While training, young neurosurgeons use realistic simulations of medical events to ensure real-life success in the future.
When neurosurgeon Ashwini Sharan, MD, started training residents at Jefferson, he searched for a risk-free way to teach them the nuances involved in drilling through bone.
At first he attached balloons to the backs of a bunch of pig scapulae and instructed his trainees to drill through without popping them.
“That was our first foray into simulation,” says Dr. Sharan, now director of the neurosurgery residency program. “We’ve come a long way since then.”
Simulation has been a buzzword in healthcare training for the past decade. And Jefferson has been a leader in the field. The Dr. and Mrs. Robert D. Rector Clinical Skills Center houses specialized equipment that enables trainees to experience and work with highly realistic simulations of medical events.
Still, among the many exercises available at the Center, none involve neurosurgery.
So Dr. Sharan and fellow neurosurgeon James Harrop, MD, both professors in the Department of Neurological Surgery, spent several years building a simulation program specifically for neurosurgery residents.
The pair initiated the effort to help translate the book knowledge learned in medical school into the technical proficiency needed for physicians.
For example, students don’t often have the opportunity to assess the power differences among the many types of drills used in the operating room, which is why Dr. Sharan started having residents use them on animal bones for practice.
“It’s a fast transition from being a fourth-year medical student to a resident and suddenly being called a doctor,” Dr. Sharan says. “We’re looking to use simulation as a way to teach a high volume of information while also letting residents get used to all of our equipment quickly — because their first time on call, they are responsible for somebody’s life.”
Laying the foundation
To standardize core lessons for junior residents, about five years ago Dr. Sharan created what he called “Neurosurgery Foundations,” a comprehensive review of the skills they needed to master right away. The Foundations program was adopted nationally and is now known in graduate neurosurgery training programs as “Neurosurgery Boot Camp.”
But trainees still lacked access to sophisticated, anatomically accurate models on which they could simulate procedures, and the Congress of Neurological Surgeons, a national organization seeking to advance neurosurgery education and technology, pushed its members to develop a formal simulation course.
Drs. Sharan and Harrop both sit on CNS’ executive board and Dr. Harrop serves as chair of the CNS simulation committee, so the two neurosurgeons eagerly accepted the challenge.
Dr. Harrop began looking for existing simulators and found a few had already been developed for cranial and vascular procedures, but none for spine and spinal cord.
“There were some computer simulation devices around, but we wanted to incorporate physical models. Virtual reality alone is just not sufficient — trainees want to use their hands, to feel what surgery is really like,” Dr. Harrop says. “I always paraphrase Jefferson’s former chairman of neurosurgery, Dr. William Buchheit, who would say, ‘The difference between being a good neurosurgeon and a great neurosurgeon is knowing how hard you can pull on something and get away with it.’”
Drs. Harrop and Sharan approached a 3D modeling company in Germany called Phacon they knew had previously made a brain model and asked if they could replicate a cervical spine. They provided Phacon with a CAT scan as its basis, and in return, Phacon shared with them dozens of options for material. The physicians took turns drilling to determine which felt most like human bone.
“Every little detail, each ligament, had choices of various materials with different densities, and we went through every one to make sure we got what we wanted,” Dr. Sharan says.
And they did. Phacon produced a cervical laminectomy surgery simulator that met their high standards.
Since then, they have worked with Phacon to develop additional models and corresponding software components for many types of procedures. They introduced these tools at the CNS Annual Meeting in Washington, D.C. in 2011, where they spearheaded a full-day practical simulation course for neurosurgery residents, complete with computer-aided evaluation of skills demonstrated on the models. The course was repeated at the 2012 Annual Meeting in Chicago and has been included as part of the fall 2013 meeting in San Francisco.
“Simulation is the future of medical education and will be increasingly required as part of our training and certification,” says Ali Rezai, MD, president of the CNS and director of the Ohio State University Brain and Spine Institute. “Even after just one day of practice on simulators, residents show great improvement. Getting drills into their hands in an educational setting has a significant impact on their OR performances.”
Dr, Rezai refers to simulation as the future of medical education — but why?
Dr, Harrop says it just makes sense.
“Simulators put you in a crisis situation and force you to respond, and then the next time you are in a crisis, you will have had some exposure and be able to deal with it better,” he says. “They don’t just teach technical skills but also introduce residents to bad situations with zero possible harm to a patient.”
