Simulation-based training: The next Revolution in radiology education?

1. Simulation-Based Training: The Next
Revolution in Radiology Education?
Terry S. Desser, MD
Simulation-based training methods have been widely adopted in hazardous professions such as aviation, nuclear
power, and the military. Their use in medicine has been accelerating lately, fueled by the public’s concerns over
medical errors as well as new Accreditation Council for Graduate Medical Education requirements for out-
come-based and proficiency-based assessment methods. This article reviews the rationale for simulator-based
training, types of simulators, their historical development and validity testing, and some results to date in
laparoscopic surgery and endoscopic procedures. A number of companies have developed endovascular simu-
lators for interventional radiologic procedures; although they cannot as yet replicate the experience of perform-
ing cases in real patients, they promise to play an increasingly important role in procedural training in the
future.
Key Words: Simulation, education, endovascular simulation
J Am Coll Radiol 2007;4:816-824. Copyright © 2007 American College of Radiology
INTRODUCTION
In surgery, as in anything else, skill, judgment, and confidence are
learned through experience, haltingly and humiliatingly. Like the
tennis player and the oboist and the guy who fixes hard drives, we
need practice to get good at what we do. There is one difference in
medicine, though: we practice on people. [1]
The intrinsic ethical tension between patients’ best
interests and trainees’ need for experience came into pub-
lic focus with the publication of the Institute of Medicine
report To Err Is Human [2]. The staggering number of
supposedly preventable medical errors cited in that
publication—more than the number of annual vehic-
ular fatalities—garnered headlines nationwide and led
to demands for increased scrutiny of medical educa-
tion practices from both politicians and the general pub-
lic. And although much has been learned in recent de-
cades about what constitutes effective adult education,
current medical training paradigms remain virtually
identical to those originally outlined by Flexner and Hal-
sted a century ago [3].
Simulation, as defined by anesthesiologist and simula-
tion pioneer David Gaba [4], “is a technique—not a
technology—to replace or amplify real experiences with
guided experiences that evoke or replicate substantial
aspects of the real world in a fully interactive manner.”
Simulation-based education methods have been widely
used in industries such as commercial aviation, nuclear
power, and the military, in which training in real-life
situations would be hazardous and mistakes disastrous.
As is often the case, however, real-life catastrophes oc-
curred before simulation methods gained acceptance and
a critical mass of support. In the case of commercial
aviation, for example, a flight simulator had been devel-
oped in 1929, but it took high pilot death rates during
World War II before flight simulation was embraced by
the Air Force as a training tool [3].
Medical education may now be at a similar tipping
point. Simulation-based training methods are being used
with increasing frequency in medical school and resi-
dency training programs [5]. The 2007 International
Meeting for Simulation in Healthcare sponsored by the
Society for Simulation in Healthcare (http://www.ssih.
org) drew more than 1,200 attendees, double the number
from the previous year. Radiologists have taken note: the
Radiological Society of North America (RSNA), the So-
ciety of Interventional Radiology, and the Cardiovascu-
lar and Interventional Radiological Society of Europe
have all established individual task forces and have joined
together to set strategy and issue recommendations for
simulation training [6]. In this article, I review the his-
torical development, types, and evaluation methods of
simulation-based training techniques in medicine in gen-
eral and radiology in particular. The potential role of
simulation in assessment and credentialing is also dis-
cussed.
Department of Radiology, Stanford University School of Medicine, Stanford,
California.
Corresponding author and reprints: Terry S. Desser, MD, Stanford Uni-
versity School of Medicine, Department of Radiology, 300 Pasteur Drive,
Mail Code 5621, Stanford, CA 94305; e-mail: desser@stanford.edu.
© 2007 American College of Radiology
0091-2182/07/$32.00 ● DOI 10.1016/j.jacr.2007.07.013
816

2. HISTORICAL DEVELOPMENT
The modern history of medical simulation began in the
late 1950s with the pioneering work in cardiopulmonary
resuscitation of anesthesiologist Peter Safar [7-9]. Stim-
ulated by research showing that expired air ventilation
administered to patients by face mask or endotracheal
tube was capable of maintaining normal blood gases in
patients, Safar began a series of studies that culminated
in his paper on mouth-to-mouth ventilation, published
in JAMA in 1958 [10]. Safar presented his findings at
conferences worldwide, including a Scandinavian Soci-
ety of Anesthetists meeting in Norway later that year. In
attendance was anesthesiologist Bjorn Lind, who intro-
duced Safar to Norwegian toymaker Asmund Laerdal.
The 3 collaborated to produce the resuscitation training
mannequin known as Resusci Anne in 1960, adding a
chest compression component after the discovery by in-
vestigators at Johns Hopkins University that external
compression of the chest could generate a blood pressure
pulse in animals. Laerdal Medical’s Resusci Anne enabled
the training of both medical professionals and laypersons
in techniques of cardiopulmonary resuscitation and has
saved countless lives since its initial development. In the
mid-1990s, two anesthesiologist colleagues of Safar’s at
the University of Pittsburgh developed a more anatomi-
cally correct airway and simulator and contracted with
the Medical Plastics Corporation of Texas for its manu-
facture. Laerdal then acquired Medical Plastics and mar-
keted the simulator under the name SimMan [7,8].
