Historically, physicians have learned new procedures by first practicing on animals, cadavers or mechanical models, eventually receiving "on-the-job training" by operating on patients under the guidance of experienced teachers. However, in a commentary published today (December 21) in the Journal of the American Medical Association (JAMA), Emory Heart Center cardiologist Christopher Cates, MD, and Anthony Gallagher, PhD, Experimental Psychologist for the Division of Cardiology at Emory University Hospital, say this paradigm needs to change -- especially in the field of cardiovascular medicine.
They point out that the rapidly expanding application of carotid stenting, which was approved by the U.S. Food and Drug Administration (FDA) in September as an alternative to carotid endarterectomy (surgically removing plaque from the carotid artery), has brought to the forefront challenges involved in training physicians to perform these procedures.
"There is mounting evidence that virtual reality (VR) training is a better, faster and safer way for physicians to learn endovascular procedures than the traditional training route," says Dr. Cates, Director of Vascular Intervention at Emory University Hospital and Emory Crawford Long Hospital.
Just as stents (tiny mesh tubes) are often used following coronary angioplasty to keep arteries open, they can also be used to prop open carotid arteries in the neck.
"Carotid stenting is an exciting new technology which certainly offers high-risk patients a less invasive option with significantly fewer bad outcomes (heart attack, stroke and death) when compared to carotid endarterectomy," says Dr. Cates. "However, unlike surgery, carotid stenting makes the physician's job more difficult because you can't see and feel tissues directly. Learning the hand-eye coordination of instruments, catheters and guide wires are sometimes more complex requiring different new skills for physicians to develop."
To help overcome these difficulties, Dr. Cates and Dr. Gallagher designed one of the first VR programs to train physicians in carotid stenting. Using simulators that look like human mannequins, physicians thread a catheter through an artificial circulatory system and view angiograms of the "patient", while measuring the ability of doctors to perform the tasks instead of practicing on patients. Emory has already trained over 103 physicians in carotid angiography using this VR technique.
In the JAMA commentary, the Emory researchers point out that if an embolus of thrombotic plaque is loosened and enters the brain during a carotid stenting procedure, the patient could have a stroke or die. "That makes the risk conferred to the patient from the physicians' traditional learning curve unacceptable and makes VR the training method of choice for this procedure," Dr. Cates emphasizes. "With VR, physicians can receive objective feedback on their performances during and after completion of simulated cases. That means trainees can be required to reach specific proficiency levels before ever doing an endovascular procedure on a patient."
Dr. Cates notes that VR training was first introduced to surgery in l991, but it has not gained wide acceptance within the medical community due to few well controlled clinical trials. However, in the last two years, two studies have shown that residents trained with VR made fewer intraoperative errors and both trials demonstrated that the technical skills acquired through training on VR simulators approximated those of experienced attending surgeon operators.
Dr. Cates concludes that more studies are needed to further document the value of VR technology. The STRIVE (Simulator Training Randomized vs. Invasive Vascular Experience) trial, headed by Dr. Cates and currently underway at Emory, is designed to compare carotid angiography VR training with standard training.