The PreOp flexible sigmoidoscopy trainer. Validation and early evaluation of a virtual reality based system

Validation of a Tool-Based Visual Anorectal Examination Advanced Simulator for the Early Detection of Colorectal Cancer

Rectal examination through proctoscopy or rigid sigmoidoscopy is a common investigation in clinical practice. It is an important diagnostic tool for the workup and management of anorectal pathologies. Performing the examination can be daunting not only for patients but also for junior doctors. There are associated risks with the procedure, such as pain, diagnostic failure, and perforation of the bowel. Simulation-based training is recognised as an important adjunct in clinical education. It allows students and doctors to practice skills and techniques at their own pace in a risk-free environment. These skills can then be transferred to and developed further in clinical practice. There is extensive research published regarding the role of simulation-based training in endoscopy, however, we identified no published study regarding simulation-based training in rigid sigmoidoscopy or proctoscopy. This study aims to establish the initial face, content, and construct validity of a tool-based visual anorectal examination advanced simulator model for proctoscopy and rigid sigmoidoscopy. This innovative, highly realistic simulated environment aims to enhance the training of healthcare professionals and improve the efficiency of detecting and diagnosing distal colorectal disease.

Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review

The role of simulation in medical education is crucial to the development of surgeons' skills. Surgical simulation can be used to improve surgical skills in a secure and risk-free environment. Animal models, simulated patients, virtual reality, and mannequins are some types of surgical simulation. As a result, feedback encourages students to reflect on their strengths and weaknesses, enabling them to focus on improvement. Healthcare simulation is a strong educational instrument, and the main goal of this is to give the students an opportunity to do a practical application of what they have learned through theory. Before taking it to the patients, they will already have certain tools they have previously acquired during the practice. This makes it easier for students to identify the knowledge gaps that they must fill to improve patient outcomes. Moreover, simulation brings a wonderful opportunity for students to acquire skills, gain confidence, and experience success before working with real patients, especially when their clinical exposure is limited. The use of simulation to teach technical skills to surgical trainees has become more prevalent. The cost of setting up a simulation lab ranges from $100,000 to $300,000. There are several ways to evaluate the effectiveness of simulation-based surgical training. Repetitive surgical simulation training can improve speed and fluidity in general surgical skills in comparison to conventional training. Few previous studies compared learners who received structured simulation training to a group of trainees who did not receive any simulation training in single-center randomized control research. Significantly faster and less time-consuming skill proficiency was noticeable in simulated trainees. Despite being anxious in the operating room for the first time, simulated trainees completed the surgery on time, demonstrating the effectiveness of surgical simulation training. Traditional surgical training involves senior-surgeon supervision in the operating room. In simulation-based training, the trainees have full control over clinical scenarios and settings; however, guidance and assessment are also crucial. Simulators allow users to practice tasks under conditions resembling real-life scenarios. Simulators can be compared with traditional surgical training methods for different reasons. For example, intraoperative bleeding may occasionally show up not only visibly on the screen but also by shaking the trocars erratically. Without haptics, training on virtual simulators can cause one's pulling and pushing forces, which are frequently greater than what the tissue needs, to be distorted. A good method of simulation training is using virtual reality simulators with haptics and simulated patients. The availability of these facilities is limited, though, and a typical session might include an exercise involving stacking sugar cubes and box trainers. The degree of expertise or competency is one area that needs clarification as medical education transitions to a competency-based paradigm. The article aims to provide an overview of simulation, methods of simulation training, and the key role and importance of surgical simulation in improving skills in surgical residents.

Performance Assessment of Subjects With Nursing Education Trained in Sigmoidoscopy by Means of a Simulator

Reports evaluating simulation-based sigmoidoscopy training among nurses are scarce. The aim of this prospective nonrandomized study was to assess the performance of nurses in simulated sigmoidoscopy training and the potential impact on their performance of endoscopy unit experience, general professional experience, and skills in manual activities requiring coordinated maneuvers. Forty-four subjects were included: 12 nurses with (Group A) and 14 nurses without endoscopy unit experience (Group B) as well as 18 senior nursing students (Group C). All received simulator training in sigmoidoscopy. Participants were evaluated with respect to predetermined validated metrics. Skills in manual activities requiring coordinated maneuvers were analyzed to draw possible correlations with their performance. The total population required a median number of 5 attempts to achieve all predetermined goals. Groups A and C outperformed Group B regarding the number of attempts needed to achieve the predetermined percentage of visualized mucosa (p = .017, p = .027, respectively). Furthermore, Group A outperformed Group B regarding the predetermined duration of procedure (p = .046). A tendency was observed for fewer attempts needed to achieve the overall successful endoscopy in both Groups A and C compared with Group B. Increased score on playing stringed instruments was associated with decreased total time of procedure (rs = -.34, p = .03) and with decreased number of total attempts for successful endoscopy (rs = -.31, p = .046). This study suggests that training nurses and nursing students in simulated sigmoidoscopy is feasible by means of a proper training program. Experience in endoscopy unit and skills in manual activities have a positive impact on the training process.

