Sunday, April 30, 2006

Surgeons, Simulators And SAGES

So Much To Learn With So Little Time

It is not just the amount of information in medicine that is expanding but also the usefulness of that information. In healthcare there is an exponential growth of information which is being used to create new treatments and operations all the time. It is one thing to keep pace with and manage the available information, but it is another thing to maintain and learn the skills required to perform the ever expanding array of new and innovative operative techniques. One way to do this is through the use of simulators. In a previous post I discussed the rational for using simulators to enhance training and reduce the potential for error. This last week I attended the SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) meeting in Dallas, Texas. While there I was reminded of the importance of simulators for the continuing education, training and development of operative skills throughout a surgeons career.

The Surgical Culture

There are barriers to the use of surgical simulators and the biggest one will arise directly from the current culture within surgery. Surgeons are very independent individuals. We don't like being told what to do and prefer giving orders as opposed to taking them. It's an extremely useful trait in the operating room and trauma room. These are environments that have little tolerance for indecision or time for debate. It often comes down to one vote and the one that counts is the surgeon in charge. Such skillful and autonomous individuals are more than likely going to provide some push-back when it comes to taking time off of their busy schedules to train on the simulator, but that is where the future of surgery is headed. Simulators will be used for basic training, research, maintenance of operative skills, acquisition of new skills and operative techniques, maintenance of board certification and hospital credentialing. Whether we like it or not surgeons are going to have to get on board with simulators. In time our culture will demand it and that will count as the one and only vote on whether we will do it or not.

Teaching Old Dogs New Tricks

When we complete our surgical residency it is assumed that we are proficient in all the skills that will be required of a surgeon throughout their career. In the early 1990's this paradigm was shattered by the introduction of an operation call laparoscopic cholecystectomy or the removal of a gallbladder using the assistance of a small operating scope and minimally invasive surgical techniques. What made this operation so radically different was the novel use of techniques not previously taught to most surgeons already in practice. Initially surgeons rejected the idea of using a laparoscope to remove a gallbladder, but in time the operation gained widespread acceptance. During this transitional period I was a surgical resident and witnessed first-hand the oftentimes awkward transformation of a surgeon use to open techniques learning the newer minimally invasive laparoscopic techniques. On many an occasion the surgical resident in training was more familiar with the laparoscopic techniques than the board certified surgeon who was supposed to be teaching them. Like I said it could be awkward. With the introduction of simulators we don't have to go through that experience ever again.

Pumping Up At The Simulator Lab

Simulators will allow us to not only develop new skills, but bring us up to date on skills we once acquired, but have allowed to atrophy from lack of use. Over time a surgeon tends to focus their career in a particular area of specialty. Some skills crossover from specialty to specialty, but some do not. Some skills never seem to be forgotten (like riding a bike) but other skills, usually more technical ones, degrade very quickly. When an old skill, which deteriorated due to lack of use, becomes uselful again, simulators will bring that skill up to an acceptable level of proficiency. Identifying the metrics needed to guarantee proficiency will take more work, but we are approximating that point. Many of the newer models of simulators (Simbionix, ProMis) have these types of metrics built into them. SAGES has also taken the lead in this endeavor with its Fundamentals of Laparoscopic Surgery educational module. The most encouraging thing I heard at the recent SAGES meeting was that everyone who is able and motivated can not only develop new skills and techniques, but can also improve an old skill that needs some tuning up. In time, simulators will become an enduring part of our surgical culture. It's time has come.

Wednesday, April 05, 2006

Simulation: Healthcare's Answer For A High-Risk Environment

To Err Is Human

Anything that has the potential to adversely affect the care delivered to patients is slowly being driven out of the Healthcare System and for good reason. In 1999 the Institute of Medicine (IOM) released its report, To Err is Human: Building a Safer Health System, which stated that between 44,000 and 98,000 Americans die each year due to medical errors. Without significant changes in our Healthcare System this estimate is expected to increase. The quandary we face though is that innovation in Medicine is dependent on research, and research, particularly high-risk research, is dependent on trial and error. So how do we build a safer Health System and utilize the advances that can be gained by potentially risky research?

Primum Non Nocerum

Healthcare has embraced the philosophy of Total Quality Management (TQM). There isn't a hospital operating in the United States that doesn't have some type of quality improvement system in place. The medico-legal risk of not having one is too high. The advantage of embedding TQM philosophy in the Healthcare System strikes at the heart of the IOM's report. We need to build a safer system and in order to do that we must create a system that has an extremely low tolerance for error. In the process of doing this hospitals and the people who work in them must become risk adverse. Protecting the patient becomes paramount in such a Healthcare System and our highest value becomes patient safety. Research, particularly research involving patients, involves risk. So how do we in the Healthcare System engage in high risk activities in a risk adverse environment?

In Search Of "Best Practices"

One of the ways is to separate what we consider experimental from the standard of care. This is not always easy as part of what we sometimes refer to as the "art of medicine" is found in the gray, indeterminate area between the two. The resolution in today's Healthcare System is to decrease the heterogeneity of specific practice patterns by focusing on the delivery of "best practices". The advantage is to eliminate worst or even mediocre practices and raise the standard of overall care. Advances in the "best practices" standard will occur through a combination of "evidence based medicine" and "practice based evidence". Evidence based medicine uses research involving specific patient populations and consensus opinions among practitioners to derive "best practices". "Practice base evidence" uses statistical methods to evaluate existing patient care databases to derive "best practices" among practitioners providing care to a general patient population. "Practice based evidence" is a relatively low-risk way to identify "best practices". Research, on the other hand, is the gold standard for evidence based medicine but carries some increased risk. What we need is a way to further reduce risk in the research we perform as well as any other areas that are inherently risky but necessary.

Simulators Aren't Just For Pilots

Simulation is in its infancy but has enormous potential as one of many strategies evolving to reduce risk in our Healthcare System. The two main areas it will affect are research and education/training. Creating and testing research models on simulators prior to exposing patients to a research protocol will reduce some of the risk inherent and necessary in experiments. "Best practices" will follow a path that goes from hypothesis, to research simulation, to clinical research, to evidence based medicine, and on to the final testing ground as practice based evidence. In addition, future medical students and residents will train on simulators to learn and further develop their skills. This will reduce some of the risk that is inherent in medical education. The old saying, "See one, Do one, Teach one", will become, "See one, Sim one, Do one". The goals of simulation are to reduce error, maintain patient safety, encourage innovation and to constantly improve quality and outcomes in our health and our Healthcare System.