Simulation in Medicine

FLAAPM, Sarasota

November 13, 2015

Twyla Willoughby, Ph.D.

Senior Medical Physicist

Department of Radiation Oncology

UF Health Cancer Center at Orlando Health

Outline

• What is a Simulation

• History of Simulation in Medicine

• Types of Simulations

• Design of the VROC

• Take-home messages for the Medical

Physicist

Simulation

simulation

noun sim·u·la·tion \ˌsim-yə-ˈlā-shən\

: something that is made to look, feel, or behave

like something else especially so that it can be

studied or used to train people

Virtual Reality

virtual reality

noun

: an artificial world that consists of images and

sounds created by a computer and that is

affected by the actions of a person who is

experiencing it

Flight Simulators

Golf Swing analysis

Police Simulator

History of Medical Simulation

History of Medical Simulation

History of Medical Simulation

History of Medical Simulation

Types of Simulated Patients

• Verbal – Role Playing

• Standardized Patients (SP) - Actors

• Task Trainers – Models (Resusci Annie)

• Computer (VR patients)

• Electronic Patient – (usually Mannequin + VR)

Task Trainer: Birthing Simulator

Task Trainer: Lumbar Puncture

Types of Simulated Patients

• Verbal – Role Playing

• Standardized Patients (SP) - Actors

• Task Trainers – Models (Resusci Annie)

• Computer (VR patients)

• Electronic Patient – (usually Mannequin + VR)

Virtual Hospitals (in Second Life)

BMC awarded NIDDK grant to study outcomes of minority

women receiving diabetes self-management education

October 9, 2015 at 2:27 AM ·

•The National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDK) has awarded a $783,906 grant to Suzanne

Mitchell, MD, a family physician at Boston Medical Center (BMC),

to study health outcomes of minority women with type 2 diabetes

who participate in group medical visits to help them manage their

diabetes. Participants will receive diabetes self-management (DSM)

education and medical advice from BMC physicians either in the

online virtual world Second Life or an in-person classroom setting.

The study aims to determine the efficacy of virtual world and

classroom groups in teaching DSM, to increase all participants'

physical activity levels, and to measure technological development

milestones of the virtual group.

Virtual Patients

Types of Simulated Patients

• Verbal – Role Playing

• Standardized Patients (SP) - Actors

• Task Trainers – Models (Resusci Annie)

• Computer (VR patients)

• Electronic Patient – (usually Mannequin + VR)

Radiology Simulation

Simulation Lab Endoscopy

Ultrasound Simulation

Surgical Simulation

My interest in Medical Simulation…

Building a Safer Health System

What can we do

to improve

training on errors

and why they

occur…

Look at what is

working in other

areas…

Vertual: VERT-The Flight Simulator for Linacs

Vertual: VERT-The Flight Simulator for Linacs

Vertual: VERT-The Flight Simulator for Linacs

www.vertual.com

The breakdown of US systems is below.

Immersive Systems

• · MD Anderson Cancer Center, TX

• · Hillsborough Community College, FL

• · College of Southern Nevada, NV

• · University of Nebraska Medical Center, NE

• · Ivy Tech Community College, IN

• · Mayo School of Health Related Science

My interest

• Disconnect between the physician and the treatment machine

• Currently no simulation training for Rad Onc Physicians

• Limited Errors training for Rad Onc Physicians.

In-kind loan from Varian Medical (Aria + Eclipse) + help and

ideas from UF faculty

“Design, Development, and Validation of a Virtual Radiation

Oncology Clinic for Radiation Oncology Error Training”

(UF Dissertation - May 2014)

Designing a Simulation System

• Issenberg SB, McGaghie WC, Petrusa ER, et al. Features

and uses of high-fidelity medical simulations that lead to

effective learning: a BEME systematic review. Med Teach

2005;27:10-28.

Review of 109 Articles that used simulators in medical

education – the top features necessary to provide

learning:

Design Top Features (Issenberg)

• Feedback

• Repetitive practice

• Integrated into overall curriculum

• Practice with increasing level of difficulty

• Adaptable to multiple learning strategies

• Clinical variations

• Controlled environment “teachable moments” i.e. mistakes

• Individualized

• Outcomes and benchmarks are clear

• Validity –realism (context for understanding)

Design: What information does Dr. use?

