Simulators deliver an edge
ticeship model of learning by random example, in which surgeons have no control over the cases patients present with, and which limit exposure to rare conditions that require immediate and decisive action.
For example, Cregan notes that even tiny amounts of certain anaesthetic agents in genetically susceptible individuals can trigger a condition called malignant hyperthermia, or excessive heat, where the body literally cooks itself.
‘‘ An anaesthetist might encounter it once in a lifetime,’’ he explains. ‘‘ If (the doctor) is prepared, then the person will live — if not prepared, then the person will die.’’
And without practising on a simulator first, that surgical trainee performing his or her first appendectomy is likely to be wholly focused on the technical aspects of the operation, to the exclusion of other concerns.
‘‘ With less situational awareness you might not realise that the patient has turned bright blue because the anaesthetist has gone off to have a cup of coffee,’’ Cregan explains.
But do skills learned in a virtual world translate to the operating theatre? And is there any evidence that the emerging role of simulator labs in surgical training can actually improve patient outcomes? The jury remains out on these questions. According to Windsor, there are only about a dozen studies in the literature to date and most of them relate to the laparoscopic (keyhole surgery) removal of gall bladders.
However, he says what evidence exists is ‘‘ encouraging’’.
Meanwhile, research into how well the Mediseus epidural simulator predicts realworld performance is yet to be publicly released but ‘‘ preliminary results are that doctors (trained on the simulator) have less stress and fewer complications,’’ says Watterson.
Despite their potential, however, Windsor warns that simulators should not be embraced as a panacea for all the issues currently plaguing surgical training.
One of his key concerns is that the simulator developments are driven by information technology specialists rather than educationalists.
‘‘ We’re not asking the fundamental question: What are we trying to achieve?’’ he asks. ‘‘ Simulators have a place but (that place) has to be defined by educationalists, not the IT guys.’’
Windsor says he, like others, is also bothered by the ‘‘ short course mentality’’ that surrounds simulator technology ‘‘ with no pre-learning or post-learning for reinforcement’’.
An article in Surgical Endoscopy (2007;21:357-366) noted that surgical residents needed time to practise their technical skills ‘‘ and will often find this time to be in the middle of the night when on call’’.
‘‘ A simulation lab that truly serves the residents will thus provide a secure environment that is optimally located in a main hospital with access after hours.’’
But the availability of this technology is limited by its costs. According to Cregan, simulators designed to replicate colonoscopic, endoscopic and laparoscopic procedures cost $250,000 each. ‘‘ These are big investments — they’re not the sort of thing we can have on every street corner.’’
Sounding a further note of caution is urologist Donald Murphy, who believes that simulators are useful, but only as one part of the staged learning process: ‘‘ You cannot learn to be a surgeon by doing virtual reality computer games.’’
As medical director of the skills laboratory at the Royal Australasian College of Surgeons in Melbourne, Murphy has developed a ‘‘ bioreality model’’ for surgical training which he believes is one step closer to the real thing.
This involves using a piece of meat — even something edible, obtained from a supermarket or abattoir — and re-establishing a blood flow to create a more realistic model for surgical training.
For example, a chicken maryland — the leg with both thigh and drumstick attached — when perfused with blood can be adapted to provide a model for replicating pyeloplasty, the surgical reconstruction of the pelvis to take pressure off the kidney.
‘‘ When I show these models to my fellow surgeons they think they are seeing live tissue,’’ says Murphy.
While re-animating dead animal tissue can sound a bit gruesome for the lay person, Murphy points out that the model he’s created is a more publicly acceptable alternative to vivisection, or cutting up live animals, which also commonly occurs in surgical training.
One thing surgeons do agree on is that any form of simulation takes trainees only as far as the tabletop.
‘‘ At some stage you have to translate your skills into a real life person,’’ says Cregan. ‘‘ Everyone can train like mad on a simulator — but at some stage you must fly the aeroplane with an instructor, and eventually go solo.’’