The director of McGill’s Steinberg Center for Simulation and Interactive Learning, Dr. Rajesh Aggarwal, tells us how augmented reality and simulation are dramatically changing the way medical professionals are trained and educated.
Rajesh Aggarwal is an Associate Professor of Surgery, a practicing microscopic surgeon and the director of McGill’s Faculty of Medicine simulation center. Originally from London, he was frustrated at the lack of practicing opportunities presented to him over the course of his medical training and surgery residency. His quest for a solution led him to work with Ara Darzi, completing his PHD in London before spending a few years practicing in the United States and finally moving to Montreal 3 years ago to join the team at McGill . He’s spent his career looking for innovative and effective ways to leverage simulation and augmented reality to improve and perfect health care training and practice.
Could you tell us a bit about your background and how you started developing an interest in simulation training?
While doing my medical training and surgery residency, I realized very quickly that there were not enough opportunities for me to train my technique in the operating room, in the wards and in the emergency rooms. When I did train, if I made a mistake, then obviously - because of the patient - my senior would take over. That meant I didn’t have a chance to see what my mistake was and more importantly my senior would take over and very rarely give me feedback.
There was also a lot of talk going on about reduction of work hours and shorter shifts for doctors, especially surgeons. So I was wondering how I was going to learn everything in time before I graduated from my residence. Obviously, when we learn how to be a sports star, or a dancer, or a musician – we do a lot of practice. But all my practice was happening in the hospital. I needed to be practicing outside of the hospital and not with real patients. That way, I could practice, make mistakes, have someone else watch me and have them tell me to do it again, and again, and again. Until I got perfect.
This is really when I found a professor of surgery in London who had a laboratory using virtual reality simulation to train in microscopic surgery. The next thing I knew, I was in London doing my PHD. We found in all of the studies we did that if you train on a simulator, you get better when you operate on patients. It sounds very simple and straightforward but really, no one had researched it before. I’ve now been here in Montreal for almost 3 years and my main job, besides being a surgeon, is to really run the simulation center in Canada – which is one of the best in the world in terms of how we train not only surgeons, but doctors, nurses, physiotherapists, nutrition staff and really anyone who is involved with the patient.
Could you tell us a bit more about all the benefits of the simulation training for current and future health professionals?
A bit of background on simulation: what we do is break it down into three golden rules. One is learning what we call procedural rules, so that means learning very basic techniques like blood pressure, heart tracings, how to put in an intravenous line all the way to how to do surgery and how to do resuscitation training. The second thing we do is to learn how to talk to a patient, so communication skills: how to really understand the patient’s problem, how to explain what we might think is the potential treatment. Here we mostly work with what we call standardised patients, so human actors who are very highly trained to really take on the role of the patient and further scenarios in order for our students and residents to really be able to engage with these patients when they’re in role. That can mean having difficult conversations with these patients about when to stop care, or how to tell patients that they have their diagnosis. And the third part is what we call team training, which is learning the very important skill of how to work with a team of different doctors, nurses and the patient itself. For example, I was operating today and working with four different nurses, two anesthesiologists, two other anesthesia nurses and then two other trainee surgeons. With about twenty people in the room, important to make sure that we communicate with each other and understand what each of us can do, so if there’s a complication, we know whether we can manage it or whether we need to call someone else.
I think that the really important thing, whether we’re doing the communication skills, the team skills or the procedural skills, is to make it as close to reality as possible and we don’t just leave people on their own. We have people watching them and after they’re done whatever we’ve asked them to do, we sit down and do what we call a debrief - we go through what they did, we give them feedback, we tell them how things could have gone better, we tell them what things they did really well and then next time they do it, they get even better. What we’re finding is that people don’t know their own mistakes and so they’ll make them again. If you don’t tell them that, then the simulation is not that useful.
There’s a lot of research data that shows that the impact of training in a simulation centers leads to better outcomes for patients in terms of clinical outcomes - it leads to better surgeries, better care for patients, better feedback from patients, and better team. Data that’s been published that shows, for example, that if you train in team training, it reduces the risk of patients dying. If you train in communication, patients will say that they felt that they had a better interaction with the doctor or nurse. If you think about it, every person that’s coming into the simulation center will see thousands of people in the next month or year. So by training the residents or medical students, we’re having an impact on hundreds of thousands of patients every year.
What do you think are the challenges you’ll be facing over the next few years?
I think one of the big challenges is that we actually need our medical students and residents to work, so they end up spending about 90% of their time in hospital providing actual services as opposed to practicing. We need our residents to be able to do the work as independent practitioners in the future, but a lot of the time, the education kind of gets left behind. There’s a great study done on nursing students in the US where they create three groups - one group has a traditional nursing education, another group has 50% simulation and 50% standard, and the other has 75% standard education and 25% simulation. When they look at outcomes in terms of whether they all pass their exams and finish nursing school, there was no difference. So you can actually have simulation be 50% of the training and they do just as well; they don’t need to be in the hospital or lectures that much.
I think we also need to understand the economic aspects of simulation. We need to realize it’s not only quicker, but also cheaper. And from there, we need to look at return on investment and think about expanding the role of simulation so it not only becomes something you’d do regularly once a month, but that it comes to include screen-based simulation like serious gaming and virtual reality with a head-up displays. You can do it quite cheaply, you don’t even need to build a simulation center, it doesn’t all have to be physical simulation, it can be very interactive game-based simulation.
For more information about the Steinberg Center for Simulation and Interactive Learning, click here: http://www.mcgill.ca/medsimcentre/