Are Simulators Paving a New Way for Continuing Education?

Technological advancements continue to permeate the daily routine of healthcare personnel. From attending Zoom webinars online to scanning barcodes to obtain product and other information, the dependence on an electronic device has become integral to the work environment. In the past several years, studies have shown a spike in the use of mobile applications ("apps"), computers, and other virtual domains. This was especially so during the height of the COVID-19 pandemic, when classes in schools across the country transitioned to remote learning fully accessible from an electronic device. Some mobile applications can be used specifically as a tool to enhance students' learning while working in a virtual environment.

Throughout the world, to compensate for the limited clinical experience being offered to their students, healthcare academic institutions are leaning toward a pedagogy that involves the incorporation of surgical simulators. Surgeons along with other medical and dental students can use surgical simulators to receive training to complete complex surgical procedures. Such a simulator allows students to "perform" the surgery in a virtual format and receive immediate feedback on the outcomes.

Simulated learning is a technique that has been used in educational practice for decades by different professionals. For example, pilots in training are required to complete numerous hours of simulated flying time before attempting any real-life scenarios.^1,2 The simulated learning approach virtually combines technical, cognitive, and behavioral skills to prepare trainees for actual events. It allows trainees to practice repeatedly in a controlled environment, promoting knowledge retention while eliminating any patient risk due to operator error.

The word "simulator" is used in the medical field as a device that acts as a simulated patient while encompassing multiple experimental activities.¹ Simulators have been commonly used in healthcare education for many decades. Even some 2,500 years ago surgical simulators were first utilized to plan advanced surgical procedures while providing patient safety.³ Since the start of the 21st century healthcare education and resident training has changed significantly through the incorporation of information technology and a shift in patient and student attitudes toward simulated learning.⁴ Simulators have been used for many years to teach physicians to perform resuscitation; without such simulation, it can be difficult to achieve the diagnosis and management of patients who are actually having cardiac emergencies and arrest.⁴ This approach has aided in the development of residents who are newly exposed to life-altering medical emergencies.

Patients may present with many complications, some of which require extensive repair and surgical intervention. Clinicians can be prepared for such situations through the integration of simulated learning experiences in their curriculum. Patient simulation is used as an educational tool to provide students with an effective way to practice patient care in a controlled and safe environment, affording them the opportunity to rehearse principles of deliberate practice and self-reflection, meaning they can practice on their own and critique and evaluate their own work.⁴ Also, students and clinicians can gain mastery of a skill with the surgical simulator by using the software multiple times.² The introduction of this new technique allows surgeons to safely practice surgical procedures while eliminating patient involvement. A medical education centered around simulation-based practices can provide students with a platform to learn mitigation of ethical tension and the resolution of practical dilemmas.²

One surgical simulator that was found to facilitate knowledge retention and improved patient outcomes is Touch Surgery^™ (TS) (Medtronic, medtronic.com).⁵ TS uses a cognitive task analysis (CTA) to assess a student's decision-making process as well as the effect on patient outcome. Completing the surgery is standard, but analyzing the decision-making process evaluates the student performance throughout the entire module. Also, the analysis is highly effective in recognizing life-threatening decision errors that may have been made during the surgery. A patient surviving the surgery does not necessarily indicate a successful surgery, as any operator error or hastily made decisions during the surgery may adversely affect the patient postoperatively.

