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Simulated neurosurgical reality: Could it fall short of the real thing?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.190254
Sir, “Reality itself, is merely an illusion, albeit a very persistent one” Albert Einstein We were enthralled by the exhaustive and pioneering experience on simulated neurosurgery in India by Suri et al.[1] The article brilliantly explores the concept of simulation, its evolution, neurosurgical models, and predicts the niche it would have in future neurosurgical education curricula. An alternate viewpoint we explored was the possibility of a neurosurgeon getting lost in the virtual world, enamoured by technology, cut-off from the “bloody” surgical field. As the excitement about simulation in neurosurgical training spreads, it also exudes a small touch of skepticism. Questions on whether the in-vitro simulation skills could be extrapolated to in-vivo skills in the operating room (with its lack of a realistic haptic feedback, and scarcity of surgical outcome validation after simulation training), lend support to the doubting Thomases. Could a new generation neurosurgical trainee get seduced by technology, enmeshed in the virtual word, detached from surgical reality? Simulation: Better than the real thing? Surgical expertise is a fine balance of anatomical know-how, cognitive and psychomotor skills, complex decision-making, and experiential knowledge.[2],[3],[4] Traditionally, surgical education relied heavily on the Halsteadian hands-on training and the surgical mentor–mentee relationship. As mentors and surgical opportunities became scarce, supervised experiential learning started falling out of fashion in a world driven by “virtual reality.” Increasing focus on patient safety, surgeon accountability and measuring surgical skills has also been a key driver in the conception and promotion of surgical simulation.[2] The prospect of honing psychomotor skills in a “close to reality” situation, without the stakes of surgical adverse events attached, is definitely exciting. The latest adaptation called “hybrid simulation” provides a patient- and pathology-specific real-time surgical environment replete with haptic feedback and patho-physio-anatomical variations.[3],[4] Nevertheless, simulation creates an illusion of an interesting world, and yet, is just short of the real thing. A leaf from aviation training: Autopilot to autosurgeon mode? “The risk of error that could lead to a disaster” is the common thread that binds aviation and surgical sciences.[5] While surgical error never risks a surgeon's life directly, a pilot's error could risk her/his life too. This makes the stakes appear higher in aviation, while it isn't really so. Static electronic gadgetry, a highly standardized environment and an “autopilot” mode characterize aviation training. On the other hand, the surgical terrain is more often less standardized with anatomical, pathological, and physiological variations.[6] There is no scope for an automated mode due to versatile and quite unpredictable biological structures and systems. Certain “mayday” situations in aviation can only be achieved in simulation labs, thus preparing for the worst scenarios. Surgical simulation rarely achieves these “mayday” situations because the solutions often lie beyond the psychomotor skills of a surgical task.[2],[6] Missing out the haptic feedback “Haptic” has its origin in a Greek term meaning “able to lay hold of” and is based on a combined sensory input from the skin, muscles, tendons, joints, and mucosae exposed to the environment.[7] Haptic perception is usually classified into kinesthetic and tactile perception. A surgeon's perceptions from the environment are distributed as visual (83%), auditory (11%), gustatory (1%), olfactory (3.5%) and haptic (1.5%) stimuli. Though hybrid simulators can achieve a near perfect haptic feedback, it still just falls short of a dynamic real-life patient with an internal milieu, a beating heart, and tissue turgor.[2] Risk of negative training Every surgical procedure is a complex array of multiple subtasks. The smooth flow of an operation is often the perfect balance of surgical psychomotor skills, economized movements, terrain familiarity, and experience.[8] Each surgical subtask in the entire surgical procedure can be classified into a skill acquisition module in simulated training (e.g., vascular anastomoses, ventricular cannulation in a ventriculo-peritoneal shunt procedure, etc.). In an unsupervised simulation lab, the focus could be on the “ends” rather than the “means” or skills to achieve the subtasks. This results in an enhanced possiblity of the trainee acquiring a 'negative” training that could be difficult to unlearn in the long run when the whole surgical procedure is undertaken in vivo. Seduced by technology, lost in the virtual world Rosser et al.[9] noted that surgeons who played the most video games (more than 3 hours/week) demonstrated better speed and accuracy in laparoscopic surgery. Hence, theoretically, it may be worthwhile to “catch 'em young” and begin simulated surgical training in high school or early medical school when psychomotor skills have a greater chance of being acquired. Surgery, however, is not just an amalgamation of complex psychomotor tasks but a process that needs an in-depth anatomical knowledge, pathological expertise, and robust decision-making skills, which develop over a lifetime of training. Too much simulation could create a surreal world of animated blood vessels, pulsating aneurysms with no stakes attached, and a future “virtual surgical warrior” who shies away from the real surgical operating room. “In vivo–In vitro” gap: Ethical challenges With increasing media attention on surgical adverse events and redefined ethical concerns, how much simulation is essential in training would become a matter of concern. As in-vitro surgical skills do not essentially translate into in-vivo skills, validation studies with outcome measures would be essential.[2] Another goal will be to establish international norms of performance for surgeons (both in-vivo and in-vitro skill benchmarks) at different levels of experience, that could be used by junior surgeons as a reference point to establish where they currently are on the learning curve.[5],[8] Supervised experiential learning vis-à-vis simulation Laymen tend to believe that trainee surgeons performing surgical procedures on real patients are dangerous.[2] There is no sufficient evidence to suggest that supervised surgical education compromises patient safety.[6] Teaching institutions often have the best surgical results, especially when backed by high volumes. Most students in a driving school learn driving with an instructor seated side-by-side. Surgeons too, like drivers, operate in a minimally standardized environment with many variations.[5],[6] Hence, if backed by sufficient theoretical knowledge and sound decision-making skills, supervised experiential learning has its unique place. As they say in surgical education parlance, “See one, do one, teach one”. Learning “on the job” is still quite irreplaceable. Futuristic perspective Simulation glitters, but all that glitters is not gold. Nevertheless, this small note of scepticism should not dampen the immense training and credentialing potential that simulation offers. We make a fervent plea for a fine balance between simulation and supervised experiential learning as well as further validation of simulation training by surgical outcome studies. “I played my game, a fantasy I pretend, but I know in reality, Ain't nothing like the real thing” …. Song Lyrics (“Ain't nothing like the real thing” by Marvin Gaye) Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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