A second simulation effort in the mid-1960s by Uni-
versity of Southern California engineer Stephen Abraha-
mson and physician Judson Denson introduced com-
puter control to mannequin simulators. Their Sim One
mannequin was built in collaboration with the aerospace
company Aerojet, which needed to develop peacetime
applications of its technologies in the military funding
lull before the escalation of the Vietnam War [8]. Given
the computer technology available at the time, Sim One
was remarkably lifelike, with, for example, pupils that
dilated and constricted and a chest that moved with
respiration. However, the simulator was never commer-
cially viable because of the limited availability of com-
puter technology and lack of demand for simulation-
based training from medical educators steeped in the
apprenticeship training paradigm [8,11]. A third simula-
tion effort, a cardiology physical examination training
mannequin called Harvey, was developed at the Univer-
sity of Miami in 1968. Harvey could reproduce a variety
of physical findings, including blood pressure, respira-
tory rate, pulses, heart sounds, and murmurs. Students
who trained with Harvey were shown to perform better
in their cardiology electives than peers who trained only
with patients [8,12].
The development of sophisticated mathematical mod-
els of physiology and pharmacology together with inno-
vations in computer technology permitted more realistic
mannequin simulators to be developed, beginning in the
1980s. Stanford anesthesiologist David Gaba and col-
leagues created the Comprehensive Anesthesia Simulation
Environment, which combined a simulated “patient” (a
mannequinwhosevitalsignscouldbemanipulatedbycom-
puter) and a real operating room equipped with actual an-
esthesia machines. This “high-fidelity simulation” used a
realistic simulated environment and focused on team-
based training, following models of crew training devel-
oped in the aviation industry. Using the Comprehensive
Anesthesia Simulation Environment system, Gaba and
his colleagues could train residents and entire medical
teams to manage rare but dire critical care events. The
system was also used to test the importance of human
factors such as fatigue on trainee performance, and their
results were used as evidence in development of the Ac-
creditation Council for Graduate Medical Education’s
duty hours limitations for residents. At approximately
the same time, a group at the University of Florida de-
veloped the Gainesville Anesthesia Simulator, which re-
created physiologic changes in response to the adminis-
tration of drugs and anesthetic gases. Both systems were
later commercialized, the Comprehensive Anesthesia
Simulation Environment as MedSim Advanced Med-
ical Simulations, Ltd., and the Gainesville Anesthesia
Simulator system as Medical Education Technologies,
Inc. [8].
As computer technologies became cheaper and more
powerful, virtual environments with visual, auditory,
and tactile (haptic) components were created that sim-
ulated a number of surgical and interventional proce-
dures. These “procedural simulators” were developed
for a wide range of clinical domains, including bron-
choscopy, endoscopy, endoscopic retrograde cholan-
giopancreatography, colonoscopy, ophthalmic sur-
gery, surgical suturing, and endovascular procedures
described in more detail below [13-20].
WHY SIMULATORS? LIMITATIONS OF
CURRENT TRAINING METHODS
The current medical education framework dates to the
early 20th century and is based on the premise that train-
ees will obtain the necessary expertise by observing and
working closely with expert practitioners [6,21,22]. After
an initial period of close oversight by attending physi-
cians, trainees are given progressively more independence
in working with patients until the requisite training pe-
riod has elapsed. This “master-apprentice” model is thus
a time-based system: trainees are assumed to have ac-
quired the necessary skills and knowledge by virtue of
Desser/Simulation-Based Training 817

3. having trained for the set period of time. And although
the system has historically worked well, there is much
room for improvement.
First, it is obvious that young physicians have different
intrinsic aptitudes and acquire skills at different rates. A
system to measure true proficiency would be preferable to
establishing a fixed time period for training. Because the
length of time physicians train is one of the main factors
in training cost, residents who become proficient quickly
could see the ultimate cost of their training reduced.
Second, attending physicians’ evaluations of trainees’
performance is subjective, and they invariably exhibit the
common biases prevalent in performance assessment,
such as the “halo effect” (the tendency to rate all perfor-
mance categories high or low on the basis of a single
trait), leniency bias, recency bias, and so on [6,23]. Sim-
ulators, which capture and record performance metrics
such as time to complete a task and the accuracy of the
result, can provide objective assessment of proficiency.
Third, studies of learning have shown that adults learn
best when they participate actively in the learning process
and are provided with timely and appropriate feedback
[24]. Simulation-based training is “hands on” and capa-
ble of providing immediate cues to trainees.
Fourth, as duty hours are limited and procedures mi-
grate to the outpatient setting, trainees’ exposure to a
wide variety of cases diminishes. Simulators can poten-
tially fill this gap. Finally, it is clear that the public’s
tolerance for being the “guinea pigs” while trainees gain
clinical experience is rapidly disappearing. Simulation-
based training methods potentially provide ample oppor-
tunities for trainees to practice complex procedures and
crisis management without putting patients at risk. In-
deed, some educators argue that simulation-based medi-
cal education is now an ethical imperative [25].
