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

Diana Peterson1, Cynthia Robertson1

Iowa State University, Ames, IA (USA) dcpet@iastate.edu, cindyr@iastate.edu
1

Abstract
Technological advances, such as online courses and virtual simulations, are altering how we teach and learn. Online courses are becoming more common. These courses give professors a unique forum to engage students from around the world, and enable students to view and review lecture material multiple times. As an added bonus, pre-recording lecture material frees faculty time, enables increasing class size, and allows faculty to devote more energy toward productive group interactive curriculum. Online courses are ideally suited for many types of lecture-based curricula; however, they are not sufficient for curriculums that necessitate hands-on activities such as gross anatomy and surgery. We are currently working to rectify this conundrum by creating high-resolution simulations in the virtual world. Our goal is to utilize virtual environments to simulate visual and haptic scenarios necessary for hands-on activities. This work will advance current technologies by: creating realistic visualizations of surgery, programming surgical complications that can be incorporated into a surgical session or manipulated by an external viewer, create animations of the anatomy and the ability of the surgeon to manually manipulate different anatomical structures, and advance current haptic functions of virtual environments 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 training exercises. These simulations have greatly improved training efficacy in participants. We anticipate that virtual surgical simulations will have similar outcomes. Current endeavors and progress toward these goals in virtual reality environments by both our group and others throughout the world will be discussed. Keywords: Novel teaching technology, education technology development, computer assisted learning, distance learning, medical education.

INTRODUCTION

Optimization of learning is the ultimate goal of all educators. For years, didactic lectures have been the most common teaching method at universities world-wide. However technological advances are slowly changing the face of education. Online courses now allow students to participate in courses from disparate locations around the world. These courses are ideal for many types of lecture-based curricula; however, they are not sufficient for curricula that necessitate hands-on activities such as gross anatomy and surgery. To address this problem, researchers are creating high-resolution virtual surgical simulations. A virtual simulation uses computer graphics to create a world that responds to the users input (gesture, verbal command, etc.). Users are able to hone their motor skills, increase their 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 a 1, 2 strong transfer of learning from the virtual experience to future real-life applications . During the last decade, the use of simulators for teaching and training has become standard. Unlike lecture based lessons, educators create active learning environments by which students are encouraged to actively think about information, make choices, and execute learning skills for defined physical tasks. Training simulators have been used extensively by commercial pilots and the military for training exercises, and have been

shown to dramatically increase both the cognitive and motor accuracy of the participants 3-8 and decrease errors. Initial surgical simulations have had similar outcomes . Unlike flight training, improved medical training has the potential to impact almost every human on the planet. The expertise of surgeons can be limited by their lack of access to physical training paradigms. Virtual reality based surgical simulations, hold significant promise for revolutionizing medical training. Successful implementation of virtual surgery in medical education will allow limitless practice sessions on a virtual body, enable students to experience the multi-variant nature of surgical procedures, allow surgical competency with both common and rare complications, and facilitate group and distance learning. Simulation training, in combination with live patient training, will enhance the acquisition of clinical skills, increase exposure to medical problems, and help to ensure uniformity of training experiences.

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. Based on the relevancy of the article, 150 articles were selected for analysis.

3 3.1

RESULTS Learning surgery

3.1.1 Motor proficiency

Surgical learning is a complex integration of medical and anatomical knowledge combined with motor function proficiency. To learn motor skills, a three-stage theory of skill acquisition 9, 10 has been widely accepted . 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 is executed more fluidly. In the final autonomous stage, the student no longer needs to think about execution to perform the task easily and accurately. Obtaining expertise in these activities is directly linked to the time devoted to deliberate 11, 12 practice . With surgical training, the opportunities for deliberate practice are rare. Therefore most surgical training programs utilize a variety of tools to facilitate learning of these techniques including models, live animals, and human cadavers to simulate human tissue and anatomy as well as physical patient simulators to emulate team training sessions. Human cadavers most closely approximate reality, however both cadavers and animals are costly and have limited availability. In contrast, inanimate models are reproducible, readily available, and generally more cost-effective than animals or cadavers, however their efficacy in training is limited. Practice with virtual surgical simulations has the capacity to provide unlimited access to motor training for surgical students while dramatically decrease training costs.

3.1.2 Group learning

Education philosophy has implied that simple learning can be attained through various methods; however acquisition of complex skills is best achieved in situational contexts 13 through social interactions . All educators know that the best way to learn a subject is to teach it. Peer collaborations are widely acclaimed to facilitate active learning. These interactions assist students to construct their understanding of a paradigm (i.e., surgical procedure), improve upon technical deficiencies, and recreate expert proficiency. Teamtraining simulations have been reported to decrease errors in both the aviation and medical 3-8 fields .

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

3.1.3 Interactive feedback

During cadaveric or live training sessions, surgeons are evaluated by external reviewers on different aspects of their surgical technique. Because evaluations are based on one or more individual from their vantage point, this system is subjective and difficult to consistently repeat between students. Conversely, the virtual teaching environment has the ability to collect a wide variety of data during each training session (e.g., precision; completion time; 12, 14-16 type, magnitude, and frequency errors; task learning time; force feedback, etc.) . 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 a debriefing to facilitate error correction. Because the output measures are objective, training can become more consistent across students.

