Medicine will always be an imperfect science, but better tools can definitely have an impact.
That’s why Queen’s University in Kingston, Ont., has made significant investments in new technologies for its Faculty of Health Sciences, which incorporates the schools of medicine, nursing and rehabilitative therapy. To better ensure its roughly 1,000 residents are well-trained in the art of surgery and resuscitation, an 8,000-square-foot clinical simulation centre is providing them with state-of-the-art mannequins and manipulative computer programs.
Traditionally, a lot of the learning has been done at the bedside with real patients, says Bob McGraw, director of the clinical simulation centre at Queen’s University. But it’s become apparent this is not always the best approach for the two sides involved and it doesn’t really provide enough opportunities for learning.
“You really need to have a focused, repetitive practice of skills to get good at something, and trying to do that in a hospital or clinic-based setting really isn’t efficient and you really can’t take your learner as far as you want to take them,” he says. “The educational philosophy of a centre like this, the bottom line is that practice makes perfect and the more you practise any skill, the better you get at it — particularly if it’s under a supervised setting.”
The newer technologies allow the faculty to closely mimic real situations. For instance, a piece of plastic skin can be draped over a board and used for suturing practice.
And then there are more complex simulators in which a resident can practise removing a gall bladder by seemingly cutting specific vessels, doing cautery and controlling the bleeding. Working off a video screen, they have instruments connected to a computer that can actually track where the instruments are moving relative to the “patient” and push back or resist — known as haptic feedback — to make it feel as if the instruments are touching a real person.
“That’s very impressive technologically,” says McGraw. “You’re not only having them watch on the video screen what they’re doing but they also have a sense of touch and feel for what’s going on. It’s not exactly like a real patient, but the technology is trying to take it as close to that as you can.”
The real magic is that this method allows a resident to practise her technique many times — such as several times on a weekend — instead of once per week or per month, he says. That’s important because individuals learn at different rates.
“What we’re focused on is a level of competency that we want to get all residents up to, so they do it as many times as they need to demonstrate that they’re where we need them to be, and this is all before we let them into the operating room.”
The computers can also track the performance of each resident, so a supervisor doesn’t have to be standing by her side each time, says McGraw.
“The computers will generate reports and that will tell the faculty how long it took a resident to do the procedure, if there were any complications, also how the instruments were moving during the procedure,” he said. “If there was repetitive poking, that would suggest a resident who’s not quite sure about what they’re doing versus someone who’s very deliberate about their activities — that shows that they’re getting better at it. It’s a measure of competence.”
The school also does a lot of training around resuscitation and the managing of critically ill patients, such as defibrillation. That’s a complex environment, says McGraw, as it can involve an inter-professional team made up of medical students, residents, physicians and nurses all working together performing roles with a very sick patient. So Queen’s mannequins are very sophisticated in terms of producing vital signs such as a heart rate, blood pressure and dilated pupils.
“(Cardiac arrests don’t) happen in a hospital very often, fortunately. So it’s really hard for people to get that experience of working together as a team in an emergency whereas in the clinical simulation centre, on any given Friday morning, our residents will participate in 10 to 20,” he says. “We can make sure that they are exposed to certain important rescue cases.”
That’s in contrast to McGraw’s training, where everything was learned at the hospital in a “very random, sort of hit-and-miss fashion,” he says.
The centre is also partnering with the computing school at Queen’s in the development of needle-tracking technology. This allows a computer to track the movements of needles in space, as people currently are unable to see exactly where the tip of a needle is going once it has pierced the skin. This is very helpful for procedures such as an epidural in trying to a find a specific location, says McGraw.
“Rather than having a blind spot and hoping they’re getting it in the right place, we’re able to do a graphic display of where the needle is in space as it approaches the spinal canal, and we think that will help them to learn better.”
The technology also allows for the tracking of a student’s performance, so supervisors can see if someone is still doing a lot of poking around instead of being very deliberate.
“Eventually, they reach a point where there is very little extra movement of the needle, so that shows you the student is getting up to the point where he can do it in a supervised setting on a patient,” he says.
And the performance tracking of the technologies may also, down the road, allow the school to better pinpoint where a student should specialize. It gives them an opportunity earlier in their training to start demonstrating their skill, says McGraw, adding the residents are actually ahead of faculty because they’re more familiar with the procedures through the training.
As for the benefits to patients, Queen’s is not yet tracking such evidence, he says.
“There is a growing body of evidence in the literature that it does help with patient safety and error rates, but we’re not quite there yet.”
And while the mannequins and computer programs are not exactly the same as real patients, students are able to suspend reality and buy into the situation, says McGraw.
“It’s not precise but it does accomplish what we want it to accomplish — we can create complex scenarios, we can engage our students so that they’re completely focused on the problem. And we have no problem having them suspend reality — this is the real thing.”
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