Development of Simulator Guidelines for Resident Assessment in Flexible Endoscopy

Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE Endoscopy VR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners’ knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.

Supporting self-regulation in simulation-based education: a randomized experiment of practice schedules and goals

Self-regulated learning is optimized when instructional supports are provided. We evaluated three supports for self-regulated simulation-based training: practice schedules, normative comparisons, and learning goals. Participants practiced 5 endoscopy tasks on a physical simulator, then completed 4 repetitions on a virtual reality simulator. Study A compared two practice schedules: sequential (master each task in assigned order) versus unstructured (trainee-defined). Study B compared normative comparisons framed as success (10% of trainees were successful) versus failure (90% of trainees were unsuccessful). Study C compared a time-only goal (go 1 min faster) versus time + quality goal (go 1 min faster with better visualization and scope manipulation). Participants (18 surgery interns, 17 research fellows, 5 medical/college students) were randomly assigned to groups. In Study A, the sequential group had higher task completion (10/19 vs. 1/21; P < .001), longer persistence attempting an ultimately incomplete task (20.0 vs. 15.9 min; P = .03), and higher efficiency (43% vs. 27%; P = .02), but task time was similar between groups (20.0 vs. 22.6 min; P = .23). In Study B, the success orientation group had higher task completion (10/16 vs. 1/24; P < .001) and longer persistence (21.2 vs. 14.6 min; P = .001), but efficiency was similar (33% vs. 35%; P = .84). In Study C, the time-only group had greater efficiency than time + quality (56% vs. 41%; P = .03), but task time did not differ significantly (172 vs. 208 s; P = .07). In this complex motor task, a sequential (vs. unstructured) schedule, success (vs. failure) orientation, and time-only (vs. time + quality) goal improved some (but not all) performance outcomes.

Medical Training using Simulation: Toward Fewer Animals and Safer Patients

This paper presents the current status of computer-based simulation in medicine. Recent technological advances have enabled this field to emerge from esoteric explorations in academic laboratories to commercially available simulators designed to train users to perform medical procedures from start to finish. Today, more than a dozen companies are producing virtual reality simulators and interactive manikins for training in endoscopy, laparoscopy, anaesthesia, trauma management, angiography, and needle insertion. For many of these procedures, thousands of animals are still being used in training. Yet simulation has many advantages that can transcend scientific, ethical, economic and logistical problems that arise when using animals. The first validation studies of medical simulators began appearing in the late 1990s, and the early results indicate that these devices measure what they are intended to, and that they can improve performance relative to traditional learning methods. In addition to expanded use for new and existing minimally invasive procedures, medical simulators will probably soon be used in physician credentialing, and they may someday allow surgeons to rehearse procedures in a patient-specific operating environment. Replacing animals with simulators in medical training is limited no longer by technical feasibility but by a willingness of the medical community to embrace it.

Simulator training in gastrointestinal endoscopy - From basic training to advanced endoscopic procedures

Simulator-based gastrointestinal endoscopy training has gained acceptance over the last decades and has been extensively studied. Several types of simulators have been validated and it has been demonstrated that the use of simulators in the early training setting accelerates the learning curve in acquiring basic skills. Current GI endoscopy simulators lack the degree of realism that would be necessary to provide training to achieve full competency or to be applicable in certification. Virtual Reality and mechanical simulators are commonly used in basic flexible endoscopy training, whereas ex vivo and in vivo models are used in training the most advanced endoscopic procedures. Validated models for the training of more routine therapeutic interventions like polypectomy, EMR, stenting and haemostasis are lacking or scarce and developments in these areas should be encouraged.

Training and competence assessment in GI endoscopy: a systematic review

INTRODUCTION

Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme.

AIMS

The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence.

METHODS

A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round.

RESULTS

The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance.

CONCLUSIONS

The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.

Performance of different categories of operators in simulated diagnostic colonoscopy

The possible involvement, although limited to the diagnostic phase of the procedure, of nonmedical staff (particularly endoscopy nurses) in lower digestive endoscopy has recently been suggested. Computer-based simulators have demonstrated objective evaluation of technical skills in digestive endoscopy. The aim of this study was to evaluate basic colonoscopy skills of endoscopy nurses (naive operators), as compared with junior physician staff and senior endoscopists, through a virtual reality colonoscopy simulator. In this single-center, prospective, nonrandomized study, 3 groups of digestive endoscopy operators (endoscopy nurses, junior doctors [<150 previous colonoscopies], expert doctors [>500 previous colonoscopies and >200/year]) completed six diagnostic cases generated by an endoscopic simulator (AccuTouch, Immersion Medical, Gaithersburg, MD). The performance parameters, collected by the simulator, were compared between groups. Five parameters have been considered for statistical analysis: time spent to reach the cecum; pain of any degree; severe/extreme pain; amount of insufflated air; percentage of visualized mucosa. Statistical analysis to compare the three groups has been performed by means of Wilcoxon test for two independent samples and by means of Kruskal-Wallis test for three independent samples (p < .05). Sixteen operators have been studied (six endoscopy nurses, five junior doctors, and five senior doctors); 96 colonoscopic procedures have been evaluated. Statistically significant differences between experts and naive operators were observed regarding time to reach the cecum and induction of severe/extreme pain, with both Kruskal-Wallis and Wilcoxon test (p < .05); all other comparisons did not reach statistical significance. Although, as expected, expert doctors exceeded both junior doctors and naive operators in some relevant quality parameters of simulated diagnostic colonoscopies, the results obtained by less expert performers--and particularly by nursing staff--appear satisfactory as in regards to most of the considered quality parameters and suggest a potential value of this device in effectively teaching basic lower digestive endoscopy to beginners in a relatively short time.

