The Simulation of Reality: The Reality of Simulation

It was 1988. I’d never used a laparoscope in my surgical or vascular training. I’d never placed a trocar into an abdomen, but what the heck - if a gynecologist could do it, why not me? To learn, I needed some simulation of reality before I could actually attempt this on a human. And after placing the trocars and scopes, I needed to safely remove a gallbladder through those tiny incisions. Easy in 2011, hard in 1988.

In 1988 the simulation was to use a live pig. Unless you’re a veterinarian, a farmer or another pig, the stakes are not that high if something goes wrong and the pig bleeds to death. This was the best form of simulation available at the time.

Today we have the reality of simulation. As the education of those specialties which are procedure-oriented has evolved, so have the tools of teaching. There are simulators that mimic reality, and in venous education, we are entering the “Age of the Reality of Simulation”. It is here and only getting better.

Most venous education courses – the AVF Fellows Course in Venous Disease, the AVF Attendings Course, the Venous Symposium, the ACP Sclerotherapy Course, the ACP Annual Meeting, etc. - have been using models developed by industry that allow for hands-on experience. These models are a good start - they give learners a sense of the steps necessary to use a device and the mechanics of a device.

But, as Dylan famously asked, “How does it feel, when you’re on your own, with no direction home, like a rolling stone?” What these models lack are realistic haptics.

Presently, there are a handful of educational options that do offer hands-on experience on real people with real venous problems. The ACP Phlebology Fellowship - which in the past was available at John Bergan’s institution and is now at New York University under the guidance of Lowell Kabnick - is a notable exception. The Venous Masters Practicum with course director Jose Almeida offers an excellent educational experience for practitioners who care for venous patients in the Dominican Republic.

And of course, in those vascular surgery and interventional radiology fellowships that have a “venous specialist”, the trainees get good hands-on experience. These are exceptions, and until the time comes that venous training is universally incorporated into the training of those I call the “Third Wave” – the up and coming residents and new physicians embracing phlebology - we will need to continue the evolution of venous education using more advanced technology such as simulator training. In fact, I believe simulator training will become part of every physicians training.

We Are Our Only Saviors

A number of companies have technologies that can give the vein specialist a real simulated experience (not an oxymoron). I have visited some of these companies and have tried out some of their programs - some venous, some arterial. The haptics are quite realistic - some better than others - but all take a step in the right educational direction.

I have asked other educational leaders to experience these technologies, as well. Our ultimate goal is to give guidance to these companies so that they can develop specific venous modules which can then be used in the various educational courses we now hold using the following proposed timeline:

  • Identify procedures that can be simulated: vena cava filter insertion and retrieval, pharmacomechanical thrombolysis, iliocaval angioplasty and stenting, endovenous ablation, etc.
  • Solicit venous societal and venous industry support for the development of these programs.
  • Convene a group of venous experts (MDs and industry) willing to advise and develop steps needed when creating a simulator module.
  • Teach the teachers how to best train students on simulators.
  • Devise metrics that can track performance and perhaps “credential” trainees – we need to prove that simulator training translates to better patient outcomes.

The above are exciting, attainable educational goals. Simulator training is needed in some form. For example, not every vein specialist who wants to develop catheter skills for iliac vein angioplasty/stenting can immediately find 5-10 patients to practice on. And candidates for pharmacomechanical thrombolysis don’t come along everyday.

The technology exists to create simulator training for these techniques. We need commitment from our educational leaders, industry leaders, and our venous societies. As with everything else that we have accomplished in venous education, the “Alliance of the Triumvirate” is key. As an example, The Fellows Course was started years ago with industry, which realized the global benefit of everyone working together. The addition of the AV F to the course recently completed the triumvirate.

No one should be doing this alone. If any of our educational leaders, practitioners and industry leaders are interested in being part of this next wave of venous education, please contact me at here or (201) 894-3252. We are approaching an educational opportunity that is new, different and fun. The simulation of reality is possible, and the reality of simulation is here. I look forward to the ride, and your support in making standardized simulator training a reality for venous education.