PRO AND CON Michelle Capdeville, MD Section Editor

Pro: Simulation Training in Transesophageal Echocardiography Mario Montealegre-Gallegos, MD,* Anam Pal, MD,† and Robina Matyal, MD*


URRENTLY, TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) training follows a time-based apprenticeship model. One of the biggest limitations of this “on-the–job” teaching model is that the clinical experience is neither integrated with the acquisition of cognitive knowledge nor graduated from simple to complex. In this model, teaching is not the main objective but merely a byproduct of patient care. Proficiency in TEE requires a cognitive understanding of normal and abnormal cardiac anatomy, as well as a threedimensional notion of the position of the probe and scan plane angle in relation to the heart and great vessels. Furthermore, TEE also requires integration of this cognitive knowledge with a psychomotor skill set necessary for probe insertion and manipulation.1 Simulation has been used in multiple medical specialties to supplement traditional clinical training. There is some evidence that simulation may facilitate psychomotor skill acquisition, cognitive knowledge acquisition, and clinical decision-making capacity of medical trainees.2–4 For TEE specifically, simulation may circumvent several limitations associated with the traditional training model. The authors present here some of the advantages of a simulation training program for TEE over traditional training, as pertains to cognitive knowledge acquisition, psychomotor skills training, and cost. COGNITIVE KNOWLEDGE

Because of its invasive nature, TEE usually is performed in patients who require complex management (eg, cardiac or vascular anesthesia) or during life-threatening events (eg, hemodynamic instability). This provides scarce opportunities for learning normal echocardiographic anatomy in a stress-free environment.

From the *Department of Anesthesia, Critical Care and Pain Medicine, and †Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Address reprint requests to Mario Montealegre-Gallegos, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, CC-470, West Clinical Center, 1 Deaconess Road, Boston, MA 02215. E-mail: mmonteal@bidmc. © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0034$36.00/0 Key words: transesophageal echocardiography, simulation 1410

Most TEE simulators with augmented reality have the ability to display the echocardiographic imaging planes and their anatomic correlation within the three-dimensional image of the heart. This realistic heart image may be rotated, labeled, and sectioned as desired to further improve spatial orientation. Trainees can learn to distinguish normal anatomy, which is the first step toward recognizing a pathological image. Another potential advantage of simulation is the possibility of graded (simple-to-complex) training in a secure, nonthreatening environment. This progressive increase in complexity contrasts with the clinical setting, in which learners may be exposed to difficult cases during the beginning of their training, potentially increasing their stress and frustration levels. Additionally, simulation allows trainees to be exposed to infrequent, life-threatening, and complex pathologies (eg, pericardial tamponade) that may not occur during their allocated clinical training time. PSYCHOMOTOR SKILL ACQUISITION AND EVALUATION

With traditional TEE training, a manual skill set is supposed to be acquired at the end of a specified time period. This model does not take into account individual variations in manual dexterity and motor learning. Traditionally used metrics for evaluating psychomotor skills in this context, such as number of errors or time until task completion, are crude and subjective. Simulation training has been shown to facilitate psychomotor skill acquisition in TEE trainees. TEE simulation also has the advantage of targeting specific weaknesses in the trainees’ performance (eg, deep transgastric view) for repeated practice. Some simulators (eg, Blue Phantom) can be used for familiarizing trainees with the hospital’s ultrasound equipment. They can practice basic knobology (ie, turning on the machine, input of patient data) and also learn to use advanced features (three-dimensional echocardiography). These types of simulator may provide opportunities to bridge the gap between simulation and clinical training. Kinematic metrics can be derived from certain simulators with haptic interfaces, and may be used to evaluate psychomotor skill acquisition. Metrics such as path length have been studied in several contexts,5 and evidence suggests they also may be applicable to TEE training.6 Currently, training programs such as Fundamentals of Laparoscopic Surgery (FLS) or Fundamentals of Endoscopic Surgery (FES) have been using these metrics as a requirement for certification. Similar metrics may be used someday

Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 5 (October), 2014: pp 1410–1411



for TEE, since current certification is primarily knowledgebased. COST-BENEFIT ANALYSIS

Traditional TEE training may result in costs related to patient complications, deterioration of equipment and billing for faculty time, among others. One of the advantages of simulation over classic clinical instruction is that, whereas the only consequence of a mistake during simulation training is an opportunity for learning, mistakes made during clinical training may be an important cause of patient discomfort or morbidity.7 The possibility of preventing patient discomfort or complications is invaluable, both in human and economic terms. Significant complications with TEE fortunately are rare, but they may be devastating.8 Although not life-threatening, other more frequent complications, such as bleeding or dysphagia, may result in significant patient discomfort and may be more frequent in inexperienced hands. Teaching in the operating

room may generate distractions from patient care and increase the probability of error in patient management. Further, simulation possesses the advantage of a decreased requirement of faculty. In the clinical setting, the trainee-toinstructor relationship is usually 1 to 1, whereas simulation may permit more trainees per faculty member. Furthermore, some simulators are equipped with self-learning tutorials, in which the simulator at least partially replaces the instructor. This less supervised environment may decrease the total cost of learning per trainee and may increase long-term retention of skills.9 CONCLUSION

Although simulation perhaps will never replace clinical training, the numerous advantages over it greatly outweigh its economic cost. The greatest potential for simulation is in the creation of “experienced beginners,” who may be better prepared for clinical training than in the traditional apprenticeship model.

REFERENCES 1. Shakil O, Mahmood F, Matyal R, et al: Simulation training in echocardiography: The evolution of metrics. J Cardiothorac Vasc Anesth 27:1034-1040, 2013 2. Bose RR, Matyal R, Warraich HJ, et al: Utility of a transesophageal echocardiographic simulator as a teaching tool. J Cardiothorac Vasc Anesth 25:212-215, 2011 3. Platts DG, Humphries J, Burstow DJ, et al: The use of computerised simulators for training of transthoracic and transoesophageal echocardiography. The future of echocardiographic training? Heart Lung Circ 21:267-274, 2012 4. Neelankavil J, Howard-Quijano K, Hsieh TC, et al: Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesth Analg 115:1042-1051, 2012

5. Obstein KL, Patil VD, Jayender J, et al: Evaluation of colonoscopy technical skill levels by use of an objective kinematic-based system. Gastrointest Endosc 73:315-321, 2011 6. Matyal R, Mitchell JD, Hess PE, et al: Simulator-based transesophageal echocardiographic training with motion analysis: A curriculumbased approach. Anesthesiology 2014 Mar 25 [Epub ahead of print]. 7. Shakil O, Mahmood F, Matyal R: Simulation in echocardiography: An ever-expanding frontier. J Cardiothorac Vasc Anesth 26:476-485, 2012 8. Piercy M, McNicol L, Dinh DT, et al: Major complications related to the use of transesophageal echocardiography in cardiac surgery. J Cardiothorac Vasc Anesth 23:62-65, 2009 9. Brydges R, Nair P, Ma I, et al: Directed self-regulated learning versus instructor-regulated learning in simulation training. Med Educ 46:648-656, 2012

Pro: Simulation training in transesophageal echocardiography.

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