cybertherapy & rehabilitation, issue 4 (4), winter 2011

Issue 4 / 2011

Medical Simulation: Empowering

the Future of Healthcare

andmuchmore...

T h e O f f i c i a l V o i c e o f i A C To R

ISSN 2031 - 278

COVER STORY:

FEATURES:A Virtual Training System for Childrenwith Upper Extremity Disabilitiesp 15

Medical Simulations for a Patient-specific Clinical Practicep 21

ASK THE EXPERT:Barr Taylorp 31

COUNTRY FOCUS:Canadap 40

Visually Realistic - Comfortable - Easy to UseDurable - Reusable - Tactilely Realistic

INJURY CREATION SCIENCEThe Next Generation of Injury Simulation Today

Prosthetic tissue, wounds, and life saving skills training devices used in the training of medical professionals • Cricothyrotomy Skills Trainer • Needle Decompression Skills Trainer • Bleeding Wound Skills Trainer • Amputation Skills Trainer • Burn Wound Skills Trainer • Odor Wound Skills TrainerMerging latest special effects technology with medical and material sciences research to replace live tissue and training.Physiologically based research and development program focused on providing enhanced training capabilities for medical professionals to include: • Basic Life Support • Patient Assessment • Hemorrhage Control • Fracture Management • Shock Prevention & Treatment

Cricothyrotomy Skills Trainer

Needle Decompression Skills Trainer

Bleeding Wound Skills Trainer

Visually Realistic - Comfortable - Easy to Use

Severe Amputation Skills Trainer

Severe Amputation Odor Simulation Wound Kit

Simulated Burn Wound Package

Visually Realistic - Comfortable - Easy to UseVisually Realistic - Comfortable - Easy to Use

FOR MORE INFORMATION, CONTACT:Mark D. Wiederhold, M.D., Ph.D. FACP

The Virtual Reality Medical Center858.642.0267 [email protected]

www.vrphobia.com

1

Letter from the Secretary General and Editor-in-ChiefProfessor Dr. Brenda K. Wiederhold

Dear Reader,

“Virtual worlds, both immersive and Web-based, areat the frontier of innovation in medical education,”wrote an anesthesiologist in 2008. As Richard Sata-va wrote 10 years ago, “The greatest power of Vir-tual Reality (VR) is the ability to try and fail withoutconsequence to animal or patient. It is only throughfailure – and learning the cause of failure – thatthe true pathway to success lies.”

Only recently, however, has the VR cost barrier beenbroken by the establishment of large, collaborativesimulation centers, as these partnerships anticipatethe influx of practitioners demanding VR training forcertification. For exam-ple, the Israel Center forMedical Simulation ispart of the licensing andaccreditation process forvarious health profes-sionals, including para-medics and anesthesiol-ogy residents. TheUniformed Services Uni-versity National CapitalArea Medical SimulationCenter, which provides 346,000 hours of simulationsper year, partners with the National Board of Med-ical Examiners, the American College of Surgeons(ACS), and the American Council of Obstetrics andGynecology. The American Board of Internal Medi-cine adopted medical simulation (med sim) for usein its certification program for interventional cardi-ologists. Med sim reaches as far as Accra Ghana, WestAfrica, where a partnership with ACS created the Med-ical and Surgical Simulation Institute.

A growing number of health professionals – physi-cians, nurses, dentists, EMTs, and others – have em-braced VR med sim because of its ability to:

• Reduce serendipity in education and training –VR can even out the variability in training should aparticular situation not present itself during thesurgical residency.

• Facilitate practice and rehearsal without patientconsequence – The resident can practice on a 3-D,haptically-enhanced simulator that matches the pa-tient’s anatomy as many times as it takes to feelcomfortable with the procedure.

• Reduce medical errors – Interdisciplinary teamscan train to reduce errors caused by team membercommunication gaps or unfamiliarity with newequipment.

• Reduce reliance on animal models – Increasingpressure by PETA and scarcity of cadavers has ac-celerated the adoption of VR simulation.

• Reduce healthcare costs – Med sim offers thepotential to decrease time spent and consequentcosts.

Before the advent of mainstream VR med sim, anes-thesiologists enjoyed 10% premium reductions be-ginning in 2001 based on malpractice claims datacollected after anesthesiologist errors were reducedbased on their work with mannequins. Today, thereis a 20% malpractice insurance rate differential be-

“‘Virtual worlds, both immersive and Web-based, are at the fron-tier of innovation in medical education,’ wrote an anesthesiologistin 2008. Now, a growing number of health professionals – physi-cians, nurses, dentists, EMTs, and others – have embraced VirtualReality medical simulation as a cost-effective method of training.”

“Only recently has the VR cost barrier been broken bythe establishment of large, collaborative simulationcenters, as these partnerships anticipate the influx ofpractitioners demanding VR training for certification... Today, there is a 20% malpractice insurance ratedifferential between anesthesiologists training withsimulators and those not trained with simulators.”

tween anesthesiologists training with simulatorsand those not trained with simulators, and themembers of this latter group are in steady de-cline.

In addition to anesthesiology, the use of VR medsim in endoscopic and laparoscopic surgery isproducing promising results in terms of effec-

tiveness and cost-effectiveness. One study of la-paroscopic surgery found that trainees who stud-ied on their own using a laparoscopic andendoscopic VR simulator achieved proficiencyjust as well as trainees who were proctored. Theindependent-study approach was less time con-suming for trainees, and certainly minimized in-structor time.

There are significant benefits to simulation train-ing, as one study focusing on endovascular pro-cedures found. After nine residents trained forthree days on the simulation, performance im-proved significantly from early on day one inthree categories:

• Total procedure time decreased 54%

• Volume of contrast decreased 44%

• Fluoroscopy time decreased 48%

Endovascular simulation training is up to 16 timesless expensive than similar training with animals,

as found by researchers in an-other study. The economicanalysis compared the rentalof an animal laboratory to thepurchase or rental of the sim-ulator Procedicus VIST (Men-tice). According to the re-searchers, consumption ofstents for each procedure isthe largest cost in the animallab, as the stents cannot be re-

trieved from the animal.

Most recently, a meta-analysis of more than 600studies involving technology-enhanced simula-tion training showed consistently large effect sizesfor knowledge, skill, and behavior outcomes, andmoderate effects for patient-related outcomes.The authors of this JAMA study are currently re-searching how to use simulation-based teachingmost cost-effectively, and we look forward to re-viewing the results of that research.

Letter from the Secretary General (continued from page 1)

As Richard Satava wrote 10 years ago,“The greatest power of VR is the ability totry and fail without consequence to ani-mal or patient. It is only through failure –and learning the cause of failure – thatthe true pathway to success lies.”

Create your own reality!Brenda Wiederhold

2

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Professor Brenda K. Wiederhold,Ph.D., MBA, BCIAEditor-in-ChiefC&R MagazineBelgium

Emily ButcherManaging EditorInteractive Media InstituteUSA

Professor Rosa M. Baños, Ph.D.University of Valencia Spain

Professor Cristina Botella, Ph.D.Universitat Jaume ISpain

Professor Stéphane Bouchard, Ph.D. Universite du Quebec en Outaouais (UQO)Canada

A.L. Brooks, Ph.D.Aalborg UniversityDenmark

Professor Paul M.G. Emmelkamp, Ph.D. University of AmsterdamThe Netherlands

Professor Luciano Gamberini, Ph.D.University of PadovaItaly

Professor Sun I. Kim, Ph.D.Hanyang UniversityKorea

Professor Dragica Kozaric-Kovacic, M.D., Ph.D.University Hospital DubravaCroatia

Professor Paul Pauli, Ph.D.University of WürzburgGermany

Professor Simon Richir, Ph.D.Arts et Metiers ParisTechFrance

Professor Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico ItalianoItaly

Professor Paul F.M.J. Verschure, Ph.D.Universitat Pompeu FabraSpain

Professor Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterUSA

Professor XiaoXiang Zheng, Ph.D.Zhejiang UniversityP.R. China

C&R Editorial BoardGENERAL INFORMATION

CyberTherapy & Rehabilitation Magazine

ISSN: 2031-278

GTIN-13 (EAN): 9771784993017

CyberTherapy & Rehabilitation Magazine is published quar-

terly by the Virtual Reality Medical Institute (VRMI), 30 Clos

Chapelle aux Champs, Bte. 3030, 1200 Brussels, Belgium and

the Interactive Media Institute, 9565 Waples Street, Suite 200,

San Diego, CA 92121, U.S.A. The magazine explores the uses

of advanced technologies for therapy, training, education,

prevention, and rehabilitation. Areas of interest include,

but are not limited to, psychiatry, psychology, physical

medicine and rehabilitation, neurology, occupational ther-

apy, physical therapy, cognitive rehabilitation, neuroreha-

bilitation, oncology, obesity, eating disorders, and autism,

among many others.

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COPYRIGHTCopyright © 2011 by Virtual Reality Medical Institute. All rights

reserved. CyberTherapy & Rehabilitation Magazine is owned

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CyberTherapy & Rehabilitation Magazine is currently indexed with PsycEXTRA.

LETTER FROM THE EDITOR-IN-CHIEFB.K. Wiederhold p 1

COVER STORYMedical Simulation: Empowering the Future ofHealthcareB.K. Wiederhold, M.D. Wiederhold p 10

FEATURESMethods and Tools for Surgical Assessment in the Simulation WorldC. Loukas p 14

A Virtual Training System for Children with Upper Extremity DisabilityK.S. Choi p 15

Simulation-Based Training: Beyond the Bells and Whistles!E. Salas, M.E. Gregory p 18

A Medical Virtual Reality Simulator inLaparoscopic Rectum SurgeryJ.J. Pan, J. Chang, X. Yang, J.J. Zhang, T. Qureshi, R. Howell,T. Hickish p 19

Medical Simulations for a Patient-specific Clinical PracticeC. Capelli p 21

Higher Order Performance Assessments Using Error Enabled Simulations: A New ApproachC.M. Pugh, J. Cannon-Bowers p 22

Mixed Virtual Learning Environments for the Simulation of Head and Neck InjuriesO. Courteille, H. von Holst, L. Felländer-Tsai p 24

PRODUCT COMPARISON CHARTMedical Simulation p 26

A Whole New World of Medical EducationN. Kissane, C. Pozner p 28

ASK THE EXPERTB. Taylor p 31

FROM WHERE WE SITG. Riva p 35

FURTHER AFIELDL. Kong p 35

COUNTRY FOCUSCanadaR. Farid, K. Begum p 40

TABLE OF CONTENTS

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Surgical Simulation UsingLaparoscopic Simulators

A Virtual Reality laparoscopic simulator, likethe one pictured above, can aid in surgical train-ing by using sensors attached to the handles,which transmit kinematic data to a portablecomputer for processing and visualization.These types of trainers can drastically cut downon training costs, while ensuring patient safe-ty and a large margin of error reduction.

Virtual Training Systems for Rehabilitation

Rehabilitation, an often costly, lengthy andtedious process, is being improved usingcomputerized training systems, such as thesystem pictured above, which encouragesself-practice and independent engagementfrom users suffering from cerebral palsy orother disorders resulting in upper extremitydisability. The software works with a pen-likehaptic device to provide real-time feedbackand easy visualization of movement on acomputer screen.

8

International Association of CyberPsychology, Training & Rehabilitation (iACToR)

Conference Participation Report Fall/Winter 2011

European Health Forum GasteinBad Hofgastein, Austria / October 5-8, 2011

The 14th annual European Health Forum Gastein (EHFG) was heldOctober 5-8, 2011, in Bad Hofgastein, Austria, with this year’s themeof “Innovation and Wellbeing – European Health in 2020 and be-yond.” EU Health Commissioner John Dalli, EC Director GeneralsPaola Testori Coggi and Robert Madelin, and Zsuzsanna Jakab, Re-gional Director of World Health Organization Europe, were amongsome 600 experts who attended the conference.

