Simulation in Echocardiography: An Ever-Expanding Frontier

Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Journal of cardiothoracic and vascular anesthesia (Impact Factor: 1.48). 03/2012; 26(3):476-85. DOI: 10.1053/j.jvca.2012.01.019
Source: PubMed
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    ABSTRACT: Since patients come to hospitals for treatment, medical training should be considered a desirable by-product of clinical care. With safety as the prime concern, the ''first do no harm'' paradigm necessi-tates that one patient should undergo one procedure. This is particu-larly challenging for clinical techniques that are invasive and require manual dexterity for acquisition of clinical proficiency; therefore, today's medical educators are being asked to do more and better in less time. While these conflicting demands are logistical challenges, they also offer considerable opportunities for innovation and quality improvement. Current graduated medical education is based on an apprenticeship model in which physicians learn with time spent in ac-credited and supervised training programs. However, medical educa-tion is evolving into a competency-based model that requires demonstration of specific milestones for progression during training and ultimate graduation. While cognitive knowledge can be tested with standardized questionnaires, adequate clinical performance is implied with successful completion of accredited training. 1 Due to variations in clinical exposure during training, environment and clin-ical exposure, the level of clinical expertise can vary considerably. Training in echocardiography in general, and perioperative transeso-phageal echocardiography (TEE) in particular, exemplifies these contra-dictions. It requires repetitive performance in a time-limited clinical exposure to acquire manual dexterity skills. Clinical exposure is neither graduated from simple to complex nor integrated with formal didactics. Understanding of echocardiographic anatomy and display also requires significant spatial re-orientation. There is also an expectation of rapid acquisition of motor skills required for probe manipulation and handling without an objective system of performance feedback. 2-4 Also, using the clinical arena for training does not ensure a skill-appropriate level of training, 4 nor does it allow the instructor to ensure that the manual and cognitive education are coordinated. Success in task completion is subjective and endpoint-based (ie, image quality). Technological impediments have precluded the use of motion analysis to objectify manual dexterity skills during clinical imaging. Finally, achievement of certification is based on cognitive testing with an assumed component of manual dexterity. Improvements in technology have heralded an era of ''mixed simu-lators,'' which have elements of physical and virtual models, to enhance the educational experience. Trainees can interact with the virtual envi-ronment and perform physical maneuvers, resulting in virtual conse-quences necessitating further corrective physical maneuvers. With no consequences of failure or risk, invasive techniques can be practiced to facilitate the acquisition of psychomotor skills. These simulators are being used to create ''facilitated learners'' with reduced learning curves and improved clinical transferability of simulator acquired motor skills. There are numerous commercially available mixed echocardiography simulators. 4 Probe manipulations made during image acquisition maneuvers with these simulators can be captured in the three-dimensional space. This data can be graphically displayed in near real-time to provide an objective feedback with motion analysis. 1,5,6
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