Registered nurse-performed flexible sigmoidoscopy in Ontario: development and implementaton of the curriculum and program

Although colorectal cancer is a leading cause of death in Canada, it is curable if detected in the early stages. Flexible sigmoidoscopy has been shown to reduce the incidence and mortality of colorectal cancer in patients who are at average risk for this disease and, therefore, is an appropriate screening intervention. Moreover, it may be performed by nonphysicians. A program to enable registered nurses to perform flexible sigmoidoscopy to increase colorectal cancer screening capacity in Ontario was developed. This program incorporated practical elements learned from other jurisdictions as well as specific regional considerations to fit within the health care system of Ontario. The nurses received structured didactic and simulation training before performing sigmoidoscopies on patients under physician supervision. After training, nurses were evaluated by two assessors for their ability to perform complete sigmoidoscopies safely and independently. To date, 17 nurses have achieved independence in performing flexible sigmoidoscopy at 14 sites. In total, nurses have screened >7000 Ontarians, with a cancer detection rate of 5.1 per 1000 screened, which is comparable with rates in other jurisdictions and with sigmoidoscopy performed by gastroenterologists, surgeons and other trained nonphysicians. We have shown, therefore, that with proper training and program structure, registered nurses are able to perform flexible sigmoidoscopy in a safe and thorough manner resulting in a significant increase in access to colorectal cancer screening.

The effect of model fidelity on colonoscopic skills acquisition. A randomized controlled study

INTRODUCTION

Colonoscopic simulators offer the opportunity for skill acquisition in the preclinical setting. Currently available simulators vary widely with respect to level of fidelity and technological sophistication. Despite the belief that more realistic is better, there is a paucity of evidence regarding the relative effectiveness of simulator fidelity (high vs low) on the acquisition of basic colonoscopic skills. We hypothesized that novice learners can acquire basic colonoscopic skills using simulators, however fidelity of the simulator does not make a difference.

METHODS

We randomly assigned novice third-year and fourth-year medical students to practice on either a low-fidelity or high-fidelity colonoscopy model. The low-fidelity model used is described in the module 16 of the American College of Surgeons/Association of Program Directors in Surgery surgical skills curriculum for residents, Phase 1: basic or core skills and tasks < http://elearning.facs.org/mod/resource/view.php?1d=450 >. The high-fidelity model was the AccuTouch colonoscopy simulator, Immersion Medical (AccuTouch CS) that has 6 different simulated scenarios for diagnostic colonoscopy (level 1-6). Both groups had 16 students and were given standard instruction by an expert with respect to the procedure and instrument handling on both models. Both groups were pretested and posttested on level 1 of the AccuTouch CS. The high-fidelity group practiced on level 2 and 4 of the AccuTouch CS, whereas the low-fidelity group practiced on the low-fidelity model for 2 sessions of 1 hour each. The computer-based evaluation parameters available on the AccuTouch CS were used to compare performances.

RESULTS

Both groups had similar demographics. There were no significant differences in the baseline performances of either group. Each group demonstrated significant improvement for insertion time and percentage of mucosa visualized. However, there were no significant differences between the groups on posttesting on any of the measured parameters.

CONCLUSIONS

Colonoscopic skill training on a low-fidelity model appears to be as effective as high-fidelity model training for basic endoscopic skill acquisition for novice learners.

The WIMAT colonoscopy suitcase model: a novel porcine polypectomy trainer

AIM

Simulation allows the acquisition of complex skills within a safe environment. Endoscopic polypectomy has a long learning curve. Our novel polypectomy simulator may be a useful adjunct for training. The aim of this study was to assess its content validity.

METHOD

The Welsh Institute for Minimal Access Therapy (WIMAT) endoscopy suitcase was designed to simulate colonic polypectomy. Participants from regional and national courses were recruited into the study. Each undertook a standardized simulated polypectomy and completed a seven-point Likert scale questionnaire examining its realism.