The basis for Gastein's typically practical and open debate was Eu-rope's aging, and ailing, population – described by one speakeras a “demographic time-bomb” – which is straining all Europeanhealth budgets. Six parallel forum discussions took place on HealthTechnology Assessment, Towards Health in 2020, Non-communi-cable Diseases, European Innovation Partnership on Active and

Healthy Ageing, and Harnessing Europe’s Social Innovation Poten-tial in Health. There was a particular emphasis on a topic dear tothe heart of the Forum's Founder-President, Prof. Dr. Günther Lein-er, who denounced a high level of unnecessary diagnostic and sur-gical procedures.

The forum also focused on dealing with the epidemic of non-communicable diseases. These types of diseases have become agrowing problem even outside the wealthy West, the EHFG not-ed, and call for due attention. Commissioner Dalli backed a pleafor more preventive medicine, with doctors actively discourag-ing smoking. Several experts called for a complete EU-wide to-bacco ban. There was also lively debate about the effect of mis-information on the Internet on what experts called a growing"confidence gap" in vaccinations.

For more information on the conference, visit www.ehfg.org.

Games for Health EuropeAmsterdam, Netherlands / October 24-25, 2011

The first annual Games for Health Europe conference,which took place in Amsterdam on October 24-25, wasa great success. The conference brought together med-ical professionals, academics and industry leaders andfeatured 468 attendees, 72 speakers, 24 partner com-panies and 22 ground exhibitors. Nine keynote speak-ers from various fields presented their visions of the fu-ture for serious games for healthcare.

Presenters included diverse specialists such as BenSawyer, the founder of Games for Health in the U.S.,Adam Gazzaley, a cognitive neuroscientist who pre-sented some remarkable discoveries on the link be-tween games and cognition, Jan-Willem Huisman,CEO of IJsfontein (a successful Dutch serious gamescompany) and Bertalan Mesco, founder of Sciencerollblog, and successful practitioner of both medicineand new media. �

The main theme of the conference was “How Games &Simulations Can Improve Health(care) and Make it Af-fordable” and topics discussed included rehabilitationgames, exergaming, active gaming and fitness, and med-ical education, training, modeling and simulation.

The next Games for Health Europe will take place No-vember 5-6, 2012 in Amsterdam.

For more information, visit www.gamesforhealtheurope.org.

The 2nd Annual World Health CareCongress Middle EastAbu Dhabi, United Arab Emirates / December 11-13, 2011

The 2nd Annual World Health Care Congress Middle East (WHCCME), co-sponsored by the Health Authority-Abu Dhabi (HAAD)and the Abu Dhabi Tourism Authority (ADTA), was a global eventin which over 600 healthcare, government and corporate lead-ers from over 25 countries came together to define objectivesand frame solutions to the challenges of healthcare reform,cost, quality and delivery.

The 2011 WHCC ME Congress featured the top innovative lead-ers and industry influencers including health ministers, lead-ing government officials, hospital directors, health system andhospital providers, patient safety directors, disease managementprofessionals and health and wellness experts, chief financialleaders, IT and mHealth innovators, decision makers from pub-lic and private insurance funds, investment and venture capi-tal principals, pharmaceutical and biotech executives, and health-care industry suppliers.

The WHCC ME agenda featured debates, case studies and bestpractices from all industry sectors to identify innovative strate-gies to improve the overall delivery of healthcare. This unpar-alleled networking event puts together senior executives tomeet and strategize on the crucial steps necessary to adapttheir health systems to operate more efficiently to decreasethe cost of care, enhance the delivery of service and improvethe patient experience.

For more information, visit www.worldcongress.com/me.

In the last few decades, medical simulation technologies have providedgroundbreaking innovations that have revolutionized surgery, and improvedteaching and training by creating realistic environments that are not onlyreusable, but can be personalized to test individual trainees’ skills withoutputting patients’ lives at risk. Simulation technology is rapidly gaining sup-port from organizations around the world for its ability to reduce errors andimprove patient safety, and its popularity is only picking up speed.

10

Medical Simulation: Empowering the Future of Healthcare

By Brenda K. Wiederhold & Mark D. Wiederhold

The advent of medical simulation tech-nologies stemmed from a diverse arrayof fields, merging together to form anew way to not only practice medicinebut teach, train and improve the livesof both patients and doctors. What onceseemed like a far off fantasy has quick-ly emerged as a promising method ofimproving healthcare and is more a re-ality now than ever before, having beenswiftly integrated into medicine andplaying a much larger role in medicalpractice than predicted.

Early Mannequin Simulators

The creation of mannequins for med-ical purposes began in the early 1960swhen a Norwegian plastic toy manu-facturer, Asmund Laerdal, developedthe Resusci Anne mannequin for CPRtraining. Life-size models of the bodyproved useful for practicing basic pro-cedures like physical exams and mouth-to-mouth, allowing students to train ona realistic figure before an actual hu-man. Not long after medical man-nequins were developed, engineers andphysicians began improving on theinanimate patients with computer tech-nology. The first high-fidelity comput-

er-controlled human patient simulator,the SimOne, developed by Laerdal, wasa lifelike model of a human patientused for anesthesia training that meas-ured physiological and pharmacologi-cal changes in real time. Although Si-mOne was not widely used, its creationmarked a turning point in computer-controlled mannequin simulation, andtechnologies thereafter replicated theessence of the SimOne.

Development of Surgical Simulators and VR

Simulators utilizing Virtual Reality (VR)emerged in the 1980s when the Nation-al Aeronautics and Space Administra-tion (NASA) at the Ames Research Cen-ter in Palo Alto, California developedthe first head mounted display (HMD)for displaying the data collected duringplanetary explorations. At the sametime, the DataGlove was developed,making interaction with 3-D virtualscenes possible. The possibility of be-ing immersed in a virtual environmentwhile also being able to interact withthe scene was what inspired the idea ofimmersive technologies for surgery, andthus the birth of surgical simulators.

Laparoscopic, or “keyhole” surgery, isa type of minimally invasive surgery(MIS). This type of procedure was intro-duced into general surgery in the late‘80s and employs the use of a camera,a fiber-optic light and joystick-like in-struments that perform the operationthrough tiny incisions. This new tech-nique saw the addition of a new mem-ber to the surgical team, the robot, con-trolled by surgeons through videogame-like controllers while looking ata computerized depiction of the actionsoccurring inside the body. The first ro-bot-assisted surgical device used on hu-mans, the RoboDoc, was developed inthe early 1990s for orthopedic surgery.Computer-controlled robotic arms per-form actions with a high degree of ac-curacy and precision, reducing pain, er-rors, and unnecessary damage leadingto shorter hospital stays and accelerat-ed recovery. More complex surgicalrobotic systems soon surfaced thatpossessed multiple applicationsthroughout general surgery. The daVinci system, developed by IntuitiveSurgical and considered one of the topsurgical robotic devices, ranges exten-sively in its abilities, and is able to per-form MISs in various fields such as urol-

COVER STORY

T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n

ogy, gynecology, colorectal and cardio-thoracic medicine, as well as procedureson almost every part of the body.

While this novel approach proved to beextremely beneficial to patients due toits minimal invasiveness, the proceduresput enormous pressure on surgeons dueto the loss of visualization it required, aswell as a degraded sense of touch andimpaired dexterity the instrumentscaused. High quality visualizations wereneeded to accurately perform the sur-gery as well as realistic haptic feedback,not to mention practice using the newvideo game-like controllers. Being ableto feel present in the surgery throughhigh quality, virtual depictions in realtime was important for surgeons per-forming laparoscopic surgery. ImprovingVR technologies allowed this sort ofseamless immersion into surgery, andwithout such technology, laparoscopicsurgery would not have thrived.

Studies have also been conducted assess-ing the benefits of practicing in VR forimproving performance in surgery. Dray-

cott et al. showed that training on a sim-ulator reduced neonatal injury by 7%.Dr. James “Butch” Rosser from the BethIsrael Medical Center has even developeda video game, Top Gun, for warming upand improving surgical trainees’ agilityand accuracy before going into surgery.Hand-eye coordination has become in-creasingly important with the introduc-tion of laparoscopic surgery, and its sim-ilarities to playing a video game, ajoystick controller manipulating figureson-screen, has earned gaming a respect-ful place in today’s world of surgicaltraining.

Training and Practice

Just like air flight simulators prove use-ful for training pilots, VR and mannequinsimulators too have been shown to beextremely beneficial for training medicalpersonnel. Combining mannequins andVR simulations for training allows for anextensive range of applications and dif-ferent methods of training. While humanactors, mannequins and videos have allbeen used in the past as teaching tools,full environment simulations (FESs) haverecently grown in utility and popularity,along with simple screen-based comput-er simulations and partial task trainersfor specific procedures. FESs include high-fidelity mannequin simulators that repli-cate medical conditions in an accurateand detailed way, placed within a realis-tic environment that creates contextualfactors that might be present in real sit-uations, for example, a difficult patient,family members, and distractions, to gainexperience responding to unusual or cri-sis situations more accurately. Thesetypes of simulations enhance the realityof training while also assessing perform-

ance more extensively and encompass-ing more competency skills than a merechecklist of tasks; not only is the med-ical procedure being measured, but pro-fessionalism, communication skills, andteamwork as well. This type of training iswidely used among anesthesiology stu-dents, laparoscopic training, cartaroidstenting training, and dentistry proce-dures, and is used by nursing studentsand emergency medical technicians(EMTs).

Training using simulation technologieshas been shown to improve accuracy and

overall performance, thus explaining itswidespread adoption. A 1999 survey con-ducted by Morgan and Cleave-Hoggshowed that 71% of anesthesia and med-ical students were taught using somekind of mannequin or simulator, and asurvey by Okuda et al. showed that 91%of emergency medicine residencies usesimulation during training, 85% of whichare mannequin-based.

High-fidelity simulators are also optimaltools for assessing the performance ofphysicians and surgeons throughout theircareer, and are useful for practicing newtechniques or procedures before perform-ing on real patients. In addition, with im-proving VR and modeling technology,physicians are hoping that in the near fu-ture they will be able to download a pa-tient’s specific data and test solutionsand different procedures on the virtualpatient before the real person to ensurethe best practice will be used.

MMVR and TATRC

While many organizations are promotingmedical simulation research and devel-opment, Medicine Meets Virtual Reality(MMVR) and the Telemedicine and Ad-vanced Technology Research Center(TATRC) have played large roles in improv-ing medical simulation technologies andoptimizing their applications in both themedical and military arenas. While bothMMVR and TATRC separately support ad-vancements in telemedicine, they haverecently teamed up, holding dual eventsfocused on improving clinical competen-cy using medical simulation for trainingand practice, with an emphasis on main-taining the skills of anesthesiologists, sur-geons, and other medical personnel. Theevents bring together leading researchersand doctors alike to assess current prac-tices, areas in which programs are lack-ing, and to produce fresh ideas on howto improve and expand on these prac-tices. These events and conferences en-courage the creative development of newtechnologies to discover best practicesand new uses, and it is because of organ-izations like these that medical simula-tion has been integrated on multiple plat-forms, such as crisis managementtraining, improving clinical competency

11

COVER STORY


With companies readily incorporating simulation intotheir medical practices the laparoscopic device markethas already become a multibillion dollar endeavor andaccording to iData Research, anticipated advancementsproject that by 2018 sales will reach approximately $7.5billion, with major corporations like Ethicon andAllergan vying for control.”

