From telepresence to virtual and augmented reality, medical simulation design (MedSIM) is capturing the attention of architects, owners, physicians, educators and medical students. What is the role of the AV designer in the process? What trends and technologies can stakeholders expect in the future?

To explore these important questions, it is useful to review medical simulation principles. According to Peter Weinstock MD, Ph.D. and Christopher Roussin Ph.D., medical simulation can be divided into four increasingly realistic “zones.” Zone 1 offers auto-feedback exercises and is typically for solitary learners. This often includes virtual simulation such as hands-on instruction of clinical skills, and it is part task training. Zone 2 includes acute situational instruction, such as clinical mock codes and may use actors or students. It requires minimal technology involvement. Zone 3 involves authentic, native teams and it facilitates team and system interaction development. It may include manikins but only on a basic level. Zone 4 usually involves high-fidelity environments, manikins, teamwork, and capture for an in-depth debrief.

AV is most critical in the last zone, Zone 4, or roughly 20 to 30 percent of medical simulation settings. Trends also suggest increasing interest in Zones 3 and 4, offering the best opportunities for third-party observation and objective reviews. Zones 3 and 4 are also conducive to richer debrief processes.

Past and Present Techniques

Historically, the practice of using animals in medical education was limited, offering incorrect anatomical subjects for optimal learning. Cadavers presented inaccurate physiology. Learning on patients presented ethical challenges and risks to patient safety. Students learning on each other as well as actors can be both painful and embarrassing, not to mention ethically questionable. In addition, using actors is a costly practice, monetarily and in the time required to train actors to portray symptoms.

Using manikins can eliminate many time and ethical challenges. Low-fidelity manikins are relatively inexpensive but not very lifelike. High-fidelity models can be expensive but mimic some tissue properties as well as exhibit some patient physiological responses. This level of figure begins to approach the real patient experience.

New computer-based and digital technologies offer diverse opportunities to simulate, but realism varies greatly. Virtual Reality (VR) is highly immersive and accommodates a limited number of users. Augmented Reality (AR) can support team-based simulation and it requires a real space to support environmental immersion. Dedicated appliance-based simulation is successful but only with one or two procedures.

How AV Can Help MedSIM Proliferate

The current capture systems include cameras, AV inputs, and metadata capture. These configurations are mostly IP-based, ranging from expensive to very expensive. Annotation and review features let the observer annotate during and after the live capture. It also provides the ability for visual and auditory review of scenarios. These elements can lead to better visualization for both the observer and student after the procedure or event’s conclusion. The debrief includes visual and audio playback of a recording with active commentary and annotation. It also provides visual and audio confirmation of performance.

The goal behind high-fidelity medical simulation is to provide a realistic, immersive environment. How realistic does medical simulation need to be to qualify as effective? Should it provide just enough detail to immerse the student and suspend disbelief? Providing “perfect” realism can be cost-prohibitive and difficult to construct. Real medical equipment can also be expensive. AV can act as a substitute for appropriate medical devices providing “real enough” experiences, enhancing the suspension of disbelief at more reasonable cost.

Medical treatment is a team effort, and Open Surgery Simulators include Team-Based Surgery. The real advantage to current manikin-based simulation it allows for interdisciplinary sessions to provide full team practice, engagement, and investigation. The common framework is interoperability.

Future Trends: AV Technology and SIM Design

Telepresence: Current AV telepresence helps bridge the distance barrier providing a cohesive environment for seamless, real-time communication. Telemedicine, a development of telepresence, eliminates the distance barrier between doctors and patients. MedSIM projects are beginning to require a telemedicine component to prepare students for real-world use. Traditional videoconference rooms are being supplanted by remotely controlled “bots” that can make the rounds locally for a doctor in another location. This practice lets medical professionals “be there” without being physically present.

Capture/Review Platform Integration: Currently, MedSIM implements AV technologies only a third of the time or less, and most simulations do not occur in a dedicated space. This is changing, however, as technologies such as capture and review systems decrease in price. AV-enabled simulation is transformative in that it supports more effective learning, retention, and research. Designing AV-equipped spaces that can simulate real medical devices and systems have been shown to immerse students more realistically. More realistic tools, paired with proper pedagogy, can help to improve learning outcomes and prepare medical students for career success.

