High-tech teachers

IT drives next generation of doc training

By Joseph Conn / July 1, 2004

When surgeon, surgical trainer and former football player James "Butch" Rosser, M.D., speaks, sports analogies follow. So do references to flying. And the military. And the space program. And video games. And "Star Trek." And of course, medicine.

And he talks fast, often in short commands, which he repeats like a coach, so he knows the team clearly understands his directions.

"Right now, we're going to have to take a page out of the NASA handbook and practice before we play," says Rosser, who uses video games and a computerized simulator to train surgeons in laparoscopy. "You can't practice on people," he says. "You've got to practice before you play."

Rosser knows surgical training programs; since the time the residency training method was conceived, practicing on patients is how residents have learned. But that paradigm is changing.

In April, Rosser gained a measure of fame when the media picked up on a study he'd done at Beth Israel Medical Center in New York. Based on skill tests taken by 12 attending physicians and 21 residents, Rosser reported young surgeons who spent more time playing video games worked 27% faster and made 37% fewer mistakes in laparoscopy than their counterparts who played video games less frequently. Rosser is adapting the aviation industry training model that uses computerized simulators as teaching tools in surgical instruction.

Rosser is chief of minimally invasive surgery and director of the Advanced Medical Technology Institute at Beth Israel. He also runs the Rosser Top Gun Laparoscopic Skill and Suturing Program, which helps train postresidency physicians to use the laparoscope with assistance from a computer simulator he helped develop.

Rosser's simulator records and scores the movements of surgical trainees based on standards established by Rosser and a team of Beth Israel researchers.

Rosser is in a vanguard of physician leaders who are turning to simulation technology to broaden and sharpen surgical skills, thus improving patient care. The most common applications of surgical simulation are in residency training programs, but the penetration is less than overwhelming.

"Most programs are using something," says LeRoy Heinrichs, M.D., a Stanford University researcher in medical simulation.

Other experts--including Rosser--say the integration of the devices into the core curriculum is low. "I'd say 25% of the programs have one and only 5% know what to do with them," but inevitably it's going to be a staple, he says.

Simulation pioneers say potential applications could be used to grant surgical privileges; test for skill remediation to support quality assurance programs; help teach risk management along with group and distance learning; and eventually award board certification.

Heinrichs, an OB/GYN and endocrinologist, is the co-principal investigator at Stanford's Haptic Audio Visual Network for Education and Training. As its name implies, HAVnet is working on surgical simulators that impart to the instruments an artificial sense of touch during training procedures.

Heinrich's team also is working on a system that creates a virtual emergency room. "We're using students to learn how this works, but an emergency department can come in and learn about team-training," Heinrichs says.

The virtual ER has six patient scenarios now, including a construction worker injured in a fall and a bicyclist hurt in a collision. Four more scenarios are under development, including two pregnancy-related emergencies, he says.

Cardiothoracic surgeon Joseph DeRose, M.D., is director of robotics at St. Luke's-Roosevelt Hospital Center and assistant professor of clinical surgery at Columbia University College of Physicians and Surgeons, both in New York.

The residency training model was first devised in the 19th century. Like DeRose, William Halstead, M.D., was a Columbia graduate. After receiving his medical degree in 1877, Halstead went to Johns Hopkins, where he was credited with developing hospital residency as the model for training surgeons.

In some ways, DeRose says, little has changed since Halstead's day, when residents earned their name by practically living in the hospital where they observed and practiced medicine. "Most of the learning we have for clinical things is practicing under supervision," he says.

In other ways, there have been big changes. The rise of patient safety as a headline issue in the wake of the 1999 Institute of Medicine report is one factor for change.

An additional pressure for change has been the rise of limited-access surgery with the wide use of scopes and the decline in open surgeries.

"When a chest is open, I can direct them," DeRose says. "I'm doing the operation when they are in effect doing the cutting and tying. With a scope (and minimal access), that's difficult. It only makes sense to have this preoperative training before you do surgery on an actual patient."

Another recent change is the reduction in resident work hours that began July 1, 2003, imposed by the Accreditation Council for Graduate Medical Education.

"We felt there should be some uniform way of training people," DeRose says, so he and a colleague are leading a team at Columbia that for the past year has been developing a curriculum for robotic surgery, including reliance on a robotic surgery simulator.

As a basis, DeRose and his colleague, thoracic surgeon Robert Ashton Jr., M.D., have adapted standards for training on the surgical robot.