“

12

and patient safety, and medical trau-ma training for military troops per-forming in battle.

Adoption and Incorporation – Certification to Financial Benefits:

The themes of improving patient safe-ty and clinical competency through

the use of simulation technologieshave increasingly become a priority formany prominent medical organiza-tions as well. The American SurgicalAssociation’s Blue Ribbon Panel rec-ommends that medical simulators beadopted into surgery as a tool for ed-ucation, teaching and verifying com-petence, and The American Board ofInternal Medicine has shown their sup-port for incorporating medical simu-lation into board exams by givinggrants to companies developing sim-ulators. The promising results of med-ical simulation technologies have eveninspired a bipartisan effort to furtherresearch, with Rep. Randy Forbes (R-VA) and Patrick Kennedy acting as in-strumental leaders in the movement.HR 4321, the Enhancing SIMULATION(Safety in Medicine Utilizing LeadingAdvanced Simulation Technologies toImprove Outcomes Now) Act of 2007,is a bill supporting medical simulationresearch and training to reduce health-care costs, improve safety and createmore simulation centers.

Many organizations have alreadyadopted medical simulation tech-niques into formal assessments of per-formance, certification programs, andboard exams. The first organization tointegrate computer-based case simu-lation into testing was The United

States Medical Licensing Examination(USMLE). The American Board of Fam-ily Practice has also incorporated com-puter-based case simulations for eachindividual examinee into their familypractice board certification exam. In-ternational organizations have also ex-panded their exams to include med-ical simulation. The Royal College of

Physicians and Surgeons of Canadause video simulations during their in-ternal medicine exam, and The IsraeliBoard of Anesthesiologists Examina-tion Committee has adopted one ofthe most extensive simulation-basedportions of their board exam, devel-oping five standardized scenarios toassess competency in a range of prac-tices from administration of anesthe-sia to trauma and operating roommanagement. Continuing medical ed-ucation (CME) programs have alsofound simulation techniques to besufficient for ensuring physicians’ skillsremain fresh; simulator-based educa-tion is required by The AmericanBoard of Anesthesiology to fulfill themaintenance of certification require-ments, and many other CME creditsare now fulfilled using simulation pro-grams.

Studies have been conducted showingthat practicing and training with sim-ulator technologies lowers the num-ber of errors performed during proce-dures, thus reducing malpractice.According to a press release by RandyForbes in 2007, the cost of medical er-rors in the U.S. can be as much as $79billion dollars a year. However, hospi-tals funded by a trial program utilizingsimulations and established by theU.S. DOD saw the rate of clinical er-

rors decrease from 30.9% to 4.4%. In2001, The Consolidated Risk InsuranceCompany (CRICO), a malpractice car-rier for the Harvard community, start-ed offering insurance premium incen-tives to anesthesiologists who weretrained in crisis resource managementat the Center for Medical Simulation,as well as grants to cover costs. Re-duced malpractice due to incentiveprograms like CRICO’s has led to oth-er similar arrangements for other spe-cialties, such as obstetrics and gyne-cology.

Resistance May Be Futile

Some physicians resist these newforms of teaching and training, sayingthat a virtual reenactment can neverreplace hands-on practice, and whileit is undeniable that real-life experi-ence will yield the best results, whatsimulation technologies offer is achance to make early learning moreeffective and provide new ways of ex-ploring techniques. In addition, withcompanies readily incorporating sim-ulation into their medical practices thelaparoscopic device market has alreadybecome a multibillion dollar endeav-or and according to iData Research,anticipated advancements project thatby 2018 sales will reach approximate-ly $7.5 billion, with major corporationslike Ethicon and Allergan vying for con-trol. Clinical, as well as financial ben-efits, make a slow in growth unlikely,and for the time being medical simu-lation is here to stay.

COVER STORY

[ ]Brenda K. Wiederhold, Ph.D.,MBA, BCIAVirtual Reality Medical InstituteBrussels, [email protected]

Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterSan Diego, [email protected]

www.vrphobia.eu

“Continuing medical education (CME) programshave also found simulation techniques to be suffi-cient for ensuring physicians’ skills remain fresh; sim-ulator-based education is required by The AmericanBoard of Anesthesiology to fulfill the maintenance ofcertification requirements, and many other CMEcredits are now fulfilled using simulation programs.”

9565 Waples Street, Suite 200

San Diego, CA 92121

Phone: (858) 642-0267

E-mail: [email protected]

Simulation-based education is a train-ing and feedback method in whichlearners practice a task repeatedly ona simulated model until reaching a pre-defined competency level. Training isperformed in a lifelike environmentwith feedback obtained either from ex-ternal observers (experts), or the sim-ulation system itself based on validat-ed assessment metrics. In minimallyinvasive surgery, the instruments andtraining models with which the user in-teracts may be real (physical reality sim-ulation) or virtual (Virtual Reality sim-ulation). As opposed to the traditionalmodel, in simulation training “permis-sion to fail” can be built into the learn-ing process without jeopardizing pa-tient safety. Other major advantagesinclude risk-free practice on complexand rare case scenarios, constructivefeedback, individualized training, andobjective assessment.

Despite the significant assets of reali-ty simulation, a major issue is the as-sessment process where the tradition-al model requires careful review of therecorded video. This clearly leads to alengthy process that is also prone to er-rors due to fatigue of the reviewer, pro-vided that most tasks require severaltrials to master. Recently, there has

been an influx ofc om p u t a t i o n a ltools enabling auto-mated performanceanalysis and assess-ment. Hand motionanalysis systemsconstitute the ma-jority of these tools,whereby specializedsensors are at-tached either onthe surgeon's handor instrument han-dle (see Fig. 1). Awell-established as-sessment metric isthe hand motiontrajectory. This is usually obtained bymeans of a motion analysis system

equipped with electromechanical or in-frared sensors. The signal emitted (or

reflected) by the sensors is acquired bya receiver placed at a fixed position

nearby the system, thus providing kine-matic measurements of the instru-

14

Methods and Tools forSurgical Assessment in theSimulation World“As opposed to the traditional model, in simulation training ‘per-mission to fail’ can be built into the learning process without jeop-ardizing patient safety. Other major advantages include risk-freepractice on complex and rare case scenarios, constructive feed-back, individualized training, and objective assessment.”

FEATURES

Figure 1: Surgical training with a laparoscopy VR simulator. Sen-sors attached to the instrument handles transmit kinematic datato a portable computer for additional processing and visualization.


By Constantinos Loukas

Visual tracking of objects of interest in the surgical sim-ulation space provides a great range of opportunities forthe development of hybrid training methods such asAugmented Reality Simulation, whereby physical andvirtual objects are mixed, allowing users to interact withvirtual models using real surgical instruments.”

“

ments in real-time. More advanced sys-tems utilize multisensory informationincluding force and torque signals, orspecialized sensor-gloves that capturehand gestures during the performanceof a laparoscopic task. The signal dataobtained are modeled with advancedcomputational techniques, such as Hid-den Markov and Multivariate Autore-gressive Models, in order to generatean assessment index based on the datacollected. These methods allow associ-ation with quantifiable parameters thatcorrelate with surgical experience.

An alternative, yet more challenging,methodology for obtaining kinemat-ic information is based purely on thevisual information obtained from the

endoscopic camera, implying a sen-sorless training environment that pro-vides greater flexibility to the trainee.In the literature there are a smallnumber of systems that attempt todetect and track the laparoscopic in-struments. The instruments are firstdetected using, for example, edge orcolor information, sometimes withthe aid of a color marker, and thentracked in subsequent frames. Visualtracking of objects of interest in thesurgical simulation space provides agreat range of opportunities for thedevelopment of hybrid training meth-ods such as Augmented Reality Sim-ulation, whereby physical and virtu-al objects are mixed, allowing usersto interact with virtual models using

real surgical instruments. Recent re-search has revealed the potential ad-vantages behind this method such asrealistic haptic feedback, objectiveassessment of performance, highquality visualizations and great flex-ibility in the development of trainingscenarios.

15

[ ]Constantinos LoukasMedical Physics Lab-SimulationCenter, Medical SchoolUniversity of AthensGreece

[email protected]

FEATURES


A Virtual Training System for Childrenwith Upper Extremity Disability:

Practicing writing skills for children with cerebral palsy can be tediousand boring. However, “by taking advantage of Virtual Reality technolo-gy, the rehabilitation process can be performed in a more interactiveand efficient manner.” Here, a novel treatment method is discussed.

By Kup-Sze Choi

Hand dexterity is essential for many activ-ities of daily living (ADL), e.g., buttoningor tying shoelaces. Among them, writingand drawing are of particular importanceto children who may spend up to 60% oftheir school time on handwriting. Properhandwriting requires well-coordinated finemotor movements of the fingers. For chil-dren suffering from motor impairment,resulting from cerebral palsy, for example,it is difficult to control the small muscles

of various fingers in order to appropriate-ly adjust the pencil’s position in their hand.Rubber pencil grips, pen tablets and oth-er assistive gadgets have been used to helpthese children regain their handwritingability. However, these devices do not pro-vide active feedback in the trainingprocess, and a tutor is required to assessthe children’s performance, to demon-strate ways of writing, or to provide guid-ance by holding and maneuvering their

hands. By taking advantage of Virtual Re-ality (VR) technology, the rehabilitationprocess can be performed in a more in-teractive and efficient manner.

VR-based Training System

A VR-based system has been developed tofacilitate hand rehabilitation through com-puterized training. The objectives are toenable self-practice by providing interac-

Providing Real-time Interactive Feedback for Hand Rehabilitation

tive visual and haptic cues as guidance, andby monitoring user performance automat-ically with quantifiable performance met-rics. The hardware consists of a generic per-sonal computer and the Phantom Omnihaptic device made by SensAble Technolo-gies, Inc. The software of the system is builtusing C/C++, OpenGL and OpenHaptics.The haptic device has a pen-like stylus,which can be grasped and maneuvered ina 3-D space. Using a piece of virtual paperlaid horizontally, users practice handwrit-ing with the stylus as if they were writingwith a real pencil (see Figure 1). When thetip of the virtual pencil-tip contacts the pa-per, the strokes are displayed simultaneous-ly on the screen, while feedback forces, i.e.,contact forces and haptic cues, are gener-ated to drive the haptic device.

Visual and Haptic Cues

Training begins by showing the image ofthe complete character or pattern in thebackground. The user is required to draw,stroke by stroke, by following the visualcues provided. The visual cues are displayedin the form of guidelines superimposedon top of the background image, as shownby the yellow lines in Figure 2. Users areguided to draw the strokes one by one se-quentially.

The users are also guided by interactiveforces when drawing along the guidelines.If the virtual pencil-tip deviates, leaving the

writing surface or moving laterally awayfrom a guideline, forces are generated topull it back to the guideline. The forces arecomputed in real time in response to theuser’s movements. In the system, two kindsof forces are provided to: (i) move the pen-cil-tip from the starting point of a guide-line towards its end, or (ii) to pull the pen-cil-tip back to the guideline if it is beingmoved away.

Quantitative Performance Assessment

User performance can be analyzed in de-tail using the quantitative metrics provid-ed by the system. Timing data includingthe time taken to complete a drawing(completion time), the time taken to drawindividual strokes (stroke-drawing time),and the time elapsed during transitionsbetween consecutive strokes (transitiontime) are automatically recorded. Further-more, undesirable maneuvers, such as in-air stroke drawing and on-paper transitions,are measured. Path length, deviation fromthe ideal path, forces applied by the user,and the trajectory of the virtual pencil tip(shown in Figure 3) can also be recordedby the system.

