Virtual reality simulators

Cosman et al raised some interesting points in their article regarding surgical simulation as a means of acquiring skills. There are, however, two areas that they do not address that really get to the heart of the matter. The first is that most of the surgical mistakes I see relate to over confidence, when a surgeon does a procedure that he or she is not skilled at doing, and worsens the situation. This is essentially a failure of judgement rather than technique, and would be helped more by work on preoperative planning than on surgical skills. This is precisely what is seen in young drivers, where the principal cause of accidents is failure of judgment (e.g. inappropriate speed for the prevailing conditions, rather than a failure of underlying technique: not knowing how to change down and use engine braking). Motor safety authorities throughout Australia are advocating more experience in the real world as a solution to this (e.g. driving in heavy traffic in the rain while on a learner’s permit) rather than suggesting further computer simulation work. Similarly, although the present generation of P-platers has grown up with driving simulators in arcades and home computer games, there has been no reduction in young driver fatalities to infer any benefit from this simulation. The other issue is that a flight simulator is predominantly an interaction between human and machine. The external environment is usually constant (e.g. it is either day or night, dry or raining). These multi-million dollar machines can be used to train and recertify pilots, usually at a cost of millions of dollars per pilot, but they only train the pilot to fly a single type of plane. A Qantas 747 captain can not simply leap into the cockpit of a 767, despite the fact that the interface is almost identical. If our simulators were to be run along the lines of commercial pilots, a surgeon would be qualified only for a single type of operation, and the cost of maintaining accreditation in that procedure would exceed most surgeons’ gross income, unless the training facility was funded from some other source. A jumbo load of passengers flying to Los Angeles from Sydney pay over $300 000 for the pilot’s skill in getting them there safely, however, few patients would be willing to pay that for a 14 h life saving operation. Even with the best simulator training, highly variable real world scenarios (e.g. wind shear and vortices) still cause crashes. In surgery, there is essentially a human to human interface, rather than a simple human to machine interface. This is much more highly variable, as a wound can be bleeding on one side and dry on the other, which never happens with tropical thunderstorms on a jet. The best way of assessing whether simulation would be beneficial, would be to compare the benefits of other forms of simulators that attempt to replicate the human to human interface. In that respect, those computer activities that simulate martial arts, or sex, would be more relevant than flight simulators. Because of the much larger numbers of people involved in such activities, it would be relatively easy to attain statistically significant results. When there is incontrovertible evidence that fighting games make you better at martial arts, and that cyber sex improves your skills in the real thing, then there will be a more compelling case for surgical simulators. Until then, the best solution would be to look at the cost per pilot of Qantas’ program of flight simulation, and then assess how far that would go to funding a top quality animal facility, together with an advertising program designed to increase cadaver donation. At a workshop last year at the Mayo clinic, 40 wrists were available for participants to dissect. I asked the convenor, how they got such a wealth of anatomical specimens, and was told that it was a result of their policy of encouraging cadaver donation.