RSNA 2004

RSNA News - October 2004

RSNA 2004 to Feature Focus Session on Medical Simulators

In order to perform procedures such as carotid stenting, you have to demonstrate a certain level of proficiency. The way to increase your proficiency is through medical simulation.— Anthony G. Gallagher, Ph.D.

Picture this: Medical students stand around a patient in an emergency room setting. The patient complains of severe abdominal pain. Following a diagnosis of sigmoid volvulus, a student injects a bolus of 10 mg morphine. The patient develops respiratory arrest and nearly dies. The patient is reprogrammed for the next lesson.

The patient isn't real. It is a high-fidelity medical simulator that talks, blinks, breathes and moves just like a real patient. Physiologic data, including heartbeat, oxygenation and blood pressure are displayed on a real-time cardiac monitor, alongside customized laboratory results and imaging studies. This particular scenario is part of an educational module created in the late 1990s by Harvard anesthesiologists John Pawlowski and Marty Gallagher at the Center for Medical Simulation in Boston.

Working with the Center, James A. Gordon, M.D., M.P.A., an emergency physician at Massachusetts General Hospital, now directs the new G.S. Bechwith Gilbert and Katharine S. Gilbert Medical Education Program in Medical Simulation at Harvard Medical School.

"Simulation is to medical education what the microscope was to science," says Nancy Oriol, M.D., Harvard's associate dean for student affairs. Originally costing up to $200,000, full-body patient simulators are now available for under $50,000.

Gary J. Becker, M.D., RSNA Board Liaison for Science and branch chief of image-guided intervention for the Cancer Imaging Program at the National Cancer Institute, agrees that medical simulators represent the future of medical education. "Following the exercise previously described, the students learned that they should have applied book knowledge in the emergency room," he says. "In the heat of battle, no one thought to reverse the effects of morphine sulfate with IV Narcan. This example of a tangible experience, with failure to recall and implement a life-saving treatment, is arguably a much better teaching method than a textbook."

At RSNA 2004 a hot topic focus session will be held on Wednesday, December 1 to highlight the use of medical simulators to educate radiologists—especially interventional radiologists. The session will also demonstrate how to use medical simulators to problem-solve in various medical scenarios.

One of the presenters, Anthony G. Gallagher, Ph.D., from Emory University, co-authored the first randomized, double-blinded study of virtual reality simulation in the training of surgical residents. The 2002 study demonstrated that residents trained on simulators to perform laparoscopic cholecystectomy performed 30 percent faster and were six times less likely to have intraoperative errors. Dr. Gallagher says a follow-up study with more complete data will be presented this month at the American College of Surgeons clinical congress.

"Minimally invasive procedures, especially image-guided interventions, are changing medicine," says Dr. Gallagher. "What we're seeing in carotid stenting is the convergence of interventional radiology, interventional cardiology, and vascular and neurovascular surgery. The FDA says that in order to perform procedures such as carotid stenting, you have to demonstrate a certain level of proficiency. The way to increase your proficiency is through medical simulation. This is a huge paradigm shift in medicine."

Focus session moderator Steven L. Dawson, M.D., an associate professor of radiology at Harvard, says medical education must be modernized. "Medicine is using the same teaching model that Egyptians used 4,000 years ago. If I'm a doctor in a teaching hospital and a sick person comes in, I learn while treating that person. If I need to learn how to treat a particular disease and no one with that disease shows up, I'm out of luck."

He adds that the system may have worked fine for many years, but times have changed. "We are in a crucial time in medical education where revolutions in computing, mathematics, engineering and education surround us," Dr. Dawson says. "Our challenge is to grab the best of these revolutions and create a new way of medical learning. Prototyping new procedures in silico gives a whole new meaning to the phrase, 'the practice of medicine.'"

Dr. Gordon will also participate in the focus session. His educational model of "full-body, immersive simulation" strives to replicate a full clinical encounter between a physician and a patient. He and his colleagues work with a robot-mannequin named "Stan," short for standard patient.

"The purpose of full-body patient simulation in my own work is to recreate a provider's emotional reaction to the care process," explains Dr. Gordon, who is an inaugural member of the Board of Overseers of the new Society for Medical Simulation. "In doing so, students using the simulator can integrate and remember material in a powerfully instructive way. Imagine a group taking care of Stan, who is having a heart attack and complains, 'Doctor, my chest hurts.' In the midst of the encounter, you could show the students a coronary angiogram to demonstrate the blocked artery. By juxtaposing 'real-time' diagnostic images alongside simulated clinical encounters, I think students can more easily integrate relevant anatomy and radiology with overall patient care."

The RSNA 2004 focus session will familiarize attendees with the state of the art of simulation and raise awareness of the concept's full potential.

Dr. Becker says medical simulators can be beneficial in:

Medical student education

Aptitude testing for specialty training

Specialty-specific clinical scenarios in residency training (e.g., response to life-threatening contrast reactions in radiology)

Procedure training—imparting essential skills, impacting the learning curve, reducing errors

Addition of advanced skills to basic ones already acquired (e.g., learning new procedures, such as carotid stenting, on a background of basic skills in angiography, angioplasty, stenting, etc.)

Re-credentialing in hospitals

Assessment (e.g., board examinations)

Maintenance of skills (practice hours logged in, as on a flight)

Practice improvement/quality assurance

"As a trustee for the American Board of Radiology (ABR), I envision the possibility of assessing a physician's ability to do a procedure," says Dr. Becker. "When a radiologist comes in for an oral exam, instead of showing an image and discussing how the patient would be managed, we could have the radiologist actually care for the patient."

Dr. Becker says medical simulation training also can help to counter the effects of the 80-hour workweek limits for residents. "There's a substantial and measurable decrease in the experience that residents are now getting," says Dr. Becker, who cites information from Boston Children's Hospital that there's been a 33 percent decline in the number of procedures performed by otolaryngology residents since the new work rules took effect. "Medical simulators could play a role to help this situation."

Dr. Becker proposes that radiology create a strategic approach to medical simulation with help from educators, RSNA staff and volunteers, academics, the simulation industry and ABR representatives. "Without a high level of commitment and an overarching approach, radiology is in danger of being left in the dust of other medical specialties," says Dr. Becker. "Emergency medicine, anesthesia and surgery embraced the topic a long time ago. Interventional cardiology is now on board as well. Although they are ahead of us, there is so much still to be done that we can certainly catch up if we seize the opportunity. But we will need a significant investment of time, energy and resources, as well as a thoughtful strategic approach that makes sense for the entire discipline."

RSNA's belief that medical simulator technology will play an increasingly important role in radiology education has resulted in a collaborative workgroup involving RSNA and the Society of Interventional Radiology.

Steven L. Dawson, M.D. (left), helps a student learn how to place a chest tube into a simulated patient. The monitor shows a representation of the internal position of the tube on an augmented display.

A hands-on exhibit on medical simulation will be featured at RSNA 2004 in the infoRAD area. For more information about the exhibit or about the hot topic focus session, "Is Medical Simulation a Part of Your Future? Education in the Era of Patient Safety," go to rsna2004.rsna.org and click on Meeting Program in the left-hand column. Also see the RSNA.org column for a mini-tutorial on how to use the online RSNA Meeting Program.