Evaluation and Future Work

The system has been implemented in a pi-lot study for children with cerebral palsy topractice writing Chinese characters, as

shown in Figure 1. In a two-week studywhere practice was conducted two times aweek during 20-minute sessions, the sub-jects showed improvements in handwrit-ing speed and accuracy (average comple-tion time and path length reduced by 50%and 30% respectively), especially for thosediagnosed with a mild degree of deficien-cy. The legibility of real handwriting on pa-per was also improved, as evaluated bylanguage teachers. Featuring interactivefeedback and quantitative assessment, thesystem has the potential to facilitate self-practice with minimal supervision from ther-apists. In the next version, tablet devices willbe adopted to offer a natural user interfacewhere the drawings are displayed directlyunder the stylus end-point. Clinical trialswith a larger sample size and longer studyperiod will be conducted to further evalu-ate the effectiveness of the system.

The author would like to acknowledge thesupport of the Hong Kong Red CrossPrincess Alexandra School and its OT teamin the project.

16

[ ]Kup-Sze Choi, Ph.D.School of NursingThe Hong Kong Polytechnic University Hong Kong

[email protected]

Figure 1 (left): System set-up: the child is hold-ing the haptic stylus to practice handwriting.

Figure 2 (above): Yellow guidelines are overlaidinteractively to show the steps in drawing an as-terisk. The red and green dots indicate the virtualpencil-tip and the starting point of a stroke.

Figure 3 (above): Trajectories of the virtual pen-cil overlaid on the images of the characters.

FEATURES Virtual Training for Upper Extremity Disabilities

Editor-in-Chief Brenda K. Wiederhold, PhD, MBA, BCIA

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The use of simulation-based training (SBT)is becoming more and more prolific inhealthcare. Simulations can include any-thing from role-playing standardized pa-tients (SPs) to high-fidelity, full-function-ing advanced mannequins. Simulationshave unique benefits as they accelerateexpertise by allowing trainees to practiceinfrequent or dangerous procedures in asafe and controlled setting. But whatmakes simulation work? What featuresfacilitate learning? What do we know fromthe science of learning? How do we go“beyond the bells and whistles”?

We know that simulation itself does notcause learning. Rather, it is the instruc-tional features embedded into it thatproduce learning outcomes. In order tobe effective, an SBT system needs to fol-low the science of learning. There areseven key components (see Figure 1) thatmaximize the effectiveness of an SBTsystem.

First, an effective simulation system in-volves defining the task requirementsand the learning objectives of the train-ing. Previous performance history (if avail-able) and skills currently possessed by

trainees are determined in order to shapethe training. The next step involves de-ciding what tasks and competencies –the knowledge, skills, and attitudes (KSAs)needed to perform the task – the SBT

system will address. This helps determinethe learning objectives for training.

The scenarios are then designed usingthe competency information and learn-

18

Simulation-Based Training:Beyond the Bells andWhistles!“Simulations have unique benefits as they accelerate expertise byallowing trainees to practice infrequent or dangerous procedures in asafe and controlled setting ... We know that simulation itself does notcause learning. Rather, it is the instructional features embedded intoit that produce learning outcomes. In order to be effective, a simula-tion-based training system needs to follow the science of learning.”

FEATURES


By Eduardo Salas & Megan E. Gregory

Figure 1: Seven interrelated and critical stages make simulation-based training work.Adapted from Oser R.L., et al.: Enhancing human performance in technology-rich envi-ronments: Guidelines for scenario-based training. In: Salas E. (ed.): Human/Technolo-gy Interaction in Complex Systems, vol. 9. Greenwich, CT: JAI Press, 1999, pp. 175–202.

ing objectives as guides. Effective sce-narios contain “trigger” events that leadto an opportunity for trainees to performthe desired competencies and tasks. Forexample, in order to train an intern onthe recognition of hypertension, an ab-normal vital sign showing high bloodpressure (the “trigger”) could be embed-ded into the scenario. Alternatively, theSP could complain of headache, dizzi-ness, blurry vision and nausea. Effectivescenarios are always realistic.

The next component is to determinehow to measure the events. Withoutmeasurement, there is no learning. Meas-ures and metrics are needed to evaluateboth outcomes (e.g., successful comple-tion of an intubation) and processes(e.g., choosing the correct procedure toperform on the patient), at the individ-ual and team levels. Considerations aregiven to both task (e.g., applying sutures)and team (e.g., mutual support) out-comes and processes. Observational pro-

tocols are developed. In an effective sim-ulation, measures are always developedwith training objectives in mind.

The next step of an effective SBT systeminvolves actually measuring the simula-tion, observing and diagnosing perform-ance. The measures created earlier areput to use. The information collected inthis step allows for determining the im-pact of the training. Additionally, this stepserves to govern what feedback will begiven to trainees. Lastly, diagnostic feed-back is given, and given in a timely man-ner. In an effective SBT system, traineesare debriefed after each simulation.

Simulation can be beneficial in many ar-eas of healthcare. One example of whereits use should be considered is to supple-ment medical team training. For instance,an operating room team may undergo asimulated operation scenario in order topractice team skills and processes that arevital to performing a successful surgery,

such as coordination, back-up behavior,and strategy formulation. While this oneexample is used to illustrate the use ofSBT in healthcare, simulation can beadapted to almost any aspect of health-care training and team training.

SBT creates learning only if the systemis designed, planned, and implementedproperly. By following the componentsmentioned previously, you will help en-sure that the training is impactful, andthat you have gone “beyond the bellsand whistles.”

19

FEATURES


[ ]Eduardo Salas, Ph.D.Megan E. Gregory, B.S.Department of Psychology,Institute for Simulation & TrainingUniversity of Central FloridaOrlando, Florida

[email protected]

A Medical VR Simulator inLaparoscopic Rectum Surgery“Recently, with the rapid growth of computer technology and power, Virtual Realitysimulators have become a viable alternative to traditional surgical training meth-ods, allowing the trainees to hone their skills by operating on a virtual patient.”

By Jun J. Pan et al.

The last two decades have seen some ofthe most exciting developments in med-icine with the advent of minimally inva-sive surgery (MIS) including both laparo-scopic and endoscopic techniques. MISreduces the surgical trauma to the pa-tient, thereby dampening the surgicalstress response. This results in better out-comes with less postoperative pain, a

shorter hospital stay and a quicker returnto normality.

Colorectal cancer is the third most com-mon cancer in the UK, with approximate-ly 40,000 new cases diagnosed annually.Surgery remains the mainstay of treat-ment and is the primary intervention in80% of cases. Although it is estimated

that 90% of cases are suitable for a laparo-scopic approach, there has been a rela-tive lack of surgeons trained to performsuch a demanding surgery. This is partic-ularly true for rectal cancer surgery whichis the most complex and technically chal-lenging for the laparoscopic colorectalsurgeon. The learning curve of a laparo-scopic surgeon can be influenced in a

number of ways. Laparoscopic trainingboxes provide the junior surgeon withtraining on inanimate objects, but offeronly mundane tasks and lack the feel ofhandling human tissue. Animal tissue canbe used but differs in anatomy to hu-mans, and although cadaveric courses areavailable they are expensive and do notallow repetitive practice. In addition, thetradition of training in animal tissue isparticularly criticized and can pose ethi-cal dilemmas. In reality, trainees in manycountries, includingthe UK, developtheir laparoscopicskills by operatingdirectly on patientsunder the supervi-sion of senior sur-geons. Recently,with the rapidgrowth of computertechnology andpower, Virtual Real-ity (VR) simulatorshave become a viable alternative, allow-ing the trainees to hone their skills by op-erating on a virtual patient. Comparedwith traditional surgical training on pa-tients, VR-based methods have the fol-lowing advantages:

• Repetitive tasks: A VR-based system canbe reused many times without risk to pa-tients.

• Variable complexity: Different scenarioscan be simulated including extreme sit-uations, allowing the response to be re-hearsed.

• Surgeon responses can be recorded:Skills and training progress can be objec-tively recorded, measured and evaluated.

Our researchers have developed a VR sim-ulation system for laparoscopic surgery onthe rectum, perhaps the most challeng-ing surgery encountered by the laparo-scopic surgeon. The hardware of our sys-tem includes a computer, a display screenand two haptic devices (Phantom Omni).These devices can be used as graspingtools, as well as dissecting instruments orenergy sources depending on the func-tion selected, and are interchangeable be-tween the two haptic devices (Figure 1).

The haptic deviceprovides 6-DOF navi-gating parameters(pitch, yaw, insertion)and force feedbackwhen there is a colli-

sion detected. The user interface (Figure2) also permits the user to use the hapticdevice as a navigation camera. We creat-ed the surface mesh model of a rectumand its surrounding tissue using data froma Magnetic Resonance Image (MRI) of therectum and by referencing real surgeryvideos, as it is simple and efficient in de-formation computation. Run-time opera-tions include soft tissue deformation, col-lision detection, cutting, rendering andcommunication with the haptic devices.Some novel techniques are applied in thissystem. A haptic force filter based on theradial basis functions can adjust the forceadaptively according to the mesh densi-ty of the contact surface. A Cosserat rodmodel has been introduced to cope withfrequent collision detection and substan-tial soft tissue deformation. It parameter-izes the centerline of the intestine withmaterial coordinates. Rigid spheres areattached to the Cosserat rod, approximat-ing the 3-D shape as bounding volumesof the intestine model. This approachmeets the system requirement of real-time graphic performance and high de-formation accuracy.

Two consultant surgeons, from hospitalsin Bournemouth and Poole, have beenclosely involved in the development of

the system from the outset. They bothprovide regular input, advising our re-searchers about the medical aspects ofthe VR model and help to evaluate theresults. The tactile feedback model hasbeen refined a number of times as a re-sult and has been developed using theirexperience of operating on patients toprovide a realistic feel. Our aim with thishaptic rendering is to provide trainee sur-geons with a VR tool with which they canfamiliarize themselves with the anatomyand steps of a procedure, at the sametime giving them a realistic tactile feel-ing and real-time visual outputs. The ul-timate aim is to shorten the surgeon’slearning curve in an era where the lengthof surgical training is being reduced.

20


[ ]Jun J. Pan, Ph.D.Jian Chang, Ph.D.Xiaosong Yang, Ph.D.Jian J. Zhang, Ph.D. National Centre for ComputerAnimation The Media SchoolBournemouth UniversityTahseen Qureshi, MBBS FRCSPoole HospitalRobert Howell, MBBS DM FRCSTamas Hickish, M.D. The Royal Bournemouth andChristchurch HospitalsUnited Kingdom

[email protected]

Figure 2: Interface of VR simulator in la-paroscopic rectum surgery.

Figure 1: VR simulator in laparoscopic rectum surgery.

FEATURES A Medical VR Simulator in Laparoscopic Rectum Surgery

The safety and performance of medicaldevices prior to their use in clinical prac-tice is currently demonstrated by the useof models. Computer models can con-tribute to creating a virtual environmentfor testing the efficacy of novel designs.Realistic simulations require informa-tion on the anatomy where the devicewill be employed, and on the physiolog-ic conditions which will affect its me-chanical behavior. Recent developmentsof modern 3-D imaging techniques, es-pecially magnetic resonance (MR) andcomputed tomography (CT) imaging,make these aspects describable in so-called patient-specific models.