Surgical simulators such as TS offer many complex procedures across a wide range of different disciplines in healthcare education. The app can be functional in one of two features: learning and testing. The learning feature offers stepwise instruction to completing a task, while the testing feature is completed with no provided instructions.⁶ Residents and medical students have used TS to practice and perform complex surgical procedures in more than 100 residency programs. For example, residents specifically in an orthopedic residency have used TS to practice carpal tunnel release procedures through repeated modules.⁷ The validity of the app was confirmed by the fact that every participant's performance improved with successive attempts.⁷ Undergraduate medical students have experienced similar levels of simulated surgical training with TS. The validity of the app was also confirmed in studies specific to the dental field. In one study, authors used TS to transition clinical rotations to a virtual experience,⁸ while in another study, the authors discussed the use of TS to increase maxillofacial surgical training.⁹

Furthermore, students and expert surgeons have used TS to perform orbital floor reconstruction. Participants were recruited from a local dental school and academic residency program to complete the orbital floor reconstruction module on TS.¹⁰ Results showed that the seasoned surgeons outperformed the novice learners in the first two modules, which acted as a measurement of validity.¹⁰

Besides TS, other surgical simulators are also available that have been integrated in some dental school curriculums, such as Virteasy Dental (HRV Simulation, hrv-simulation.com), Simodont^® Dental Trainer (Nissin Dental Products, nissin-dental.net), and DentSim (Indizium, indizium.com). Virteasy Dental is a dental surgery simulator that can accelerate student training and lets instructors monitor their development. It is aimed at simplifying training for performing procedures and making diagnoses. Simodont uses highly developed haptic technology that is customized and adjusted for use in medical simulation. Supported at more than 80 dental schools worldwide, Simodont offers skill transfer into the physical world through, for example, training on virtual reality manual dexterity blocks allowing students to encounter and practice real-world patient scenarios in a safe learning setting. DentSim functions simultaneously as a visual, audible, and practical learning channel. Benefits of the DentSim unit over traditional phantom heads, according to the manufacturer, include the following: knowledge is acquired in a complex multimodal learning environment with a high level of interactivity and audio-visual information; clinical relevant work facilitates problem-oriented learning; 3-dimensional spatial work is derived from 2-dimensional knowledge; 2-dimensional error analysis can be used to quickly analyze 3-dimensional preparations; and all preparation exercises are recorded for error and effectiveness analysis.

Surgical simulation that eliminates the chances of operator error negatively impacting the patient has transformed the educational realm. While traditional methods of lecturing in the healthcare field provide a foundational clinical knowledge, actual clinical training can be daunting. Textbook readings and bedside teaching for residents and medical students, who rely on clinical experience to progress in a career, provide limited information.⁴ Use of surgical simulators have been proven to effectively facilitate a virtual learning environment for students in the medical field and most recently the dental field (Figure 1).¹¹

In addition to students, already-established practitioners have been incorporating simulators into their daily learning environment. Doctors have been using simulators to complete continuing education certification requirements. For example, the American Journal of Surgery had surgeons participate in a laparoscopic hernia course to assess the validity and feasibility of using a simulator in medical continuing education. Results showed that simulation-based medical education courses had a positive impact on clinical practice, especially for the hands-on experience.¹² By practicing via simulation clinicians are able to strengthen their skillset while simultaneously decreasing any hospital interaction and eliminating patient exposure.³

Organizations, universities, and hospitals that require simulated certification courses are already using simulators for cardiopulmonary resuscitation (CPR) trainings. There is, however, no evidence of simulators being used for specialized dentistry courses. In order to integrate simulation successfully, validated educational models need to be used and all aspects of training-assumptions, activities, resources, and outcomes/impact-must be included (Figure 2).

TS is a simulation platform that uses virtual reality (VR) and CTA to allow trainees to practice and rehearse surgery step by step. CTA is the underlying methodology used in the TS app. CTA concentrates on "tasks" that individuals are expected to perform.^1,13 Surgical procedures on TS are created with leading surgical experts in the field, using a CTA approach. This creates a map of an operation. The medical visualization team layers this onto a VR patient.CTA helps one understand the experts' reasoning processes so an educator can teach others about them. With a specific emphasis on decision-making, CTA divides a process into its cognitive phases. CTA is the method used in the TS simulations to elicit an expert understanding of what is needed to perform a complex task.CTA defines the mental mechanisms and options that experts use to accomplish an objective and/or solve a complex question.¹³ CTA is commonly used to understand work processes, advise decision support systems architecture, and build resources to support human performance effectively.

