A-Peterson INTED(2013).pdf

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UTILIZING VIRTUAL REALITY IN TEACHING AND TRAINING:PROGRESS TOWARD VIRTUAL SURGICAL SIMULATIONS

Diana Peterson1, Cynthia Robertson11Iowa State University, Ames, IA (USA)[email protected],[email protected]

Abstract

Technological advances, such as online courses and virtual simulations, are altering howwe teach and learn. Online courses are becoming more common. These courses giveprofessors a unique forum to engage students from around the world, and enable studentsto view and review lecture material multiple times. As an added bonus, pre-recordinglecture material frees faculty time, enables increasing class size, and allows faculty todevote more energy toward productive group interactive curriculum.

Online courses are ideally suited for many types of lecture-based curricula; however, theyare not sufficient for curriculums that necessitate hands-on activities such as gross anatomyand surgery. We are currently working to rectify this conundrum by creating high-resolutionsimulations in the virtual world. Our goal is to utilize virtual environments to simulate visualand haptic scenarios necessary for hands-on activities. This work will advance currenttechnologies by: creating realistic visualizations of surgery, programming surgicalcomplications that can be incorporated into a surgical session or manipulated by anexternal viewer, create animations of the anatomy and the ability of the surgeon to manuallymanipulate different anatomical structures, and advance current haptic functions of virtualenvironments so that the surgeon has a full sensory experience (they can see, hear, feel,and experience a realistic surgical procedure).

Simulations have been used extensively by commercial pilots and the military for trainingexercises. These simulations have greatly improved training efficacy in participants. Weanticipate that virtual surgical simulations will have similar outcomes. Current endeavorsand progress toward these goals in virtual reality environments by both our group andothers throughout the world will be discussed.

Keywords: Novel teaching technology, education technology development, computerassisted learning, distance learning, medical education.

1 INTRODUCTION

Optimization of learning is the ultimate goal of all educators. For years, didactic lectureshave been the most common teaching method at universities world-wide. Howevertechnological advances are slowly changing the face of education. Online courses now

allow students to participate in courses from disparate locations around the world. Thesecourses are ideal for many types of lecture-based curricula; however, they are not sufficientfor curricula that necessitate hands-on activities such as gross anatomy and surgery. Toaddress this problem, researchers are creating high-resolution virtual surgical simulations.

A virtual simulation uses computer graphics to create a world that responds to the usersinput (gesture, verbal command, etc.). Users are able to hone their motor skills, increasetheir ability to process information quickly, and explore information in a non-linear fashion.Because the learning experience is a model of a real world situation, students have astrong transfer of learning from the virtual experience to future real-life applications

1, 2.

During the last decade, the use of simulators for teaching and training has becomestandard. Unlike lecture based lessons, educators create active learning environments by

which students are encouraged to actively think about information, make choices, andexecute learning skills for defined physical tasks. Training simulators have been usedextensively by commercial pilots and the military for training exercises, and have been
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shown to dramatically increase both the cognitive and motor accuracy of the participantsand decrease errors. Initial surgical simulations have had similar outcomes

3-8.

Unlike flight training, improved medical training has the potential to impact almost everyhuman on the planet. The expertise of surgeons can be limited by their lack of access tophysical training paradigms. Virtual reality based surgical simulations, hold significant

promise for revolutionizing medical training. Successful implementation of virtual surgery inmedical education will allow limitless practice sessions on a virtual body, enable students toexperience the multi-variant nature of surgical procedures, allow surgical competency withboth common and rare complications, and facilitate group and distance learning. Simulationtraining, in combination with live patient training, will enhance the acquisition of clinicalskills, increase exposure to medical problems, and help to ensure uniformity of trainingexperiences.

2 METHODS

The current paper is based on current virtual reality medical simulations under

development in my laboratory and previous documented educational benefits of such

technology. Ideology is derived from Pubmed searches for articles containing virtual

reality, surgical simulation, medical education, learning, and virtual technologies. Basedon the relevancy of the article, 150 articles were selected for analysis.

3 RESULTS

3.1 Learning surgery

3.1.1 Motor proficiency

Surgical learning is a complex integration of medical and anatomical knowledge combinedwith motor function proficiency. To learn motor skills, a three-stage theory of skill acquisitionhas been widely accepted

9, 10. In the first cognitive stage, a student intellectualizes the

physical task, and the procedures for the task are carried out in distinct steps. During this

stage, motor performance is erratic and inconsistent. During the second integrative stage,the student thinks about the distinct steps of the procedure, but the motor control isexecuted more fluidly. In the final autonomous stage, the student no longer needs to thinkabout execution to perform the task easily and accurately.