Patient-specific modeling has been usedto develop new applications in the rap-idly growing field of interventional car-diology, namely supporting the devel-opment of minimally invasiveprocedures for the treatment of valvu-lar pathologies. In 2000, Professor Bon-hoeffer demonstrated the feasibility ofreplacing a heart valve without resort-ing to an open-heart surgical operation:a biological valve, sewn into a stent, wascrimped onto a catheter, inserted intoa vein in the leg and guided to the heart.

The device, Melody® Transcatheter Pul-monary Valve (Medtronic Inc.), offeredchildren and adults suffering from a fail-ing pulmonary valve a revolutionary op-tion for treatment without being forcedto undergo high-risk surgery. Addition-ally, in 2002, a transcatheter procedurewas successfully performed in the aor-

tic position (TAVI) as an alternative fordealing with the most common valvepathology in Europe and the U.S. Sincethen, this approach has seen ground-breaking success with more than 40,000patients treated to date. However, thenumber of patients who could poten-tially avoid surgery is still limited by the

number of devices which are rarely im-plantable in a patient population thatvaries in terms of morphology and dy-namics.

Hence, the pre-implantation assessmenthas become crucial. Next to well-estab-lished imaging techniques, we have de-

veloped patient-specific models in whichwe simulate the device implantationphase. MR and CT images are acquiredand post-processed to create a 3-D mod-el of the patient’s anatomy (Figure 1).One or more models of devices are thenvirtually implanted by finite elementsimulations. The final configurations are

21

FEATURES


Medical Simulations for aPatient-specific Clinical Practice

By Claudio Capelli

“Patient-specific modeling has been used to develop new appli-cations in the rapidly growing field of interventional cardiology,namely supporting the development of minimally invasive pro-cedures for the treatment of valvular pathologies ... the out-comes of these simulations can provide clinicians with furtherevidence on the feasibility of implants, as well as advise engi-neers about the risk of structural issues.”

Computer models can contribute to creating avirtual environment for testing the efficacy ofnovel designs ... Recent developments of modern3-D imaging techniques, especially magnetic reso-nance and computed tomography imaging, makethese aspects describable in so-called patient-spe-cific models.”

“

FEATURES Medical Simulations for a Patient-specific Clinical Practice

explored to assess the success of the pro-cedure in a large population of patients(Figure 2). The best placement strategyand the distribution of stress were as-sessed. Results from the computationalmodel are validated by bench experi-

ments (Figure 3) and clinical results, sup-porting the reliability of the computa-tional findings.

In general, the outcomes of these simu-lations can provide clinicians with fur-

ther evidence on the feasibility of im-plants, as well as advise engineers aboutthe risk of structural issues. At the Uni-versity College London’s Institute of Car-diovascular Science and the Great Or-mond Street Hospital for Children(London, UK), this technique has fostereda better understanding of episodes of de-vice fractures, supported the first implantof a novel device for percutaneous pul-monary issues in a human, and exploredthe potential of minimally invasive alter-natives for patients suffering from a fail-ing bioprosthetic aortic valve.

In the future, our aspiration is a more ex-tensive implementation of medical sim-ulations in clinical practice. A multidisci-plinary approach of this kind can openthe doors to safer and more effective pro-cedures tailored to the characteristics ofevery patient.

In the operating room environment, masteryof surgical skills requires both technical excel-lence and excellence in operative decision mak-ing. Recognizing and correcting errors for bothof these skills is a vital component of surgicaltraining. When the goal of training is achieve-ment of expertise, deliberate practice shouldbe strategically incorporated as part of the learn-

22

Higher Order Performance Assessments UsingError Enabled Simulations: A New Approach

“Surgical procedure simulators that allowfor error prevention, error recognition anderror rescue offer training opportunitiesthat may exceed those possible in the livesetting as error avoidance and patientsafety trump trainee independence.”

By Carla M. Pugh & Janis Cannon-Bowers


[ ]Claudio CapelliInstitute of Cardiovascular ScienceUniversity College LondonUnited Kingdom

[email protected]

Figure 1 (above): Patient-specificmodel: from MR images (left) to 3-D

model (right).

Figure 2 (upper right): Simulations ofimplant of percutaneous valve devices inpulmonary artery of highly different pa-

tients’ morphologies.

Figure 3 (right): Validation process of de-vice implantation into a patient-specific

model: comparison between experimental(left) and computational (right) outcomes.

ing process. Many characteristics once be-lieved to reflect innate talent are now be-lieved to be the result of intense practiceextended over many years. Proper im-plementation of deliberate practice re-quires strategically designed performanceassessments and high quality, structuredfeedback. Performance-based assess-ments have been defined as behavior-re-lated measurements in settings designedto emulate real-life contexts or conditionsin which specific knowledge or skills areactually applied. In essence, performance-based assessments require evaluationduring the performance of tasks that arevalued in their own right. In contrast,pencil-and-paper tests derive their valueprimarily as indicators or correlates ofother valued performances.

Overall, performance-based assessmentsare well positioned to measure complexskills including communication and dis-ciplinary knowledge which are consid-

ered important competencies in med-ical and surgical training. Surgicalprocedure simulators that allow for er-ror prevention, error recognition and er-ror rescue offer training opportunitiesthat may exceed those possible in thelive setting as error avoidance and pa-tient safety trump trainee independ-ence. Figures 1-3 show images of ven-tral hernia repairs completed by three

different surgicalresidents during ap e r f o r m a n c e -based assessmentgrounded in an er-ror framework. Allof the participantswere senior levelresidents (fourthor fifth year) fromdifferent trainingprograms. In Fig-ure 1, a number oferrors can be seen:a) there are no an-choring stitches, b)the mesh does notcompletely coverthe hernia defect,and c) the mesh isnot completely flator flush to the abdominal wall. In Fig-ure 2: a) the anchoring stitches are notwell positioned for the mesh size and b)

the mesh does not complete-ly cover the hernia defect. InFigure 3: a) the mesh is toolarge for the defect, b) themesh is off-centered, and c)some of the mesh tacks aretoo far away from the meshedge. This surgical proceduresimulator allows for independ-ent operative decision makingwhich allows for error preven-

tion, recognition and rescue. Figures 4-5show the complete system.

Error-enabled simulations allow for high-er order training and assessment. More-over, in the process of recognizing and cor-recting errors and near misses, thepossibility exists that the newly developed,behavioral adjustment may still result inan error or worsening of an already rec-

ognized error. The theoretical basis for thiswas described by Wirstad. In essence, asknowledge-based behaviors are employedwhen a situation is novel or unexpected,the resulting behavior represents a moreadvanced level of reasoning. Moreover, inthese situations, the cognitive workloadis typically greater than that noted for ba-sic skill- or rule-based behaviors and mayincrease the likelihood of making errors.Recognizing and correcting errors is a vi-tal component in the process of achiev-ing mastery both for individuals and highfunctioning specialized teams.

FEATURES


23

[ ]Carla M. Pugh, M.D., Ph.D. Janis Cannon-Bowers, Ph.D.Center for Advanced Surgical Edu-cation, Northwestern UniversityChicago, Illinois

[email protected]

Figures 1-3: Three hernia repairs with different types of errors.

Figures 4: Error enabled box trainer style simulator insimulated operating room.

Figures 5: Participant and assistant performing a hernia repair.

“Recognizing and correctingerrors is a vital component in theprocess of achieving masteryboth for individuals and highfunctioning specialized teams.”


FEATURES

“New immersive and authentic learning environments are needed toenhance the interactive visualization and understanding of injury mech-anisms in a contextualized accident history. The Visualization throughImaging and Simulation educational model is namely a mixed simula-tion-based virtual learning environment that aims to improve the clini-cal diagnosis and treatment of head and neck injuries for medical edu-cation, in particular, for specialist training in orthopedics.”

By Olivier Courteille, Hans von Holst & Li Felländer-Tsai

The quality of clinical decision making in the treatment of trau-ma patients could be significantly improved by promoting thehistory of the accident as an important supplement to generallyaccepted diagnostic tools like computerized tomography (CT) ormagnetic resonance (MRI). However, this kind of investigation iscomplex and involves a biomechanical perspective in the diag-nosis, a knowledge that is not part of the curriculum for physi-cians, physiotherapists, occupational therapists or nurses today.

This is particularly the case of injuries in the head and neck re-gion which are often acute and multi-faceted, involving hard andsoft tissues. Thus, to be able to handle these cases and decide onproper investigation and treatment procedures, medical studentsand residents need to be trained with more dedicated learningtools to learn the underlying anatomical and physiological, as wellas biomechanical, properties of such injuries.

Educational Computer Simulation Model

New immersive and authentic learning environments are thusneeded to enhance the interactive visualization and understand-ing of injury mechanisms in a contextualized accident history.Embracing the increasing trend advocating for integrated simu-lations, joined efforts led by the Royal Institute of Technology(KTH) and the Karolinska Institute (KI) in Sweden gave birth to theVIS-Ed (Visualization through Imaging and Simulation) education-al model. VIS-Ed is namely a mixed simulation-based virtual learn-ing environment that aims to improve the clinical diagnosis andtreatment of head and neck injuries for medical education, in par-ticular, for specialist training in orthopedics and neurosurgery.

VIS-Ed enables a dynamic integration of a biomechanical simulation,featuring the interactive visualization of injuries, into a virtual patient(VP) framework, providing the conceptualization of accident history.

Mixed Virtual LearningEnvironments for the Simulationof Head and Neck Injuries

24

Figure 2: Dynamic integration ofa bio-mechanical simulation intoa virtual patient framework.

Figure 1: Visualizations of injury risk due to a lateral impactto the torso (red areas showing high risk for injury, © KTHhead and neck model).

25


FEATURES

Through the VP-based contextualizationof the accident history, this educationalmodel favors experiential learning, whichis beneficial for knowledge acquisition, re-tention and skill transfer. Moreover, the in-teractive biomechanical simulation of theinjury makes it possible to easily visualizetherapy and rehabilitation outcomes, andconsequently, better understand their im-pact over time on patient condition.

Virtual Patient

The patient cases are portrayed using Vir-tual Patients, where trainees can investi-gate the clinical case, make decisions andexplore the consequences of their actions.This includes taking the patient’s medicalhistory, examining the patient, and order-ing lab/imaging tests.

Interactive Visualization of Traumabiomechanical Events

The 3-D interactive visualization of biome-chanical events related to the accident isbased on the Finite Element Method (FEM),where the user can easily explore the forcesthe skull, neck and soft tissues have been ex-posed to. The animated biomechanical sim-

ulation can display, in detail, the impact onthe cervical vertebrae and muscles.

Ongoing Work

A preliminary study with a motorcycle acci-dent case was recently undertaken involvingnine participants (five medical students andfour residents). We investigated how traineescan take advantage of these integrated visu-alization techniques to better understandhow head and neck injuries should be han-dled clinically. Data collection included:

• The perceived usefulness of the model

• Participants’ appraisals about the educa-tional potential of this mixed learning tool

• Suggestions for technical and educationalimprovements

The preliminary results were very promising.Participants were very positive about VIS-Edand overwhelmingly favored this kind of(mixed) learning method to the traditionalone. They also perceived that this computer-mediated activity would help them to betterunderstand and visualize biomechanical in-juries and the effectiveness of suggested ther-apy. Finally, they believed they would be bet-ter prepared to assess and treat similar headand neck injuries if such models were to beimplemented in the medical curriculum.

Levels of acceptability and satisfaction werehigh and valuable recommendations for fur-ther improvements of the VIS-Ed model andits learning components were also provided.

A new control study is currently investi-gating if VIS-Ed can significantly improvethe clinical diagnosis and treatment inhead and neck trauma situations for un-dergraduate student education and spe-cialist training in orthopedics.

