AAOS Now

Published 7/1/2014
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Peter Pollack

Simulation as a Tool to Move the Value Equation

“Most of us think of virtual reality when we think of simulation, but it’s important to remember that simpler models like sawbones exercises or even sewing on pig’s feet can be meaningful and impactful,” explained Donald S. Bae, MD, speaking at the annual meeting of the Pediatric Orthopaedic Society of North America (POSNA).

“How does simulation add value?” he asked. “With increased volume and improved performance, we can improve our clinical outcomes. In one study of general surgery residents, for example, trainees who were randomized to virtual reality training were 58 percent faster and had three times fewer errors in their first attempt at performing laparoscopic cystectomies.”

Dr. Bae pointed out that a number of forces are driving interest in simulation, including expectations for improved outcomes, greater safety, and physical responsibility. He explained that several studies using even simple simulation to train residents have been associated with decreased time to proficiency and better performance.

“Simulation can add value by driving down costs, improving efficiency, and lowering complication rates,” he said. “Complications are very costly. For surgical complications, the payer contributions can be into the tens of thousands of dollars.

“In addition, simulation can help address changing opportunities as technology advances and techniques evolve,” he continued. “It appears to be particularly effective in arthroscopy and minimally invasive surgery. And perhaps most important, simulation is ideal for online learning. Most of us learn best independently, in an experience-based fashion, with single and double loop feedback and deliberate and reflective practice. Simulation can be done on-demand, repeatedly, without patient risk.”

Simple model, improved outcomes
Dr. Bae credited initiatives such as the International Pediatric Orthopaedic Symposium Top Gun program for increasing awareness of the importance of simulation in pediatrics. Top Gun is a joint effort of POSNA and AAOS, in which trainees are challenged in a timed, motor skills accuracy contest testing fundamental skills related to pediatric orthopaedics. Another goal of the competition is to foster partnerships in simulation and surgical education.

“Both institutional and local efforts to incorporate simulation in training exist,” said Dr. Bae. “For example, at my institution we believe—as many others do—that casting is becoming a lost art. Given the frequency of cast saw burns, the costs associated with treatment, and the little training that people get now in casting and cast removal, we decided to put together a cast saw training simulation. We started simply, with a commercially available wrist model, and added temperature sensor probes so we could record surface temperatures. In experiments, we found that we were able to monitor and assess temperatures above the threshold for pain, as well as skin necrosis.

“Using this relatively simple model, we now have a more robust simulation, involving both adaptive construction as well as actual cast application, using objective measures and temperature measures, in hopes of improving outcomes and patient safety.”

Dr. Bae took the opportunity to discuss his participation on a task force that is addressing the issue of simulation in orthopaedics.

“Our goal is to provide POSNA members with simulation toolkits that can be used by educators, practitioners, and learners,” he said.

“So what can we all do now?” he asked. “The first step is to look into our own practices for opportunities to move the value equation. We can start simply by measuring outcomes and complications. Simulation can start simply and does not have to be expensive or high fidelity to be effective. Through research and collaborative efforts we can all share data, resources, and the lessons we’ve learned.”

Disclosure information: Dr. Bae—DTRX, Johnson & Johnson, VVUS, Lippincott Williams & Wilkins, ASSH, POSNA.

Peter Pollack is the electronic content specialist for AAOS Now. He can be reached at ppollack@aaos.org