EXECUTE SUMMARY
Recently, prominent technological entities have explored whether gamified simulation, which is the integration of game mechanics into a virtually-induced simulation, can be a plausible solution to the dilemma of “not enough experience” in psychomotor-dependent training for surgical residents. Existing Virtual-Reality Simulators, among others, are venturing into the arena via combining the dexterity of robotic surgery technologies and the sophisticated animated 3D Graphics environment. Emerging technologies that incorporate surgeon educators as active agents in developing these solutions will prove to be a much more usable and accepted alternative to the traditional approach of passive observation to surgical procedures. Gamified trainings can be considered as a low-cost option once the dexterity training and cognitive load needed for analyzing surgical procedures are in optimal coherence. This could lead into an enhanced evidence-based care with measurable performance agents of quality surgical training and residents’ competency in future research.
INTRODUCTION
In the past few years, a notable perturbation was expressed regarding the level of competency in conducting surgical procedures by graduating general surgery residents. American Board of Surgery (ABS) have conducted oral certifying examinations to evaluate the residents upon graduation, the organization was concerned with the awareness that these students portrayed a significant disparity between knowledge and practical experience of important operative areas in general surgery. Residents have also expressed uncertainty in their level of competency and readiness to enter practice despite participating in a five-year program. Undisputed, 80% of graduates now prefer to extend training. The purpose of this essay is to portray how impactful is the integration of gamified surgery educational technologies for a better long-term healthcare delivery and management. (Richard H. Bell, 2009)
BACKGROUND:
There are approximately 1,203 teaching hospitals that are conducting residency programs in the U.S. (Association, American Hospital)
Within these teaching hospitals’ infrastructure, it is undisputable that the significance of surgical department and its residency program are very high. Circa. 48 Million surgical inpatient procedures are conducted in the US (National Center for Health Statistics, 2009), with an approximate of 160,000 surgeons who are embedded in the healthcare US workforce as of 2016, and with a rapid growth of 14%. (Pittsburg Tribune-Review, 2009) Moreover, 48% of average revenue is benefitted from surgical services at any given hospital. (Agency For Healthcare Research and Quality)
3.0% of errors that are constituted by high risk specialties such as surgery are considered preventable. These preventable erroneous events can be one of the undesirable variables of costly litigations and post-error risk mitigation efforts. (Sarker)
In addition, it is argued that the government is subsidizing an average of $15 Billion a year to cover the annual salaries and training of circa. 115,000 medical residents. (Association of American Medical Colleges, n.d.)
DISCUSSION
Learning Methodologies in Surgical Education
The classical approach in conducting surgical education is widely known as “See One, Do One, Teach One”. Though, many have disputed that this method is no more coherent with the current times given that it puts patient safety at risk, it can still be regarded as an applicable method once combined with other state-of-the-art frameworks that can supplement solid support in providing efficient surgical teaching. As long as the method is evolving, “See One, Do One, Teach One” can still achieve its goal of teaching residents to the level of credible competency and also provide patients with an evidence-based care, safe and trustworthy operational experience. (Sendra V. Kotsis, 2013)
Prior exploring potential supporting tools for surgical education, it is of utmost importance to revise briefly the crucial learning principle that all educational systems are founded on. The learning pyramid below summarizes the most important aspects of retaining information methods vs. its optimization strength. As it is portrayed, only 5% of information retention is absorbed during lectures, yet in contrast 75% is obtained from practice-doing which is considered as a participatory teaching method. Demonstration method, in the sphere of surgical training, is widely considered as “operational experience observation”, is at only 30% optimization level. In this prevailing method, residents watch the conduction of a certain surgical procedure by their surgeon professors. Undoubtedly, “See One, Do One, Teach One” fits well into the learning framework of Kolb’s “learning by doing” model of experience, observation, thinking, and action. “See One”, in this context, means to observe the procedure, thereupon thinking and analyzing of the procedure is expected from the student, “Do One” means to act upon what has been observed and understood, later “Teach One” comes into play as the experience necessary to conduct the hands-on procedure.
