Posts Tagged ‘virtual surgery’

drwietimg_4481In 1999, the Institute of Medicine published a study that concluded the following: medical errors in the US cost the lives of as many as 98,000 people each year (and run up a $17- $29 billion bill to boot). Ten years later, the Safe Patient Project reported that, rather than showing improvement, in the intervening decade the situation may have actually gotten worse—to the tune of more than 100,000 deaths each year as a result of “preventable medical harm.” Given that the CDC puts the number of deaths from hospital infections alone at around 99,000 annually, the SPP’s number seems conservative.

Let me put this into perspective. A Boeing 737—the most popular aircraft family in service today—seats 360 people, give or take. So consider this: the Safe Patient Project’s estimate of preventable fatalities is akin to 277 airliners plummeting to Earth and killing everyone on board—every year. How long do you think the FAA—or the public, for that matter—would stand for that?

Fortunately there’s a solution: video games.

Being a videogamer doesn’t get a lot of respect in a lot of mainstream professions, but it has been instrumental to me in becoming a surgeon.”

red_dragon

Red Dragon simulator, ISIS

That’s Dr. Andy Wright, surgeon and core faculty member at the University of Washington’s Institute for Simulation and Interprofessional Studies (ISIS). The Institute’s goal is to use technology to improve the quality of healthcare education, patient safety, and surgical outcomes. Simulations are particularly effective as they allow trainees to easily repeat procedures until they’re successful, and provide a safe place for them to fail when they’re not. In Dr. Wright’s experience, the skill and manual dexterity necessary to play video games proficiently translate directly to surgical simulators—resulting in more effective training and fewer accidents in the OR.

Gamers have a higher level of executive function. They have the ability to process information and make decisions quickly, they have to remember cues to what’s going around [them] and [they] have to make split-second decisions.”

Accomplished gamers show heightened abilities to focus on critical elements while maintaining peripheral awareness of the surrounding environment, function amidst distraction, and effectively improvise if a situation doesn’t go according to plan. Past studies have repeatedly demonstrated this, and it makes sense: effectively navigating through and surviving a video game’s virtual world demands it. There are other characteristics of video games that make them particularly well-suited to prepare surgeons for the operating room: you interact with the game’s world through a video screen, and you have to be adept at manipulating images and items with a handheld controller. These skills are especially useful in the areas of laparoscopic (see my previous post here) and robot-assisted surgery.

da Vinci Surgical System

da Vinci Surgical System

Take da Vinci, for example. It’s a robotic surgical system that allows surgeons to perform delicate, complex procedures through tiny incisions. The da Vinci system combines 3D, high definition video with four interactive robot arms (there’s even a dual-console option where trainees can watch an actual procedure, and a switching mechanism that allows surgeons and trainees to exchange control during an operation). Surgeons manipulate these arms using precision controllers that scale the speed and range of their movements down to the much smaller size of the surgical instruments, allowing for unparalleled accuracy. Put simply, the most advanced robotic surgical system in the world employs an interface intimately familiar to video gamers.

Take gaming into the land of simulation, though, and you can start tapping into the medium’s real power. Virtual reality (VR) simulators are an effective means of getting fledgling surgeons comfortable with a variety of procedures, allowing them to perform a given surgery dozens of times before ever opening up a live patient. They also provide an environment in which surgeons can, in essence, fail safely. Within a simulation, they can develop critical skills and expertise without putting anyone at risk, experimenting with different techniques, learning what does—and doesn’t—work, and becoming safer and more effective. A 2002 Yale University study provided strong evidence for this: surgical residents trained in VR were 29 percent faster and six times less likely to make mistakes than their non-VR trained colleagues.

virtual_surgery-chirurgie_virtuelle_1You can also customize a simulation to closely reflect reality, matching the conditions and characteristics of actual patients. In 2009, Halifax neurosurgeon Dr. David Clarke made history when he became the first person to remove a brain tumor in a patient less than 24 hours after removing the same tumor virtually, on a 3D rendering of that same patient. Two years later, doctors in Mumbai performed PSI knee replacement surgery on a patient after first running the operation virtually on an exact 3D replica of the patient’s knee.

Earlier this year, VR training took another leap forward: using the online virtual world Second Life, London’s St. Mary’s Hospital developed three VR environments—a standard hospital ward, an intensive care unit, and an emergency room—and built modules for three common scenarios (at three levels of complexity, for interns, junior residents, and senior residents) within them. According to Dr. Rajesh Aggarwal, a National Institute for Health Research (NIHR) clinician scientist in surgery at St. Mary’s Imperial College,

The way we learn in residency currently has been called ‘training by chance,’ because you don’t know what is coming through the door next. What we are doing is taking the chance encounters out of the way residents learn and forming a structured approach to training. What we want to do—using this simulation platform—is to bring all the junior residents and senior residents up to the level of the attending surgeon, so that the time is shortened in terms of their learning curve in learning how to look after surgical patients.”