TYPES OF SIMULATORS: TERMINOLOGY
Simulation devices that reproduce only a limited portion
of reality, such as a model of a body part, are often called
“part-task trainers.” These are most often used for tech-
nical or psychomotor skills training, such as venipunc-
ture. Part-task trainers range in sophistication from
home-grown devices fabricated from familiar household
objects (think of the “olive in a turkey breast” phantom
used to train radiologists in ultrasound-guided breast
biopsies), to high-tech systems such as the Harvey man-
nequin, described above, which trains students in cardiac
findings on auscultation.
Another way to classify simulators is by the technology
they use. “Simulated or standardized patients” are actors
trained to act as patients to train medical students in
interviewing techniques, physical examinations, and
more general communication skills. Standardized pa-
tients have become a common part of the curriculum in
medical schools and of objective-structured clinical ex-
aminations. Mannequins with purely mechanical com-
ponents are termed “physical model simulators.” One
example is the CPR mannequin Resusci Anne, described
above. “Computer-based” systems may be designed like
computer games in which the user interacts with a virtual
environment via devices that control the scene. ER-sim,
an online simulation game (Legacy Interactive, Holly-
wood, California; http://www.ersim.com) is one such
example. Tactile (haptic) feedback is now technologi-
cally feasible and is an essential component of surgical,
endoscopic, and endovascular simulators. “Hybrid
simulators” combine a physical model or mannequin
with a computer that modifies simulated physiologic
parameters. “Immersive simulators” create a complete
3-D world in which users are made to feel as if they are
operating entirely within the simulated environment.
Users move their bodies in space and are able to interact
with computer-created scenes. One often cited example
is the US Marine Corps combat simulator [26], in which
a virtual locomotion control enables the user to move
through the scene by walking in place. This technology
has recently been incorporated into the latest generation
video games, though as yet it has not been developed into
a medical simulation tool.
VALIDATION AND ASSESSMENT OF
SIMULATORS
The simulation literature has adopted specific terminol-
ogy from the domain of educational testing to evaluate
simulation systems [3,27,28]. Face validity describes
whether the system looks like what it is designed to
represent, in other words, if it is sufficiently realistic for
the user to suspend disbelief while performing the simu-
lated task. Assessment should also include a subjective
evaluation of the ease of use of the interface and whether
subjects enjoy using the simulator (usability testing).
Content validity, a psychometric concept, describes the
extent to which a simulation exercise reproduces all as-
pects of the real-world experience. Content validity de-
scribes whether a simulator accurately reproduces the
process it is supposed to model and must be tested by
expert practitioners. Concurrent validity describes how
closely subjects’ performance on a simulator correlates
with their performance on a gold standard measure of
proficiency. So for example, surgeons with recognized
expertise should perform significantly better on a simu-
lator than novices. Predictive validity describes the extent
to which good performance on the simulator predicts
good performance on real patients.
With current software, it is possible to design any
number of virtual environments to simulate a variety of
818 Journal of the American College of Radiology/Vol. 4 No. 11 November 2007

4. tasks. The difference between a useful simulation and a
mere computer game based on a medical scenario is the
degree to which the exercise meets the validity criteria
above. Evaluations of simulator technology should have
professional educators or psychologists as coauthors to
define the tasks to be modeled and to prove rigorously
that learning has taken place [29]. In addition, there
should be a set of performance metrics integrated into the
simulator to record trainees’ correct and incorrect ac-
tions. And these metrics should be meaningful, not sim-
ply easy or convenient to measure. For example, current
endovascular simulators track metrics such as the overall
time required to perform a procedure, the volume of
contrast used, C-arm handling, and so on. But as yet,
they cannot capture information on detailed catheter
manipulation skills or errors in judgment [6]. Finally,
actions on a simulator should follow the laws of physics
[3]. When a trainee makes an error, its true physiologic
consequences should be reflected in the system. There is
controversy about whether it is psychologically harmful
to allow trainees to “kill” their patients via their actions in
simulators. Nevertheless, errors must be allowed to occur
in simulators so that trainees can see potential conse-
quences and hopefully limit them to the virtual world
rather than the real one.
Simulators for Laparoscopic Surgery
When laparoscopic surgery was introduced in the 1980s,
surgeons needed new visuospatial and psychomotor skills
that were difficult to acquire on the job in the operating
room. Centers specializing in teaching laparoscopic tech-
niques used either animal models or inanimate objects
inside boxes (“box trainers”) to allow surgeons to gain
facility in the method. Ultimately, virtual reality simula-
tors with immersive visual environments and tactile feed-
back were developed [21]. Although simulator-based
training seems intuitively to be useful, to date there have
been few randomized, double-blind, controlled trials
proving that simulators are effective. One such study,
conducted by Seymour et al [30], showed that residents
trained to perform laparoscopic cholecystectomies with a
simulator used correct dissection technique, made 6
times fewer intraoperative errors, and had shorter oper-
ating times than those who did not. Residents not trained
using virtual reality were 5 times more likely to injure the
gallbladder or burn nontarget tissue. Another study from
Seymour’s group [31] showed that virtual reality training
in the use of an angled laparoscope significantly im-
proved the operative performance of novices. Recogniz-
ing the potential of simulation, the American College of
Surgeons has established a formal accreditation process
for education programs that meet standards and criteria
devised for simulation-based training. To date, 7 institu-
tions have been designated as level I American College of
Surgeons–accredited education institutes [32].