RESULTS

In all, 17 participants completed the questionnaire: 15 (88.2%) gastroenterologists, one (5.9%) colorectal surgeon and one (5.9%) experienced endoscopic nurse specialist. Of the gastroenterologists, seven (46.7%) were consultants and eight (53.3%) were senior trainees or Post CCT (Certificate of Completion of Training) fellows. The mean number of real-life polypectomies performed by the cohort was 156 (95% CI 35-355). The highest scores were for 'mucosal realism' (median score 6.0, P=0.001), 'endoscopic snare control' (median score 6.0, P=0.001), 'handling the polyp' (median score 6.0, P=0.001) and 'raising mucosa' (median score 6.0, P<0.001). Of the 15 parameters examined only three were not statistically significant in favour of the simulator. These were 'anatomical realism of sessile polyps', 'resistance of scope movement' and 'paradoxical motion'. The overall score for the simulation was 6.0 (P < 0.001). There was no significant difference between the level of difficulty of the simulator compared with real life (median score 4.0, P = 0.559).

CONCLUSION

The WIMAT colonoscopy suitcase model has excellent content validity for several parameters. This may have potential applications in medical training and assessment.

Poor discriminatory function for endoscopic skills on a computer-based simulator

BACKGROUND

Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes.

OBJECTIVE

To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills.

DESIGN

Prospective, observational, non-randomized, parallel cohort study.

SETTING

Single academic center with accredited gastroenterology training program.

PARTICIPANTS

Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians.

INTERVENTION

Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys.

MAIN OUTCOME MEASUREMENTS

The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed.

RESULTS

Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy.

LIMITATIONS

Small sample size.

CONCLUSION

The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.

Simulation in surgery: a review

The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these technical skills can be learnt away from the operating theatre. The aim of this review article is to discuss the importance of surgical simulation today and its various types, exploring the effectiveness of simulation in the clinical setting and its challenges for the future. Surgical simulation offers the opportunity for trainees to practise their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance. This enables better patient safety and standards of care. Surgical simulators can be divided into organic or inorganic simulators. Organic simulators, consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. Inorganic simulators comprise virtual reality simulators and synthetic bench models. Current evidence suggests that skills acquired through training with simulators, positively transfers to the clinical setting and improves operative outcome. The major challenge for the future revolves around understanding the value of this new technology and developing an educational curriculum that can incorporate surgical simulators.

The emerging role of screen based simulators in the training and assessment of colonoscopists

Incorporation of screen based simulators into medical training has recently gained momentum, as advances in technology have coincided with a government led drive to increase the use of medical simulation training to improve patient safety with progressive reductions in working hours available for junior doctors to train. High fidelity screen based simulators hold great appeal for endoscopy training. Potentially, their incorporation into endoscopy training curricula could enhance speed of acquisition of skills and improve patient comfort and safety during the initial phase of learning. They could also be used to demonstrate competence as part of the future relicensing and revalidation of trained endoscopists. Two screen based simulators are widely available for lower gastrointestinal endoscopy training, with a third recently produced in prototype. The utility of these simulators in lower gastrointestinal endoscopy training has been investigated, and construct and expert validity has been shown. Novices demonstrate a learning curve with simulator training that appears to represent real learning of colonoscopy skills. This learning transfers well to the real patient environment, with improvements in performance and patient discomfort scores in subsequent initial live colonoscopy. The significant limitations of currently available screen based simulators include cost implications, and restrictions on a role in certification and revalidation. Many questions remain to be answered by future research, including how best to incorporate screen based simulators into a colonoscopy training programme, their role in training in therapeutic endoscopy and the impact of simulator training on patient safety.

Global Assessment of Gastrointestinal Endoscopic Skills (GAGES): a valid measurement tool for technical skills in flexible endoscopy

BACKGROUND

Simulators may improve the efficiency, safety, and quality of endoscopic training. However, no objective, reliable, and valid tool exists to assess clinical endoscopic skills. Such a tool to measure the outcomes of educational strategies is a necessity. This multicenter, multidisciplinary trial aimed to develop instruments for evaluating basic flexible endoscopic skills and to demonstrate their reliability and validity.

METHODS

The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) Upper Endoscopy (GAGES-UE) and Colonoscopy (GAGES-C) are rating scales developed by expert endoscopists. The GAGES scale was completed by the attending endoscopist (A) and an observer (O) in self-assessment (S) during procedures to establish interrater reliability (IRR, using the intraclass correlation coefficient [ICC]) and internal consistency (IC, using Cronbach's alpha). Instrumentation was evaluated when possible and correlated with total scores. Construct and external validity were examined by comparing novice (NOV) and experienced (EXP) endoscopists (Student's t-test). Correlations were calculated for GAGES-UE and GAGES-C with participants who had performed both.

