UW med students prepare with cutting edge technology

Medical students at the University of Washington who want to become surgeons no longer have to worry so much about killing or injuring patients while learning their chops.

Thanks to video-game technology, some creepily realistic rubber skin, fake organs, mannequins and other simulation devices (including a full-scale fake operating room), budding surgeons at the UW now test their skills in the virtual world. More important from a patient's perspective, the UW is increasingly moving toward requiring all medical, nursing, pharmacology students and others to master such simulated realities before ever touching a live human being.

The UW's Institute for Simulation and Interprofessional Studies is where medicine meets the arcade.

The goal of the UW's world-renowned program in medical simulation -- which has been around in various forms for decades but was only recently reconfigured into a comprehensive institute -- has become much broader than simply using new technologies to train doctors how not to kill or injure patients. It's also about training them how to play well with others, which studies show is just as critical as surgical dexterity for avoiding many kinds of medical mistakes.

"OK, put a staple on either side before you cut," said Dr. Brian Ross, executive director of the institute, pointing to a computer screen displaying a fairly realistic-looking intestine squirming around inside someone's gut.

UW pre-med student and institute technician Todd Krienke had his hands on two pistol-like handles with rods extending into the guts of the computer -- simulated laparoscopic abdominal surgery. Following Ross' instructions, Krienke deftly manipulated the triggered devices to gently handle and examine sections of the virtual bowel. They were looking for an obstruction, perhaps some scar tissue that needed removal.

"This program gives them feedback to tell them if they are grabbing it too hard, causing tissue damage," Ross explained. He told Krienke to demonstrate a bad maneuver, a poorly placed cut, which rapidly filled the computer screen with blood and made clear that the patient wasn't doing too well.

Nearly all abdominal surgeries (and many other kinds of surgery) are now done using laparoscopy -- with these kinds of probes, tubes, cameras and other kinds of tubes inserted through tiny incisions -- to reduce the use of the much more traumatic and dangerous method of having to cut a gaping hole in the stomach or chest of a patient.

When laparoscopic surgery (or "keyhole" surgery) first came into wider use something like 15 years ago, Ross said the new surgical technique was introduced according to the time-honored medical education tradition of "see one, do one, teach one." Surgeons were shown how to do it (initially by the device manufacturer), did it themselves, then eventually maybe taught medical students.

"The problem with this approach is that if you see it done wrong, you do a hundred wrong and then teach others to do thousands wrong," Ross said. "Practice doesn't necessarily make perfect. Sometimes practice just makes it permanent."

Many medical schools today still have medical residents do some of their first procedures on patients, he said.

"I don't think this is the way we need to do things anymore," Ross said. "I'd rather be able to tell some surgical resident, after 25 unsuccessful tries on a simulated patient, that maybe he ought to consider going into pathology."

An increasing number of studies in medical journals (with the texts referring to video games "Super Monkey Ball" or "Star Wars Revenge"), he noted, show that error rates and operating times can be significantly reduced when surgeons practice their skills in virtual reality before heading into the operating room. Ross said the UW is even trying to interest Microsoft in adapting its Xbox for use as a regional telemedicine tool for teaching students at remote locations.

"It has the best graphics and would be perfect for this, with some tweaking," he said. No word yet from Redmond on that front, however.

Brenda Zierler, associate dean in the UW School of Nursing, said simulation training is useful for doing much more than improving individual skills. Different forms of virtual training are already used at the UW for training nurses, dentists, pharmacists and others, Zierler said, but what's really needed is an effort to combine the training.

"A big problem in health care is lack of teamwork," she said. Studies show that the many different health professions share 20 percent to 30 percent of the same training, but continue to be educated in "silos" with little emphasis on how they will have to work as a team in the real world.

"Something like 70 to 80 percent of the errors in health care are due to poor communication, lack of teamwork," Zierler said.

Medical students are still taught to think of themselves in a largely hierarchical way, she said, and as if all they need to understand is their own job. Just telling students in the classroom to work together, with each other and with other professions, doesn't seem to really work, she said.

"There's so much to learn in all our professions that we often fail to see the whole picture, and the whole patient," Zierler said.

Numerous studies have shown, she added, that this failure to instill teamwork at the very beginning of the health care education is causing tens of thousands of patient deaths and hundreds of thousands of injuries.

Thanks to a number of new grants from private foundations and the federal government, the UW plans to use the institute now to bring the professions together into the same operating or hospital room and perhaps kill a few mannequins or cut a few virtual veins in the interest of protecting real patients.

The Department of Defense has awarded a $4.4 million grant to the institute aimed at this, and two philanthropies, the Josiah Macy Jr. Foundation and the Hearst Foundation, have donated $990,000 and $250,000 to the UW's goal of using simulation to stimulate teamwork in health care.

"Simulation gives us the permission to fail," said Dr. Richard Satava, a UW professor of surgery, institute member and one of the Army's top advisers on medical matters. Allowing students the freedom to fail and using simulation technologies to emphasize collaboration, Satava said, will transform the health professions.

"This is going to change the way medical education is done," he said.

It's a fairly bold prediction, but coming from him it may be worth taking seriously.

Satava was the first physician ever to work for DARPA (the Defense Advanced Research Projects Agency, which invented the Internet) and is one of the world's leading pioneers in medical robotics. He came to the UW, at the request of UW surgery chairman Dr. Carlos Pelligrini, to help launch the institute.

Satava said he believes the use of collaborative simulation training and related technologies is fundamental to the future of medicine. The UW, he said, is uniquely positioned to become the world leader in this new field given the region's combined talent in medical research and information technologies.

In fact, he said, the UW School of Medicine's responsibility for medical education across five states (Washington, Alaska, Montana, Idaho and Wyoming -- 25 percent of the U.S. land mass) almost requires that it become the leader in telemedicine and in expanding the use of "virtual realities" in health education.

"There's really nothing else that's going to be like this," Satava said.