US_cardio_Herzeele.qxp 17/7/08 09:43 Page 44
Interventional Cardiology
optimal levels of force-feedback. The majority of these calibration and Proficiency-based curricula aim to train future endovascular therapists
maintenance tasks are carried out by research fellows at our institution and have the potential to bring the different professions involved in CAS
(following manufacturer training), but skilled technical support is required for together. Vascular surgeons are familiar with patient selection and
heavy usage periods, especially those involving more challenging post-procedural care, but need more catheter skills training, radiologists
endovascular cases such as CAS.
38
Hence, although it has been suggested are often less familiar with overall patient care, and cardiologists
that VR training is less expensive than live animal training, it is unlikely that probably need training in the novel anatomical territory of the carotid,
many institutions will be able to afford such expensive resources. However, despite having endovascular skills. VR simulation is not only a good way
to be useful these simulators should be available to all trainees in specialist to train technical skills, it also allows the entire interventional team to
surgical skills centers.
39,40
Furthermore, current simulators require the learn how to work together. The anesthetist, radiographers, theater
presence of an expert mentor to ensure correct learning and to provide nurses, and angiography suite nurses can acquire both the technical and
immediate feedback on errors, since the current assessment parameters non-technical skills (team working, leadership, situation awareness,
need to be enhanced. decision-making, task management, and communication) that are
mandatory to be able to perform CAS. The interventional team can be
Proficiency-based Stepwise Curriculum Incorporating acquainted with rare complications and learn how to manage crisis
Virtual Reality Simulation situations in a simulated environment. These team training sessions can
While the focus of training in endovascular skills has been on the new take place in a simulated interventional suite, allowing feedback by
opportunities presented by simulators, it is obvious that the key is not the knowledgeable instructors.
43
simulator; rather, it is the curriculum that incorporates a simulator.
41
As simulator training alone is not sufficient for a physician to be certified The EVEREST members hope to be able to encourage the academic centers,
as competent to perform interventional care,
16
the overall approach to different professional societies, and medical device companies who already
training endovascular skills should be graded and provided within a provide structured training programs to work together and develop a
stepwise structured proficiency-based training curriculum rather than standardized approach to endovascular training, including the simulation
over an unpredictable and often short training period. Aggarwal et al. training described above.
The Future of Virtual Reality Simulation
Interventional specialties may become early users of VR simulation for
To avoid the isolation of acquisition of
board examination. They can use simulation to transform an oral
examination from a verbal description of how a procedure is performed to
technical endovascular skills from
actual observation of how a candidate performs a procedure.
16
Physicians
cognitive and clinical skills, simulation
and interventional teams working in low-volume centers can refresh and
maintain old skills using VR simulation. They can learn a new procedure
training needs to be integrated into an
that was invented after the physician’s post-graduate training or familiarize
appropriate curriculum.
themselves with new devices. Furthermore, the endovascular therapist and
the interventional team can be exposed to complex and life-threatening
events and learn how to manage crisis situations in a simulated
environment without exposing patients to risk. Physicians can not only
have developed a framework for this type of systematic training and ‘warm up’ on a simulator before beginning interventions, but VR
assessment of technical skills (STATS).
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The curriculum needs to consist simulation now allows endovascular therapists to practice complex
of teaching the cognitive component, including error identification, endovascular procedures before performing them in vivo using the
followed by a test before allowing a subject to start simulator-based PROcedure Rehearsal Studio™ (Angio Mentor) or Mission Rehearsal (VIST).
training of psychomotor skills. The procedure needs to be deconstructed The endovascular therapist and his or her team can plan the approach,
into tasks and steps; key tasks need to be identified and used to enhance choose the endovascular tools, and address potential complications before
the assessment parameters of the current VR simulators. Subsequently, a procedure. Furthermore, these types of rehearsals might influence
trainees can learn these endovascular skills in a safe environment on decision-making in the treatment of symptomatic carotid artery lesions.
standardized models, which can then transfer to improved performance
in the real environment. Studies in the US and Europe (EVEREST) are currently investigating the
feasibility of the PROcedure Rehearsal Studio for CAS and the
Evidence-based training curricula, which define which simulated implications from an economic point of view. VR simulation provides an
endovascular tasks, how often, and in which order they should be opportunity for training and assessment of endovascular skills prior to
performed, are currently under development and need to be validated prior real life experiences. To avoid the isolation of acquisition of technical
to widespread use in endovascular training programs. These will allow endovascular skills from cognitive and clinical skills, simulation training
trainees to benefit from a flexible training curriculum including VR needs to be integrated into an appropriate curriculum. Simulation-based
simulation that is tailored to their pace, learning comprehension, and training is unlikely to replace real-life experience, although it may
schedule. They will have the opportunity to practice interventional skills become an adjunct to teaching and maintaining basic and advanced
and procedures in order to meet objective standards of proficiency prior to endovascular skills, with the hope of shortening and flattening the
performing high-risk procedures such as CAS in real patients. learning curve our patients are subjected to. ■
44 US CARDIOLOGY
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