Obtaining expertise in these activities is directly linked to the time devoted to deliberatepractice

11, 12. With surgical training, the opportunities for deliberate practice are rare.

Therefore most surgical training programs utilize a variety of tools to facilitate learning ofthese techniques including models, live animals, and human cadavers to simulate humantissue and anatomy as well as physical patient simulators to emulate team trainingsessions. Human cadavers most closely approximate reality, however both cadavers andanimals are costly and have limited availability. In contrast, inanimate models arereproducible, readily available, and generally more cost-effective than animals or cadavers,

however their efficacy in training is limited. Practice with virtual surgical simulations has thecapacity to provide unlimited access to motor training for surgical students whiledramatically decrease training costs.

3.1.2 Group learning

Education philosophy has implied that simple learning can be attained through variousmethods; however acquisition of complex skills is best achieved in situational contextsthrough social interactions

13. All educators know that the best way to learn a subject is to

teach it. Peer collaborations are widely acclaimed to facilitate active learning. Theseinteractions assist students to construct their understanding of a paradigm (i.e., surgicalprocedure), improve upon technical deficiencies, and recreate expert proficiency. Team-training simulations have been reported to decrease errors in both the aviation and medicalfields

3-8.


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Although not fully implemented with current technologies, virtual surgical simulations willallow students and experts to interact world-wide. This will enable students to repeatedlytest their proficiency, obtain assistance from global experts in various techniques, andbecome teachers to other students world-wide. Open sharing of perceived difficulties andsuccesses will assist surgical skills acquisition globally, and may provide the impetus fornovel surgical techniques into the future.

3.1.3 Interactive feedback

During cadaveric or live training sessions, surgeons are evaluated by external reviewers ondifferent aspects of their surgical technique. Because evaluations are based on one or moreindividual from their vantage point, this system is subjective and difficult to consistentlyrepeat between students. Conversely, the virtual teaching environment has the ability tocollect a wide variety of data during each training session (e.g., precision; completion time;type, magnitude, and frequency errors; task learning time; force feedback, etc.)

12, 14-16. This

data collection is objective, provides a comprehensive view of all of the subjects actions(from multiple viewpoints), and the surgery can be recorded and played back during adebriefing to facilitate error correction. Because the output measures are objective, trainingcan become more consistent across students.

3.1.4 Student attentionStudents today have been extensive exposure to various forms of technology (i.e., virtualreality games, skype, facebook, etc.). Whether such exposure has altered their attention fortraditional lecture-style learning is still under debate; however students widely acknowledgean interest in virtual style learning platforms

17, 18. This increased interest may be due one or

more factors. First, virtual reality is a novel learning environment. New technologies tend tocapture the attention of the populous for short periods of time. Second, interest may also beattributed to conditioning of the students based on previously enjoyed gaming experiences.Our learning capacity and interests are based on previous experience. Therefore studentswith gaming backgrounds may find the virtual learning environment comforting, fun, andsee the challenges of learning more like play than work. Third, interest may be higher dueto faster and easier learning acquisition. Unlike traditional lectures, virtual platforms arebeing developed to engage multiple sensory modalities (e.g., vision, auditory, touch).

Research has shown that engagement of multiple senses greatly facilitates learningacquisition across modalities

19-21. Whatever the reason, students are interested in learning

in a virtual environment. Because these technologies have been shown to augment thelearning of complex tasks, virtual education that will likely capture the attention of studentsinto the future.

3.2 Training efficacy of virtual simulations

Simulation technologies have been used for years to improve the motor and cognitivefunction of users for specific, difficult tasks that are necessary for the preservation of humanlife. Flight simulations, for example, have been reported to dramatically increase thefunctionality of pilots and decrease errors. The use of flight simulations is thought to play asignificant role in decreasing deaths from 3214 (1972) to 703 (2011;

22). Because of the

noted increase in training efficacy, simulators were implemented by the Federal AviationAdministration as a critical tool in pilot training

23. Like flight simulations, surgical simulators

have been shown to dramatically increase the skill of surgeons, decrease the operationaltime, and decrease errors and post-operative complications

12, 24-38. With these types of

evidences, A Food and Drug Administration panel recently recommended the use of virtualreality simulation as an integral component of a training package for carotid arterystenting

39. I expect that further government recommendations and regulations will be

implemented in the future as these technologies advance.

