Professor John Windsor is co-founder of SIMTICS, an interactive learning company that provides web based simulations for allied health and medical procedures. He holds a personal Chair in Surgery at the University of Auckland and is a Consultant Surgeon at Auckland City Hospital. ILH asked him about simulation-based cognitive learning and what inspired him to launch SIMTICS.
What do you love most about teaching medical students?
(My teaching extends regularly to nurses, paramedics, surgical trainees and qualified surgeons, etc. in addition to medical students.)
What do you see as missing from medical education and training today? What gets in the way of students learning?
There is great rigidity in the educational frameworks and delivery mechanisms. We are moving into the age of personalized medicine, and I think this needs to be matched with personalized learning. There are some extremely exciting developments in education, which are often overshadowed by educational technology.
The internet has not been properly exploited as a platform for the delivery of education in healthcare. E-learning has just been an add-on to existing frameworks and pedagogy, and has not been used to re-invent the learning paradigm. We are excited about the cloud, about interactivity, about artificial intelligence, about open source, about virtual worlds etc. We are just at the beginning of an extraordinary revolution in learning.
What provided the inspiration to develop the SIMTICS technology?
I was involved at the very beginning of the laparoscopic surgery revolution, teaching the first course in the United Kingdom. This new technique was a game changer. For the first time we had digital images of entire procedures – but we also had a whole surgical workforce deficient in essential skills for the new approach. My return to New Zealand in 1991 gave me the opportunity to develop and build a state of the art skills training and simulation center, the first in Australasia. So I have a lot of experience in the development, delivery and assessment of short courses to teach clinical skills and procedures. I learnt about how technology easily drove courses, and how courses needed to be repeated because people forget what they learned (look up Hermann Ebbinghaus’s work), and how courses have negative effects such as taking people out of the work place.
And also how expensive they are to run. The math does not work. That delivery model is not scalable.
I also learnt, through my international travel and teaching, about ‘education faddism’. Every self-respecting institution wanted their own skills laboratory even before we could demonstrate their reliability, validity and cost-benefits.
Describe the problem you were trying to solve with SIMTICS. How did you research this?
The frustration of learning how to do clinical procedures and surgical operations was apparent from the beginning of my training.
Apprenticeship learning is reliant on the random admission of patient cases. It might be months before one saw a second similar case, for instance. Not ideal for reinforcing learning. Traditional training exposes you to many ways to do things, and while this might be considered a strength, it is also a weakness when there happens to be a proven and preferred approach. Learning is also random in terms of preceptorship. You might go for 6 months without getting quality personal attention. There was no prior testing. There was no formal briefing/debriefing. Then the limitation of working hours for medical professionals started to impact education, especially in Europe and Australasia. It significantly reduced the opportunities for learning on the job.
The laparoscopic revolution and the establishment of skills centers (as above) was also a problem. There was the cost of dedicated buildings, staff, equipment, and maintenance. There was the opportunity cost of taking people out of the workplace for courses with the result in reduced service delivery (read: income). There was also the problem of tutor fatigue. We clearly needed another way of teaching procedures. We needed something that was lower cost, consistent, repeatable, and available anywhere.
What influenced the design of the SIMTICS technology?
The first step for us was to develop a conceptual framework.
It was based on a musical analogy, but provides a robust way of thinking about training and technology. And it is a direct counter to the expensive physical simulators which to be honest are still trying to find their market.
In music, notes are combined together to create a melody, and multiple musicians can play that tune in harmony. In the same way, complex medical procedures can be deconstructed into their component steps and skills, many of which can be taught cheaply on bench tops with readily available and cheap models and task trainers. These individual steps are like learning how to play individual musical notes. Procedures require understanding how the skills and steps are put together – in the same way as individual notes are put together to create a melody. Procedures can be taught by cognitive simulation –which obviously needs to be reinforced with clinical practice in an apprenticeship or supervised model (as we have). Learning how to work in a team is the third dimension – like multiple musicians playing in harmony – and there are exciting opportunities for this in simulation environments and virtual worlds.
The approach we developed with the SIMTICS integrated cognitive simulator was tested in a randomized controlled trial on learning how to do a laparoscopic appendectomy. This showed significant benefit, but it also showed the importance of timeliness – that we need to offer learning opportunities at the optimal time in the learning continuum of our students.
Simulation is not a new paradigm for learning and gaming. Why is simulation exciting in the medical training field? Why flight simulation as the model?
Simulation allows repetitive learning in a safe environment where there are no consequences from error. Flight simulation is an excellent model because it has been established in the high-risk aviation industry and is readily understood as a key contributor to achieving and maintaining an outstanding safety record. It is safer to fly than to go to hospital. We have some catch-up to do in health care.
You say your research showed that the majority of the knowledge that someone needs to perform a procedure is cognitive. What does that mean in an education context?
Athletes and musicians know all about skills development. There is no substitute for deliberate and guided repetitive learning and practice. However simulation-based learning means that the cost of the learning is not borne by those in the grandstand, in the audience and in our case, the patients.
The more learning that can take place prior to patient contact, the safer it is for the patient. Most of the learning that is required about how to do a clinical procedure is mental – understanding the reasons for doing something (indications and contra-indications), understanding the precautions (ensuring safety), understanding the order of the steps of the procedure (optimal sequence for reliable outcome), understanding the possible variations that can occur and how to respond to them (preparedness), understanding how to assess outcome (for continuing improvement).
Cognitive simulation is a point of difference, as it emphasizes that much of procedural learning is a mental process, and that much of the learning can therefore take place before doing the procedure. The term “psychomotor” actually means the origination of movement in conscious mental activity. So we are not just talking about the physical performance of a mechanical task, because to perform this psycho-motor task we need to train both elements, cognitive and physical. This is relevant to both gaining and maintaining procedural skills.
Is the cognition element of SIMTICS products your secret sauce, the differentiator in the marketplace? Please explain.
Yes, it is a point of emphasis and difference, which opens a new way of delivering learning. It is integrated, because simulation is combined and synchronized with the other elements of learning: reading, hearing and seeing. And this integration is ideally with an entire curriculum.
The simulator allows the student to make right and wrong answers, to repeat, to experience different scenarios, and to be assessed. This interaction is vital to learning.
What are the risks of learning a medical procedure online, without interaction with the instructor and other classmates?
SIMTICS does not certify competence, which means there are no risks since it does not replace supervised learning.
The advantage is that it accelerates learning such that a student becomes aware of deficiencies that can be targeted in courses or hands-on learning opportunities. And when students have done pre-learning online, it also means that lab sessions can be more in-depth, and at a higher level, focused on application of the cognitive learning.
What are the biggest challenges of e-learning?
Getting past the limited mindset and expression of e-learning that is prevalent today (words and images), to incorporate interaction, simulation, decision-making, assessment, etc.