Growing public resistance to patients being used as teaching material is fuelling the rise of surgical simulators, reports Denise Cullen
WHEN it comes to surgery, everyone agrees experience is the greatest teacher. Everyone, that is, except the patient upon whom a trainee intends to perform his or her first appendectomy. Surgical trainees have traditionally acquired their technical skills Grey’sAnatomy - style — in the operating room, working alongside more senior surgeons in an apprenticeship model.
But patients these days aren’t so keen on a real-life version of ambitious surgical intern Cristina Yang doing a running whip stitch on their still-beating heart. ‘‘ Public opinion is increasingly resistant to having patients used as teaching material,’’ explained professor Oscar Traynor, of the Royal College of Surgeons in Ireland, at the Royal Australasian College of Surgeons’ annual scientific congress in Christchurch, New Zealand, last month. ‘‘ We need to develop a new model of technical skills acquisition.’’
Enter virtual-reality simulators, which mimic the look, and even the feel, of performing actual surgical procedures. They provide for trainee surgeons what flight simulators provide for prospective pilots — the opportunity to hone their skills without killing anyone.
That is not so flippant as it sounds. An article in the British Medical Journal (2000;320:774-777) revealed that all forms of medical error results in as many as 18,000 unnecessary deaths in Australia each year, and more than 50,000 patients becoming disabled.
These figures are contentious; Bryce Cassin, manager of clinical safety and quality projects with the Australian Commission on Safety and Quality in Healthcare, argues they are an ‘‘ overestimation’’, and that it’s ‘‘ not clear how many surgical deaths are preventable, as the contributing factors are complex and not well understood’’.
However, Monash University researchers have noted that the number of errors committed is inversely proportional to a surgeon’s experience; and that there is a bigger chance of surgeons making mistakes in up to a dozen surgical procedures undertaken immediately after training.
Simulators — used in surgical training only for the last two to three years — reduce the risk of trainee surgeons injuring humans and give them permission to safely make mistakes, one of the necessary pre-conditions to learning, explains Patrick Cregan, associate professor of surgery at the University of Western Sydney.
Their use remains ‘‘ patchy’’ because of their complexity and high cost — around $250,000 for some machines — and the practical issues of developing curricula with simulation training as an integrated part, says John Windsor, professor of surgery at the University of Auckland and founding director of the Advanced Clinical Skills Centre in New Zealand.
Windsor points to the aviation industry, where simulation has progressed to a sophisticated tool even for experienced pilots.
‘‘ We have aviation at 100 per cent and surgery lagging way behind,’’ says Windsor. ‘‘ It’s difficult to know whether governments are going to mandate it, or whether training institutes (like the RACS) will do this first.
‘‘ Until then it is going to be advanced in centres with a particular interest and (as) diffuse as funds allow, until we get legislation that requires this approach.’’
Today’s high-tech simulators can replicate complete procedures, including keyhole gall bladder removal, sinus surgery and investigative procedures to examine the insides of the colon and womb.
They force trainees to make judgment calls and complete complex tasks using their visual perception. The most sophisticated simulators have ‘‘ force feedback’’ technology, where trainees can feel resistance against the instrument when it presses or pulls, according to the tissue that they are supposedly ‘‘ cutting’’ or moving through at the time.
This can be crucial when it comes to practising procedures that rely mostly on touch — such as epidurals, which provide pain relief during labour. The procedure involves inserting a large hollow needle into the patient’s spine and advancing it until the epidural space — identified by a sudden loss of resistance — is reached. Sliding the needle even a couple of millimetres too far can cause complications ranging from headaches to spinal cord damage, explains anaesthetist Leonie Watterson, chair of the Australian Society for Simulation in Healthcare. The Division of Anaesthesiology and Intensive Care at the University of Queensland reported that such headache-provoking punctures occurred in about 1.7 per cent of cases in teaching hospitals.
These high stakes, coupled with the difficulties associated with dealing with labouring women suffering severe pain, make it ‘‘ extremely stressful’’ for junior doctors trying to learn on real patients.
Accordingly, Watterson was involved in the development of the Mediseus epidural simulator, launched less than two years agoSimulator labs also prepare surgeons for a wide variety of difficult situations.
This differs from the traditional apprentContinued inside, page 19
Trial run: Surgeon Donald Murphy, left, and Matt Jackson simulate keyhole surgery at the Royal Australasian College of Surgeons