RESULTS

For the 139 completed evaluations (60 NOV, 79 EXP), IRR (A vs. O) was 0.96 for GAGES-UE and 0.97 for GAGES-C. The IRR between S and A was 0.78 for GAGES-UE and 0.89 for GAGES-C. The IC was 0.89 for GAGES-UE, and 0.95 for GAGES-C. There were mean differences between the NOV and the EXP endoscopists for GAGE-UE (14.4 +/- 3.7 vs. 18.5 +/- 1.6; p < 0.001) and GAGE-C (11.8 +/- 3.8 vs. 18.8 +/- 1.3; p < 0.001). Good correlation was found between the scores for the GAGE-UE and the GAGE-C (r = 0.75; n = 37). Instrumentation, when performed, demonstrated correlations with total scores of 0.84 (GAGE-UE; n = 73) and 0.86 (GAGE-C; n = 45).

CONCLUSIONS

The GAGES-UE and GAGES-C are easy to administer and consistent and meet high standards of reliability and validity. They can be used to measure the effectiveness of simulator training and to provide specific feedback. The GAGES results can be generalized to North American and European endoscopists and may contribute to the definition of technical proficiency in endoscopy.

Proficiency-based laparoscopic and endoscopic training with virtual reality simulators: a comparison of proctored and independent approaches

BACKGROUND

Virtual reality (VR) simulators for laparoscopy and endoscopy may be valuable tools for resident education. However, the cost of such training in terms of trainee and instructor time may vary depending upon whether an independent or proctored approach is employed.

METHODS

We performed a randomized controlled trial to compare independent and proctored methods of proficiency-based VR simulator training. Medical students were randomized to independent or proctored training groups. Groups were compared with respect to the number of training hours and task repetitions required to achieve expert level proficiency on laparoscopic and endoscopic simulators. Cox regression modeling was used to compare time to proficiency between groups, with adjustment for appropriate covariates.

RESULTS

Thirty-six medical students (18 independent, 18 proctored) were enrolled. Achievement of overall simulator proficiency required a median of 11 hours of training (range, 6-21 hours). Laparoscopic and endoscopic proficiency were achieved after a median of 11 (range, 6-32) and 10 (range, 5-27) task repetitions, respectively. The number of repetitions required to achieve proficiency was similar between groups. After adjustment for covariates, trainees in the independent group achieved simulator proficiency with significantly fewer hours of training (hazard ratio, 2.62; 95% confidence interval, 1.01-6.85; p = 0.048).

CONCLUSIONS

Our study quantifies the cost, in instructor and trainee hours, of proficiency-based laparoscopic and endoscopic VR simulator training, and suggests that proctored instruction does not offer any advantages to trainees. The independent approach may be preferable for surgical residency programs desiring to implement VR simulator training.

Computer-based endoscopy simulation: emerging roles in teaching and professional skills assessment

Advances in endoscopy simulation are reviewed with emphasis on applications in teaching and skills assessment. Endoscopy simulation has only been realized recently in a computer-based fashion because of advances in technology, but several studies have been performed both to validate computer-based endoscopy simulators and to assess their potential role in training. Multiple studies have shown that simulators can distinguish between clinicians at different skill levels and also have shown improvement in clinician skill, particularly at the early stages of training. This article summarizes those studies. The cost versus benefit of endoscopic simulators is also discussed, as well as the upcoming role of simulators in judging competence and as a tool in the credentialing process.

Randomized controlled trial of virtual reality simulator training: transfer to live patients

BACKGROUND

New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients.

METHODS

A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments.

RESULTS

In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance.

CONCLUSIONS

Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement.

Expert and construct validity of the Simbionix GI Mentor II endoscopy simulator for colonoscopy

OBJECTIVES

The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts.

METHODS

Four groups were selected to perform one hand-eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200-1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost.

RESULTS

Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51).

CONCLUSION

In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.

Acquiring basic endoscopy skills by training on the GI Mentor II

BACKGROUND

Achieving proficiency in flexible endoscopy requires a great amount of practice. Virtual reality (VR) simulators could provide an effective alternative for clinical training. This study aimed to gain insight into the proficiency curve for basic endoscope navigation skills with training on the GI Mentor II.

METHODS

For this study, 30 novice endoscopists performed four preset training sessions. In each session, they performed one EndoBubble task and managed multiple VR colonoscopy cases (two in first session and three in subsequent sessions). Virtual reality colonoscopy I-3 was repeatedly performed as the last VR colonoscopy in each session. The assignment for the VR colonoscopies was to visualize the cecum as quickly as possible without causing patient discomfort. Five expert endoscopists also performed the training sessions. Additionally, the performance of the novices was compared with the performance of 20 experienced and 40 expert endoscopists.

RESULTS

The novices progressed significantly, particularly in the time required to accomplish the tasks (p < 0.05, Friedman's analysis of variance [ANOVA], p < 0.05, Wilcoxon signed ranks). The experts did not improve significantly, except in the percentage of time the patient was in excessive pain. For all the runs, the performance of the novices differed significantly from that of both the experienced and the expert endoscopists (p < 0.05, Mann-Whitney U). The performance of the novices in the latter runs differed less from those of both the experienced and the expert endoscopists.

CONCLUSIONS

The study findings demonstrate that training in both VR colonoscopy and EndoBubble tasks on the GI Mentor II improves the basic endoscope navigation skills of novice endoscopists significantly.