Simulators in Critical Care
As described above, a great deal of simulation technology
was developed initially by anesthesiologists. A detailed
review of simulator training in clinical care is beyond the
scope of this article, but many studies have been per-
formed to show that high-fidelity simulation improves
the performance of anesthesia and emergency medicine
teams in managing crises [11,13, 33-37].
Endoscopy
Computer-based simulators have been developed for a
variety of endoscopic procedures [14]. Unlike the lapa-
roscopic simulators, to date, no rigorous prospective
studies have been performed on the effectiveness of en-
doscopy simulators. One pilot concurrent validation
study of an upper endoscopy simulator suggested that
experts performed better than trainees and novices [14],
but another study found no benefit to simulator training
[18]. For flexible sigmoidoscopy, one study found that
bedside training resulted in better scope insertion, nego-
tiation of the rectosigmoid region, and other endoscopic
tasks compared with simulator training. Another study
showed an advantage with simulator training for the very
early stages of learning colonoscopy that disappeared
once 30 procedures had been performed by the non-
simulator-trained group [20]. Overall, recent work sug-
gests that simulation may be useful during the early stages
of endoscopic procedural training, but it cannot replace
traditional bedside instruction [14].
SIMULATORS IN RADIOLOGY
In a sense, radiology educators have long made use of
simulation-based training in the form of “hot seat” con-
ferences. Providing residents with examples of unusual
cases in an unknown case-discussion format is a critical
component of training, because the full scope of clinical
entities they will likely see during decades of practice
might not be predictably encountered during the train-
ing period. In recent years, there have been efforts such as
the RSNA’s Medical Imaging Resource Center, the ACR’s
Case-in-Point series, AuntMinnie.com’s “Case of the Day,”
and others to enable multimedia, case-based learning on a
large scale. In addition, radiology educators in certain sub-
specialties have begun to create online teaching modules to
exploit the ease of disseminating information in digital
form. The Cleveland Clinic Pediatric Radiology module
(available at https://www.cchs.net/pediatricradiology/)
is one particularly successful example.
True immersive simulations in the radiology domain,
though, are much newer. As volumetric data sets have
Desser/Simulation-Based Training 819

5. become available and computer technology has im-
proved, simulators that enable physicians to interact with
high-fidelity reproductions of human anatomy have be-
come feasible. Monsky et al [38] used a sonographic
simulation system (UltraSim; MedSim Advanced Medi-
cal Simulations, Ltd., Fort Lauderdale, Florida; http://
www.medsim.com/products/products.html) to teach
and evaluate the performance of two consecutive classes
of 8 first-year residents in scanning and interpreting 10
test ultrasound cases in the abdomen and pelvis. The
UltraSim system consists of a full-size mannequin with
realistic body contours and a soft torso surface, an ultra-
sound “probe,” and an ultrasound scanner console and
monitor. The probe is actually a 3-D position sensor that
interacts with the mannequin and stored commercially
available 3-D teaching data sets that have been created
from sonograms performed on real patients. Study re-
sults showed that the simulator improved residents’ ab-
dominal and pelvic scanning technique, as well as their
self-assessment scores. The investigators concluded that
the simulator was useful for both training and the evalu-
ation of residents’ performance.
At the 2006 annual meeting of the RSNA, preliminary
work on a radiographic simulator for training technolo-
gists in the positioning of cervical spine radiographs was
presented. A high-resolution, computed tomographic
data set of the head and spine is used to create a virtual
patient, and students manipulate a computer animation
of an x-ray tube to project the virtual beam through the
spine. The resultant x-ray projection is calculated from
ray projection algorithms and displayed on a second
monitor. Students can practice positioning the standard
views of the cervical spine initially with “fluoroscopic”
feedback, and later without feedback, all without expos-
ing patients to radiation [39].
Crisis management in radiology is another area suit-
able for simulation training. Medina et al [17] developed
a computer simulation of pediatric and adult patients
undergoing sedation, analgesia, and contrast media com-
plications during radiologic procedures, but to date have
not published studies of its effectiveness. More recently,
Mainiero et al [40] conducted a high-fidelity medical
simulation exercise with an interactive anesthesia man-
nequin in whom the physiologic scenario of a life-threat-
ening contrast reaction was simulated. Six first-year radi-
ology residents were tested on their ability to perform 16
critical actions necessary to stabilize the patient. The
exercise exposed several areas of weakness, and 5 of the 6
residents agreed that the training was a valuable educa-
tional experience.
