technical skill acquisition, thus lowering training costs. It is not that the leadership in the medical professions has been slow to embrace simulation. The Accreditation Council for Graduate Medical Education (ACGME) long ago dictated that surgical training programs must have simulation capability, and the American College of Surgeons (ACS) has certified 76 simulation centers as Accredited Education Institutes (AEIs). It would seem, therefore that the ground is fertile for simulators to gain a viable and important place in the preparation of patient care providers of all levels and in facilitating an objective process of graded autonomy. Despite these efforts, the adoption rate continues to be slow, even with increased demand and burgeoning scope of medical practice, procedures, and technologies. There are two main reasons for this: (1) the business model that supports surgical simulation and (2) the simulators themselves.

The Business Model - Who Pays?

Simulators can be expensive to create, particularly those that incorporate technologies such as virtual reality (VR), augmented reality (AR), or haptics. There has been much debate as to the value of some of these technologies compared to lower-fidelity solutions such as box trainers or other devices that provide the capability for multiple repetitions. However, it is becoming more accepted in the scientific literature that the development of muscle memory improves with the degree of objective measurement and relevance to actual procedures. VR and AR technologies represent the cutting edge of capabilities that are available to supplement patient-based experiential training.

But, who will pay the $1.5 million necessary to develop a prototype simulator and then productize it for a partial task trainer with 6-7 degree-of-freedom (DOF) haptics? And once they are developed, who will purchase them for $100,000–$300,000 apiece? Simulation centers are unlikely to do so, as they are more reliant on donations of such equipment (with at least a 1:3 or 1:2 ratio of donations to discounted purchases).

Who will bear the lifecycle costs of such equipment and provide the necessary updates?

Why would Johnson & Johnson spend $1–2 million developing a simulator for its Ethicon Inc. surgical training centers if that simulator would facilitate the use of equipment purchased from a competing manufacturer such as Covidien?

Until these questions can be answered, development of high-end simulators will suffer. A potential business model may exist when new equipment or techniques require a skill set to be attained before use on patients or for credentialing. In these cases, an equipment developer could co-release the new device along with a training simulator that documents the level of skill achieved. This strategy will also promote product acceleration into the market space, thus increasing access and sales. This approach has been used in simulation-based training for robotics-assisted and minimally invasive surgery, albeit with inappropriate timing and risk to patient safety.

Another innovation will be the soon-to-be available open-source technology platforms on which learning content can be placed. By adopting open-source models, the cost of creating VR and AR simulators can be reduced by 50% or more, thus providing greater opportunities for value-added market penetration in medical education.

Notwithstanding the lack of financial horsepower, the medical community is beginning to respond to the huge demand for technology to augment the process of training. Recent initiatives can be found in the orthopedic surgical community and others that have begun to adopt simulation and make curricular changes that can fully accommodate, respond to, and benefit from available and pending technologies. For the most part, however, even simulation centers that are populated with millions of dollars of equipment, have not adequately integrated the simulators into curriculum development or performance assessment, and thus fail to maximize their capabilities. One of the main problems is that training in such environments is not paid for per se, so there are no economic incentives for medical educators to make optimal use of these technologies. Moreover, faculty are rarely paid or incentivized for teaching in the simulation center - highly skilled medical practitioners are seen as having more value billing for patient care. Ultimately, new business models must be created to respond to the need, the customer, and the consumer.

Simulators, Manufacturers, and the Claims They Make

Approximately 30 companies, often very small ones, make a variety of products that fall within the rubric of medical simulation. These include simple box trainers or physical models with varying degrees of fidelity and with or without anatomic/tissue material properties or relevant pathological/physiological capabilities. Physical models and augmented physical models rarely provide the integrated capability for objective performance assessment or exhibit the anatomic or pathophysiological variations encountered in clinical practice. Further, simulator design and construction are often driven by engineers remote from the end users. Although end users lack instructional design knowledge and may not understand the role of muscle memory/repetition in cognitive processes, skill acquisition, complex decision making, and adult learning, they do provide valuable insights to the design process.