Display Technology (Including Goggles and Glasses): Display technologies are more common in real-world medical stages, therefore, they also should also be present in MedSIM installations. Large, ultra-high-definition displays in operating rooms let team members observe the surgeon in greater detail for more engaged participation. Teams can also aggregate disparate device readouts into one unified dashboard. Augmented Reality glasses can integrate heads-up displays of those dashboards so participants can stay focused on the subject. This type of integration will be making inroads to the MedSIM installation in the near future. These glasses are also superimposing scans, such as an MRI, to accurately address the procedure site. AR glasses can provide similar superimpositions over manikins for simulated patient specific Gross Anatomy and/or procedure simulation.

Another key trend is Virtual Reality-based remote, robotic control during procedures. A doctor can be in another area or facility while local staff is stationed in the treatment room. As VR simulates complete environments, this requires proper practice to ensure that medical providers are fully comfortable communicating and operating the equipment during procedures.
Looking Ahead: Notable MedSIM Technology Trends on the Horizon

Visual Feedback: Adding capture and substituting medical devices with AV can make visual feedback more prolific in the simulation situations. This can add value and make learning more rigorous than basic simulation.

Realistic VR/AR: Virtual Reality and Augmented Reality technologies are diverse; they have varying space, equipment, and infrastructure support requirements. VR can be as simple as a computer screen with a virtual environment or as sophisticated as fully immersive goggles. The space required can range from a basic desktop to a small room with strategically placed sensors to track and create the environment. A setup of this ilk would increase the realism of the experience. Similarly, AR can utilize a tabletop or intricately outfitted room with appropriate props. The infrastructure required varies, from a power outlet and network connection to a room with sensors requiring structure and pathways. Add to that list the high-bandwidth wireless needed to increase mobility. In larger installations, control rooms may be necessary to monitor, support, capture, and intervene.

Suspension of Disbelief: Realism is the crux of simulation; designers need to make an environment feel as real as possible. How can designers help to offer detailed, realistic experiences while staying on budget? AV technology is helping solve this problem, making it progressively easier to deliver better images and sound at the same or lower prices.

Surgical Effects: AV and computer technologies are making surgical effects more realistic, easier, and tidier. The current process uses surgical “cut suits” and real instruments. As we evolve toward VR, the mess will be virtual and the instruments will be simulated with tactile feedback, making it feel more real.

Tissue Models (Part Task): This will likely remain, however, virtual reality can mimic tissue models. VR can potentially alleviate storage needs for physical models. VR also offers the versatility to leverage one station and simulate multiple tasks.

Instrument Simulation: There are two types of instrument simulations including Tactile and Haptic feedback. Many trainers use Haptic feedback but these are task specific. Future trends suggest increased usage of micro haptic exoskeletons coupled with VR to simulate muscle feedback for improved realism.

Hardware: Manikins are becoming startlingly realistic, able to simulate many physiological conditions like pupil dilation, real pulse sites, and even perspiration. Robotics allows for a surgeon to work in a micro field and or/to be remote from the actual patient, making complex procedures more accessible. Simulation will need to incorporate these techniques to help train and prepare local surgical teams dealing with micro or remote procedures, and not just providing the doctor a way to practice. Look for increased interest in Visual Clinical Sim (OSCE style), Virtual Manikin Sim, AR Sonography, Gross Anatomy, and more.

Just-in-Time / AR Procedure Training: In a recent episode of the TV series The Good Doctor, the main character practiced a procedure with AR technology and a companion doctor, using real patient data and renderings, just before performing the procedure on the real patient. While portrayed on a fictional program, this is a real scenario that is being considered in many facilities. It can work with a high-fidelity manikin or the team can use it to walk through a procedure before performing it in real-time.

Team-based Simulation: Medical treatment is a team effort.  High-fidelity simulation with capture in a substantially realistic setting allows teams to collaborate and address possible issue that an individual cannot solve alone.

Simulated Hospital Floor: Often in nursing schools, and increasingly in more interdisciplinary settings, simulating hospital floors–from patient rooms to nurse stations, pharmacies to emergency rooms–is becoming more common.  Working through complex issues such as simulated patient transport and code blue scenarios, students benefit from the nuanced realism and varied task training.  This “complete experience” contributes to richer skills preparation and learning retention, resulting in improved patient outcomes.

As technologies advance and become less cost-prohibitive, AV technologies make medical simulation a goal within reach.  Smart integrated AV designs will be required to bring these dreams to reality.