Training for Carotid Intervention: Preparing the Next Generation

BACKGROUND

Carotid interventions are performed to reduce the cumulative risk of stroke. The success of the procedure is dependent upon maintaining low operative risk. This article reviews the current state of training for both carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS).

METHODS

Medline searches were performed to identify articles with the combination of the following key words: carotid, endarterectomy, stent, training, assessment and simulation. Manual searches of the reference lists and related papers was conducted.

RESULTS

Training and assessment for CEA and CAS follows the traditional apprenticeship model. There is no formal training protocol or objective means of assessment for either carotid endarterectomy or stenting. Models and simulators to allow for training and assessment away from the operative theatre have been developed, and exist for both CEA and CAS.

CONCLUSION

The technology exists to allow for both training and assessment of competency to take place in a controlled and objective environment for both CEA and CAS. The use of simulation needs to be robustly evaluated and assessed to both complement and augment existing training programs to ensure that the highest standards of care are maintained for treatment of carotid territory disease. Objective competency based training and assessment is no longer unattainable. Simulators augment this process and without them operative exposure is sporadic and crisis management infrequent.

The compactEASIE is a feasible training model for endoscopic novices: a prospective randomised trial

BACKGROUND

The objective benefit of a training using the compact Erlangen Active Simulator for Interventional Endoscopy-simulator was demonstrated in two prospective educational trials (New York, France). The present study analysed whether endoscopic novices are able to reach a comparable level of endoscopic skills as in the above-described projects.

METHODS

Twenty-seven endoscopic novices (medical students, first year residents) were enrolled in this prospective, randomised trial. The compact Erlangen Active Simulator for Interventional Endoscopy-simulator with an upper GI-organ package and blood perfusion system was used as a training tool. Basic evaluation of endoscopic skills was performed after a practical and theoretical course in diagnostic upper GI endoscopy followed by a stratified randomisation according to the rating in endoscopic skills into intensive (n=14) and control group (n=13). The intensive group was trained 12 times every second week over 7 months in 4 endoscopic disciplines (manual skills, injection therapy, haemoclip, band ligation) by skilled endoscopist (three trainees/simulator). Assessment was performed (single steps/overall) using an analogue scale from 1 to 10 (1=worst, 10=optimal performance) by expert tutors. The control group was not trained. Blinded final evaluation of all participants was performed in January 2003.

RESULTS

We observed in all techniques applied a significant improvement of endoscopic skills and of the performance time in the intensive group compared to the control group (p<0.001). The comparison with the previous projects showed that the intensively trained novices achieved comparable levels of performance to the GI fellows in the New York and France Project (at least 80% of the median score in three out of four techniques).

CONCLUSION

Endoscopic novices acquired notable skills in interventional endoscopy in the simulator by an intensive, periodical training using the compactEASIE.

Surgical simulation: a current review

BACKGROUND

Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.

The complementary Erlangen active simulator for interventional endoscopy training is superior to solely clinical education in endoscopic hemostasis--the French training project: a prospective trial

BACKGROUND

The Erlangen Active Simulator for Interventional Endoscopy (EASIE) using ex-vivo porcine organs was introduced in 1997. The present study should analyze whether repeated EASIE simulator training in endoscopic hemostasis led to superior performance compared with a traditionally educated group. The results were compared with a similar project in New York.

METHODS

Thirty-five French GI fellows were enrolled. Baseline skills evaluation was performed in four disciplines (manual skills, injection/coagulation, clip application and variceal ligation) using the compactEASIE-simulator equipped with an upper gastrointestinal organ package for bleeding simulation. The same, translated evaluation forms (from the prior New York project) were used. Subsequently, fellows were randomized into group A (n=17, only clinical education) and group B (n=18, additional three simulator trainings). Group B was trained the next day and after 4 and 7 months by experts of the French Society of Gastrointestinal Endoscopy. Both groups performed routine and emergency endoscopies at their home hospitals during the study period. Both groups were re-evaluated blindly after 9 months.

RESULTS

The learning curve for group B showed a significant improvement in all disciplines (P<0.004) whereas group A improved significantly in only two of four disciplines at blinded final evaluation (manual skills P=0.02, injection/coagulation P=0.013). The direct comparison of groups B and A at blinded final evaluation showed significantly superior ratings for group B in all disciplines (P<0.006) and significantly shorter performance times in two disciplines (P=0.016 each). The comparison with the similar 'New York project' revealed that preexisting differences in skills were adjusted by the training.

CONCLUSION

Complementary trainings (three workshops in 7 months) in endoscopic hemostasis using the compactEASIE improved skills compared with a solely clinical education. The results of the 'New York project' were confirmed and benefits were independent from the medical educational system.

Technical skills examination for general surgical trainees

BACKGROUND

The technical skills of surgical trainees are difficult to assess and compare objectively. This study involved a structured, multistation, technical skills examination that enables the stratification of surgical trainees.

