Two pediatric otolaryngologists from Ohio realized the need for better surgical training on annual humanitarian visits to Escuela Hospital Antonio Lenin Fonseca in Nicaragua. On this year’s trip, Dr. Gregory Wiet and Dr. D. Richard Kang of Nationwide Children’s Hospital and The Ohio State University brought with them a surgical simulator meant to help close the training gap.
Here are excerpts of my recent interview with Dr. Wiet:
You’ve been visiting Nicaragua for several years now to perform surgery on children and to train doctors. This year, you brought a surgery simulation system. Tell me about that.
My area of research is in surgical simulation development. This system is the result of a project funded by the National Institutes of Health. The goal of the project is to develop a system to allow trainees — people learning ear surgery — to practice in a non-threatening environment. That’s the whole purpose of simulation. It’s similar to the way airline pilots use simulation to practice their skills in an environment where no one could potentially be injured.
For the past 10 years or so, myself and a group of investigators here have been working on developing this project. We see a very wide application for it, not just in the U.S., but in countries where training is really not available. Through the course of our humanitarian efforts, Dr. Kang and I going down to Nicaragua, [the surgery is] one of the areas that the physicians there have had a desire to learn more about. It’s an area where they felt like they didn’t have as much experience as they’d like. It’s a matter of merging these two interests: seeing there was a specific need and [developing] the system enough that it would be useful.
Is the simulator meant to train physicians to perform a specific type of surgery?
The one we brought down is specific for ear surgery. The methodology is such that it could potentially be applied to other areas.
So this was an initial test system to see how it works?
That’s right. We recently finished a study of about eight institutions across the country. We had U.S. trainees randomized to practicing in traditional fashion and practicing using the simulator. We compared their performance after this two-week training period. There was really not much difference between the two groups. Because we have shown some efficacy, we felt like this would be a good chance to bring [the system to Nicaragua] and start exposing it to the trainees we’ve been affiliated with over the years.
What does the system look like and how does it work?
It’s like working at a regular PC or desktop computer. There are two types of interfaces. We have a visual interface that can either use a standard monitor to display the image or a set of goggles that the individual looks through. The reason for the goggles is that the surgery in real life is done under a microscope. To emulate the experience a surgeon would have doing ear surgery, the mounted goggles are the representation of the microscope.
There is also a haptic interface [for] the sense of touch. That is a device composed of a pen-shaped object that has an arm attached to it. It’s attached to a base. The pen-shaped object represents the drill. The surgery we’re simulating uses a drill to drill away bone from behind the ear to gain access to the critical structures that need treatment. Most of the surgery is done with the drill in hand, so this haptic device represents the drill. It has a series of motors and brakes that deliver forces back to the hand. If you were to take that pen in your hand, look at the visual representation of the drill [on the screen] and touch the bone on the screen, you’d feel it giving you resistance in your hand. That’s important because surgery is a manual dexterity skill. It requires us to have the feedback of instruments touching surfaces.
How does this system improve on the old model of teaching surgical technique in this region?
In particular in Nicaragua, they don’t really have access to the traditional sorts of training. It’s one thing to be able to read books and watch videos. But you’re not going to learn to drive a car by watching videos and reading books. You have to get behind the wheel and push the accelerator. In the U.S., [this type of surgical training is] done in temporal bone labs [using] ears from humans that donated their body to training in the medical school. This ear bone is removed and mounted. You practice your surgery on a real human bone. Obviously, it’s not attached to a live patient. That requires someone to donate their body, but it also requires a specialized laboratory with all the equipment you would have in an operating room. They just don’t have facilities for things like that in Nicaragua.
Are you beginning the work with this system in just one hospital?
There’s only one training program in Nicaragua — at least that we’re aware of — that trains ear, nose and throat surgeons. That’s the hospital where we’re based.
What’s the next step? Are you planning to build systems for different types of surgeries?
Just to develop one system takes quite a large effort. We’ve been developing this system for the last 10 years. The last grant we finished, a five-year grant, was about $1.5 million. To try to develop other sorts of systems simultaneously is a little bit difficult.
But it’s not just the development of the system, per se. In order for you to feel comfortable training someone on this, you have to do validation studies that firmly establish the efficacy of the training. From our perspective, it was a pilot exposure to see how they felt about using it in the midst of a short training program. In order for someone to learn a technical skill, they can’t just be put in front of a simulator. There has to be a whole curriculum that’s developed around it that teaches not just the motor skills but all the cognitive knowledge that goes along with that.
Do you have anything else to add?
Simulation technology is starting to take off in the medical and surgical field because of the advantages demonstrated through the aviation industry. This is something I think we’ll be seeing more of. It makes so much sense and really can mitigate the training curve [and] standardize training. There may be, at some point, computer-derived metrics integrated into the simulator. There are a lot of implications for this going forward.
Photo: Dr. Wiet tests the surgery simulation system