Figure 1.0 The Learning Pyramid that describes the average student retention rates per method
The Gap between Theory and Practice
Yet, it is stated at a recent study that out of 300 surgical procedures that a general surgeon ought to be proficient in performing, residents were exposed to only 83 of them for over 5 times, 31 procedures for at least 1 time, and the rest were never exposed on a hands-on setting, let alone practical operative experience. (Richard H. Bell, 2009)
Given these stark contrast, it is argued that one of the reasons for the scarcity of psychomotor-training requirements of any surgical program is due to the barrier of obtaining a suitable environment to train resident surgeons without tampering with is potentially considered as ethically-questionable. For instance, obtaining more dead bodies from morgues to supply more students and accommodate more practical errors that naturally occur during any operative training.
Figure 2.0 A typical sketch of surgical procedure
The difficulty to explain complex surgical procedures via traditional means such as lectures, sketches, and passive observation of an actual operation, were the main concerns that Surgeon Professors expressed regarding the certainty of delivering quality education in these programs. According to ACGME, one of the most important domain of competency expected of graduating surgery residents is Patient-Care. Thus, it is fundamental that they are competent enough to perform these procedures with mastery prior entering professional practice.
Figure 3.0 A portrait of a Manikin for Brain Surgery
The Emergence of Manikin-based Simulation Centers
Simulation centers became an integrated framework in the modern medical education systems around the U.S, these centers provide a vast array of simulations for students to choose from. The existing learning environment is usually equipped with the popular Manikin-based patient simulators that are personifying patients to whatever medical case the educator see fit, yet it is well regarded that “patient” engagement is dormant given that there is low interaction. Manikin-based patient simulators are arguably more suitable in other medical trainings such as diagnosis or inpatient care coordination for nursing, however, sophisticated surgical errors cannot surface from this learning environment, let alone timely rectification of the erroneous act. Nevertheless, the most prominent benefit of simulation centers for medical training in general is the opportunity to evolve the learning setting towards a more participatory learning methodology of practice-doing. This inclination is already a positive stepping stone for the introduction of intelligent and interactive systems in the near future.
Gamification as a Functional Nostrum
Gamification, on the other hand, is an inter-disciplinary field with an aim to integrate game mechanics into a virtually-induced learning environment. It follows a cycle that aims to retain the users of the systems with an incremental engagement and performance improvement. Initially the system ought to introduce a relevant challenge that the end-user attempts to solve in order to unlock the other tier challenges. Once the user is engaged in active problem-solving and successfully completes the task, the system rewards the user by either accumulation of points or other forms of incentives. The end-user is promptly introduced into a much more complicated challenge with the invitation to solve it, after significant incremental loop cycles, the intelligent system can now accumulate feedback and start recognizing patterns from its wide array of active user base. This will help in modifying and enhancing the user ‘gamified’ experience.
Figure 4.0 A demonstration of the gamification cycle
Gamification, as a framework, does not reckon heavily on static simulation templates but rather on the fundamental logic and decision-making tree behind each process, the cutting- edge element about it is that it can proactively learn from pattern recognition. Gamifying surgical procedures, however, rely densely on the fusion of biomimicry, biomedical engineering, biophysics, computing prowess, and lastly but not least strong gaming principles such as state-of-the-art animation graphics and user experience design. This emerging discipline can become a plausible nostrum to the dilemma of “not enough experience” in psychomotor-cognitive trainings necessary for future surgeons.
Figure 5.0 Resident exploring the learning environment of VR-based Surgical game.
Socio-Economical Significance of Quality Surgical Outcome
Implementation of gamified virtual-reality, augmented-reality, and artificially - intelligent computing systems in medical learning environments can drastically influence the landscape of the management of healthcare, due to several reasons such as cost-effectivity, efficiency, efficacy, and higher patient safety. Minimizing patient risks and causal surgical errors will save time, resources, and unsolicited complications that healthcare administrators usually deal with in direct effect of malfunction in the Surgical department. Fundamentally speaking, undesirable litigations, lawsuits, and cycles of post-error treatment costs in labor time and monetary compensations can all be partially rooted to insufficient surgical experience prior entering practice in real life patients. The shift to technologies that cater to the uplifting of quality surgical trainings and competency can be strongly considered as a proactive and strategic decision by the healthcare management which as a key player in administering and enhancing the overall healthcare delivery infrastructure.
