Simulation Faces Technological, Regulatory Obstacles on Way to Mainstream

Despite obvious advantages for trainees and veteran practitioners, the future of medical simulation as a widely integrated part of curricula is still contingent on factors including technological breakthroughs, training standards and the simulators themselves.

“Simulation will be a major player in training and accreditation, but my guess is it won’t be for another 10 or 15 years,” said Craig B. Glaiberman, M.D., an interventional radiologist and assistant professor of radiology at the University of California Davis (UC Davis) Medical Center in Sacramento.

Variety of Simulation Products Offer Different Advantages

Craig B. Glaiberman, M.D. University of California Davis	Ronald L. Arenson, M.D. University of California, San Francisco
Amrita Kumar, M.D.,M.Sc. Arrowe Park Hospital and Mersey Deanery	Steven Dawson, M.D. Massachusetts General Hospital, Harvard Medical School

Dr. Glaiberman has had experience with a number of simulators at the Mallinckrodt Institute of Radiology in St. Louis as well as UC Davis, which is home to the Center for Virtual Care. The center features two lifelike training mannequins that blink, speak and breathe and also have a heartbeat, pulse points, dilating pupils and other realistic anatomical features that allow students to practice intravenous drug delivery, CPR, catheterizations, basic obstetrics and airway management and respiratory therapy for adult and pediatric patients.

The center also utilizes Medical Simulation Corp.’s SimSuite™ virtual training system that allows students and residents to practice renal and iliac interventions and carotid artery stenting on the Simantha™ endovascular simulator. In addition to the mechanics of a procedure, SimSuite simulates hemodynamic and physiologic responses, said Dr. Glaiberman.

“There are code scenarios that demonstrate airway management, interactions with medications, responses to anesthesia or just basic histories for hemodynamics, so you can actually watch the physiologic response to the medication and the dose.”

What his experiences have taught him, said Dr. Glaiberman, is that commercial simulators have different advantages. While SimSuite focuses heavily on clinical scenarios and interpersonal interactions among the clinical team, the Mentice VIST™ system has excellent haptics and tool simulation for procedures and “gives very good tactile feedback,” he said.

“An Israeli company called Simbionix has shown great promise for patient anatomy, patient history, haptics and the ability to use specific tools,” he said.

Along with allowing trainees to practice without risk to real patients, simulation also affords the opportunity to perform procedures not otherwise encountered in significant volume, Dr. Glaiberman said. “Residents need to be involved witha certain number of carotid, iliac and renal interventions and may not be exposed to that many proceduresduring their training. With simulation we’re hoping to bridge some of those gaps.”

Simulation can also close gaps for physicians with advanced skills, said Ronald L. Arenson, M.D., chair and Alexander R. Margulis Distinguished Professor of Radiology at the University of California, San Francisco (UCSF) and RSNA Liaison for the Annual Meeting and Technology. “SimSuite can create random simulated complications such as changes in hemostasis among other complications internal radiologists don’t often encounter,” said Dr. Arenson.

Future of Simulation Tied to Standards Consensus

Currently the Joint Commission is moving toward more specific standards for maintenance of certification (MOC), which could involve simulation, Dr. Arenson said. “The commission might decide that clinicians would have to do, say, 100 of a certain procedure per year to remain certified. Simulation will be the vehicle by which they can maintain their certification.”

The UC Davis Center for Virtual Care features two lifelike training mannequins that blink, speak and breathe and also have a heartbeat, pulse points, dilating pupils and other realistic anatomical features. The simulators can be injected, intubated and catheterized for patient care training. Image courtesy of UC Regents.

The future of simulation, however, still awaits a consensus on standards for credentialing and MOC in terms of both the procedures trainees must perform and the type of simulator used to perform those procedures.

“In today’s commercial market there are no fully validated simulators,” said Amrita Kumar, M.D., MS.c., a radiology registrar at Arrowe Park Hospital and Mersey Deanery in Merseyside, Great Britain, whose research is part of the U.K.-based Collaborators in Radiological and Interventional Virtual Environments (CRaIVE), a consortium of clinicians, physicists, computer scientists, clinical engineers and psychologists, which includes RSNA members.

“Even though there have been no broadly accepted guidelines for the validation of simulators in the past, investigators in the U.S. and Europe are currently working to establish guidelines,” said Dr. Kumar.

CRaIVE’s chair, Derek A. Gould, M.D., is a member of the Society of Interventional Radiology (SIR) and serves on RSNA’s Joint Medical Simulation Task Forcealong with RSNA President Gary J. Becker, M.D., and Stephen Dawson, M.D. Earlier this year, Dr. Dawson presented at an RSNA/SIR-sponsored session focusing particularly on guidelines for interventional radiology.

“We culled SIR experts representing different subspecialties, community practices, academic practices and large private practices, as well as an educational psychologist,” said Dr. Dawson,an interventional radiologist and program lead in medical simulation at Massachusetts General Hospital and an associate professor at Harvard Medical School in Boston. “We assigned values based on clinical relevance to each step in a very long list of individual steps for interventional procedures.”
Simulators developed by non-radiologists are not able to distinguish the critical steps that should be scored more heavily during a simulation exercise than steps of lesser clinical consequence, Dr. Dawson said.

“The goal is to develop a scoring system that can be integrated into the software that the machines are already running. If we present a mathematical basis for measuring the performance, then we can imbue the machines with a whole new level of relevance to practice.”

Procedural simulation technology is far more complex than technology based on visual simulation, such as video games, said Dr. Dawson. “Gaming would be useful for coronary angiography or colonography, anything image-based,” he said. “But I don’t think gaming is a way to teach procedural knowledge anytime soon.”

CRaIVE Projects Aim to Advance Simulation

There are two ongoing CRaIVE simulation projects for interventional procedures, said Dr. Kumar. One, the Imaging Guided Interventional Needle Simulation, or ImaGINe-S, uses a PC, monitor and graphic user interface, stereoscopic goggles and two SensAble Technologies Phantom® Omni haptic devices with different resistance levels—one for the needle, that can penetrate tissue, and one for the ultrasound probe, that cannot—to deliver the “feel” of the procedure.

Haptics, a technology that interfaces with the user via the sense of touch through force, vibrations and/or motion, is still emerging, he said.

“Haptic devices can give force feedback for inserting a needle in a straight motion,” Dr. Dawson said, “but for angiographic procedures that involve more than a straight needle stick, I think the challenge is going to be greater.”

The second CRaIVE project will attempt to address that challenge with a physics-based virtual environment for guidewire and catheter insertion. “For ultimate fidelity, we will determine and localize the forces experienced by an operator using miniature sensors, enabling the ‘feel’ to be accurately reproduced,” said Dr. Kumar. “This will allow us to simulate needle puncture and introduce a guidewire and catheter into a blood vessel with realistic behavior of tissue and vessels.”

Simulation remains a very small part of the curriculum at most institutions and establishing its clinical relevance for certification and MOC standards may be slower than once predicted, radiologists agreed.

“Eventually simulation will come into the mainstream, and we will be better off, but I don’t think we’re ready,” said Dr. Dawson. “We still need to make sure the simulators we’re developing will really transform how we think or transform how we use our hands and eyes.”