Simulators in Interventional Radiology
Interventional radiology promises to be the radiologic
subspecialty in which simulators will have the biggest
impact on training and credentialing. The spectacular
images now achievable with noninvasive imaging modal-
ities such as computed tomographic angiography have
reduced the number of purely diagnostic angiograms,
thereby minimizing the opportunities for trainees to ac-
quire the basic catheter manipulation skills necessary for
more advanced interventions such as angioplasty and
embolization [28,41,42]. In addition, competitor spe-
cialties outside radiology have long been interested in
acquiring the skills necessary to perform catheter-based
interventions. A number of endovascular simulators have
been developed that allow practice with the manipula-
tion of catheters and guidewires, contrast media injec-
tion, and real-time fluoroscopy (Table 1, Figures 1 and
2). The recent US Food and Drug Administration deci-
sion to approve one manufacturer’s carotid stent, contin-
gent on the company’s devising a training system that did
not put patients at risk, set a precedent and provided a
major impetus for the development of endovascular sim-
ulators [3,43]. A number of validation studies are now
ongoing. Nicholson et al [44] conducted a face and con-
tent validity study of the Procedicus VIST simulator
(Mentice, Göteborg, Sweden; Table 1) with 100 practic-
Table 1. Some common commercial endovascular simulators
Trade Name Manufacturer Web Site
Procedicus VIST
endovascular
simulator (Figure 1)
Mentice, Göteborg, Sweden http://www.mentice.com
Angio Mentor (Figure 2) Simbionix USA Corporation,
Cleveland, Ohio
http://www.simbionix.com/ANGIO_Mentor.html
Simsuite Medical Simulation
Corporation, Denver,
Colorado
http://www.medsimulation.com/education_
system/centers.asp
CathLabVR system Immersion Medical
Corporation, San Jose,
California
http://www.immersion.com/corporate/products/
820 Journal of the American College of Radiology/Vol. 4 No. 11 November 2007

6. ing interventionalists averaging 12.4 years of endovascu-
lar experience. Specialties represented included 71 inter-
ventional cardiologists, 21 vascular surgeons, and 1
interventional radiologist. The users attended a 1.5-day
course in which they received training on the simulator
and then were asked to perform 1 right carotid arterio-
gram, 1 left carotid arteriogram, and 1 total right and left
carotid angiogram on the system. After the 3 cases were
completed, the realism of the Procedicus VIST simulator
experience was evaluated on a 5-point, Likert-type scale.
Subjects were asked about the appearance of the anat-
omy, the realism of the physical behavior of the proce-
dure tools, and the overall assessment of the technical
tasks in the procedure. The results showed good simula-
tion of aortic arch and carotid vascular anatomy, excel-
lent realism in catheter and guidewire movements, and
overall excellent realism in the procedure.
Using a different endovascular simulator (Simsuite;
MedicalSimulationCorporation,Denver,Colorado;Table
1), Dawson et al [45] offered a series of 2-day endovas-
cular skills training workshops for vascular surgery resi-
dents in the first year of vascular specialty training. A
vascular surgeon familiar with the simulator supervised 9
residents one on one in catheter, sheath, and wire han-
dling; angioplasty balloon inflation; and stent deploy-
ment in the domains of aortoiliac, renal, and carotid
artery disease. Performance metrics recorded automati-
cally by the simulator software included total procedure
time, fluoroscopy time, the volume of contrast medium
used, time to treat complications, and the total number
of balloons, stents, and wires used. Faculty members also
provided subjective feedback to trainees on their perfor-
mance. Results on the index aortoiliac case showed that
compared with performance on day 1, simulation train-
ing enabled trainees to perform the case 54% faster with
a 48% decrease in fluoroscopy time and a 44% decrease
in the volume of contrast material administered. Post-
training questionnaires indicated that the trainees found
the experience sufficiently realistic to be useful in training
and felt that there would be benefit from practicing on a
simulator during their fellowships. The direct cost of the
program was $2,146 per resident, including the cost of
the simulator but not including loss of the trainee’s ser-
vices during the 2-day period of the course.
One randomized controlled study of 20 general surgery
residents learning catheter-based interventions showed that
the group receiving simulator training performed better
than the control group in 2 consecutive lower extremity
endovascular cases [46]. A number of other endovascular
simulation studies have been performed, but to date,
virtually all have involved vascular surgeons or vascular
surgery residents [45, 47-50]. Recently, the Society of
Interventional Radiology created the Task Force on
Medical Simulation, chaired by Aalpen Patel, MD, of the
University of Pennsylvania. Together with the Cardio-
vascular and Interventional Radiological Society of Eu-
rope, they have created a strategic plan in which they note
the limitations of the current master-apprentice training
models and outline plans for creating, validating, and
promoting medical simulation in interventional radiol-
ogy training [6,42,51]. Their mission is to identify the
proper role of current simulation technologies in training
Fig 1. The Procedicus VIST endovascular simulator
(Mentice, Göteborg, Sweden). The operator selects
wires, catheters, balloons, and so on, on the control
screen (left) and manipulates them via an introducer
at the “groin” of the plastic model. A fluoroscopic
image of the virtual procedure is shown in the right
screen. The simulator provides haptic feedback to the
user on the basis of the devices chosen and the
vessel being studied and simulates contrast flow and
resultant hemodynamics. The system also keeps
track of the user’s performance for use in assess-
ment. (Courtesy of Mentice.)