An ever-deepening nationwide focus on reducing medical errors and enhancing patient safety has placed increased emphasis on simulation training, as it has become less acceptable to have residents “practice” procedures for the first time on actual patients.
“The neurosurgery training approach has traditionally been an apprenticeship model: see one, do one, teach one. But simulation is obviously safer. In many cases, real-world training is dangerous or even impossible,” Dr. Harrop says, explaining that while cadaver dissection provides a great educational foundation for undergraduate students, simulation technology makes more sense during post-graduate training.
Previously, neurosurgery residents occasionally worked on cadavers, but they can be difficult to obtain and prepare. Some animal bodies are more affordable than humans and anatomically similar, but they can be associated with infection and disposal concerns.
Simulation also helps compensate for restrictions on resident work hours; an 80-hour workweek has forced GME programs to make adjustments in order to deliver the same level of training as before the limitation was imposed 10 years ago.
“Learning a surgical skill requires hours of repetition. You need to have experience, review experience, modify experience, re-create experience,” Dr. Harrop says. “When I was a resident, I stayed in the operating room all day, then took care of other duties at night. I never went home, but everything got done. With hour restrictions nowadays, residents have much less exposure to the OR, and we have to supplement their education in the most efficient manner.”
Many neurological procedures are performed infrequently, Dr. Harrop adds, and simulation allows residents to establish a comfort level with situations seen only rarely in the clinic.
Residents doing simulation exercises receive grades for their technical performances as well as an exam, which gives physicians a way to evaluate their trainees objectively — something they have sought for some time. Drs. Harrop and Sharan are striving to formalize a standard scale by which all neurosurgery residents’ skills are measured.
“Resident salaries are paid for by the U.S. government and the taxpayers of America want to know: What kind of doctors are we paying for?” Dr. Sharan says. “These tools will help us answer that.”
Looking to expand
The duo is in the process of integrating the CNS simulation course into the curriculum for neurosurgery residents at Jefferson. And since virtually no validity studies in the neurosurgery simulation arena have been conducted, they are looking to other institutions to do the same.
“We need to validate our skills assessment tools. Several other schools will be getting these models, and then we can compare results, looking for consistency,” Dr. Harrop says. He is building a Web platform so that residents can log onto a computer to access the academic portion of the program, then move onto a simulator for a performance test. As the program expands, score compilations would provide an overview of potential deficiencies in training across the country.
“Residency directors will be able to see where they need to spend more time with trainees,” says Dr. Harrop, who believes that obtaining a medical license might soon require meeting a proficiency score that can only be provided by simulation-based testing.
Dr. Sharan agrees, predicting that “as soon as in the next five or 10 years, before residents are allowed to drill or sew or cut on the brain, they will have to log 20 or 50 or however many hours on a simulator,” he says.
The Accreditation Council for Graduate Medical Education already mandates simulation training for some specialties, such as general surgery and obstetrics/gynecology.
“This is evolving technology. Ultimately, I think virtual simulation will provide core knowledge for first-year residents, and then hands-on simulation will come in the second and third year,” Dr. Sharan says. “But that’s not for us to decide. The future of neurosurgery simulation really depends on the American Medical Association and its residency review committees. It’s up to us to show them why it works.”
Although a No-Brainer, Simulation Has Limitations
Even as advances in technology and equipment progress, simulation is not without its limitations. For one thing, surgery is often unpredictable, and simulators cannot impart the “emotional training” that takes place when the unexpected occurs.
In time, Dr. Harrop hopes science and technology will evolve to better mimic real life.
“A problem is that when you are using a simulator, you can remain 100 percent dedicated to that task. That’s not reality. In the OR, there’s lots of background noise,” he says. “Surgeons have to be very good multitaskers — we must be able to listen and perform, keeping several balls in the air at all times.”
He and Dr. Sharan are considering making residents wear headphones streaming distracting sounds during simulation training in the future to examine whether performance is compromised.
Also, as with most medical equipment, simulation technology is expensive; physical models and virtual reality components can cost hundreds of thousands of dollars. There are bills in both the House and Senate that could lead to simulation funding, but Drs. Harrop and Sharan agree that it is daunting to think that residency programs may have to rely only on their own university resources to fund simulation curricula.
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