"You're controlling these arms from wrist motions in a console," DeRose says. "They're exactly the same motion that you use with your hands. The robot mimics the motion of the human wrist" and, unlike a scope, "there are no nonintuitive motions. It makes you much more accurate," he says.

The robot simulator can be set to record mode, which helps check the "flight path of the arms, whether they were safe (motions) or not safe, good or bad," he adds. "This will blossom out to change the way we train surgeons, and maybe how to learn," he predicts.

Though surgical robots are expensive--each costs about $1.2 million--and rare--there are only about 170 in the U.S.--the demand for robotic surgery will rise.

With the robot, a surgeon can install up to two coronary artery bypass grafts, or CABGs, during a session and need only make incisions of 4 to 5 centimeters between the ribs to provide an opening for the robot's 8-millimeter-wide arms and its 12-millimeter camera, says DeRose, who played golf with a patient about a week after a robotic CABG procedure.

For now, surgical simulators are having their widest use at teaching hospitals, according to Kevin Kunkler, M.D., medical director for Immersion Medical, a manufacturer of several surgical simulators with prices ranging from about $30,000 to more than $100,000.

Matthew Blum, M.D., is an assistant professor of surgery and section chief of thoracic surgery at Chicago's Northwestern Memorial Hospital. Northwestern has an Immersion Medical simulator it is working into its training routine.

"Where these fit into the curriculum is being defined," he says.

Blum recently set up a trial, comparing residents who had taken training in bronchoscopy with and without the use of the hospital's $40,000 simulator. The device looks like a short gymnastics balance beam with a human faceplate on one end.

Blum ran a test himself on the efficacy of the device, observing the performance of one group of trainees who used the simulator versus the performance of another group who did not.

"The guys who trained on the simulator were just as fast and competent as someone who had done several bronchoscopies," he says.

For now, Blum says, the usefulness of the device ends at training. Simulators aren't going to being used for certification anytime soon, he says.

"The boards are struggling to make certification more realistic," Blum says. "(Simulators) may well be used in the future, but I don?t see that in the immediate future."

Heinrichs agrees that the machines are "not quite" up to the sophistication level that would be required by the boards. Yet, Heinrichs says he knows from experience that there's a need for a better way to certify physicians' surgical skills.

Heinrichs, a former associate examiner with the American Board of Obstetrics and Gynecology, says, "We had very, very poor methods for examining" the trainees' skills. Heinrichs adds that surgical residency training is only the first of a four-phase evolution for simulation.

"The next step is physicians in the field," he says. He adds: "This is the largest group of potential users. They are wanting to keep up with the times . . . (but can't) do another three-year residency.

"There are a lot of people who after 30 years still don't do laparoscopy. They feed patients to younger colleagues in their office. That's one way to do it. But if you're a radiologist and want to put in stents, well there are simulators now . . . to learn to thread a catheter into a vascular structure."

A third step Heinrichs envisions is remediating the surgical skills of physicians with spotty performance records.

Heinrichs says he knows of no U.S. hospital that has adopted passage of a simulator skills test as a credentialing criteria.

But he cites a colleague in Sydney, Australia, who said a hospital there requires physicians who are away for more than a week to pass a simulator skills test before they are permitted to admit patients.

He predicts, "Once these have been validated again and again, (the specialty boards) will say, 'Yes, we're going to use them for primary certification.'" Heinrichs says he sees the arc of acceptance for simulators as residency training at first, next moving to credentialing, then remediation and finally primary certification.

Harrith Hasson, M.D., an Albuquerque gynecologist and developer of a laparoscopic simulator, the LTS 2000, will be a course director with Richard Satava, M.D., at a session that will cover the role of simulation in residency training on Sept. 29 during the 13th International Congress and Endo Expo in New York, sponsored by the Society of Laparoendoscopic Surgeons.

Satava is a professor and researcher of robotic surgery, surgical simulation and objective assessment of surgical skills in the department of surgery at the University of Washington, Seattle. "This is really the first postgraduate program that deals with the issue of how to implement training of laparoscopic surgery in general surgery, OB/GYN and neurosurgery," Hasson says.

The full-day course targets residency program leaders, attending physicians and residents. "There are probably less than 10% of the big (surgical residency) programs that are actively involved with simulation," Hasson says. In two to five years, simulation will become an integral part of surgical residency training, depending on how fast physician executives embrace the idea, he says. "If they become stakeholders in this, then it will go very fast."