Fig 2. The Simbionix ANGIO Mentor (Simbionix USA
Corporation, Cleveland, Ohio). The user operates
wires, catheters, syringes, and other devices at the
foot of the simulator. A simulated fluoroscopic image
is displayed on the right-hand screen. The left-hand
screen shows a simulated image of the C-arm fluo-
roscopy procedure. The simulator device provides
haptic feedback to the user on the basis of the de-
vices chosen and the vascular environment. (Cour-
tesy of Simbionix USA Corporation.)
Desser/Simulation-Based Training 821

7. and to guide the evolution of simulation methodologies.
They note that at present, simulators have not been
shown to be adequate for training novices in catheter
manipulation skills and cannot substitute for actual pa-
tient experience. Furthermore, as in the aviation indus-
try, simulators should be used only in the context of an
overall curriculum in interventional procedures and with
the oversight of professional societies and regulatory au-
thorities [6,28,41,42,51]. In the future, they argue, stan-
dard measures for testing and validating simulators
should be developed. As with the Digital Imaging and
Communications in Medicine standard, simulator man-
ufacturers should work together to ensure cross-platform
compatibility among simulator devices so that, for exam-
ple, an anesthesia simulator could interface with an en-
dovascular procedure simulator to model the physiologic
changes expected if a catastrophic event such as vessel
rupture occurs. The joint task force envisions that in the
near future, there will be numerous interventional radi-
ology simulation training modules proven to transfer
skills, reduce errors, deliver clinical benefit, integrated
into training curricula and validated for certifying and
credentialing examinations [6].
SIMULATION: THE FUTURE
As noted previously, powerful forces are converging to
drive the future of medical simulation. The current mas-
ter-apprentice model of resident education is “an expen-
sive anachronism” [28] that sorely needs updating. Edu-
cation researchers have shown that adults learn best by
doing, not by listening and observing [24]. Simulation
exercises provide medical trainees with hands-on experi-
ence and have the potential to accelerate learning dramat-
ically, particularly early in training, without exposing
patients to any risk. Second, and in part fueled by the
Accreditation Council for Graduate Medical Educa-
tion, the medical culture is changing from the passive
acceptance of time-based training to a proficiency-based
model in which core competencies must be documented.
Simulation-based methods have the potential for both
training and assessment and could prove hugely benefi-
cial in credentialing efforts. Third, societal acceptance of
trainees’ need to learn at the potential expense of patient
care has vanished, necessitating the development of new
training models that do not put patients at risk. In anes-
thesiology, a culture change to zero tolerance for operat-
ing room errors, rather than the acceptance of extremely
low error rates, was needed to catalyze high-fidelity sim-
ulator development. A similar systems-based approach to
minimizing and ultimately eliminating individual error
is beginning to take hold in other subspecialties as well.
Nevertheless, the wholesale adoption of computer
simulators before validation would be irresponsible. Sim-
ulation devices must be designed carefully, with input
from psychologists who have analyzed the factors that
constitute expert performance and need validation by
domain experts to show proof of effectiveness. This will
be time consuming and expensive. Some of the expense
may ultimately be offset by decreased liability in the form
of lower malpractice costs. But with health care dollars
limited, it is unclear whether forces mobilizing for uni-
versal access to medical care will trump those advocating
improving patient safety with simulator training. And
with doctors’ motivations increasingly suspect in the lay
press, simulator deployment must be integrated into a
thoughtfully structured subspecialty curriculum, with
approval and oversight of regulatory authorities, or risk
being viewed simply as a means to quickly credential
competitor specialists to perform lucrative procedures.
The Interventional Radiology Joint Simulation Task
Force has outlined 1-year, 3-year, and 5-year to 10-year
plans for the development of training standards, profes-
sional education methods, practice building, and simulator
research and the dissemination of information about simu-
latortrainingtothepublic[51].Otherradiologysubspecial-
ties, such as gastrointestinal fluoroscopy, could also benefit
from the development of simulators. Although the number
of diagnostic upper and lower gastrointestinal studies has
decreased dramatically since endoscopy was developed,
practicing radiologists still perform these procedures, and
residentsnowencountermanyfeweropportunitiesforprac-
tice during training. Unlike interventional radiology, how-
ever, there are no device manufacturers with a financial
interest in catalyzing development of gastrointestinal proce-
dural simulators, so radiology societies, such as the RSNA,
the American Roentgen Ray Society, and the Association of
University Radiologists, will likely need to play a role. In the
future,atieredtrainingparadigmmayemergeinprocedure-
based specialties, one in which inexpensive lower fidelity
simulation devices substitute for patients during the steep
phase of trainees’ learning curve, followed by higher fidelity
simulation supplementing procedural experience with pa-
tientsasskillsmature.Onceproveneffective,simulatorswill
likely find a role alongside conventional oral and written
examinationstodocumenttechnicalproficiencyforcreden-
tialing and recertification examinations.
