Simulation and Medical Performance Peter G. Schulam, M.D., Ph.D. Associate Professor Department of Urology Eric Savitsky, M.D. Associate Professor Department.

Simulation and Medical Performance

Peter G. Schulam, M.D., Ph.D.Peter G. Schulam, M.D., Ph.D.

Associate ProfessorAssociate Professor

Department of UrologyDepartment of Urology

Eric Savitsky, M.D.Eric Savitsky, M.D.

Associate ProfessorAssociate Professor

Department of Emergency MedicineDepartment of Emergency Medicine

CASIT andCASIT and

David Geffen School of Medicine at UCLADavid Geffen School of Medicine at UCLA

To Err is HumanInstitute of Medicine November 1999

44,000 – 98,000 44,000 – 98,000 deaths per year as a deaths per year as a result of medical result of medical errors.errors.

Cost of $17-29 billion Cost of $17-29 billion per year.per year.

Medical Errors

Performance Level of 99.9%Performance Level of 99.9%

Airline-2 dangerous landings/dayAirline-2 dangerous landings/day

Banking-32,000 checks incorrectly Banking-32,000 checks incorrectly deducted/hourdeducted/hour

Types of Errors

DiagnosticDiagnosticError or delay in diagnosisError or delay in diagnosisFailure to act on results Failure to act on results

TreatmentTreatmentError in drug dosingError in drug dosingDelay in responding to an abnormal test Delay in responding to an abnormal test Error in performanceError in performance

Medical ErrorsLocations

Intensive Care UnitsIntensive Care Units

Emergency DepartmentsEmergency Departments

Operating RoomsOperating Rooms

Why?

Lack of standard credentialingLack of standard credentialing

Fragmented health care systemFragmented health care system Lack of access to all informationLack of access to all information

Human variabilityHuman variability

Physician Variability

# of

com

plic

atio

ns

# of procedures

Learning Curve

Traditional Training

Problems with the apprenticeship modelProblems with the apprenticeship model Variability of experienceVariability of experience Practice on real patientsPractice on real patients InefficiencyInefficiency

CostCost The OR is an expensive classroomThe OR is an expensive classroom

Lack of standardized proficiency criteriaLack of standardized proficiency criteria

Surgical TrainingLaparoscopic Cholecystectomy

Southern Surgeons Club - 2.2% incidence of bile Southern Surgeons Club - 2.2% incidence of bile duct injuries in first 13 pts/group (control 0.2%) duct injuries in first 13 pts/group (control 0.2%) NEJM 1991NEJM 1991

8,839 lap cholecystectomies by 55 surgeons - 90% 8,839 lap cholecystectomies by 55 surgeons - 90% of bile duct injuries occurred during first 30 cases of bile duct injuries occurred during first 30 cases Am Surg 1995Am Surg 1995

54% of surgical errors are potentially preventable 54% of surgical errors are potentially preventable Nat Acad Press, 1999Nat Acad Press, 1999

Training Simulators Inanimate modelsInanimate models

Animal modelsAnimal models

Cadaveric modelsCadaveric models

Virtual realityVirtual reality

Inanimate Models

BenefitsBenefits CheapCheap Reuse materialsReuse materials Accessible at Accessible at

any timeany time Minimal Minimal

psychological psychological stress inhibiting stress inhibiting learninglearning

Inanimate Models

LimitationsLimitations Lack of realismLack of realism Can only Can only

simulate the simulate the most basic most basic taskstasks

Difficult to Difficult to monitor monitor progressprogress

Animal Models BenefitsBenefits

Realistic Realistic physiologyphysiology

Closer to Closer to realistic realistic anatomyanatomy

Complex Complex proceduresprocedures

More realistic More realistic working working environmentenvironment

Animal Models

LimitationsLimitations ExpensiveExpensive Ethical issuesEthical issues Difficult to Difficult to

monitor monitor progressprogress

Cadaveric Models

BenefitsBenefits

Realistic Realistic

anatomyanatomy

Rohen & Yokochi. Color Atlas of Anatomy. 1993

Cadaveric Models

LimitationsLimitations ExpensiveExpensive Physiologically Physiologically

unrealisticunrealistic Unnatural Unnatural

tissue tissue propertiesproperties

Difficult to Difficult to monitor monitor progressprogress

Rohen & Yokochi. Color Atlas of Anatomy. 1993

Virtual Reality Simulators

Benefits of Virtual Reality

Unlimited availabilityUnlimited availability Potential for a variety of tasks/proceduresPotential for a variety of tasks/procedures

From non-anatomic to surgical “pre-flight”From non-anatomic to surgical “pre-flight” Allows for repetitive skill assessmentAllows for repetitive skill assessment

Minimal psychological stress inhibiting learningMinimal psychological stress inhibiting learning Monitors trainee activity/improvementMonitors trainee activity/improvement

Benefits of Virtual RealityVirtual Mentor

Computer can guide a trainee through a procedure Computer can guide a trainee through a procedure

and provide immediate feedbackand provide immediate feedback Fulfills the continual, high-quality feedback Fulfills the continual, high-quality feedback

requirement for efficient learningrequirement for efficient learning Establish metricsEstablish metrics

Limitations of Virtual Reality

Complexity of organ modelingComplexity of organ modeling

Lack of force feedbackLack of force feedback

Procedure based systemsProcedure based systems

Potential >> Today’s RealityPotential >> Today’s Reality

Holy Grail

Simulation of a patient’s data set Simulation of a patient’s data set allowing for allowing for

pre-procedural planningpre-procedural planning

Procedural Outcome

DiagnosisDiagnosis HistoryHistory Physical ExamPhysical Exam Ordering of data (labs and xrays)Ordering of data (labs and xrays) Interpretation of dataInterpretation of data

InterventionIntervention Familiarity/Dexterity with the tool setFamiliarity/Dexterity with the tool set Understanding the order of the operationUnderstanding the order of the operation Familiarity of the anatomyFamiliarity of the anatomy Adapting to anatomical variabilityAdapting to anatomical variability Controlling surgical mishapsControlling surgical mishaps

Decrease Physician VariabilityTask Specific Simulation

Definition of Simulation

“ “A device or exercise that enables the A device or exercise that enables the participant to reproduce, under test participant to reproduce, under test conditions, phenomena that are likely to conditions, phenomena that are likely to occur in actual performance” occur in actual performance”

KrummelKrummel