Future Directions

• More targeted interactive and immersiveeducational models are needed on headand neck injuries and their prevention.

• The range of use of VIS-Ed like Mixed Vir-tual Learning Environments extends be-yond undergraduate student educationand specialist training for physicians andalso includes physiotherapists, occupation-al therapists and nurses.

• Safety promotion and injury promotionhave also been identified as natural areasfor VIS-Ed (like consequences of violencein schools, childcare clinics and young par-ents, drivers’ license education, life guardtraining, etc.).

[ ]Olivier Courteille, Ph.D., M.Sc.Karolinska InstitutetLi Felländer-Tsai, Ph.D., M.D.Hans von Holst, Ph.D., M.D.Karolinska University HospitalSweden

[email protected]

Figure 3a: Screenshot of the VirtualPatient's Medical History.

Figure 3b: Screenshot of the VirtualPatient’s lab section displaying a 3-Dreconstruction of a cervical spine CT.

Figure 4: Screenshot of 3-D simulations showing the impact of an accident on cervi-cal vertebrae.

26

PRODUCT

BabySIM

Abdominal

Opening & Closure

Trainer

Spinal Injection

Simulator

Physician and

Surgeon Training

Colonoscope

Training Model

SMART STAT

Keystones

Certificate

MetiMan

Combat Medic

System

Ultrasound Heart

Phantom

Host Site

Instructor Train-

ing: Simulation as

a Teaching Tool

DESCRIPTION OF PRODUCT

simulator baby features realistic touch and feel with features such as palpable pulse,

urine output, bowel sounds, blinking eyes and pupil dilation; facilitates learning of

critical care interventions including infant CPR, airway management, drug admin-

istration and defibrillation

pad featuring a refined abdominal wall used for surgical access to the abdomen

including procedures such as incisions: linear, ellipse, flaps, shaped; subcutic-

ular undermining; interrupted suturing techniques; suturing, stapling and use

of adhesive strips

spinal simulator that allows for realistic demonstration and practice of all spinal in-

jections such as spinal anesthesia, spinal tap, epidural analgesia, caudal analgesia,

sacral nerve block, and lumbar sympathetic block

interactive experience using 3-D technology to simulate instrumentation, anatomy,

complex processes, procedures and surgical techniques; includes Tutorial and Per-

form Modes, and haptics strategy

colonoscope simulator made of soft, flexible, airtight material allows for realis-

tic insertion and withdrawal training, insufflation, suction and difficult maneu-

ver techniques

full-body, adult mannequin which can be used for EMS, nursing, and trauma skills

and helps users gain experience in cardiac and medical disease care

an immersive, multi-course healthcare simulation experience including develop-

ing a simulation scenario for piloting, submitting reflection papers, and participat-

ing in rounds

mannequin-based simulator with built-in, wireless system and can be used for ba-

sic assessment and practicing chest tube insertion, general ongoing care, pre and

postoperative care, experience with complications including deep vein thrombosis,

suctioning and trachea care with hypoxia, etc.

virtual training simulator for field medics; simulates patient care in a highly volatile

battlezone, built-in performance evaluation system to provide real-time feedback

with data stored for future reference

simulator heart consisting of a completely anthropomorphic external and internal

anatomy, useful for teaching and developing ultrasound examination skills and

techniques as well as demonstrating 3-D ultrasound capabilities

four-day course designed for educators who wish to create high-quality healthcare

simulation programs; clinical, behavioral, and cognitive skills through simulation are

taught to the participants with the daily schedule including simulation scenarios,

lectures, small and large group discussions, and practical exercises with feedback

MANUFACTURER

METI

Limbs & Things

Ltd.

3-DMed

mySmartSimu-

lations

Kyoto Kagaku

Co., LTD

WorldPoint

Sim-One

CAE Health Care

Virtual Reality

Medical Center

CIRS

Center for

Medical

Simulation

Product Comparison Chart:Medical Simulation

PRODUCT COMPARISON

RESEARCHERS:

Rasheda Farid & Khodeza BegumEditorial Department, C&R Magazine

www.vrphobia.eu, [email protected]

Wounds of War IV: Pain Syndromes: FromRecruitment to Returning TroopseDITeD By:Professor Dr. Brenda K. Wiederhold, Ph.D., mBA, BcIA

WOUNDS OF WAR IV: PAIN

SyNDROmeS – FROm RecRUITmeNT

TO ReTURNINg TROOPS

On September 30-October 2, 2011 theNATO Advanced Research “Wounds of WarIV: Pain Syndromes – From Recruitmentto Returning Troops” drew over 25 emi-nent experts from 11 countries to discussthe topic of increased pain syndromes inour service men and women.

Held in Sudkärnten, Austria at the HotelAmerika-Holzer, discussion topics includedincreased pain syndromes as a result ofmissions, as well as how pain syndromesmay be prevented. Research has shownthat those who have served in both com-bat missions and peacekeeping operationsare at an increased risk for pain syn-dromes. The ultimate aim of the workshopwill be critical assessment of existingknowledge and identification of directionsfor future actions. The co-organizers ofthe workshop alongside Professor BrendaK. Wiederhold included Professor KresimirCosic, Professor Mark D. Wiederhold andColonel Carl Castro.

Full papers will be published with IOS PressTO ORDeR: [email protected]

The Interactive Media Institute9565 Waples Street, Suite 200 – San Diego, CA 92121

phone: (858) 642-0267 – fax: (858) 642-0285 – www.interactivemediainstitute.com

The post-conference book will reflect the key topics

discussed in the four sections at the workshop:

First Session

Vulnerability to Pain SyndromesSecond Session

Diagnosis and Assessment of Pain SyndromesThird Session

Treatment of Pain SyndromesFourth Session

Clinical Updates on Pain Syndromes

Medical education has entered a virtualworld. The Neil and Elise Wallace Simu-lation, Training, Research and Technolo-gy Utilization System Center at Brighamand Women’s Hospital, known as STRA-TUS, has taken the lead in teaching stu-dents and training clinicians throughsimulation. On the campus of theBrigham and Women’s Hospital inBoston, Massachusetts, STRATUS is hometo high-tech mannequins that talk,breathe, have a palpable pulse, and cango into cardiac arrest. In addition tothese human simulators, STRATUS alsouniquely has a high-tech micro-simula-tion center for computer-based simula-tion and education, as well as a partialtask simulation center for hybrid simu-lation and hands-on procedures. Thefull-scale operating room is completewith authentic anesthesia equipment,high definition laparoscopic monitorsand surgical booms, real instruments,and scrub sinks.

This operating room also doubles as abirthing suite with a sophisticated man-nequin that can deliver a baby and sim-ulate postpartum hemorrhage events.Upon delivery, again with hybrid simula-tion, the suite can transform into aNeonatal Intensive Care Unit, with focustransitioned from delivery to neonatal

care. STRATUS also has an “arcade” whichcontains laparoscopic surgical trainers,endoscopic simulators, ultrasound train-ers, and Virtual Reality surgical simula-tors. The arcade is also the home to anendovascular suite that enables cardiol-ogists, interventional radiologists, andendovascular surgeons to master sophis-

ticated vascular catheterizations in a sim-ulated environment.

Using the experience of simulation as acatalyst for learning, STRATUS recognizesthe primary importance of debriefing par-ticipants after each scenario. Based onadult learning theory, STRATUS is found-

“Based on adult learning theory, STRATUS is founded upon ‘learning bydoing.’ In addition to the hands-on clinical opportunities which ignite manyinsightful discussions related to clinical diagnosis and management, STRA-TUS [Simulation, Training, Research and Technology Utilization SystemCenter] at Brigham and Women’s Hospital also emphasizes the importanceof teamwork and communication in the healthcare environment.”

28


FEATURES

A Whole New Worldof Medical Education

By Nicole Kissane & Charles Pozner

Figure 1: Using the endovascular trainer, this clinician is successfully placing a stentin the mannequin’s clogged coronary vessel.

ed upon “learning by doing.” In additionto the hands-on clinical opportunitieswhich ignite many insightful discussionsrelated to clinical diagnosis and man-agement, STRATUS also emphasizes theimportance of teamwork and commu-nication in the healthcare environment.Courses specifically designed for team

training have shown to improve out-comes and provide learners with expe-rience in high acuity, yet infrequent, sce-narios. Code Team Training, Trauma

Team Training, andObstetrical TeamTraining are all examples of curricula de-signed specifically for maximizing team-work. The curricula for these programsare created around a specialty-specificscenario, however, the focus of the de-briefing is the same: communication,

leadership, teamwork,safety, and outcomes.

STRATUS is available toevery department through-out the hospital and pro-vides each specialty withspecific simulation-basedtraining and educationalopportunities. The learn-ing community at STRA-TUS includes doctors, nurs-es, therapists, paramedics,

and technicians. The future of STRATUSis focused around its learners by provid-ing clinicians with the unique opportuni-ty to improve performance – at the clin-

ic, by the bedside, in the operating room,and during an emergency – where it mat-ters most, and where patient safety is toppriority.

29


FEATURES

[ ]Nicole Kissane, M.D.Charles Pozner, M.D. STRATUS Center of Medical Simu-lationBrigham and Women’s HospitalBoston, Massachusetts

[email protected]

Figure 2 (top): Trauma team members worktogether to save a life ... in simulation.Figure 3: Students interested in medicalcareers participate in emergency codetraining, practicing basic and advanced lifesupport skills.

“The curricula for these pro-grams are created around a spe-cialty-specific scenario, however,the focus of the debriefing is thesame: communication, leader-ship, teamwork, safety, and out-comes.”

Ask the Expert:Barr Taylor

Brenda K. Wiederhold: What is yourcurrent position?

Barr Taylor: I am a Professor of Psy-chiatry at Stanford Medical Schooland Director of the Laboratory for theStudy of Behavioral Medicine.

BKW: What is your main line of cur-rent research?

BT: I am interested in primary andsecondary prevention using Internet-based programs and other new tech-nologies to reach defined populations.We have two large projects underway.In one, we provide a universal and tar-geted/selective prevention programto all 9th grade students at a localhigh school. Students are assigned toone of two “tracks” based on baselineweight. If they are “normal” weightthey get a healthy weight regulationprogram that focuses on good nutri-tion, exercise and body image. If theyare overweight or obese they get aprogram that helps with weight main-tenance or weight loss. The programlasts 10 weeks and is delivered in thecomputer lab, during the physical ac-

tivity class. There is a huge need forsuch programs in schools, particular-ly online programs combined withother activities. I believe schools can(need to) play a pivotal role in promot-ing healthy weight regulation and

emotional health among youth. Wehave another program designed tofoster positive body image in collegestudents. This program combines en-vironmental activities with onlinescreening so that college students areprovided programs based on risk:no/low risk (StayingFit), risk of eatingdisorder (StudentBodies) and/or refer-ral for clinical services.

I have also been interested in com-bining teletherapy with online and In-ternet-based interventions. We havea project right now in Australia that

uses telephone-based psychotherapyto promote lifestyle change (weightregulation and exercise) and improvemood in patients with heart diseaseand depression. In published studieswe have shown the benefit of home-

based nurse case management formultifactorial risk reduction in pa-tients with heart disease and depres-sion. I think the telephone is the mostunder-utilized tool in medicine!

BKW: In one of your papers youwrite: “Given its potential to reachlarge populations it would seem ide-al to provide obesity prevention pro-grams over the Internet …” Can youtell me how you see technology im-pacting (positively or negatively) obe-sity, and more generally, metabolicdisorders?

