Augmented Reality, Other Trainers for Complex Disease

When the economy showed signs of instability in 2007, Lindsay Murphy was laid off from her job at a hospital. Two years later, still with no job and no health insurance, she had to file bankruptcy and lost her home. But tough finances were not the main source of her anxiety-even more difficult for Lindsay was not knowing the cause of her severe bleeding and pain. Without insurance, she began to visit a popular clinic dedicated to women’s health for her care.

What transpired was a long road of misdiagnosis, which she later learned is common in endometriosis patients. The clinic’s doctors said she had pelvic inflammatory disease. They gave her a shot, but she continued to reel in pain. Upon return, she was put on antibiotics and asked to leave.

Lindsay Murphy's Story

I had a hysterectomy at 33 years old. It truly released me from my pain and gave me a chance at a high-quality life. To this day, there is no pain. My surgeon removed my endometriosis, but there is still no cure for the disease. It's been a long road to recovery, and I've had to learn to manage the damage the disease has done. I've made tremendous progress. Although I’m not the athlete I was years ago, I am active. After years of no answers and four surgeries, I now have a pain-free life. I feel good that I helped the medical community learn more about the disease, but there are still many more questions than answers.

After a job interview in Denver, she collapsed on the street; when she woke, she called her mother. “That is no UTI,” she said. It would take another three years of misdiagnosis and botched surgeries before Lindsay would finally recover, finding relief from debilitating pain. She eventually found a trained specialist and endometriosis was finally diagnosed.

It took a well-trained surgeon.

“This is a specialty disease,” says Mary Lou Ballweg, president of the Endometriosis Association, a worldwide group dedicated to research and awareness of the disease. “It is the characteristic of determination that I have come to appreciate-those doctors who keep coming back to understand the disease.” She points out that 89 million women around the world have endometriosis and are searching for effective treatment, concerned about pain and infertility. “It is ruining their lives.”

Even more women, one in four, have fibroids. And there are many other undetected, misunderstood diseases that are complicated to treat. Lowering the numbers and the costs that go with them actually requires investment that will lead to better detection and surgical training.

“A four-year residency is not enough,” says Mona Orady, MD, director of Robotic Surgery Education at Cleveland Clinic: “I see women after they have had unfinished, poorly performed surgeries every single day.” Orady believes hospitals need to adopt stratification where they designate what is routine and what requires simulation and other forms of surgical training. “There are higher levels of care and, for that, high-quality training is essential.”

Orady encourages simulation training by incentivizing it. She sets the bar and requires passage in order to operate. Many other centers of excellence are now setting their own requirements. The Robotic Training Network (RTN) has unified robotics training and testing at over 50 institutions, with participating hospitals including Johns Hopkins and Harvard. The RTN curriculum, which includes cognitive testing and skills evaluation through physical models and simulation, is growing rapidly in popularity.

At Columbia, we have begun implementing the RTN curriculum on both the resident and fellow training level. As the Vice-Chair & Chief of Gynecology at Columbia University Medical Center, I can tell you that the days of learning-as-you-go on patients are not acceptable. Surgeons must simulate to proficiency before entering the actual operating room.

What’s New?

Most hospitals that use the da Vinci® robot also use simulation training to some degree. This technology, created by Mimic Technologies, has been independently validated by research and academic medical centers around the country. Mimic has also recently developed training technology for traditional laparoscopic surgery that supports the surgical assistant in robotic procedures. The goal is to help all members of a robotic surgical team perform at a high level.

Mimic’s training director, Todd Larson, is a former Walter Reed Army Medical Center specialist, and agrees with Orady that most surgeons coming directly out of residency have not reached a level of competency that allows them to perform advanced surgical procedures. Consequently, they will seek Fellowship training or some other advanced training to acquire those skills. Mimic Technologies has partnered with the Florida Hospital Nicholson Center to develop simulation training to aid the specialist in safely acquiring advanced skills. 

According to Larson, most surgeons who participate in simulation training note improvement. They are evaluated through technology called M-Score, which measures performance and provides an actual score on areas that represent their strengths and weaknesses. This type of assessment is meant to improve training efficiency, since the surgeon can then focus on his or her own specific deficiencies.

Once surgeons complete their training, they must meet the credentialing standards of the hospital where they are practicing. Currently, there are no universal standards or benchmarks for robotic surgery. Each individual hospital has its own standards for credentialing and privileging. There is an effort through the American College of Surgeons to develop the Fundamentals of Robotic Surgery; however, these standards are still in development. Since the Joint Commission requires ongoing professional practice evaluation to ensure surgeon competency, simulation can serve not only as an objective performance measure but also as a tool to maintain competency utilizing advanced technology, such as robotics. Surgeons claim that individual high surgical case volumes lend themselves to maintaining one’s skills. This is why objective-based simulation can serve as a great tool for skills maintenance and overall competency. As Orady and Larson point out, surgical skill is individualistic and skills decay will vary with each individual practitioner. However, by continuing to use simulation, a surgeon can continue to evaluate and maintain his or her skills.

