Surgeons should practice on computers, not people

February 18, 2010: 10:00 AM ET

Pilots train on flight simulators, so why do physicians learn only by doing?

By Curt Rawley, Chairman and CEO, SensAble Technologies

Rawley: Pilots train on simulators, why not surgeons? Photo: SensAble

Rawley: Tech can help surgeons develop a human touch. Photo: SensAble Technologies

Technology has transformed entire industries, from manufacturing and farming to media and marketing. So why has tech transformation eluded medicine, and medical education to be specific?

It's time we stop training doctors and surgeons in the same apprenticeship model that has been used for a hundred years. Despite many studies showing that surgeons need between 60 to 500 repetitions of a procedure to achieve proficiency, medical schools usually provide 10 to 20 repetitions on cadavers – with the rest of the training left up to supervised surgery.

Yet recent restrictions in allowed hospital hours mean that residents spend less time in patient encounters – and perhaps fall short of needed repetitions.  We make pilots log hours in flight simulators; we should make surgeons go through similar training.

Cost is not a factor anymore

Ten years ago, the cost of simulation technology for medical procedures may have been an impediment.  Today, computational power has gone down in price and up in performance.  Realistic graphics and haptics – the science of artificial touch -- make it possible for organizations using my company's haptic technology and others to build highly lifelike simulators that deliver multi-sensory experiences, including the exact sight, sounds and feelings of a procedure.

With simulation, practice poses zero risk to patients, lowers demands on professor/attending physicians' time, and hopefully means fewer adverse effects and ultimately, lower malpractice insurance costs.

Advanced medical simulation democratizes access to experience between big city teaching hospitals with their highly specialized expertise and unlimited access to the cadaveric body parts used for practice – and hospitals in smaller cities or more geographically remote settings.   Simulators are the next generation's basic skills trainers, and not just for surgeons.

Learning by feeling

Simulators can help doctors learn new procedures, or practice handling conditions and complications they don't see every day. Touch-enabled simulators can teach blind procedures, such as epidurals, that surgeons, nurses and phlebotomists can only learn by feeling.

Advanced simulation can objectively assess the manual skill required to perform a specific procedure.  For example, an older surgeon may develop a tremor and his hand may not be steady enough for him to operate – or a newer surgeon may lack manual dexterity.  Once validated, simulator performance could be tied to state licensure or certifications by specialty medical boards.   Such competency tests might then become a way to lower malpractice insurance rates, in the same way some states allow this for teenagers who take driver education.

Taking a metaphor from sports, Dr. R. M. Satava and colleagues at Yale and Arizona State University have advanced the concept of "pre-operative warm-up." Dr. Satava and others have shown that warming up their hands in advance by using a simulator – the way an athlete warms up before a game - has benefits.  Innovators at Stanford have gone even further with  "virtual body doubles" made from the patient's own CT scans -  so the pre-operative surgical planning and practice can be done on each patient's individual  morphology.  The idea is particularly compelling with procedures such as sinus surgery or vascular catheterization where risks are high and anatomy can vary greatly from patient to patient.

In a more proactive approach, we could implement such technology as a form of skills analyzer, like pilots must use breathalyzers in some countries before taking control of the cockpit, as a mechanism to make sure surgeons aren't too tired or shaky to operate.

Gerald B. Healy, MD, professor of otology and laryngology at Harvard Medical School and past president of the American College of Surgeons, said the recent health-care reform debate failed to address many festering issues in graduate medical education such as diminished patient encounters for surgical trainees. This is a result of changes in medical practice and limitations on training hours, at a time when specialization has intensified.  "Unless we have a 21st century approach to educating surgeons and keeping them current, we are going to increase the risk to patients," Dr. Healy said.

The Obama administration's allowance of stimulus funding for medical education centers is certainly a step in the right direction.  To supplement this Reps. J. Randy Forbes (R-VA) and Patrick Kennedy (D-RI) co-sponsored the Enhancing SIMULATE Act of 2009 seeking $50 million in additional funding.

These are worthy and important first steps.  Whether the Federal budget can support additional funding for advanced medical simulation is an open question.  Yet at a time when an estimated 88 percent of patient safety incidents are avoidable -- when malpractice litigation costs $30 billion annually -- and when we've tasked ourselves to unleash innovation in other markets - isn't it time we stopped asking "Why spend for medical simulation?" and ask "Why not?"

Rawley is chairman and CEO of SensAble Technologies, a leading provider of haptic devices used in medical simulation, customized medical implant design, and pre-operative surgical planning.

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