Impacts of Gamified Training in Residents’ Psychomotor Performance
It is too early in implementation stage to have a tangible performance evaluation due to direct effect of gamified simulation training technologies, undoubtedly the field itself is at an exploratory phase yet. However, from efficiency’s prospective, it has been argued that we can take pilots’ simulated training as a strong reference onto how surgical students’ psychomotor performance can be positively improved.
If this is an argument to take into consideration, then we can speculate a rise of disruptive platforms by which artificial intelligent agents are assisting surgical residents’ through all the game tournaments and challenges designed into the program. These aid tools shall be customizable upon the need and requirements of its respective user. Game mechanics infused into a controlled virtual setting with immersive psychomotor manipulations will prove to be useful in closing the gap between operative experience and surgical education. As a limitation however, emerging technologies could experience higher barrier to entry if the program’s content is not authenticated and endorsed by surgical associations and authority figures. Nevertheless, if the subject matter experts such as Surgeon Educators are also actively engaged in the production of these high-tech solutions, these tools will radically change the landscape of Medical Education.
Impacts of Gamification on Managerial and Financial Systems
At a recent pilot study comparing the training conducted on virtual reality robotic simulator and the dry laboratory robotic surgery platform, it was concluded that there was strong preference for the virtual reality simulator. Benefits which were unique to the simulator platform were the computerized performance feedback, the ease of setup, and the autonomy of use. (Tergas, 2013) From Financial prospective, this is a clear indicator of a cost-effective, reusable, and automated solution. This can be easily managed since it is computerized and automated into self-paced program segments, the healthcare management can also have a clearer path towards tracking and evaluating the overall performance and retention of its’ residency programs.
CONCLUSION
In conclusion, emerging technologies that incorporate surgical residents and their educators as active agents in developing these gamified solutions will prove to be a much plausible alternative to a stronger overall surgical competency. The conditions still remain whether simulated virtual environments can fully replace the need of an actual body-actual for surgical training in the future. Gamified simulated trainings can be considered the go-to option once the dexterity training and surgical procedure memory recall are in coherence. This shall result in an evidence-based and measurable performance agent for the future of surgical training evaluation. Lastly, given that this field is at its infant stage yet, it is but intriguing to watch closely the unfolding of the new era of how medicine is taught, trained, and conducted in the operating rooms of the future.
ACKNOWLEDGMENT
I would like to thank Dr. Boren and Dr. Simoes for their immense support in writing this intellectual piece. #Mizzou
REFERENCES
Tergas, A. I., Sheth, S. B., Green, I. C., Giuntoli, R. L., Winder, A. D., & Fader, A. N. (2013). A Pilot Study of Surgical Training Using a Virtual Robotic Surgery Simulator. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 17(2), 219–226. http://doi.org/10.4293/108680813X13654754535872
Bell, R. H., Biester, T. W., Tabuenca, A., Rhodes, R. S., Cofer, J. B., Britt, L. D., & Lewis, F. R. (2009). Operative Experience of Residents in US General Surgery Programs. Annals of Surgery,249(5), 719-724. doi:10.1097/sla.0b013e3181a38e59
Kotsis, S. V., & Chung, K. C. (2013). Application of the “See One, Do One, Teach One” Concept in Surgical Training. Plastic and Reconstructive Surgery,131(5), 1194-1201. doi:10.1097/prs.0b013e318287a0b3
Agency For Healthcare Research and Quality. (n.d.).
Association of American Medical Colleges. (n.d.). https://www.aamc.org/advocacy/gme/71152/gme_gme0001.html.
Association, American Hospital. (n.d.). AHA Hospital Statistics.
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Pittsburg Tribune-Review. (2009).
Richard H. Bell, J. (2009). Operative Experience of Residents in US General Surgery Programs. Annals of Surgery.
Sarker, S. K. (n.d.). Errors in Surgery. International Journey of Surgery.
Sendra V. Kotsis, K. C. (2013). Application of See One, Do One, Teach One Concept in Surgical Training. Plastic and Reconstruction Surgery.
Tergas, A. (2013). A Pilot Study of Surgical Trainin Using a Virtual Robotic Surgery Simulator. JSLS: Journal of the Society of Laparoendoscopic Surgeons.
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