“There is a lot of equipment in the hospital that has the potential to cause harm. Robotics is certainly no different," says Larson. “What is unique about robotics is the means to safely acquire and maintain a surgeon’s skills through simulation and advanced training." [[{"type":"media","view_mode":"media_crop","fid":"27424","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_582556338049","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2662","media_crop_rotate":"0","media_crop_scale_h":"223","media_crop_scale_w":"300","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Screenshot of augmented reality surgical training software.","typeof":"foaf:Image"}}]]

Since gynecology is becoming more specialized, the need for advanced training is even more necessary. Mimic is also working on an augmented reality product that will simulate hysterectomy, coming out this fall. Augmented reality combines three-dimensional (3D) computer-generated objects and text and superimposes them onto real images and 3D surgical video footage, all in real time. The surgeon then has the feeling of being in an actual surgery. This accompanying video provides a brief example of how this augmented reality training software will work.

Larson says this is needed because the current controlled basic training environment is incomplete: “The current animal model used in training does not adequately emulate actual practice. What would be ideal is to perform the procedure in a simulated environment and be objectively evaluated on your performance.” Hospitals are constantly looking for the safest way to acquire skills, learn the specifics of the surgical procedure, and learn how to manage potential complications.

“We believe this is the future of GYN training,” says Mimic CEO Jeff Berkley, PhD. “Practicing surgery on animals will only take us so far. Through augmented reality, we hope to expose surgeons to a wide variety of surgical scenarios that they would not normally encounter as a part of the typical case load. This approach may help limit the amount of learning that must not take place on real patients.”

Berkley explains that it was gynecologists who were the first to make the aggressive push toward simulation testing to gain surgical privileges. This is due, in part, to the access issues of training in the OR. “Gynecology training is special-it is tougher to get to the volume of surgeries you need,” he says. “It can be tough to keep up those needed skills. That is why we have made women’s health a priority, because skills maintenance through simulation should play a larger role in gynecology.”

Another development that is being scientifically supported by The New European Surgical Academy (NESA) is a European robotic system called Telelap Alf-X, which allows the surgeon to indirectly “feel” the tissues they are manipulating during surgery. The system is already certified in Europe and more than 100 clinical studies are under way. Experts are predicting that many new surgical robots, which will enable the sense of touch, will become available. The additional market competition should help bring down the cost of robotic surgery.

Training to Save Costs

Speaking of cost, Berkley recommends that hospitals begin looking at education and training as an investment rather than simply an expense. Despite reports that claim that hospitals profit from some errors, repeated surgeries and residual damage from poor surgeries have been shown long term to be quite expensive for both patients and hospitals, with cumulative annual estimates nearing $1.5 billion.^1,2 In the United States, it's been reported that patients undergoing surgery experience "never events" about 80 times each week-mistakes that safety advocates say never should happen.³ These mishaps add up to $1.3 billion in medical liability payouts alone over 20 years. The study’s surprise was the conclusion that surgical errors involve surgeons of all experience levels.

The advantage of practice on the simulators and mentored cases is improved OR performance that prevents these costs. Studies are showing that simulation testing can help hospitals gauge whether a surgeon is ready for the OR. Such a proactive approach can be more cost effective than reacting only after a surgeon makes a mistake. Much of the new, independent rules that hospitals are implementing now require more training such as this. It appears that administrators are listening to the argument that quality of care and costs are associated.

Team Approach for Training

The other important area of training is through teamwork. “Depending on the case, if there is damage to the colon, for example, I may want a general surgeon with me in the OR because it is not my normal expertise," says Melinda Henne, MD, former head of infertility at Walter Reed and a consultant for the Air Force. Richard Satava, MD, a general surgeon and Professor Emeritus of Surgery at the University of Washington, Seattle, agrees that bringing on either a generalist or a specialist helps a great deal with training. “If there is an area the gynecologist feels uncomfortable with, we can be helpful,” he says. “The ureter can be unfamiliar, the kidneys, the bladder. But the colon is a particularly uncomfortable area for many GYNs because if you injure the bowel and there is leaking, it can be catastrophic.”

Satava also mentions that with the trend of super specialization there is less and less emphasis on the role of the general surgeon. But since they operate so often and have very broad experience in the many aspects of abdominal surgery, it can be quite helpful to include them as partners in the OR. “This is a time when there are more requirements and pressures on specialists. And, at the same time, there are fewer hours of experience for newer surgeons. In anticipating a difficult operation, there is no question that a general surgeon will increase the quality of the surgery and the safety for each patient.” And it’s not just a general surgeon. Satava also recommends specialists, “You may want to include a urologist in the room.”

As a surgeon, I know firsthand that when implementing this team-based approach, it is important to ensure that all members are equally skilled in their areas of focus, otherwise the whole process breaks down. For example, if the colorectal surgeon is not competent at managing bowel endometriosis, then the work performed by the infertility specialist is compromised and patient outcomes are impacted.

Patients such as Lindsay have come to learn that for tough surgeries, a better-trained surgeon is essential.

References:

1. Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res. 2008;43:2067-2087. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613997/. Accessed August 27, 2014.

2. Cabrera M, Cavanaugh M, Pico P. How hospitals can avoid surgical mistakes. March 1, 2013. Available at: http://www.kpbs.org/news/2013/mar/01/how-hospitals-can-avoid-surgical-mistakes-do-not-p/. Accessed August 27, 2014.

3. Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgical never events in the United States. 2013;153:465-472. doi: 10.1016/j.surg.2012.10.005. Epub 2012 Dec 17.