Professor John Windsor chose to specialize in pancreatic surgery because he saw this vital and difficult-to-reach organ as “the last frontier of general surgery, with huge challenges and still much to learn.” This gives you an idea of Windsor’s curiosity and drive — two qualities that led him to found SIMTICS.
SIMTICS is an innovative e-learning company that uses online simulation technology to train students in medical procedures. Windsor, who is Professor of Surgery at the University of Auckland, New Zealand, knew that you can’t teach practical procedures in a classroom and in the hospital. With the random presentation of patients it is not possible to plan systematic training. What is more, patients are less happy to be trained on. A new approach was needed and Windsor set out, with his colleagues, to develop a new way to train large numbers, even in remote areas, through low cost, high tech web-based simulation.
Windsor was inspired by the success of flight simulation for effectively training people in the high-risk aviation industry. In a similar way SIMTICS is using web technology to train for performing complex procedures while reducing risks to patients. Students can learn at their own pace from anywhere and are no longer as reliant on the availability of suitable patients and teachers.
Windsor joined me for an enlightening Q&A on his perspectives on education and innovation; how e-learning is revolutionizing medical training; and his motivations, concepts and experiences behind SIMTICS.
What has influenced your approach to medical procedure training?
An important influence was homeschooling our five children until they were teenagers which taught my wife and I a lot about learning. We learned about differential readiness and different learning styles. We learned about how periods, classes, assigned topics, and homework and didactics are barriers to learning. A child who is learning will keep running with something they are interested in. They’ll be more spontaneous because they enjoy their learning. To force a kid to take a step they’re not ready for will turn them off. In homeschooling the learning is self-paced. That allows a child to stay on task and keep mining that opportunity for as long as they like. The success of homeschooling, which was a radical departure from traditional education, gave me courage to try something new with teaching in medical school.
Another important input for me was being involved from the very beginning of the laparoscopic revolution. This 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 new skills for the new technique. My return to New Zealand in 1991 meant that I had the opportunity to develop and build a skills training and simulation center–the first in Australasia. But ultimately this too influenced me because of the increasing cost of providing skills and procedural training by short courses and refresher courses. Without huge subsidies it is difficult to provide a sustainable training program through dedicated skills centers with expensive hardware-based virtual reality simulators and there is the problem of ‘tutor fatigue.’ Taking people out of the work force for training also reduces service output.
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 often drove courses, how courses needed to be repeated to address knowledge decay, how courses take people out of the work place and how expensive they are. I also learnt through my international travel and teaching about education faddism. Every self-respecting institution wanted their own multi-million dollar skills laboratory even before there was evidence for the reliability, validity and cost-benefits of simulation training. We still do not know if patients do better (the final and most important outcome variable) because of the new ways we teach.
How does the e-learning model fit with medical education?
Our education and frameworks are still last century. The learning space, the learning journey is more complex than it used to be. With the Internet, we should be designing things that are simpler and much more efficient. I don’t think we’ve been radical enough in thinking how learning might be.
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 theory and practice, which are often overshadowed by educational technology. Further, the use of the web as a platform for the delivery of education in healthcare is in its infancy. As such e-learning has tended to be an add-on to existing frameworks and pedagogy, and has not been used to re-invent the learning paradigm.
The biggest challenge of e-learning is getting past the limited mindset and current approach (limited to words and images) to incorporate interaction, simulation, decision-making, assessment and feedback. These are all possible. We should be supporting more personalized learning off-campus, so that teacher face-time can focus on higher-value activities, and in particular identify specific training needs through e-learning. That has been one of our goals at SIMTICS.
What motivated you to change the medical education delivery model?
The frustration of learning how to do clinical procedures and operations was apparent from the beginning of my training. Learning is reliant on the random admission of cases. It might be months before one saw a second similar case to practice what she had learnt the first time around. Not ideal for reinforcing learning. Further it is difficult to integrate all the inputs, which come at different times from past experience, experts, books, videos, conferences. To bring all learning media together on one learning platform was our goal.
So we started brainstorming about how procedural skills might be learnt in a cost-effective, individualized, durable, and accessible way that integrates and extends existing curricula and takes advantage of the internet and the cloud. The need drove a vision.
How did these experiences all add up to the formation of SIMTICS?
There were three of us at the beginning: a frustrated South African surgeon who was compelled to re-sit his surgical exams in New Zealand, a pediatrician who was a computer and IT expert, and there was me as surgical educator. It was the surgeon who suggested that it would be nice to bring all the learning materials together in one place to facilitate learning. It was the pediatrician who convinced us it could be done in an integrated and educationally sound way. So we sketched out, on a napkin, the computer interface that brought the core media elements together.
The surgeon missed his exam, the pediatrician retired and I was left standing, but not before we made some real progress with the concept. We did enough to win a national award and were offered a two-year residency in the IceHouse business incubator. This gave us the opportunity to build a business around the idea.
Why is cognitive simulation the cornerstone of SIMTICS technology?
Cognitive simulation is a point of difference for us, as it emphasizes that much of procedural learning is a mental process. And that much learning can take place before actually doing the procedure. There is an excellent study which demonstrates that mental rehearsal is just as effective as repeated practical courses for maintaining procedural skills, which emphasizes the importance of the cognitive element of procedural learning.
The SIMTICS integrated cognitive simulator allows the student to read the steps of the procedure and understand the basis for it, to watch an expert perform it, to interact with the anatomy relevant to the procedure, and then to do the procedure, with visual clues. The latter guided learning can be turned off and the procedure repeated as an assessment. This can all take place before the procedure is done in a patient. The procedure might be putting in a urinary catheter or a chest drain, performing a lumbar puncture or suturing a wound. And the learning experience can ensure that the right thing is done at the right time and in the right way to ensure a safe and efficient outcome for the patient. The learner gains confidence with competence.
The simulation component is special because of its simplicity. Rather than breaking the bank with a fully interactive state of the art gaming technology, we realized that this is not required for learning. When a complex procedure is deconstructed and the steps taught in sequence, it is possible to capture these sequences. The can be used as ‘pre-rendered’ sequences which play out when the right decision is made, or not if the decision making is wrong.
SIMTICS was the result of identifying an urgent need and creating an innovative solution. What does it take to become an innovative thinker? Is it within everyone’s grasp?
Innovation starts with an idea, and is usually fueled by a need. Being aware of needs and being skeptical about common solutions is important. The reality is that truly original ideas are rare, like the splitting of the atom to release nuclear energy. Most innovations come from new applications of existing ideas, a sort of cross pollination. An example of this is the innovation of putting a light weight power generator in a soccer ball so that kids playing football in the dusty village square can provide electricity for lighting or the water pump for the family. The power generator technology is not new, but the application is innovative. I think we have done this at SIMTICS by bringing together ideas in education and technology and applying this within a new e-learning paradigm of cognitive simulation.
Images: John Windsor, SIMTICS