CONCLUSION
Simulation-based training methods, which have saved
countless lives in the fields of aviation, nuclear power,
and the military, are beginning to gain a foothold in
medicine. The old, time-based, “see one, do one, teach
one” apprenticeship model for training residents is being
supplanted by an outcome-based model in which tech-
nical proficiency and a core knowledge base must be
documented. Simulation techniques can be used for
822 Journal of the American College of Radiology/Vol. 4 No. 11 November 2007

8. both training and assessment and are poised to meet
the needs of residency and fellowship program direc-
tors and accreditation and credentialing bodies that
increasingly require documentation of proficiency.
The costs of acquiring simulation equipment and of
designing and conducting simulation exercises may ul-
timately be offset by more efficient training and reduced
liability costs, but only time will tell.
REFERENCES
1. Gawande A. The learning curve: like everyone else, surgeons need practice.
That’s where you come in. The New Yorker. January 28, 2002:52-61.
2. Kohn JT, Corrigan JM, Donaldson MS, eds. To err is human: building a
safer healthcare system. Washington, DC: National Academy Press;
1999.
3. Dawson S. Procedural simulation: a primer. Radiology 2006;241:17-25.
4. Gaba DM. The future vision of simulation in health care. Qual Saf Health
Care 2004;13(suppl):i2-10.
5. Issenberg SB. The scope of simulation-based healthcare education. Simul
Healthcare 2006;1:203-8.
6. Patel AA, Gould DA. Simulators in interventional radiology training and
evaluation: a paradigm shift is on the horizon. J Vasc Interv Radiol
2006;17:S163-73.
7. Acierno LJ, Worrell LT. Peter Safar: father of modern cardiopulmonary
resuscitation. Clin Cardiol 2007;30:52-4.
8. Cooper JB, Taqueti VR. A brief history of the development of mannequin
simulators for clinical education and training. Qual Saf Health Care
2004;13:11-8.
9. Grenvik A, Schaefer J. From Resusci-Anne to Sim-Man: the evolution of
simulators in medicine. Crit Care Med 2004;32(suppl):S56-7.
10. Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration;
airway obstruction during manual and mouth-to-mouth artificial respira-
tion. JAMA 1958;167:335-41.
11. Bradley P. The history of simulation in medical education and possible
future directions. Med Educ 2006;40:254-62.
12. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for
health care professional skills training and assessment. JAMA 1999;282:
861-6.
13. Binstadt ES, Walls RM, White BA, Nadel ES, Takayesu JK, Barker TD,
et al. A comprehensive medical simulation education curriculum for
emergency medicine residents. Ann Emerg Med 2007;49:495-504.
14. Gerson LB, Van Dam J. Technology review: the use of simulators for
training in GI endoscopy. Gastrointest Endosc 2004;60:992-1001.
15. Anderson JH, Raghavan R. A vascular catheterization simulator for train-
ing and treatment planning. J Digit Imaging 1998;11(suppl):120-3.
16. Dawson SL, Cotin S, Meglan D, Shaffer DW, Ferrell MA. Designing a
computer-based simulator for interventional cardiology training. Cathe-
ter Cardiovasc Interv 2000;51:522-7.
17. Medina LS, Racadio JM, Schwid HA. Computers in radiology. The
sedation, analgesia, and contrast media computerized simulator: a new
approach to train and evaluate radiologists’ responses to critical incidents.
Pediatr Radiol 2000;30:299-305.
18. Sedlack RE. Validation of computer simulation training for esophagogas-
troduodenoscopy: pilot study. J Gastroenterol Hepatol 2007;22:1214-9.
19. Sedlack RE, Baron TH, Downing SM, Schwartz AJ. Validation of a
colonoscopy simulation model for skills assessment. Am J Gastroenterol
2007;102:64-74.
20. Sedlack RE, Kolars JC. Computer simulator training enhances the com-
petency of gastroenterology fellows at colonoscopy: results of a pilot
study. Am J Gastroenterol 2004;99:33-7.
21. Dutta S, Krummel TM. Simulation: a new frontier in surgical education.
Adv Surg 2006;40:249-63.
22. Riles TS. Surgical training: the past, the present, and the future. Ann Vasc
Surg 2005;19:140-1.
23. Bacal R. A performance management bias and error glossary. Available at:
http://www.work911.com/performance/particles/bias.htm. Accessed April
2, 2007.
24. Collins J. Education techniques for lifelong learning: principles of adult
learning. RadioGraphics 2004;24:1483-9.
25. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical educa-
tion: an ethical imperative. Acad Med 2003;78:783-8.
26. US Naval Research Laboratory. Immersive simulation. Available at:
http://www.nrl.navy.mil/aic/ims/. Accessed October 1, 2007.
