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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.