Tools that utilize CTA are also being used to contribute to training and instruction design by providing learners with comprehensive teaching on how to execute target tasks at high levels of competence. These techniques also provide a measurably higher amount of valuable knowledge about the successful performance of tasks than other information recognition methods. Evaluations indicate that CTA offers 12% to 43% more data than non-CTA-based methods for documenting performance-relevant processes.¹⁴

Research provides clear evidence of the advantages of CTA when used as part of the teaching design. In contrast to more conventional training design using expert-based task analysis, one study recorded an overall post-training performance and learning benefit of about 46% for CTA training.¹³

Surgical simulators have been implemented into many different healthcare programs worldwide for several reasons. They boost patient care confidence, reduce patient risk, facilitate knowledge retention, are useful in conjunction with traditional teaching methods, and increase clinical advancement. Students feel more comfortable and less agitated knowing that if something goes wrong it can be resolved immediately, unlike when working on an actual patient where an accident or error can be critical and may make the difference between life and death.

Surgical simulation allows for continual practice and immediate feedback. By eliminating the risk of iatrogenic harm to patients, assessing clinical competence creates a legitimate culture of safety.¹⁵ The safety of patients undergoing an extensive surgical procedure is imperative to assessing the success of a surgery. To achieve the highest level of fidelity, surgical simulators replicate patient-specific complications to allow surgeons to practice in such situations before seeing the patient in person.³ The augmented reality equips surgeons with the confidence to proceed with patient care and reduce operating room difficulties.

Although surgical simulators have many benefits, implementing a new teaching technique can be challenging for many reasons. Integrating a surgical simulator into the curriculum comes at a cost. While those simulators that have high-fidelity can replicate complete operations, they are very expensive and, thus, less attainable.³ Lower-fidelity simulators are more readily available but tend to teach only basic surgical skills; therefore, a cadaver or animal simulator might be just as effective.¹⁶ Thus, it is hard for many institutions and residency programs to acquire a surgical simulator as a supplement to clinical-based practices. Also, surgical simulators require training for learners to comprehend the technology, and faculty calibration is recommended. Despite surgical simulators having these limitations, research does support their essential use in clinical practice.¹⁷ In addition, surgical simulators give educational programs the opportunity and ability to expand on clinical reinforcement.

While students may be able to recite the surgical steps necessary for a given procedure it does that mean they are proficient in surgery. It also does not mean they can deal with complications of surgery. Students must build a foundational knowledge before entering any clinically based practice. The use of surgical simulators then adds on to the foundational knowledge by bringing it to life and exposing students to preclinical experience without the fear of complications arising during the practice surgery.¹⁸ Some educators even believe that the learning process may be easier due to the more controlled and safer setting as compared to an actual operatory. The comfortability is an important factor that plays into the operating on a live patient; someone who does not feel a certain level of comfort will be less likely to progress with the surgery.

When considering integration of a surgical simulator into a teaching/learning process, several challenges and opportunities should be considered, as outlined in Figure 3.

Simulated learning helps bridge the gap between lecture recordings and clinical experience. Using a CTA, a simulator can assess the learners' performance, in both academic institutions and continuing education programs. Surgical simulation is a technique that is expected to continue to grow as more dental institutions and their stakeholders lean more toward standardization of simulation tools.

The authors have no disclosures to report related to this article.

Tahir Hamza, BDS, MS
First-Year Postgraduate Resident, Department of Periodontics and Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania

Robert A. Conca, DMD
First-Year Postgraduate Resident, Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, Massachusetts

Irina F. Dragan, DDS, DMD, MS
Adjunct Associate Professor, Department of Periodontology, Former Director of Faculty Education and Instructional Development, Tufts University School of Dental Medicine, Boston, Massachusetts

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