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  • Surgical education has adopted the aviation paradigm and given computer simulation a central role in training
  • Simulation in general surgery training programs will become a mandate by 2008 through the Accreditation Council for Graduate Medical Education

Dr. Grunwald
NATIONAL REPORT — Like surgery, pilot training involves the acquisition and perfection of precision skills for work that carries almost no margin for error. No wonder then that surgical education has adopted the aviation paradigm and given computer simulation a central role in training. Simulation in general surgery training programs will, in fact, become a mandate by 2008 through the Accreditation Council for Graduate Medical Education. These advances are likely just the tip of the technological iceberg, Tiffany B. Grunwald, M.D., tells Cosmetic Surgery Times . "Surgical simulation is clearly the future of all surgery," says Dr. Grunwald, who has researched and published on the application of simulation and simulated environments in surgical education and is currently finishing her training in plastic and reconstructive surgery at the University of Southern California.

Soft tissue simulation, surgical simulation and robotics are each already being used regularly for training, and robotics is making particular inroads in the fields of urology, cardiac surgery and general surgery, notes Dr. Grunwald.

FLATTENING THE CURVE The key advantage of surgical simulation is its ability to "train-out" some of the learning curve before residents apply their skills in the operating room. In an age of long work weeks and cost constraints, the benefits are substantial. "Residents are working around 80-hour work weeks, and attending surgeons have even less time available, so simulation can offer training in the basics of surgery," Dr. Grunwald explains. "That means the time in the operating room can be best utilized for refining skills and getting the most from the expert surgeon." That doesn't mean the 100-year tradition of the Halstedian apprenticeship method is obsolete, however. In fact, surgical simulation can only help improve the apprenticeship experience, she adds.

"Nothing can take the place of operating alongside an expert surgeon, but expert surgeons teach best when they have well-educated pupils looking to improve and hone their skills," says Dr. Grunwald. "So there is no threat to 'live teachers' — simulation will simply allow more efficient use of their time."

DRY RUN TIMES FIVE The benefits of such simulation are supported in a recent study from Stanford University that concluded that residents performing cleft lip repair reached a plateau on their learning curve after an average of five cases. Such procedures require a complex set of surgical markings, which Dr. Grunwald notes are arguably the most important part of the procedure. The study prompted the development of a program that allowed residents to go through five simulated cases the night before a procedure, making marks on a 3-D image of the patient. "This meant that the attending surgeon didn't have to wipe off their marks and start over," she says. "The results haven't been published yet, but the researchers found improved performance in pre-operative training."

ROBOTIC BOON In addition to simulation, robotics is breaking ground in countless ways in surgical training. One of its most important applications in surgery is the ability to magnify the surgical field and reduce tremor, says Dr. Grunwald.

"Tremor is always a problem when operating under the microscope. We operate with very small movements and in awkward positions much of the time, so if the robot can scale down our movements, we can operate in a more 'natural' way."

TECHO-REACH Simulated surgery and robotics aren't just training physicians outside of the immediate confines of the operating room. They're training them outside of urban areas and even well beyond U.S. borders into developing countries. Combined with wireless technology, simulated programs and multimedia systems can present concepts in languages and mediums tailored just for a specific audience.

"With multimedia, we can bridge the gap between patients and their doctors, crossing cultures, languages and socioeconomic boundaries," Dr. Grunwald notes.

Major international philanthropic medical agencies such as Operation Smile and Mending Kids International have already made great use of such tools to educate families and physicians in underdeveloped countries, she explains.

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