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Simulation and Medical
Performance
Peter G. Schulam, M.D., Ph.D.
Associate Professor
Department of Urology
Eric Savitsky, M.D.
Associate Professor
Department of Emergency Medicine
CASIT and
David Geffen School of Medicine at UCLA
To Err is Human
Institute of Medicine November 1999
44,000 – 98,000
deaths per year as a
result of medical
errors.
Cost of $17-29 billion
per year.
Medical Errors
Performance Level of 99.9%
Airline-2 dangerous landings/day
Banking-32,000 checks incorrectly
deducted/hour
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to act on results
Treatment
Error in drug dosing
Delay in responding to an abnormal test
Error in performance
Medical Errors
Locations
Intensive Care Units
Emergency Departments
Operating Rooms
Why?
Lack of standard credentialing
Fragmented health care system
Lack of access to all information
Human variability
Physician Variability
# of complications
Learning Curve
# of procedures
Traditional Training
Problems with the apprenticeship model
Variability of experience
Practice on real patients
Inefficiency
Cost
The OR is an expensive classroom
Lack of standardized proficiency criteria
Surgical Training
Laparoscopic Cholecystectomy
Southern Surgeons Club - 2.2% incidence of bile
duct injuries in first 13 pts/group (control 0.2%)
NEJM 1991
8,839 lap cholecystectomies by 55 surgeons - 90%
of bile duct injuries occurred during first 30 cases
Am Surg 1995
54% of surgical errors are potentially preventable
Nat Acad Press, 1999
Training Simulators
Inanimate models
Animal models
Cadaveric models
Virtual reality
Inanimate Models
Benefits
Cheap
Reuse materials
Accessible at
any time
Minimal
psychological
stress inhibiting
learning
Inanimate Models
Limitations
Lack of realism
Can only
simulate the
most basic
tasks
Difficult to
monitor
progress
Animal Models
Benefits
Realistic
physiology
Closer to
realistic
anatomy
Complex
procedures
More realistic
working
environment
Animal Models
Limitations
Expensive
Ethical issues
Difficult to
monitor
progress
Cadaveric Models
Benefits
Realistic
anatomy
Rohen & Yokochi. Color Atlas of Anatomy. 1993
Cadaveric Models
Limitations
Rohen & Yokochi. Color Atlas of Anatomy. 1993
Expensive
Physiologically
unrealistic
Unnatural
tissue
properties
Difficult to
monitor
progress
Virtual Reality Simulators
Benefits of Virtual Reality
Unlimited availability
Potential for a variety of tasks/procedures
From non-anatomic to surgical “pre-flight”
Allows for repetitive skill assessment
Minimal psychological stress inhibiting learning
Monitors trainee activity/improvement
Benefits of Virtual Reality
Virtual Mentor
Computer can guide a trainee through a procedure
and provide immediate feedback
Fulfills the continual, high-quality feedback
requirement for efficient learning
Establish metrics
Limitations of Virtual Reality
Complexity of organ modeling
Lack of force feedback
Procedure based systems
Potential >> Today’s Reality
Holy Grail
Simulation of a patient’s data set
allowing for
pre-procedural planning
Procedural Outcome
Diagnosis
History
Physical Exam
Ordering of data (labs and xrays)
Interpretation of data
Intervention
Familiarity/Dexterity with the tool set
Understanding the order of the operation
Familiarity of the anatomy
Adapting to anatomical variability
Controlling surgical mishaps
Decrease Physician Variability
Task Specific Simulation
Definition of Simulation
“A device or exercise that enables the
participant to reproduce, under test
conditions, phenomena that are likely to
occur in actual performance”
Krummel