"We are working to validate the use of simulation in graduate medical education training so that one day we can use it to replace a certain amount of clinical training involving live patients", stated lead author and course instructor David Dawson, a professor of vascular surgery at the UC Davis Vascular Center.
"We wanted to see if our teaching methods were working. We knew we were seeing improvement, but we didn't know just how much", David Dawson stated. He and his colleagues tested nine course participants on the first day of the course prior to any training, and again on the second day after receiving eight hours of simulation-based training, as well as classroom instruction, computer-based training and tabletop-procedure demonstrations.
After simulation training, residents were able to reduce procedure time by 54 percent, volume of contrast dye by 44 percent and fluoroscopy time by 48 percent. Reducing these measures in clinical practice translates into increased safety and decreased cost to the health care system.
"That's because fluoroscopy involves small doses of radiation and large volumes of contrast dye can result in kidney damage in the patient", David Dawson stated. "There is no doubt that when one of our trainees goes on to perform procedures on patients, he or she will be much better prepared."
Traditional vascular surgery involves operations to repair arteries that have either developed an aneurysm, a ballooning of the vessel wall that can result in a fatal rupture, or have become blocked due to atherosclerosis, a gradual build-up of plaque over time. Peripheral plaques, which are made up of fats and cholesterol, can restrict blood flow to organs or limbs, depending on where they form. Plaques can cause vessel occlusions or embolism if pieces break off and become lodged in a critical part of the circulation, such as the brain.
Endovascular treatment of these conditions involves a small incision in the skin, the placement of catheters, use of balloons that are inflated to open blocked vessels, and the insertion of stents - small, mesh-like tubes - to hold the vessel open, or combinations of the techniques. Physicians must operate remotely, watching the movement of their tiny instruments and equipment on a video monitor.
The course, now three years old, is taught in the UC Davis Center for Virtual Care. It has included participants from 11 residency programmes in five Western states: California, Arizona, Oregon, Utah and Washington. The published results are based on surgery residents who participated in the programme during its second year.
During the two-day course, the doctors practised a variety of skills, including manipulation of catheters, use of sheaths, wire handling, angioplasty balloon inflation and deployment of stents. Trainees were guided via computer through various scenarios using a virtual reality set-up that involved watching video monitors while manipulating instruments in a high-tech mannequin. All components of the course are part of the commercially available endovascular simulation called SimSuite.
According to David Dawson, simulation-based training will be a part of the future of medical education. "The real goal is to train doctors to do complex procedures and make it efficient in terms of reducing the risks to patients, as well as saving time and money", he stated. UC Davis invests $300.000 to $400.000 annually on the simulation tools and service support to meet its endovascular educational objectives. David Dawson said that studies by others estimate an average savings of $50.000 per resident trained on simulators due to increased efficiency and decreased use of operating rooms.
David Dawson, himself a pilot and former NASA medical officer, compares simulation-based medical training to the use of flight simulators in the aviation industry and notes that some physician accreditation organisations are already including performance on simulators as part of their exams. "But, for simulation training to become widespread, we need additional studies to provide further validation that proficiency with simulators translates into better, safer care for patients", David Dawson stated.
UC Davis co-authors include Eugene Lee, assistant professor and William Pevec, professor and chief of vascular surgery. Boston Scientific Corporation provided an educational grant to defray the costs of the programme, but UC Davis faculty was solely responsible for the curriculum development and teaching. The grant paid direct costs for participants travel and simulator use. Jennifer Meyer is an educational specialist employed by Medical Simulation Corporation, the company that produced the SimSuite endovascular procedures simulator.