Generate pre-calculated

plans, and generate DRR/

images to represent patient

treatment

Outcomes & benchmarks are clear

VROC Scenario Template: Patient Design

Section 1: Demographics

Case Title Virtual Patient Name

Scenario Name Simulation Developer

Date of Development Learning Groups

Diagnosis Virtual Patient MR #

Reference ID #

Section 2: Curriculum Development

Educational Rationale:

List Learning Objectives Below: Use ACGME Core Competencies and abbreviations as follows:

Medical Knowledge (mk) Patient care (pk), Practice-bsed learning and improvement (pli),

Interpersonal and communication skills (cs), Professionalism (pr), systems-based practice (sbp)

Objective 1

Guided Study Question 1

Reference 1

Scenario: Who, what?

Do you intervene?

Do you allow errors?

When would the simulation

stop?

Have you considered mental

stress on trainee? (PTSD, etc.)

Feedback: should be immediate/ relevant.

• MatLab saves as an XLS file format: Sample Below

ptv 50.4 gtv ctv

Dice Similarity 0.692 0.357 0.657

Expert Volumes (cc) 308.149 27.371 206.58

Trainee Volumes (cc) 398.631 108.088 199.736

% of Target Missed 20.654 11.706 35.385

Normal Tissue (cc) 154.128 83.921 66.254

CONTOUR comparisons report

Should allow for clinical errors (example of a

simulated “incorrect” portal film

Error simulations

• Can simulate any geometric or dosimetric errors.

• Designed to be able to be used to simulate or replicate any

error reported into RO-ILS (with the same severity index as

RO-ILS).

• No matter what error is simulated – a Report of “key”

metrics is generated in VROC

Feedback after error has occurred.

RCA Analysis Form

RCA Analysis Form

RCA Analysis Form

RCA Analysis Form

RCA Analysis Form

RCA Analysis Form

VROC Summary

• The VROC system is a set of code, forms, and instructions on

how to create patients that can be used in a stand-alone ARIA

/ Eclipse

• Can run in real-time

• Errors of all kind can be simulated within the VROC

• The RCA tools could be used independently to help to train

all workers on how to conduct a root cause analysis.

How we can utilize Simulation for Training?

1. Almost all of us use Simulation of some sort for

training (i.e mock patients, end-to-end tests,

phantoms, etc.)

2. Write scenario with learning objectives and

measureable endpoints for each training

3. Do Orientation for your trainees – assign roles and

know what each person is to do.

4. Decide ahead of time if you will intervene or

allow errors to pass through

How we can utilize Simulation for Training?

5. Debrief: Immediately following the simulation

give feedback on how each trainee performed and

also ask each trainee for feedback on the overall

experience.

6. Each year have your therapists/techs/ residents

conduct a Mock Root Cause Analysis.

7. Learn more about Simulation programs at your hospital or

facility.

How we can utilize Simulation for Training?

http://www.floridahealthsimalliance.org/

“The Largest Medical Education Simulation Center Hard at

Work”

•University of South Florida Health CEO Dr. Stephen Klasko

discusses today’s medical training technology.

Gordon Center & FHSA Partner to Deliver Simulation

Education throughout the State

Throughout the 2014-15 academic year, the Gordon Center

provided iSim fundamentals courses in three regions of the state

utilizing the regional training centers and network of FHSA. The

courses targeted Florida healthcare educators who want to

implement or enhance the use of simulation in their educational

programs and to improve their instructional skills. Special effort

was given to serve historically under-resourced disciplines in

emergency medical services and nursing at Florida's state and

community colleges.

Thank-you.

Virtual Reality in Healthcare Market, Markets for Remote Surgery,

3D Modeling, Pain Distraction and Other Applications) Global

Industry Analysis, Size, Share, Demand, Future, Growth, Trends,

Opportunities (Psychology, Radiology, Oncology) Segmentation

And

Published: Oct 22, 2015 4:45 p.m. ET

Companies profiled include

• 1. Artificial Life Inc.

• 2. Aruba Networks

• 3. CAE healthcare

• 4. Foursquare

• 5. Simulab Corp

• 6. Laster technologies

• 7. Immersion Corporation

• 8. Qualcomm

• 9. Samsung

• 10. Theraism

• 11. Vuxix Corp.

• 12. Worldciz LLC

• 13. The Virtual Reality Medical Center

• 14. Brainlab AG

• 15. GE Healthcare

• 16. Medtronic, Inc.

• 17. Intuitive Surgical, Inc

• 18. Stryker Corporation

• 19. Vital Images, Inc.