METHODS

Twenty-two surgeons (five basic surgical trainees, eight junior specialist trainees, four senior specialist trainees and five consultants) participated in the study. All undertook a five-station technical skills examination consisting of three synthetic simulations (bowel anastomosis, vascular anastomosis, saphenofemoral dissection) and two virtual reality-based (flexible sigmoidoscopy and laparoscopy) assessment stations. Video-based analyses and in-built computer scoring were used to measure each surgeon's performance. The mean rank was determined for each variable, and the sum of the mean ranks produced a total score.

RESULTS

There was a significant improvement in overall performance with increasing seniority (P<0.001). Significant differences were observed between basic surgical trainees and junior specialist trainees (P=0.019), and between junior and senior specialist trainees (P=0.048), but not between senior trainees and consultants.

CONCLUSION

This examination successfully differentiated surgical skill, both between surgeons with different grades of experience and within the target study group of specialist trainees. The examination is feasible in terms of the timeframe needed to complete tasks, cost, and efficiency in performing video-based assessments.

Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy

BACKGROUND

The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience.

OBJECTIVE

To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy.

DESIGN

Randomized, controlled, blinded, multicenter trial.

SETTING

Academic medical centers with accredited gastroenterology training programs.

PATIENTS

First-year GI fellows.

INTERVENTIONS

Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure.

MAIN OUTCOME MEASUREMENTS

A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time.

RESULTS

Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar.

CONCLUSIONS

Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training.

Simulator training in endoscopic hemostasis

Simulation of upper gastrointestinal (GI) hemorrhage provides the opportunity to practice endoscopic hemostasis without the risk of patient harm and time limitations. Various models have been developed to simulate an acute bleeding source in the upper GI tract to evaluate the feasibility of new endoscopic devices or to practice interventional techniques in a calm and controlled environment. Increasingly available ex vivo models provide this opportunity without the ethical concerns involved with live-animal courses. Validation studies have proven acceptance of ex vivo models and improved clinical performance by repetitive training using these models.

AccuTouch Endoscopy Simulator: development, applications and early experience

These studies suggest that there are several potential advantages to use of the AccuTouch simulators, including (1) improvement of the endoscopic training of trainees before patient contact, (2) possible evaluation for procedural competency, and (3) possible cost savings, increasing the productivity of faculty while the trainees are developing competency using the trainers. Other potential advantages might include the training of endoscopists in new diagnostic and therapeutic techniques and even new devices before patient contact. With continued improvement in software and hardware, endoscopic simulators will become an integral part of endoscopic training programs.

Evidence-based assessment of endoscopic simulators for training

This article focuses on some important key questions: Can the currently available simulators distinguish between the skill levels of a novice who has never performed endoscopic procedures and an expert who teaches the procedure? Do the cases on the simulator accurately simulate the difficulty of the procedure and the skill required to perform therapeutic maneuvers? What is the evidence that the currently available simulators can supplement or even replace bedside training? When are simulators most useful in the learning period? This article examines the published evidence regarding the efficacy of the current generation of endoscopic simulators in endoscopic training.

Virtual Reality in Ophthalmology Training

Current training models are limited by an unstructured curriculum, financial costs, human costs, and time constraints. With the newly mandated resident surgical competency, training programs are struggling to find viable methods of assessing and documenting the surgical skills of trainees. Virtual-reality technologies have been used for decades in flight simulation to train and assess competency, and there has been a recent push in surgical specialties to incorporate virtual-reality simulation into residency programs. These efforts have culminated in an FDA-approved carotid stenting simulator. What role virtual reality will play in the evolution of ophthalmology surgical curriculum is uncertain. The current apprentice system has served the art of surgery for over 100 years, and we foresee virtual reality working synergistically with our current curriculum modalities to streamline and enhance the resident's learning experience.

A Meta-Analysis of the Training Effectiveness of Virtual Reality Surgical Simulators

The increasing use of virtual reality (VR) simulators in surgical training makes it imperative that definitive studies be performed to assess their training effectiveness. Indeed, in this paper we report the meta-analysis of the efficacy of virtual reality simulators in: 1) the transference of skills from the simulator training environment to the operating room, and 2) their ability to discriminate between the experience levels of their users. The task completion time and the error score were the two study outcomes collated and analyzed in this meta-analysis. Sixteen studies were identified from a computer-based literature search (1996-2004). The meta-analysis of the random effects model (because of the heterogeneity of the data) revealed that training on virtual reality simulators did lessen the time taken to complete a given surgical task as well as clearly differentiate between the experienced and the novice trainees. Meta-analytic studies such as the one reported here would be very helpful in the planning and setting up of surgical training programs and for the establishment of reference 'learning curves' for a specific simulator and surgical task. If any such programs already exist, they can then indicate the improvements to be made in the simulator used, such as providing for more variety in their case scenarios based on the state and/or rate of learning of the trainee.