3.1.4 Student attention

Students today have been extensive exposure to various forms of technology (i.e., virtual reality games, skype, facebook, etc.). Whether such exposure has altered their attention for traditional lecture-style learning is still under debate; however students widely acknowledge 17, 18 an interest in virtual style learning platforms . This increased interest may be due one or more factors. First, virtual reality is a novel learning environment. New technologies tend to capture the attention of the populous for short periods of time. Second, interest may also be attributed to conditioning of the students based on previously enjoyed gaming experiences. Our learning capacity and interests are based on previous experience. Therefore students with gaming backgrounds may find the virtual learning environment comforting, fun, and see the challenges of learning more like play than work. Third, interest may be higher due to faster and easier learning acquisition. Unlike traditional lectures, virtual platforms are being developed to engage multiple sensory modalities (e.g., vision, auditory, touch). Research has shown that engagement of multiple senses greatly facilitates learning 19-21 acquisition across modalities . Whatever the reason, students are interested in learning in a virtual environment. Because these technologies have been shown to augment the learning of complex tasks, virtual education that will likely capture the attention of students into the future.

3.2

Training efficacy of virtual simulations

Simulation technologies have been used for years to improve the motor and cognitive function of users for specific, difficult tasks that are necessary for the preservation of human life. Flight simulations, for example, have been reported to dramatically increase the functionality of pilots and decrease errors. The use of flight simulations is thought to play a 22 significant role in decreasing deaths from 3214 (1972) to 703 (2011; ). Because of the noted increase in training efficacy, simulators were implemented by the Federal Aviation 23 Administration as a critical tool in pilot training . Like flight simulations, surgical simulators have been shown to dramatically increase the skill of surgeons, decrease the operational 12, 24-38 time, and decrease errors and post-operative complications . With these types of evidences, A Food and Drug Administration panel recently recommended the use of virtual reality simulation as an integral component of a training package for carotid artery 39 stenting . 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 the aviation industry. Virtual flight simulators have the ability to mimic numerous types and styles 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 be developed. 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

instruments by manipulating objects within a box. More recently, full-scale human models such as Metiman (CAE Heathcare, Montreal, Canada) have been developed that enable individuals 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 the learning 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 surgical procedures. However, virtual surgeries are typically shown with idealistic clean anatomy that does not accurately depict a real surgery. Additionally, most of these types of programs are either non-interactive videos or limit user participation to accurate actions. Because some of the most memorable and useful learning occurs due to use mistakes, these programs offer limited teaching functionality. Within the last year, several groups have attempted to create interactive virtual surgeries. th One of the best examples was unveiled October 6 , 2012 by a group at University Hospital in Cleveland, OH. Their Surgical Rehearsal Platform utilizes CT/MRI scans from individual patients to recreate a surgical condition for the express purpose of practicing a surgical technique prior to live surgery. With only the relevant anatomy portrayed, the surgeons are able 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 of surgical technique from the beginning of the surgery to the end. Therefore its primary function 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 the surgical environment should be realistic and dynamically adaptable by the end user. Because no two surgeries are identical, a wide variety of surgical complications should be programmed into the system. Our laboratory is currently working to create a virtual training simulation: 1) with accurate and visually realistic anatomy, 2) animated anatomy that can be manipulated by the end user, and 3) with variable surgical complications that can be controlled by an external source. To accomplish this goal, 3D anatomical reconstructions of human CT scans have been initiated. Accurate animations of each structure are currently being performed. An example can be seen in Fig. 1 below.

Figure 1. Reconstruction of male human skeleton with forearm, biceps, and triceps muscles at different stages of animation. To create a virtual surgery, the 3D anatomy is transferred from a volume rendered state into the virtual world, and a virtual human is reconstructed. An example of a virtual human within a preliminary virtual suite is shown in Fig. 2. We will utilize custom fluid dynamic, virtual reality, 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 maximally engage and evaluate student outcome measures.

Figure 2. Virtual male anatomy is shown reclining on a surgical table. The skin and muscles are transparent to better visualize bone and heart.

3.2.3 Negative aspects of virtual simulations

Current virtual simulations have several technological limitations that should be addressed in future systems. First, virtual simulations are timely to create and take a large amount of processing power. To fully implement these systems for general use, they must be created to function on commercially available computer systems. If the processing needs for the programs are too great, the program will stall. Stalling will impede student learning and may corrupt performance measures. As outcome assessments are vital for the success of the system, they need to be reliable and repeatable for each user. Second, previous virtual surgeries have required high skill proficiency for instructors. These issues have decreased over the years as learning platforms advance; however future simulations should be user friendly for all participants. Third, we must note that surgical simulation training is an augmentation of training and not meant to replace instructors or live training sessions. Several reports indicate that simulation training alone does not provide adequate training 25 for physicians . Success in virtual surgeries does not imply that the student should perform surgeries unsupervised. Competency measures for human practice should always be finalized under real surgical conditions.

CONCLUSIONS

Researchers investigating the efficacy of virtual reality as a teaching tool have been impressed 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 education or other subjects that require motor training. As technology advances, virtual simulations have the potential to benefit learning, design, analysis, and communication within the university setting. Because of its networking capabilities, the virtual environment will allow global teamwork with experts, and thus improve the quality of teaching, training, and research world-wide.

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