The proving ground in medical education is moving from actual flesh and blood to the virtual bits and bytes of computers. Ultimately, if virtual reality meets its potential, by the time medical and nursing students get near a real patient, they will have honed their techniques and made the inevitable beginners' mistakes on 100 simulated patients.
Even better, prior to a difficult procedure, surgeons will be able to rehearse repeatedly on a three-dimensional image containing data or characteristics specific to the patient who will be on the operating table.
Creativity and high hopes abound, but not much data exist yet on effectiveness.
"A couple of years ago, virtual reality was defined as a technology in search of an application," said Faina Shtern, M.D., associate director for research and technology affairs at the U.S. Public Health Service's Office on Women's Health. She has seen a dramatic evolution on the technical side. "What it lacks at the moment is solid clinical testing and evidence. Some centers are striving toward clinical testing, but to the best of my knowledge, clinical data are still in early stages."
Conversations are shifting from "what we will do" to "what we are doing," said Helene M. Hoffman, Ph.D., assistant dean of curriculum and educational computing at the University of California, San Diego School of Medicine. "People are beginning to talk about outcomes."
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There is something to be said for letting inexperienced students cut their procedural teeth on computer-generated models instead of on real people who feel real pain.
"Teaching residents on live patients is not a great way to provide medical education. We are trying to create a way that is much more efficient and safer for patients," said Jeffrey S. Levy, M.D., medical director of education and technology initiatives at the University of Pennsylvania Health System in Philadelphia. "Even under strict supervision by an expert, it is very difficult for a learning physician to perform a new procedure on a patient for the first time."
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With the VR hysteroscope, students can practice diagnosing and treating problems that cause abnormal uterine bleeding, such as polyps, fibroids, or cancer. Varying degrees of difficulty will make the scope useful for medical students, residents, or experts who want to practice a new procedure. The software can simulate a 0.5-cm polyp that is easily accessible or a 4-cm polyp that is tricky to maneuver around. The system is designed to add complications that might occur during a procedure, to help students prepare before getting into the real thing.
Levy's challenge is to move his system from a very expensive Silicon Graphics computer onto a standard personal computer to make it less costly and easier to mass produce. He hopes to do that within the next year and a half. In testing, Levy expects to see a "significant decrease in the learning curve and in the complication rate, and an improvement in patient care."
Away From the Stress
Virtual reality laboratories that focus on technique mastering are popping up at nursing schools. The University of Maryland, Baltimore, has installed a dozen different simulated environments, including a neonatal care unit, critical care, oncology, and home care. Nursing students interact with computers and work on mannequins that are wired to react to the nurses' actions.
Barbara R. Heller, Ed.D., dean of the UM School of Nursing, said she expects this environment to work better than the traditional means of teaching in tertiary care, for example. "The one thing we know about clinical learning situations: They are life and death, very high stress," Heller said. "They are certainly not conducive to a learning experience." Outcome and efficacy results comparing the simulated environments to the more traditional setting in which students are assigned immediately to the clinic are due within the year.
Advocates are inspired by the space program. "The success of NASA proves that by simulating every conceivable situation in space flight you can oftentimes familiarize astronauts with very complex situations. Their performance will improve and their comfort level with handling unexpected events will improve a lot," said L. Michael Glodé, M.D., professor of medicine at University of Colorado Health Sciences Center in Denver and editor in chief of ASCO Online.
Where's the Human Contact?
Some clinicians worry that technology threatens important humanistic elements of the doctor-patient relationship. Michael Kirsch, M.D., a gastroenterologist in Highland Heights, Ohio, recently wrote in ACP-ASIM Observer: "Our embrace of technology has taken us too far away from the bedside." He laments that radiologic imaging techniques have replaced the probing hands of yesterday's experienced diagnosticians. Even the stethoscope, he says, is becoming little more than a prop dangling around the physician's neck.
