Virtual Experts: How Surgery Simulations Are Changing Training

Cardiovascular medical education programs feel increased pressure to incorporate simulation training in their curricula. Shorter residency training periods  and more stringent quality measures are on the verge of upending the traditional apprenticeship model in favor of more simulation. Despite these factors, implementing a curriculum featuring robust simulation training remains a challenge.

Surgical simulators come in a few different flavors. Simple bench models simulate small components of larger operations using synthetic or biological tissue. They provide a solid and generally inexpensive option to most training centers.

More complex systems include virtual reality simulators and human performance simulators. They are computer-based, and while the user can manipulate laparoscopic tools, it still only affects virtual organs and doesn’t provide the same tactile sensation as a physical object. Human performance simulators are high-end simulators that can replicate an entire operating room environment, fusing a realistic physical component and a computer interface.

Trainees in Progress

To compare training with simulation to training without, a study looked at 27 cardiology trainees’ improvement in cardiac catheterization performance before and one week after training.


Technical Performance Score Without simulator training:
20 (out of 44)


After simulator training:
24 (out of 44)


Median Score Improvement:
No simulator training: +1
With simulator training: +6

Source: Circ Cardiovasc Interv 2012;5:672-679

Simulation is best for a novice trainee when first learning a technical skill, says Neil Fam, MD, of the Terrence Donnelly Heart Centre at St. Michael’s Hospital in Toronto. “These are complex motor tasks which are repetitive and you really need to practice to master those basic skills. It would make sense to practice those repetitive motor tasks in a simulated environment rather than on a patient where there are implications for making errors."

Fam and colleagues evaluated the use of catheterization simulation in a small cohort of cardiology trainees (Circ Cardiovasc Interv 2012;5:672-679). The simulator looked like a mannequin with a port in the leg into which users can insert catheters and guidewires. After a baseline cardiac catheterization performance assessment, 27 cardiology trainees were randomized to either mentored training on the simulator or to a control group with no simulator training.

"Residents assigned to the simulation arm, especially the more junior residents who had less experience, had pretty dramatic improvement in their technical and cognitive skills compared with residents who just went through the regular apprenticeship model," says Fam. Lower baseline scores were associated with larger differences in postintervention scores between the simulator and control groups, indicating greater benefit for less proficient operators.

"It doesn't really train you to be a master, but it basically creates a pre-trained novice who's now ready to do procedures on patients,” explains Fam.

Challenges remain

Studies into simulation effectiveness have been limited in number and scope, despite some promising initial results. The limitations, however, didn’t stop the Accreditation Council for Graduate Medical Education (ACGME) from mandating that cardiovascular fellowship training programs include simulation as a component of fellow training.

The mandate is short on specifics, though, and there’s a Wild West feel to simulation training practice, with no standards for curricula. To shed some light on the issue, the Society for Cardiovascular Angiography and Interventions (SCAI) Simulation Committee last year shared the results of a survey of 59 ACGME-accredited interventional cardiology programs. Respondents were bullish on the ability of simulators to help trainees yet only 23.7 percent used simulation as a teaching technique in their interventional cardiology fellowship courses.

One concern is cost: Simulators can range from $90,000 to $250,000. There are regional simulation centers where multiple institutions can share equipment, but this is rare, according to Sandy M. Green, MD, of Geisinger Medical Center in Danville, Penn., and lead author of the SCAI paper. Institutions often find other cost-conscious ways of allocating simulation resources.

“What ends up happening is simulators that can be used as dual-purpose machines get used across different programs at the same institution," he says, giving the example of a transthoracic echo simulator used by emergency medicine and a cardiology training program.

Overall, though, there isn't much financial motivation to create a simulation curriculum, says Green. "A lot of training programs and centers are getting squeezed rather tightly financially, and spending extra money on things like this—unless it ends up being federally mandated—becomes difficult."

Forward-thinking programs looking to institute a simulation curriculum can follow the example set by the University of Southern California’s (USC’s) Keck School of Medicine in Los Angeles. There, Craig J. Baker, MD, and colleagues implementied a cardiac surgery simulation curriculum using a structured approach to demonstrate its feasibility (J Thorac Cardiovasc Surg 2012;144:7-16).

Six cardiothoracic surgery residents and nine faculty members evaluated more than 50 common surgical procedures to determine the need for simulation, selecting 21 for curriculum development. These procedures were then categorized into 12 monthly modules, which received overwhelmingly positive satisfaction scores from residents and boosted their self-confidence scores.

Baker explains that every institution is going to have its own needs and advantages. USC, for instance, benefits from having access to a fresh tissue cadaver laboratory. However, the curriculum design project still offers a useful model to other programs. “Not every program is going to want to go through the seven steps of formal curriculum development, but this will at least show everybody a way they can implement a simulation program at their own institution locally," says Baker.

Cleared for takeoff

The analogy that supporters of simulation in cardiovascular surgery often make is that of airline pilot training. The Federal Aviation Administration has specific mandates for using simulators in training. Similar motivation in cardiovascular surgery might ignite an explosion of curricula as simulation companies and other organizations see an opportunity to develop evidence-based programs. Moreover, cost concerns could be assuaged if it is definitively proven that “pretrained novices” on simulators reduce radiation exposure and length of stay compared with trainees learning on the job.

Green remains optimistic. "It may take payers saying 'We want people tested and trained on these things' in order to provide more global implementation,” he says. “It’s too good of a tool not to use.”