Chapter 8: Simulation in Cardiac Surgery

INTRODUCTION

Of the many developments in cardiothoracic surgery, the introduction of a broad spectrum of simulation techniques for education and training of students and residents as well as ongoing faculty training are among the most exciting and critical for the continued advancement of the specialty. There are increasing demands for safety during training, for training to be more effective and efficient, and have minimal impact on the process of patient care. The productivity of training for physicians has advanced in many ways; simulation is one approach to teaching that offers solutions to challenges in training in general and especially in cardiac surgery. In this chapter, we describe a spectrum of simulation technologies and techniques that are being applied to address these challenges. We also address approaches to using simulation to its greatest effect and speculate about future technologies and applications and how they will be integrated into education at all levels of experience.

BACKGROUND

Simulation has been described as a “technique, not a technology, to replace or guide real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.”¹ The roots of simulation in medicine can be traced back for centuries. More recent applications in the 1960s and 1970s for training in specific tasks include the Sim One for teaching in anesthesia residency, Resusci Anne for training in cardiac life support, and Harvey for teaching about cardiology to medical students.² The more modern era of simulation began in earnest in the late 1980s with the development of more realistic mannequins for teaching basic skills and management of crises in anesthesia. Surgeons have long used various forms of simulation, from tying knots on paperclips placed in clay to cadavers and animals. The first use of a model simulator was introduced by Howard in 1868 in which a mannequin was created to teach hernia repair.³ But, more technology-based forms of task trainers for various surgical and procedural skills appeared beginning in the late 1980s.²

For many reasons, the use of simulation is growing in all of healthcare, and specifically in cardiac surgery. Ziv and colleagues described the adoption of simulation in surgical training as an ethical imperative noting patient safety as their cause.⁴ With patients having increased acuity, practicing outside of the operating room is critical for mastering tasks to quickly develop critical skills without exposing patients to increased risk. Practice via simulation has been shown to increase speed for completion of coronary anastomosis⁵ as well as increase speed and accuracy of mitral valve annuloplasty.⁶ Through deliberate practice (rehearsing a task or behavior repeatedly), simulation provides the ability to advance the mastery of some skills more quickly, reducing operating time related to training. Simulation is also the preferred modality to improve teamwork and communication and to practice emergencies not frequently seen during training. It enables surgeons and ...