31

Director of the Laboratory for the Study of Behavioral Medicine, Stanford Medical School

&

“Our programs could be improved by integrat-ing games and other activities ... the impor-tance of tailored interventions that are cost-

effective, easily-disseminated, and engaging toyouth must be balanced with the goal of pro-

moting increased activity.”

“There is a huge need for such programs in schools, par-ticularly online programs combined with other activities. Ibelieve schools can (need to) play a pivotal role in promot-ing healthy weight regulation and emotional healthamong youth.”

INTERVIEW

BT: Our work has recently focused onreaching all members of a definedpopulation, for instance, all 9th gradestudents in a school. In many schoolshalf or more of 9th grade studentsare overweight or obese and manyare at risk of developing diabetes. Apreventive intervention needs to ad-dress the unique needs of the stu-dents who are overweight and obeseand a more universal curriculummust be provided to healthy weightstudents. Furthermore, the curricu-lum should avoid stigmatizing stu-dents while simultaneously reducingweight and shape concerns, the lat-ter being a risk factor for eating dis-orders. We have designed programsto achieve these aims that can be de-livered to all 9th grade students in aclass.

Preliminary data from several recentstudies suggests that use of the pro-gram was associated with increasedconsumption of healthy foods and adecreased consumption of unhealthyfoods, and with weight loss in the 40%of kids who were overweight/obese.Our programs could be improved byintegrating games and other activi-ties. It can seem counterintuitive topromote computer-based interven-tions while encouraging students toreduce sedentary activity. However,the importance of tailored interven-tions that are cost-effective, easily-dis-seminated, and engaging to youthmust be balanced with the goal ofpromoting increased activity. Howev-er, these programs can and should becombined with classroom and otheractivities.

BKW: How does obesity preventionimpact body image?

BT: This is a hugely important ques-tion. We have found, as have others,that obesity prevention, when doneproperly, can reduce weight and shapeconcerns. I believe it is a myth – anda dangerous one – that weighing kidsin school is bad, because, for instance,it may increase the risk of eating dis-orders. When done with respect to thestudent’s privacy and with properfeedback there is no evidence thatweighing students in school is harm-ful; rather, it creates a database that

permits us to deal with this epidem-ic in our society.

BKW: What first interested you in obe-sity and metabolic disorders?

BT: In the 1970s I was education di-rector of an amazing study, in which

whole communities were randomizedto mass media plus community or-ganization efforts to reduce cardio-vascular risk. The study had a positiveeffect on improving risk. I also servedas Associate Director of the StanfordCardiac Rehabilitation Program andsaw the sometimes devastating effectsof these disorders first hand. I even-tually decided to focus on adolescentand college students to address riskfactors at an early age.

BKW: What do you think we should doto move this research forward?

BT: A. We need a national focus andcenter that provides free, healthylifestyle programs to schools! Somecountries are moving in this direction.These programs need to be developedusing innovative methods that are like-ly to make them more effective, suchas the use of adaptive designs, smarttrials and continuous quality improve-ment. The programs should be linkedto measured outcomes in schools.

B. We need to figure out how to com-bine Internet-based programs withschool, community, and home-basedactivities and to take advantage of so-cial networks.

C. We researchers need to make moreinteresting and engaging programs us-ing apps, games, Virtual Reality pro-

grams, monitoring devices, etc.

D. Once we have a core program forschools, we can discover and add en-hancements – such as games.

E. We need to have a way to fundschool-based prevention programs.

The schools are broke and the teach-ers overworked. I think Internet pro-grams need to be easy to deliver with-in protected/private school networks.I think it will be necessary to seek lo-cal commercial sponsorship.

BKW: What are you most proud of inyour career?

BT: First, my students. Second, prob-ably, is helping to establish the scien-tific basis that led the Joint Commis-sion on Accreditation of HealthcareOrganizations to require inpatient to-bacco cessation programs for individ-uals who were smoking before admis-sion and want to quit.

BKW: What do you predict as the newtrends for technology and healthcarefor the next decade?

BT: The next big trend will be findingways to manage weight loss/mainte-nance via linking “consumption” (e.g.,food purchases in restaurants andmarkets) and other lifestyle activitiesto weight changes/goals via phones,and other electronic devices.

BKW: What drives you?

BT: Flyfishing and getting StayingFit(our school-based healthy weight reg-ulation program) to 50,000 studentsnext year!

32

ASK THE EXPERT Barr Taylor

“I have also been interested in combining telether-apy with online and Internet-based interventions... In published studies we have shown the benefitof home-based nurse case management for mul-tifactorial risk reduction in patients with heart dis-ease and depression. I think the telephone is themost under-utilized tool in medicine!”

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Within the emerg-ing cybertherapyfield, a central roleis played by Virtu-al Reality (VR). Ifwe check the twoleading clinicaldatabases – MED-LINE and PSYCIN-FO – using “Virtu-

al Reality” as keywords we can find 3,336papers listed in MEDLINE and 730 inPSYCINFO (all fields query, accessed 11November 2011).

The first VR healthcare applications start-ed in the early ‘90s to address medicalstaff’s need to visualize complex medicaldata, particularly during surgery and forsurgery planning. Actually, surgery-relat-ed applications of VR fall mainly into

three classes: surgery training, surgeryplanning and augmented reality for sur-gery sessions in open surgery, endoscopy,and radiosurgery. A couple of years later,

the scope of VR applications in medicinehas broadened to include neuropsycho-logical assessment and rehabilitation. Ingeneral, VR in healthcare has two faces.

For physicians and surgeons, the ultimategoal of VR is the presentation of virtualobjects to all of the human senses in away that is identical to their natural coun-

terpart. As noted by Professor Richard Sa-tava, as more and more of the medicaltechnologies become information-based,it will be possible to represent a patient

with higher fidelity to a point that theimage may become a surrogate for thepatient – the medical avatar. In thissense, an effective VR system, as dis-cussed widely in this issue, should pro-vide realistic body parts or avatars thatinteract with external devices, such as

35

By Giuseppe Riva

FROM WHERE WE SIT:The Two Faces of Virtual Reality: Medical Simulation andExperiential Interface

“As noted by Professor Richard Satava, as more and moreof the medical technologies become information-based,it will be possible to represent a patient with higher fideli-ty to a point that the image may become a surrogate forthe patient – the medical avatar.”

For decades, simula-tion in nursing edu-cation and medicaltraining has been in-corporated into theteaching and learn-ing process in theform of static man-nequins, role play-ing, scenario set-

tings, case studies and other techniques.However, the use of high-fidelity simulations

to prepare students in critical thinking, self-reflection and complex clinical environmentshas recently become a progressively popu-lar educational tool. The ability of high-fi-delity simulations to simulate realistic clin-ical situations without risk to patients opensup new avenues in the development of med-ical and clinical competence for nursingstudents.

In healthcare, simulations provide a naturalframework for the integration of basic andclinical mechanisms, allowing nurses to learnhow to accurately and safely care for patientsin less threatened environments.

Furthermore, high-fidelity simulations canmimic the environments in disaster situa-tions, especially those that involve outsideprofessionals such as paramedics, police-men, or firemen. SimMan, made by Laerdal,is an example of a high-fidelity simulator.SimMan is a computerized, interactive, life-sized mannequin driven by pre-definedsoftware to provide realistic patient re-sponses and outcomes for care training.Utilizing this innovative technology de-creases the need for diverse clinical sites,equipping nursing schools with a cost-ef-fective tool they have needed. The Nation-al Council of State Boards of Nursing an-

FURTHER AFIELD:Integrating High-Fidelity Simulation in Nursing and MedicalTraining for Seamless Care

By Lingjun Kong

continued on page 37

36

ticipates that high-fidelity simulation willcontinue to grow in presence as an evalu-ation and teaching strategy tool in the fu-ture of clinical and nursing education.

The use of high-fidelity patient simula-tion effectively facilitates learning underthe right conditions, according to a sys-tematic review by B. Issenberg et al. Inaddition to its use in offering clinical vari-ations and diverse situations, high-fideli-ty simulation provides a range of diffi-culty levels for tasks and innovativelearning strategies, as well as controlledand safe practice environments allowingfor repetitive practice. Furthermore, sim-ulations let nurses capture clinical vari-ations and conduct individualized andoutcome-based learning experiences tofulfill the unique needs of each user. Newgraduates are prepared for critical think-ing and reflective skills, and real-timenursing practice correlated with the qual-ity of patient care.

In Asia, Singapore was the first countryto integrate advanced simulation facili-ties for nursing education. Funded bythe Lee Foundation, the Critical CareNursing Simulation Laboratory of theNational University Hospital (NUH)opened in 2007. The $250,000, 100-square foot laboratory is used to conductpractical training in its High Dependen-cy and Intensive Care Unit rooms.

The most integral component of the lab-oratory is a high-fidelity simulation man-nequin, which can simulate almost allcritical medical conditions when cou-pled with their state-of-the-art comput-er and audio-visual system. The man-nequin can replicate critical medicalconditions with vital statistics, ECGwaves, and even physical responses.Nurses at NUH are able to safely prac-tice their clinical skills prior to interact-ing with real patients, thus greatly im-proving the quality of care that theyprovide. In addition to allowing studentsto gain experience in critical skills such

as airway management, immobilization,and basic and advanced life support, theintegration of the Critical Care NursingSimulation Laboratory has offered thesystematic training of doctors and nurs-es alongside one another. When tailoredfor a specific situation, the high-fideli-ty simulation allows both doctors and

nurses to practice their skills to providecooperative care for patients. NUH iscontinuing to expand their program tooffer the course to a larger percentageof their staff. Hospitals in neighboringcountries, such as Indonesia, Thailand,and Malaysia, have also expressed inter-est in using the laboratory to train theirown nurses.

The second high-fidelity simulation lab-oratory in Asia was The Virtual Integrat-ed Nursing Education Simulation Labo-ratory (VINES) at The Far EasternUniversity Institute of Nursing in thePhilippines. VINES integrates hospital-likequalities into their laboratory, as well ashigh-fidelity mannequins for safe andcontrolled environments for its studentnurses.

According to results from the PhilippineNurse Licensure Examination, as well asemployment statistics, The Far EasternUniversity Institute of Nursing is consis-tently one of the top nursing schools inthe country. Since the incorporation ofVINES, the school can provide repetitiveand customized nursing lessons in a

non-threatening arena, further expand-ing the avenues of education providedat the Institute.

Despite the many benefits of simulationeducation in nursing schools, a large gapexists between academic simulations andclinical reality.

It is still a recently adopted technologythat raises many questions in nursing ed-ucation: How can it be used effectivelyin its role of the clinical development ofstudents? How can it be seamlessly in-tegrated to be a key part of educationcurriculum? Factors that need to be con-sidered include variations in faculty skillsets and how these changes can be ad-dressed; changes in teaching evolvinginto student-centered approaches; hightechnology practices being integratedinto clinical settings; and the need forhigh quality training devices, and highexpectations of students. With furtherdevelopment, the integration of high-fi-delity simulations holds the promise ofbridging the gap between nursing edu-cation and clinical practice.

[ ]

“The use of high-fidelity patient simulation ... pro-vides a range of difficulty levels for tasks andinnovative learning strategies, as well as con-trolled and safe practice environments allowingfor repetitive practice. Furthermore, simulationslet nurses capture clinical variation, and conductindividualized, outcome-based learning experi-

Lingjun Kong, PMPVirtual Reality Medical CenterSan Diego, California

[email protected]

surgical instruments, as closely as pos-sible to their real models.

