For the first time, a mathematical theory which has proved to be successful in digital gaming and engineering, has been applied to improve training in medicine.
A new training device, with computer graphics and a virtual needle, will recreate the sensation of advancing a needle through the layers surrounding the spinal cord. This will enable trainees to perform “virtual” spinal anaesthesia and ultimately benefit “real” patients, say international researchers.
The tool was the result of an international collaboration, the “MedCAP” project, funded through the EU Leonardo da Vinci Lifelong Learning Programme, which is headed by the Department of Anaesthesia, at Cork University Hospital (CUH) and University College Cork (UCC), and includes the Interaction Design Centre of the University of Limerick, the University of Graz in Austria, the University of Pecs in Hungary, and a UK-based biotech company, Medic Vision.
Scientists say the tool is a major breakthrough in the way medical procedural skills are taught, and could be used widely in hospitals and training institutes within three years. George Shorten, Professor of Anaesthesia and Intensive Care Medicine at Cork University Hospital, said, “The tool will function for a specific purpose for anaesthetists at the moment, and the intent is it will then be used as proof of concept for use in other procedures.”
What does the theory say?
Competence-based Knowledge Space Theory, on which the tool is based, was developed by Dietrch Albert and colleagues at the University of Graz. The theory can be applied to determine how well one performs within a defined “competence space”. This entails breaking down a procedure into small “bite-sized” bits.
“Each of these ‘bits’ can then be defined in terms of a test or question such that if I can pass that test or answer that question, then I can be deemed to ‘have’ that portion of the competence. Some of these ‘bits” will have specific relations with others: for instance, if I know the answer to one question, one might reasonably assume that I can answer another without having to ask. You can imagine a 3D space made up of all these ‘bits’ of a procedure. I can find out where I am in this space by addressing a limited number of tests or questions. That’s a very short version of a very complicated theory!” says Shorten.
Types of feedback in medical training
In current practice, after an examination or a viva, trainees are essentially told that they have either passed or failed. “While this may tell trainees that they need to learn more or work harder, it is very limited in the instruction it gives to the trainee,” says Shorten.
“For the actual process of learning, it is much more valuable if we can present, a real, fleshed-out, detailed, personal description of where they are in their overall learning of the procedure. Someone may be strong on the knowledge of anatomy of the spine, but they may be poor in terms of the efficiency of movement they use to introduce the spinal needle.
That sort of information is extremely valuable for a trainee as he or she progresses along the learning curve. Such an assessment tool can also inform a trainer where exactly
the strengths and deficiencies lie, he says.
Importance of virtual training
Medical practitioners believe that the manner in which doctors are trained for procedural skills which have a manual element needs to change. “Ideally, patients should not be exposed to trainees who have not yet achieved competence at a procedure”, says Shorten.
In the past, in the “apprenticeship approach”, a relatively naive trainee would, under supervision, actually be in control of a procedure that might have important safety implications for the patient. “That very much needs to change, and in many fields, we are moving towards some form of simulation-based training, where skills or experience can be gained without a patient being involved in the initial stages,” says Shorten.
Also, important changes in working practice around Europe mean that the opportunities for doctors to learn procedural skills in the clinical setting are dwindling. “Traditionally, doctors in training might have worked more than 100 hours a week, and during that time had lots of exposure to procedures and patients. For many reasons (including changing patient expectations and the implementation of the EU Working Time Directive), that time will be substantially less. Therefore, the opportunities for learning procedural skills will become much less,”says Shorten.
Why spinal anaesthaesia?
Spinal anaethesia is a commonly performed procedure: it is used to facilitate many surgical procedures such as hip replacement or caesarean section. “We’ve selected this procedure because it contains the essential elements of many other medical procedures: a visual component, (what I see dictates what I do), an haptic element (what I feel dictates what I do), and it is likely to be influenced by human factors (fatigue, anxiety that some serious injury could result, interaction with the patient during the procedure).
Trainee anaesthetists stand to gain
The tool is quite specific to one procedure, which trainee anaesthetists typically learn in the first two years, says Shorten.
The MedCAP team is looking to make the virtual tool available via learned bodies which deliver training programmes, such as the College of Anaesthetists in Ireland, simulation-based centres which run training programmes, and directly to trainees. “Although our focus is not currently on the commercial value, we would like to see a product that could be purchased by individuals as well as training bodies,” says Shorten.
The tool is specifically designed for personalised learning. “Medical students and doctors are typically taught in groups and the way in which they learn is quite different if they are participating collaboratively. In the future, it is likely that doctors will need to take greater personal responsibility for their own learning and to identify their shortcomings, he says.
“The trainee who uses this device could benefit through self-directed learning. The information he or she would need to progress, at least to a certain level, is provided within the device itself. This means that they can identify areas of weakness for themselves to concentrate their learning efforts,” says Shorten.
Limitations of the tool
Currently, much of the material contained within the tool is based on case scenarios, so that a trainee can follow a particular patient, step by step, through an entire case. Shorten says, “At the moment, we have a case library of just six cases, but we are working on expanding this”. Also, while the simulator has extremely high fidelity that is well tested for the haptic feedback for the hand advancing the spinal needle, the researchers have made no attempt to replicate the activity of the non-procedure hand. “This simulator does not address the function of the non-dominant hand,” he says.