27. Reznek MA, Rawn CL, Krummel TM. Evaluation of the educational
effectiveness of a virtual reality intravenous insertion simulator. Acad
Emerg Med 2002;9:1319-25.
28. Gould DA, Kessel DO, Healey AE, Johnson SJ, Lewandowski WE. Sim-
ulators in catheter-based interventional radiology: training or computer
games? Clin Radiol 2006;61:556-61.
29. Johnson S, Healey A, Evans J, Murphy M, Crawshaw M, Gould D.
Physical and cognitive task analysis in interventional radiology. Clin Ra-
diol 2006;61:97-103.
30. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training
improves operating room performance: results of a randomized, double-
blinded study. Ann Surg 2002;236:458-63.
31. Ganai S, Donroe JA, St Louis MR, Lewis GM, Seymour NE. Virtual-
reality training improves angled telescope skills in novice laparoscopists.
Am J Surg 2007;193:260-5.
32. American College of Surgeons. Listing of ACS accredited education insti-
tutes. Available at: http://www.facs.org/education/accreditationprogram/
list.html. Accessed April 10, 2007.
33. Overly FL, Sudikoff SN, Shapiro MJ. High-fidelity medical simulation as
an assessment tool for pediatric residents’ airway management skills. Pe-
diatr Emerg Care 2007;23:11-5.
34. Gaba DM. Improving anesthesiologists’ performance by simulating real-
ity. Anesthesiology 1992;76:491-4.
35. Gaba DM, DeAnda A. The response of anesthesia trainees to simulated
critical incidents. Anesth Analg 1989;68:444-51.
36. Grenvik A, Schaefer JJ III. Medical simulation training coming of age.
Crit Care Med 2004;32:2549-50.
37. Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm in
pediatric medical education: teaching neonatal resuscitation in a simu-
lated delivery room environment. Pediatrics 2000;106:E45.
38. Monsky WL, Levine D, Mehta TS, et al. Using a sonographic simulator to
assess residents before overnight call. AJR Am J Roentgenol 2002;178:
35-9.
39. Desser TS, Ahlqvist J, Dev P, Hedman L, Nilsson T, Gold GE. Learning
radiology in simulated environments: development of a simulator for teach-
ing cervical spine radiography [abstract]. Available at: http://rsna2006.
rsna.org/rsna2006/V2006/conference/event_display.cfm?em_idϭ4428655.
Accessed March 28, 2007.
40. Mainiero MB, Shapiro M, Murphy B. Use of high-fidelity medical sim-
ulation in the education of radiology residents in contrast reaction man-
agement. Presented at: 54th Annual Meeting of the Association of Uni-
versity Radiologists; Austin, Tex; 2006.
Desser/Simulation-Based Training 823

9. 41. Gould DA. Interventional radiology simulation: prepare for a virtual
revolution in training. J Vasc Interv Radiol 2007;18:483-90.
42. Gould DA, Reekers JA, Kessel DO, et al. Simulation devices in interven-
tional radiology: validation pending. J Vasc Interv Radiol 2006;17:215-6.
43. Gallagher AG, Cates CU. Approval of virtual reality training for carotid
stenting: what this means for procedural-based medicine. JAMA 2004;
292:3024-6.
44. Nicholson WJ, Cates CU, Patel AD, et al. Face and content validation of
virtual reality simulation for carotid angiography: results from the first
100 physicians attending the Emory Neuroanatomy Carotid Training
(ENACT) program. Simul Healthcare 2006;1:147-50.
45. DawsonDL,MeyerJ,LeeES,PevecWC.Trainingwithsimulationimproves
residents’ endovascular procedure skills. J Vasc Surg 2007;45:149-54.
46. Chaer RA, Derubertis BG, Lin SC, et al. Simulation improves resident
performance in catheter-based intervention: results of a randomized, con-
trolled study. Ann Surg 2006;244:343-52.
47. Aggarwal R, Black SA, Hance JR, Darzi A, Cheshire NJ. Virtual reality
simulation training can improve inexperienced surgeons’ endovascular
skills. Eur J Vasc Endovasc Surg 2006;31:588-93.
48. Dayal R, Faries PL, Lin SC, et al. Computer simulation as a component of
catheter-based training. J Vasc Surg 2004;40:1112-7.
49. Hsu JH, Younan D, Pandalai S, et al. Use of computer simulation for
determining endovascular skill levels in a carotid stenting model. J Vasc
Surg 2004;40:1118-25.
50. Patel AD, Gallagher AG, Nicholson WJ, Cates CU. Learning curves
and reliability measures for virtual reality simulation in the perfor-
mance assessment of carotid angiography. J Am Coll Cardiol 2006;
47:1796-802.
51. Becker GJ, Connors B, Cardella J, et al. SIR and CIRSE joint medical
simulation task force strategic plan. Available at: http://www.sirweb.org/
clinical/cpg/CIRSE_SIR_Joint_Strategy_7-14-06.pdf. Accessed March
27, 2007.
824 Journal of the American College of Radiology/Vol. 4 No. 11 November 2007