"You don't lose humanity because you have a new tool," countered Richard M. Satava, M.D., professor of surgery and director of the Yale/NASA Commercial Space Center. "There's no difference between a stethoscope and an MRI. "Just because it's bigger, doesn't mean it's inhumane." He is reminded that early physicians were convinced that the stethoscope was an instrument of the devil that would separate patient from physician.
Still, diagnosis needs to improve. Recent studies have shown that physicians are failing to discover life-threatening disorders that are only revealed on autopsy. A 10-year, retrospective study at Medical Center of Louisiana in New Orleans found that 44% of malignancies found at autopsy had gone undiagnosed or misdiagnosed. In 57% of these cases, the underlying cause of death was the undiagnosed cancer.
The authors caution that the population studied was mainly indigent, and more acute problems may have masked the malignancies. But these rates are similar to those found in other studies.
These findings point to the "giant gap" between what high-tech diagnostic medicine can do in theory and what it accomplishes in practice, wrote George D. Lundberg, M.D., former JAMA editor, in an editorial accompanying the study. With increased reliance on CT scans, MRI, and ultrasound, the autopsy rate has plummeted from about 50% in the 1960s to 10% in U.S. teaching hospitals and 5% in community-based hospitals today. Critics of the drop charge that important learning opportunities are being missed.
Plenty of researchers are working on simulated anatomy programs that they say go one better
than work on cadavers. Martin McGurn, a vice president at HT Medical Systems, Inc., of
Rockville, Md., sees medical simulators as a step up from lab animal and cadaver training.
"We can simulate a live human environment, which we can't do with cadavers or
animals."
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"The medical community scoffs at that," McGurn admitted. But 15 years ago, the same revolution was happening in air travel. Now flights are 90% controlled by computers, he said, and the main worry is keeping the pilots from falling asleep at the wheel for lack of things to do.
Yale's Satava is not convinced that robots will take over, but they will bring improved precision and magnified views to help physicians manipulate the tiniest vessels and nerves.
Beyond the Slide Show
Universities have begun moving virtual reality from the laboratory to the lecture hall, according to UCSD's Hoffman. In a recent student lecture at UCSD, a three-dimensional simulated skull was introduced to point out the autonomic cranial nerves and their pathways. "Trying to show that in a diagram is very problematic," she said. The lecturer was able to reach into the graphic and virtually grab the skull to move it around. The students were impressed with the technology.
Hoffman plans to test the method's impact in a double crossover experiment in which half the students learn head and neck anatomy in a VR setting. The other half use a cadaver. Students would then trade resources for another lesson. Both groups would take the same written and practical exams.
"If the VR system performs as well as the dissection group, that's all I need," said Hoffman. "Virtual reality has a whole lot of other advantages." She expects to see VR improve student testing too, from rote identification of body parts to application of anatomy in clinical problem solving.
Others are trying to liberate education from the classroom. "Classroom-based learning is very inefficient," said John M. Harris, Jr., president of Medical Directions, Inc. of Tucson, Ariz.
His company's Virtual Lecture Hall, or VLH.com, combines distance learning with computer-based instruction that responds to the user's decisions. It brings medical education closer to the apprenticeships of the past, according to Harris. "You practice, somebody watches you and shows you how to do it better."
With National Cancer Institute funding, he just finished a pilot study of an Internet-based program that teaches primary care physicians and medical students to evaluate pigmented lesions based on accepted decision rules. Studies show primary care physicians lack the experience and have little confidence in their ability to manage these lesions.
The program walks physicians through nine scenarios and gives tailored responses to their choices on diagnosis and follow-up. Those who pilot tested the program "were significantly better at applying the decision rules they learned and more confident after looking at an hour's worth of education," Harris said.
Proponents of virtual reality say it will only augment physician interaction with patients.
"Virtual reality won't replace most of the hands on," said Hoffman. "It will empower the hands on to be more skillful and more directed."
Shtern is waiting for the data. "I think people are striving to find technical solutions to clinical needs. Whether or not medicine becomes hands off in the process is difficult to say. This only can be shown through clinical testing. That's where virtual reality needs more extensive research," she said. "We'll see through clinical studies whether it will be beneficial to patients."
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