After running interns and junior and senior residents through the VR training, researchers compared their performances of specific procedures against those of attending surgeons. They found substantial performance gaps between interns, residents, and attendings—validating the VR scenarios as training tools. As Dr. Aggarwal explained,

What we have shown scientifically is that these three simulated scenarios at the three different levels are appropriate for the assessment of interns, junior residents, and senior residents and their management of these cases.”

In the future, the team at St. Mary’s plans to study how this type of VR training can improve clinical outcomes of patients treated by residents—ultimately using this tool to bring their interns’ and residents’ skills up to the level of the attendings, help them better manage clinical patients, and, at the end of the day save lives.

surgery-2-300x200What can surgeons do for six minutes that enhances performance, reduces errors, and improves patient outcomes?

Play video games.

As unlikely as it sounds, specialists in laparoscopic surgery are finding that they can improve their results in less time than it takes to boil water, simply by picking up a controller and getting their game on. I can hear the protests already. Video games are a scourge, a blight. They’re incubators of violence, and responsible for the downfall of modern society. They can’t possibly offer anything positive.

Actually, they can. Laparoscopic surgery is minimally invasive and very small-scale: surgeons insert a tiny video camera and set of miniature surgical instruments into a patient and use video game-style controllers—like joysticks and d-pads—to manipulate these tools from outside the body. This requires precise hand-eye coordination, keen depth perception, and a high level of manual dexterity—the exact skills needed to excel at video gaming, and which games are uniquely suited to develop. According to Dr. James C. Rosser, a laparoscopic surgeon at Florida’s Celebration Health hospital,

I use the same hand-eye coordination to play video games as I use for surgery… I could come in, sit down, and put this [the surgical tool controller] in my hand and not find it foreign to look on that screen and do something with my hands.”

Dr. RosserDr. Rosser proved this in 2002, while practicing at Beth Israel Medical Center. He had 33 surgeons participate in a three-month study that involved, among other activities, playing a series of video games before simulating laparoscopic surgery. About half of the participants had a history of game play, though all of them played throughout the study. Researchers compared the results between participants, as well as against non-gaming colleagues. Across the board, they found that surgeons who played video games were faster and more accurate than those who didn’t—dramatically so: at the low end of the skill spectrum, gaming docs made a third fewer errors and were a quarter faster than their non-playing counterparts. Among participants, the most skilled surgeon gamers were nearly half again as accurate and more than a third faster than those at the bottom of the heap. Further, after controlling for extent of training and number of cases completed, the best predictors of surgical success were video game skill and amount of past gaming experience. Said surgeon and participant Asaf Yalif,

We were surprised and actually awed by the fact that your video game skill, meaning how well you play, as well as the number of hours you have spent on video games were very highly correlating — meaning if you do this well you will be less error-prone, you will be faster and you will perform better at laparoscopic surgery.”

Dr. Rosser recently conducted a follow-up at Celebration Health hospital with 300 laparoscopic surgeons, half playing a video game just prior to scrubbing in. The results? A six-minute video game warm-up resulted in more effective performance and better patient outcomes.

Another study at the University of Rome, Italy, published this past February in the journal PLOS ONE, provides further evidence of gaming’s impact on laparoscopy. Researchers gathered 42 post graduate students in general, vascular and endoscopic surgery, and split them into two groups. Both groups received standard training, but one group also trained on the Nintendo Wii. After four weeks, the Wii group showed significant performance improvement in several areas, including economy of instrument movements and efficient cautery. The authors’ conclusions? The Wii could be a valuable tool for laparoscopic training, and an effective, inexpensive, and entertaining means of enhancing standard surgical education.

Surgeons can’t operate on live patients every day. It’s a numbers game: there just aren’t enough people who need surgery to go around. Other means of honing surgical skills—such as simulators—are therefore critical. The catch is that typical medical simulators run into the hundreds of thousands of dollars—an expense that can be hard for many hospitals to swallow. A game console—like the Wii, Xbox, or Playstation—costs a fraction of that, and provides a viable and effective way to keep surgeons sharp.

Consider this: According to both the Institute of Medicine and the Safe Patient Project, medical errors in the United States run up between 17 and 29 billion dollars in hospital expenses, and result in around 100,000 deaths each year. If video games can reduce even a fraction of these, then perhaps it’s time to get our surgeons playing.

You can find Dr. Rosser’s JAMA Surgery article here.

The New York Times has a piece about Dr. Rosser here.

And you can learn more about Dr. Rosser’s recent work here.

For information about the study at the University of Rome, check the link to PLOS ONE

… and the write-up in Science Daily.