However, there is another way of usingVR in healthcare. Clinical psychologists

and rehabilitation specialists use VR toprovide a new human-computer interac-tion paradigm in which users are nolonger simply external observers of im-

ages on a computer screen but are activeparticipants within a computer-generat-ed 3-D virtual world. Within the virtualexperience the patient has the possibil-ity of learning to manage a problematic

situation related tohis/her disturbance. Thekey characteristics of vir-tual environments forthese professionals areboth the high level ofcontrol of the interactionwith the tool without theconstraints usually foundin computer systems,and the enriched experi-

ence provided to the patient.

For both sides, a critical advantage isthat virtual environments are highly flex-

ible and programmable. They enable thetherapist to present a wide variety ofcontrolled stimuli, and to measure andmonitor a wide variety of responsesmade by the user. This flexibility can alsobe used to provide systematic experien-tial training to optimize the degree oftransfer of training or generalization oflearning to the person's real world en-vironment.

“The first VR healthcare ap-plications started in the ear-ly ‘90s to address medicalstaff’s need to visualize com-plex medical data.” Giuseppe Riva, Ph.D.

Istituto Auxlogico ItalianoItaly

[email protected]@auxologico.it[ ]

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With the aid of the provincial governments, theCanadian federal government addressed shortcomingsin the field of mental healthcare after realizing that thissegment had been neglected. Using the engagementand feedback from people of all sectors, it helped to laythe groundwork for a deliberate and thoughtful planwhich is now leading to the steady development of anew mental healthcare strategy for the country.

[ ]C&R in Canada

he growth of psychology as a sep-arate field was not considered inCanada until the last half of the19th century. The first psycholo-

gy course was taught by Thomas Muccul-loch at Dalhousie University in easternCanada in 1838. Ten years after the estab-lishment of the first psychology laborato-ry in Germany in 1879 by Wilhelm Wundt,James Mark Baldwin, one of Wundt’s stu-dents, founded the first psychology labo-ratory in Canada. Although individual psy-chology departments began expanding inthe 1920s, it was not until the 1940s thatpsychology was truly separated from phi-losophy.

Overcoming Roadblocks:Constitutional and Personal

Attitudes

According to the Canadian constitution,individual provinces are responsible forthe sector of mental healthcare, meaningthe country does not have a supreme men-tal health strategy.

Researchers have estimated that almostone in every five Canadian adults will ex-perience some type of mental illness in ayear. However, many do not get propertreatment or have access to care. The qual-ity and quantity of services available tothose affected is insufficient to meet theirneed. Additionally, fear of stigma keepsmany from seeking help, while others areunable to afford treatment.

The Canadian Senate Committee on So-cial Affairs, Science and Technology cameto the conclusion that Canada was in crit-ical need of a “profound transformationof the mental healthcare system … a gen-uine system that puts people living withmental illness at its center, with a clear fo-cus on their ability to recover.”

A Step Forward for Mental Healthcare

The federal government, with the collab-oration of provisional and territorial gov-ernments, announced the creation of theMental Health Commission of Canada

(MHCC) in 2007. Its mission was to has-ten the development of a mental healthstrategy for Canada, acknowledging thatall the jurisdictions had neglected mentalhealth needs and were faced with thesame challenges.

The MHCC developed a framework for aMental Health Strategy between June 2007and September 2009, aiming to increaseawareness of mental health and structurean official strategy for the country to fol-low to properly address the issue as a uni-fied nation.

The Structure and Process

The Commission felt it was important toengage a wide range of people in order todevelop the framework, including thosesuffering from mental health issues, theirfamilies and caregivers, advocates, mentalhealth service providers, researchers andpolicy experts. A phased approach wasadopted by the Commission to reach itsgoal, primarily focusing on what a trans-

T

> COUNTRY FOCUS


40

AUTHORS:

Rasheda Farid &Khodeza BegumEditorial DepartmentC&R Magazine

[email protected]

41

> COUNTRY FOCUS

formed mental health system might looklike (Phase 1 – completed), and secondly,on how to achieve this vision (Phase 2 – inprogress).

The main goal of Phase 1 was the develop-ment and refinement of a framework doc-ument, aiming towards “Recovery and Well-Being,” and using a broad public andstakeholder engagement process including:

1) Engagement of the extended Commis-sion: Eight permanent Advisory Commit-tees in the Commission representing botha broad range of perspectives and Canada’sdemographic and cultural diversity provid-ed advice to the board and assisted the Com-mission in engaging with the broader stake-holder community. Most of the advisorycommittee members were individuals whowere asked to contribute their personal per-spectives based on their experience of men-tal health issues or illnesses. Additionally,there was a consumer council, comprisedexclusively of people living with mentalhealth issues.

2) Online participation Web site – publicand stakeholders: A customized participa-tion Web site was designed to collect in-put and opinions from the general publicand stakeholder groups using open-endedand close-ended questions, as well as a freeform option where the audiences couldgive qualitative comments. The site in-creased engagement due to its accessibil-ity and privacy, and allowed the Commis-sion to reach out to the youth, youngeradults and other hard to reach groupswhose voices are often unheard.

3) 12 Regional Dialogues: From Februaryto April 2009, regional dialogues were heldwhich brought together a cross-section of30-40 participants, demonstrating a mixof individuals who had experienced men-tal health problems or illnesses, and theirfamily members, caregivers, and policy-makers, among others. Participants re-ceived the opportunity to learn about theproposed framework and provide feedback,and their full participation was encour-aged.

4) Focused Dialogues: These dialoguesaimed at obtaining a deeper understandingof specific needs and concerns of Canada’saboriginal people, and of health and socialservices professionals to ensure they werecorrectly reflected in the final frameworkdocument.

5) Consultations with Federal/Provincial/Ter-ritorial Governments: The Commission inte-grated various meetings regarding the com-plexity and lasting effect of jurisdictional issuesin the field of healthcare, and the need for acollaborative approach to address mentalhealth issues. Additionally, the Commissionheld facilitated dialogues with members ofthe Canadian Public Health Network’s Men-tal Issue Group and a session that brought to-gether representatives of over 10 federal de-partments (justice, health, etc.) to participatein dialogue on the draft framework.

A Lasting Impact

This initiative led to a complete redraftingof the framework document to reflect pub-

C&R in Canada


34

81.4

1.58

41

9.27

80

0.794%

7.1%

34

85.2

3.7

8

10.9

Population (Million)

Life Expectancy (Years)

Fertility Rate

Population Median Age (Years)

Population Density (Persons Per Sq Km)

Percentage of Urban Population

Annual Population Growth Rate

Unemployment Rate

Hospital Beds (Per 100,000)

Percentage of the Population (15 and Above)

Satisfied with Current Healthcare System

Lifetime Prevalence of Panic Disorder

(Percentage of General Population)

Lifetime Prevalence of Mood Disorders

(Percentage of General Population)

Total Expenditure on Health

(as Percentage of GDP)

lic and stakeholder input, including theaddition of a vision statement, refram-ing of the goal statements and reword-ing of key concepts. It also signified thestarting point of a new dialogue on men-tal health in Canada. Project evaluationresults showed that the majority of therespondents and participants appreciat-ed the opportunity to contribute to thecreation of a mental health strategy andplanned to stay linked with the Commis-sion’s work to develop a strategy basedon their online experience.

The Commission’s goal of moving to-wards a comprehensive national mentalhealth strategy is a high-level, long-termpolicy objective that requires majorchanges in how mental health legisla-tion, policies, programs and practices aredeveloped and delivered by Canadianprovinces and territories. The Commis-sion will continue to involve different de-mographics, perspectives and regions tohelp raise awareness, build capacity andsupport advocacy to the levels necessaryfor sustaining a national dialogue on thiscritical issue, and lead decision makersto recognize and support mental healthissues as a priority.

The Evolution of Therapy

Canada’s first Computer Assisted Reha-bilitation Environment (CAREN) systemshave been implemented in Ottawa andEdmonton to utilize Virtual Reality (VR)medical treatment systems for the careof both military and civilian patients.CAREN systems will create a secure, con-

trolled, therapeutic learning environmentfor soldiers requiring physical and men-tal rehabilitation. It will allow participantsto become part of their simulated envi-ronment and interact with it, while aim-ing to foster hope, provide opportunityand nurture independence for peoplewho have faced challenges due to cer-tain illnesses or injury.

Dr. Edward Lemaire of the Ottawa Hos-pital Rehabilitation Center is directly in-volved with the development of the sys-tem and points to ways in which therehabilitation will affect activities of dai-ly living. “Downtown Ottawa is now pro-grammed into CAREN to allow people tomove in their virtual community duringtherapy,” he says. The lab’s collaborativeresearch is fostered by close contact withother CAREN system labs in Israel, theNetherlands and the U.S.

Canadian universities, as well, are em-ploying VR in their labs to address health-care concerns. Dr. Stephane Bouchard, aprofessor and researcher at the Univer-sité du Québec en Outaouais, focuses onthe impact of cognitive behavorial ther-apy on anxiety disorders, and the waysin which telepsychotherapy can be de-livered through video conferencing.Bouchard uses VR to study and treat arange of afflictions, from specific pho-bias to more complex anxiety disorders,including panic disorder and social anx-iety. The work can be used for a broadrange of applications and Bouchard says,“Most of the environments we developin the lab could be used for preventionor treatment [of mental disorders].”

The Advancement of Telemedicine

Canada is leading the way for the use oftelemedicine and the Ontario Telemed-icine network is one of the biggest tele-health networks in the world. In 2010,the satisfaction rate of Canadian patientsusing telemedicine was almost 95%. In-ternationally, their telehealth organiza-tions enjoy a high profile with compa-nies operating in Latin America, Africa,Europe and the Middle East. Over 85%

of Canadian telehealth companies exporttheir products. Moreover, tele-guided sur-gical operations involving doctors inCanada and Japan, and Canada andFrance, have proved successful.

Other forms of computing technologywill enhance all aspects of physical reha-bilitation, Lemaire says. “This includesVR applications in the clinic, home andworkplace,” he states, “wearable systemsfor diagnostic analysis and biofeedback;intelligent assistive devices (includingsmart prosthetics, exoskeletons, etc.);more intelligent wheelchair controls; andsmarter outcome reporting systems toassist with clinical decision making,among others.”

While the Canadian healthcare systemmay be undergoing major structuralchanges, a bright future lies ahead forthe development of health informationhighways and innovative telehealth ap-plications. The research and developmentand export capacity of the Canadian tele-health industry shows the field is readyto offer a large range of products andservices on the international market. Anaging and demanding consumer will un-doubtedly provide more momentum forthe development of home telecare sys-tems and more accessible health andwellness information on the Internet, inaddition to diverse types of new tech-nologies to support healthcare issues.The government’s commitment to pro-viding its population with acceptablemental healthcare options and treat-ment, based on their ongoing supportand input, speaks to its capacity to em-brace change and the coming years willassuredly see novel, exciting develop-ments in the field.

42

> COUNTRY FOCUS

Sources:

Personal communication withStephane Bouchard, Ph.D. and Ed-ward Lemaire, Ph.D., and the WorldHealth Organization.

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CYBER17 will bring together researchers, clinicians, funders and policymakers to share and discusstrends in healthcare and technology. CYBER17 continues to seek input from a wider segment of the sci-entific community, and is interested in attracting experts in clinical therapy and rehabilitation, cognitivesciences, social sciences, and computer sciences dedicated to shaping the future of health & well-being.

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2. The Influence of New Technologies: technology's influence onbehavior and society (e.g., positive technology for well-being,healthy ageing, and inclusion).

3. The Imprint of Social Networking: the exploration of social net-working tools on individual behavior and societal relations.

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2012 CALL FOR PAPERSSUBMISSION/REGISTRATION

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cybertherapy & rehabilitation, issue 4 (4), winter 2011

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