In the mid-1970s, Myron Krueger coined the term "artificial reality" to describe the ability to simulate synthetic realities with the aid of computers. In 1987, a computer scientist named Jaron Lanier coined the term "virtual reality." It was during this period that a visionary general surgeon, Richard Satava, recognized that the concepts described by Krueger and Lanier could be applied to medical training. Dr. Satava has since led a crusade to apply this technology to medical procedures through countless lectures and multidisciplinary conferences like "Medicine Meets Virtual Reality" and by funding projects in this area through the Department of Defense.

Excited by the potential for virtual reality training, pioneering academic surgeons began widely promoting virtual reality technology. However, the initial hype led to false expectations and the surgical community became highly critical of early surgery simulation.

At the time, virtual reality and medical simulation projects were limited by technological factors such as computing processing speed, graphical display hardware, data storage capacity, and data transmission bandwidth. Another significant problem was that computer scientists developed the initial surgery simulators without sufficient collaboration with surgeons. As a result, projects were often demonstrations of computer science and engineering principals that did not necessarily address the needs of the medical community. Applications demonstrated "proof of concept," but initially did not result in practical tools that could be used for medical education. As a result, the majority of the medical community considered surgical simulators impractical, expensive, unrealistic, and lacking of proper validation for use.

Successful simulation projects now involve not only collaborations between members of the medical and computer sciences but also the cognitive sciences.

Cognitive scientists remind us that it is paramount that a simulator provide effective training, not perfect realism (11,12).

Simulation fidelity should be matched with training requirements because high fidelity simulators are not necessary for all tasks. It is the embedded instructional features in a simulator that make training effective (13).

Repeatedly practicing something incorrectly without instructional feedback on the correct method will just reinforce bad behavior. It is also advantageous to embed carefully crafted scenarios with "triggers" that provide opportunities to practice and assess important behaviors. Such an example in urology would be to provide cues for the user to diagnose and manage a CO2 embolism management during a laparoscopic radical nephrectomy. Salas and Burke (13) have stated, "Simulators should not only capture performance outcomes, but must also capture the moment-to-moment actions and behaviors." Such detailed moment-to-moment information is necessary in order to provide feedback as to how to improve performance. Salas and Burke stress that the education experience should be guided toward learning key competencies and that there is a reciprocal partnership between subject matter experts and learning/training specialists (13).

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