Thus, current simulators as a group fail to be responsive both to trainers and trainees. They provide a costly platform for certain knowledge acquisition (usually for a single, very circumscribed pathology) with some limitation on repetitions and no access to the variability that is encountered during experientially gained clinical knowledge acquisition. Clearly the paradigm must flip to end user and learning sciences as the donor.

Members of the medical training leadership agree that technology will play a vital role in the future of medical training, and that the following are essentially nonexistent:

  • True multidisciplinary involvement in cognitive/procedural task analysis and analysis of training solutions to achieve specific training goals.
  • Surveillance of evidence-based practice prior to the development of training objectives, training systems, and metrics design.
  • Incorporation of the above into a plan of embedded learning strategies and scaffolded guided practice for adult learning.
  • Completion of the steps from pre-prototype iteration to implementation and evaluation before launching into an appropriately modified curriculum and training environment.

Also lacking in current simulators is significantly rigorous validation. The term is used with abandon as a marketing tool without the support of appropriately scrupulous and robust science. One reason for this is that the conduct of transfer-of-training validation exercises is inordinately expensive and does not necessarily provide the scientist or consumer with the level of answer that is appropriate for the training environment and goals. There are other ways of proving value.

These issues must be addressed before simulators will take their rightful place as a critical adjunct to experiential medical training. Carefully designed and validated next-generation simulators will enable exposure to a variety of pathologies, increase the cognitive pathways that the practitioner has experienced prior to patient care, and create healthcare professionals who can expertly perform procedures before they have ever entered an operating room. This not only benefits patients, who will be more comfortable if a surgeon has that déjà vu feeling during surgery rather than a feeling of surprise, but also benefits accrue to society at large in terms of fewer errors, safer surgery, and reduced costs.

In summary, the deficiencies of technology-assisted adjuncts to medical training are manifest and multiple. As the thought leaders in healthcare move to appreciate the importance of value-based healthcare education to attain and sustain safe practice for the population, quality simulation-based solutions will become the norm, and market-sustainable business practices will be developed. How long this takes remains to be seen. But from the patient’s point of view, the sooner the better.

About the Authors

Howard Champion MD, FRCS (Edin), FRCS (Eng), DMCC, FACS, has a 35+ year history as a trauma surgeon, leader in civilian and military surgical education, and driving force behind the development of trauma scoring, centers, and systems. He was instrumental in developing technical trauma surgery training courses, i.e., the Definitive Surgical Trauma Skills (DSTS) propagated by the International Association for Trauma Surgery and Intensive Care (IATSIC) and the Definitive Surgery for Trauma Care Course (a joint offering of the Uniformed Services University of the Health Sciences [USUHS], the Royal Defence Medical College, and the Royal College of Surgeons in London), which he co-convened and taught for 10 years (1997−2007). Dr. Champion was a founding member of the American Trauma Society and the Committee on Tactical Combat Casualty Care, and founder and president of IATSIC, the Eastern Association for the Surgery of Trauma, and the Coalition for American Trauma Care. Throughout his career, he has led the effort to introduce objectivity and standardization to surgical education, both as a clinician and as President and CEO of SimQuest, a pioneer in developing simulation-based training systems for emergency and non-laparoscopic procedures such as hemorrhage control, open surgery, microsurgery, and burr hole drilling.

Jan Cannon-Bowers, PhD, holds MA and PhD degrees in Industrial/Organizational Psychology from USF. She served as Assistant Director of Simulation-Based Surgical Education for the Department of Education at the American College of Surgeons from 2009 -2011. Previously, Dr. Cannon-Bowers served as the US Navy’s Senior Scientist for Training Systems where she was involved in a number of large-scale R&D projects directed toward improving performance in complex environments. In this capacity she earned a reputation as an international leader in the area of simulation and game-based training, team training, training evaluation, human systems integration and applying the science of learning to real-world problems. Since joining academia, Dr. Cannon-Bowers has continued her work in technology-enabled learning and synthetic learning environments by applying principles from the science of learning to the design of instructional systems in education, healthcare, the military, and other high performance environments.


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