IRQ Articles

Feature: Bridging the gaps 

06-10-2020 11:08

The role of simulation in interventional radiology training nRSQvaUhRsidBzdkyI3v_Twitter_Bird2.png

By Andrew Kesselman, MD, and Ronald Winokur, MD, FSIR  Summer 2020


A major challenge at many academic teaching hospitals is providing a balance of trainee hands-on experience and education while maintaining patient safety and confidence in their providers. In addition to procedural education challenges, the evolution of new interventional procedures or techniques requires a learning curve for experienced practitioners to gain skill and confidence. A similar challenge exists in low- to middle-income countries where a lack of skilled practitioners and resources can limit the widespread availability of interventional radiology services.

Incorporating simulation into education can bridge the gaps in trainee procedural training, reduce the learning curve for new procedures and allow access to hands-on training in areas of the world where it is otherwise difficult to gain technical skills. Many of these challenges have been highlighted during the recent COVID-19 pandemic, which may open the door to broader inclusion of simulation in IR training programs.

Benefits of simulation-augmented education and training

Simulated education first became popular as a part of flight training and has since been utilized in both procedure-based and surgical training for skill acquisition in laparoscopic surgery, colonoscopy, bronchoscopy, endovascular aortic repair (EVAR) and ultrasound-guided needle placement. The effect of simulation in these procedural areas includes decreased procedure time, increased accuracy, decreased errors in laparoscopic surgery, decreased reliance on senior physician assistance, improved ability to identity endoscopic landmarks, improved technical skill acquisition in ultrasound guidance, decreased procedure time in EVAR and fewer endoleaks.

Simulation-based training reinforces real-world experiences with mock experiences that can lead to improved technical performance through repetition, identification of skills and behavior, and objective feedback that may not be available in the clinical environment. Educational programming can be modified to teach specific skills or to perform entire procedures for assessment of knowledge and proficiency. Additionally, the simulator can provide guidance on procedural steps, anatomy and catheter selection to help junior trainees overcome the initial barriers required for performance in live patient procedures. In order to advance the apprenticeship model of medicine, research demonstrating the added value of simulation to bolster the safety, efficacy and uniformity of IR education is needed.

We can divide simulation as it applies to IR into low-fidelity and high-fidelity modalities. Low-fidelity simulators often consist of simplified perishable units, lack realistic or situational context, and often differ in general appearance than what would be used in real-world clinical settings. Some examples of low-cost materials used in these low-fidelity models include food products and ultrasound gel molds. Low-fidelity simulators can be useful single-task trainers predominantly for ultrasound-guided vascular access, ultrasound-guided nephrostomy access, ultrasound-guided biopsy, catheter exchange, and even inferior vena cava filter placement and retrieval.

Photos provided by Ronald Winokur, MD, FSIR

High-fidelity simulation models use haptics to create a realistic and sophisticated model for endovascular procedures with high acceptance by trainees at all levels of training. High-fidelity simulators can provide realistic visualization, tool interaction and tactile feedback while simulating multiple pathologies or case scenarios. High-fidelity simulator use is becoming more widespread as a training tool by medical device companies and among teaching institutions.

Enhancing education in resource-limited areas

Access to interventional services is highly variable in low- to middle-income countries and efforts to increase access and awareness are underway through organizations like RAD-AID International. A relative lack of consumables and expertise can make the practice of IR in these underserved regions of the world very challenging. Creating and supporting IR training programs in these country sites within teaching institutions offers one strategy for sustainability. With appropriate supervision, broad skill sets, managed expectations and well-delineated goals, domestic IR teams can help initiate and support interventional services overseas.

Simulation offers a novel option for training both domestically and overseas. Low-fidelity simulators are useful for international outreach, given their low cost and increased accessibility. High-fidelity endovascular simulators may play an increasing role in resource-limited areas as this technology is becoming more accessible worldwide. Benefits to the use of this technology in overseas work include exposure to low-volume or absent procedures in clinical practice, absence of exposure to radiation, and no increased need for new disposables—which can be very costly in these regions. Partnerships between aid organizations and simulation technology manufacturers can provide access to machines (e.g., a portable endovascular simulator) that allow for overseas deployment with use in IR curricula, workshops and symposia.

Learning during COVID-19

During the COVID-19 pandemic, due to shortages of personal protective equipment (PPE) and deferral of elective procedures, maintaining conventional trainee education has been challenging. Trainees may be limited to participating in interventional procedures only during emergent cases in order to lessen their exposure and conserve PPE.

Given the restrictions strongly affecting IR trainee education during this time period, compromises to IR trainee education can be mitigated using novel educational tools such as low-fidelity and high-fidelity simulation. High-fidelity endovascular simulation can help build and maintain endovascular skillsets such as microcatheterization and embolization techniques, especially for procedures such as uterine artery embolization or prostate artery embolization. Self-guided and proctored simulations sessions can supplement periods of trainee inactivity.

Groups performing simulation should be kept under five individuals with mandatory gloving, donning of face masks and cleaning protocols for both the participants and equipment to comply with Centers for Disease Control and Prevention (CDC) recommendations. Lessons learned during the COVID-19 pandemic and the successes with applying simulation may foster increased utilization and innovation for implementation in the future. 

Future applications

Future avenues to explore in interventional simulation include learning management systems and immersive experiences. Learning management systems allow for access to analytical data and reporting metrics to identify training and learning gaps. Integration of these systems into endovascular simulator use would benefit trainees by creating a more comprehensive experience, allow training program directors access to performance time and metrics, and create clear goals for competence. Leveraging this simulation technology by bringing it directly into the IR suite will allow for an even more realistic experience and may translate to better outcomes. Finally, incorporating artificial intelligence and augmented reality modules may offer more options for improving adaptability of current simulation platforms and change the way we view our IR suite. These exciting developments are underway and may be available in the near future.

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