Report of a group developing a virtual reality simulator for arthroscopic surgery of the knee joint

Apprenticeship training of surgical skills is time consuming and can lead to surgical errors. Our group is developing an arthroscopic virtual reality knee simulator for training orthopaedic residents in arthroscopic surgery before live-patient operating room experience. The simulator displays realistic human knee anatomy derived from the Visible Human Dataset developed by the National Library of Medicine and incorporates active force-feedback haptic technology. Our premise is that postgraduate year 2 residents completing a formal virtual education program who are trained to reach a proficiency standard in the techniques and protocol for an arthroscopic knee examination will complete a diagnostic arthroscopy on an actual patient in less time with greater accuracy, less iteration of movement of the arthroscope, and less damage to the patient's tissue compared with residents in the control group learning and practicing the arthroscopic knee examination procedures through the residency program's established education and training program. The validation study, done at eight orthopaedic residency programs, will commence in early 2006 and will take one year to complete. We anticipate that proficiency obtained on the simulator will transfer to surgical skills in the operating room.

Advances in colonic imaging: technical improvements in colonoscopy

Colonoscopy has been available since the early 1970s and has become critical to the diagnosis and management of colorectal disorders. Features of the modern colonoscope and its variants are discussed, including the role of paediatric and variable stiffness colonoscopes for difficult insertion. The place of magnetic endoscope imaging systems and simulators in routine colonoscopy and training are examined. Finally, several recent innovations are used to illustrate how colonoscopy may evolve in the future, including new takes on the current instrument as well as potentially revolutionary pain-free, technically-easy, robotic devices for examination of the bowel.

The reliability of multiple objective measures of surgery and the role of human performance

BACKGROUND

There is a need for reliable and valid objective methods of technical skills in surgery. Six-bench surgical top stations have been combined to assess basic surgical trainees (BSTs) objectively. The current study examines its reliability and validity across repeat sittings.

METHODS

Eleven surgical trainees (6 senior BSTs and 5 higher surgical trainees [HSTs]) undertook 5 sittings of the 6-station assessment designed to be completed within 90 minutes. The 6 stations consisted of knot tying, suturing, closure of enterotomy, excision of sebaceous cyst, laparoscopic task, and instrument examination. Methods of analysis employed were motion analysis, observation with criteria, and inbuilt simulation metrics.

RESULTS

On analysis 3 knot tying and suturing stations exhibited significant differences in either time or movement; any difference was over by the second run. The intertest reliabilities were .66, .74, .55, .51, and .65 for the 5 runs. The intratest reliability across repeated sittings varied from .56 to .96. The inter-rater reliability for video assessment varied from .77 to .94.

CONCLUSION

The assessment is reliable and valid across repeated sittings. Its use in assessment of basic technical skills needs to be encouraged.

Validation of a flexible endoscopy simulator

BACKGROUND

Virtual reality (VR) simulation is a rapidly proliferating adjunct of surgical training. Numerous devices have evolved as educational tools in a variety of fields. Whether these tools can be used for validation of physicians' skills has yet to be determined. The objective of this study was to determine whether the GI Mentor (Simbionix, Lod, Israel) flexible endoscopy simulator construct could distinguish experienced endoscopists from beginners.

METHODS

Seventy-five surgical attendings, fellows, and residents were recruited for participation in the study. Two cohorts were used and these groups were selected from 2 separate scientific sessions. Participants completed a standardized questionnaire documenting their endoscopic training and experience. Physicians subsequently were designated as experienced or beginner after their endoscopic training and experience were evaluated. All participants completed 1 of 2 colonoscopic simulations. The GI Mentor objectively evaluated performance on the basis of programmed data points, including the time to reach the cecum, the percentage of mucosa visualized, the completed polypectomy rate, the percentage of time spent in clear view through the lumen, the percentage of time that the patient was in pain, and overall efficiency.

RESULTS

In both simulations, experienced endoscopists were more efficient than beginners (.32%/s vs. .26%/s, P=.02; and .53%/s vs. .37%/s, P=.03) and achieved a greater polypectomy rate (78% vs. 43%, P=.03; and 87% vs. 48%, P=.01). Furthermore, experienced endoscopists visualized more of the colonic surface (86% vs. 82%, P=.02) and spent a greater proportion of the time in clear view of the lumen (55% vs. 47%, P=.05) than beginners completing the first simulation. In the second simulation, experienced participants reached the cecum more rapidly than beginners (175 vs. 262 s, P=.01).

CONCLUSIONS

The G1 Mentor VR colonoscopy construct appears valid. Significant performance differences were shown between the experienced and beginner cohorts. The beginner participants in this study were all physicians with some degree of endoscopic experience. Therefore, the G1 Mentor distinguished endoscopists of varying experience and exposure. Further validation studies are needed to evaluate the breadth of programs inherent to this simulator and to determine whether it may be used in the future for qualification and certification purposes.

Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone

BACKGROUND

The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods.

METHODS

Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed.

RESULTS

Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone.

CONCLUSIONS

compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.