3.2.1 Past and current technology

The use of simulators in medical practice is far behind what is currently available for theaviation industry. Virtual flight simulators have the ability to mimic numerous types andstyles of aircraft as well as multiple flight conditions and problems. Medical simulators are

not yet this advanced. Like flight simulators, physical simulator models were the first to bedeveloped. These simulators enable physicians to feel the lumps on an artificial breast,practice suturing on skin-like material that bleeds, or practice motor skills with laparoscopic


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instruments by manipulating objects within a box. More recently, full-scale human modelssuch as Metiman (CAE Heathcare, Montreal, Canada) have been developed that enableindividuals to practice basic medical procedures in real-life situations (e.g., CPR training,combat scenarios). Although these simulators have proven to have an impact on thelearning and success of trainees, they are unable to mimic a full surgical procedure.

Over the last decade, computerized surgical procedures have become popular. Numerous

training videos have been created to familiarize individuals with specific surgicalprocedures. However, virtual surgeries are typically shown with idealistic clean anatomythat does not accurately depict a real surgery. Additionally, most of these types of programsare either non-interactive videos or limit user participation to accurate actions. Becausesome of the most memorable and useful learning occurs due to use mistakes, theseprograms offer limited teaching functionality.

Within the last year, several groups have attempted to create interactive virtual surgeries.One of the best examples was unveiled October 6

th, 2012 by a group at University Hospital

in Cleveland, OH. Their Surgical Rehearsal Platform utilizes CT/MRI scans from individualpatients to recreate a surgical condition for the express purpose of practicing a surgicaltechnique prior to live surgery. With only the relevant anatomy portrayed, the surgeons areable to plan and visualize their surgical approach for that specific patient. Although this is a

huge step in the right direction, this platform does not allow for a realistic practice ofsurgical technique from the beginning of the surgery to the end. Therefore its primaryfunction would be in assisting surgical practice in experienced surgeons.

3.2.2 Current progress

To get the most out of a surgical practice session, all aspects of a surgery as well as thesurgical environment should be realistic and dynamically adaptable by the end user.Because no two surgeries are identical, a wide variety of surgical complications should beprogrammed into the system. Our laboratory is currently working to create a virtual trainingsimulation: 1) with accurate and visually realistic anatomy, 2) animated anatomy that can bemanipulated by the end user, and 3) with variable surgical complications that can becontrolled by an external source. To accomplish this goal, 3D anatomical reconstructions ofhuman CT scans have been initiated. Accurate animations of each structure are currently

being performed. An example can be seen in Fig. 1 below.


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Figure 1. Reconstruction of male human skeleton with forearm, biceps, andtriceps muscles at different stages of animation.

To create a virtual surgery, the 3D anatomy is transferred from a volume rendered state intothe virtual world, and a virtual human is reconstructed. An example of a virtual human withina preliminary virtual suite is shown in Fig. 2. We will utilize custom fluid dynamic, virtualreality, and human computer interface software that has been created at Iowa State

University to visualize anatomical structures during skin incisions, recreate bleeding,interface haptic and auditory feedback, and create a learning environment to maximallyengage and evaluate student outcome measures.

Figure 2. Virtual male anatomy is shown reclining on a surgicaltable. The skin and muscles are transparent to better visualizebone and heart.

3.2.3 Negative aspects of virtual simulations

Current virtual simulations have several technological limitations that should be addressedin future systems. First, virtual simulations are timely to create and take a large amount ofprocessing power. To fully implement these systems for general use, they must be createdto function on commercially available computer systems. If the processing needs for theprograms are too great, the program will stall. Stalling will impede student learning and maycorrupt performance measures. As outcome assessments are vital for the success of thesystem, they need to be reliable and repeatable for each user. Second, previous virtualsurgeries have required high skill proficiency for instructors. These issues have decreasedover the years as learning platforms advance; however future simulations should be userfriendly for all participants. Third, we must note that surgical simulation training is anaugmentation of training and not meant to replace instructors or live training sessions.Several reports indicate that simulation training alone does not provide adequate trainingfor physicians

25. Success in virtual surgeries does not imply that the student should perform

surgeries unsupervised. Competency measures for human practice should always befinalized under real surgical conditions.

4 CONCLUSIONS

Researchers investigating the efficacy of virtual reality as a teaching tool have beenimpressed with the stunning visual and sensory effects that it is able to portray to users.With future development, it will become a powerful instructional tool for medical educationor other subjects that require motor training. As technology advances, virtual simulationshave the potential to benefit learning, design, analysis, and communication within the

university setting. Because of its networking capabilities, the virtual environment will allowglobal teamwork with experts, and thus improve the quality of teaching, training, andresearch world-wide.


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