Virtual training

SAY the words “computer game” and the image most people will conjure up is that of a spotty youth bathed in an electron glow of his TV screen shooting alien warships out of a virtual sky until the early hours.

But as the technology behind such games has advanced in leaps and bounds, developers and educators have begun to see advantages in what it can offer to the business of medical and dental training. In a climate of cuts, reduced availability of cadavers, increased litigiousness and a limitation in junior doctors’ training time, virtual simulation training is increasingly being seen as a safe and cost-effective solution in these testing times.

Right at the forefront of the developments in virtual reality (VR) training are the surgical simulators that allow trainees to learn and practise a host of laparoscopic skills, from tissue manipulation and suturing to cholecystectomy and angioplasty.

Haptic feedback

Professor Mike Larvin, director of education at the Royal College of Surgeons of England, which recently opened a stateof- the-art clinical skills unit with a simulated operating theatre, is a leading proponent of simulation as a training tool in general and believes it is just a matter of time before VR plays its part.

He says: "The great thing about simulation is you can make mistakes that would rarely happen in real life. You can set up a scenario where a mistake is likely to happen, just as a pilot might learn to fly with only one engine. It’s probably not going to happen often in the pilot’s career, but it means you can prepare for the rare and dangerous situation that you are unlikely to face as a trainee because you don’t have enough years under your belt."

Virtual reality is still in the evaluative stage at the College as certain technological limitations are ironed out, in particular the question of ‘haptic feedback’. This is the simulator’s ability to mimic, for example, the feel of probing, cutting or suturing tissue.

"We regard electronic haptic simulation as being very much still in its infancy. We’re only using it on a research basis. The trouble is, if you’re putting a stitch into an artery, your technique is governed by the feedback you get, the firmness of the tissue.

"That’s the reason it’s still in evaluation. And that’s also why we use fresh frozen cadavers. You just can’t beat that at the moment. It’s the next best thing to operating on a real human being."

But there’s a limit to the number of human cadavers we get donated, he adds. "If we had really good VR with the proper haptic feedback, we could get trainees through far more exercises before they got on to a real patient. So when it comes it is going to contribute greatly to safety."

Drill skills

If lack of haptic feedback is currently holding back VR simulator adoption in surgical training, the same is not true in the dental school at King’s College London. Here dentists, in collaboration with scientists from the University of Reading and Birmingham City University, have created a ‘hapTEL’ (haptic technology-enhanced learning) workstation that allows trainees wearing VR glasses to drill into an imaginary tooth, visualised on a computer screen. They can both see inside the virtual patient’s mouth and feel the difference, say, between drilling hard enamel and softer decayed tooth.

The system has won a number of major awards and the team behind it are currently in the process of negotiating its manufacture for commercial distribution. At a fifth the price of the traditional phantom head chair, one key advantage is cost. Another is the ability to record the students’ actions.

Project manager Dr Jonathan San Diego says: "The hapTEL system records, through computer logs, each student’s performance on preparing cavities, thereby providing feedback to the student and tutor on how much decayed material has been removed, how much healthy tooth has been retained, whether the student has ‘drilled’ through to the pulp and so on."

The developers envisage a time when workstations will be available to students in a university library, thus allowing them to hone their skills in their own time. There is also a clear potential for use in assessment as well as, for example, dentists returning to the profession after an absence.

Currently only drilling is on the virtual menu, but the team believes more advanced dental treatments such as filling a cavity, performing crown and bridge work and administering an injection are future possibilities.

In fact, the technology for administering virtual injections is already available. Virtual Veins, developed by UK Haptics, allows users to learn and practise the skills needed for venepuncture and other IV procedures in many different types of patients, complete with a realistic 'pop' feedback when the needle is correctly inserted in the vein.

The simulator, which is currently being trialled in the NHS Blood & Transplant unit, also provides metrics to allow performance to be measured and the firm’s MD, Gary Todd, expects it to be on the market early next year.

Away from hands-on aspects of medical and dental practice, virtual reality is also starting to make its presence felt in the areas of diagnosis, patient management and teamworking scenarios.

Medical avatars

At Imperial College London, the Faculty of Medicine has been developing a region in the online game Second Life where students can practise patient management in a virtual ward. The game attempts to mimic all the realities of patient management – even to the point where doctors can’t gain access to the patients if they haven’t washed their hands.

The student’s avatar can move around, locate a patient, see their notes, click for signs and symptoms, perhaps listen to breath sounds and order investigations. The results of these investigations, which might include real X-ray images and ECG tracings, then enable the student to make a final diagnosis. At each step, note cards will inform the student if they are right or wrong and offer additional feedback to support the learning.

Maria Toro-Troconis, who developed the game-based platform, has said that they are looking at the possibility of partnerships with other colleges across the country: "It would be great to have different people interacting and communicating in one online game and we have plans to do that with other medical schools."

In another game-based example, the games firm TruSim has developed Patient Rescue, in collaboration with County Durham and Darlington NHS Foundation Trust. The game aims to teach young doctors to recognise the signs of patient deterioration (in this case from hypovolaemia, hypoxia or sepsis), use set protocols to assess a patient’s condition and intervene effectively.

The game automatically generates a new patient each time, with different signs and symptoms, and the player’s task is to use the assessment tools to determine the correct intervention to stabilise the patient's condition and keep them from dying.

Mary Matthews, TruSim’s business development director, says that what trainers particularly liked was that the game could be used for assessment as well as training. "Because the game tracks every move the trainee makes, you are able to see where they are going wrong and which units they need to redo. Also, if everybody is having problems with one particular unit then you may want to look at the teaching of that particular unit."

Despite the positive response to the game, says Matthews, TruSim is currently looking for investment to take it further, adding to the number of medical conditions. Hinting at perhaps another stumbling block beyond technological limitations, she suggests it is probably only when members of the Xbox generation reach the decision-making levels of the health services that games like these will be fully exploited.

Either way, it won’t be long before the electron glow of VR simulation arrives at a healthcare training facility near you.

Adam Campbell is a freelance journalist and regular contributor to MDDUS publications