Cognitive Simulation Engines

One of the oldest cognitive "simulators" is the surgical atlas. Frank Hinman Sr.'s Atlas of Urological Surgery has been an invaluable source and reference for physicians in practice as well as urology trainees to prepare them cognitively for the cases they were to encounter. The use of videotapes, though a less accessible media, added another level of presence. Both of these training tools are effective but passive in nature.

Computer-based simulators created to train the cognitive aspects of procedural training arguably provide "virtual reality," though they are less immersive in nature than those that also provide technical skills training. Considering that it has been argued that 85% of performing a surgical procedure involves the cognitive domain, cognitive simulators have probably been unrightfully de-emphasized and underutilized in surgical curriculum. A couple of examples with a potential role in urologic curriculum have been provided. Advanced cardiac life support is required of every new surgical intern. One of the first computer-based medical simulators was designed by Dr. Howard Schwid, an anesthesiologist in Seattle, Washington. The anesthesia simulator recorder to train management of critical events combined a graphic display of the operating room with mouse-driven input and uses an integrated set of physiological and pharmacological models to predict patient responses. It has undergone multi-institutional content, concurrent, construct and predictive validity for management of emergency situations in a population of anesthesiology trainees. Such a program has not been tested in residents of other specialties, but could be examined for its utility in surgical curriculum (40-48). Sweet et al. recently designed SimPraxis , a software engine that provides interactive cognitive simulation and rehearsal of complex open surgical procedures. It has a DVD format and runs on a standard laptop and combines the simple format of an atlas with video as well as mentored instruction and provides objective feedback to the user. The prototype pelvic lymph node trainer begins with the indications, technical tips, and potential complications of the surgery from an expert author. It challenges the user to choose the actor (surgeon or assistant) and the appropriate instrument and then to apply the instrument in the correct position for each of the defined tasks of the operation. When performed correctly, the simulator plays the video clip of the subtask with commentary. Incorrect cognitive decisions are followed by instruction on the proper technique and the user is then allowed to try again. A "practice" mode provides mentorship in the form of hints from a "virtual" expert in the field. A "testing" mode is web-enabled and designed to monitor and log the user's selections including any requests for assistance. The software logs the frequency and types of errors. This record is then available for submission to residency directors, CME administrators, and/or later review by the user. Face and content validity have been established and construct, concurrent and predictive validity studies are underway (49).

The simplicity of such an approach circumvents some of the financial/technical roadblocks that virtual reality technical skills trainers have encountered.

When designed and studied in coordination with their technical skills trainer counterparts, cognitive trainers may actually be able to determine not only if an error has occurred but also dissect whether it was an error in cognition, psychomotor skills, or visual spatial orientation.

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