Oct. 02, 2020
Mayo Clinic routinely uses sophisticated neurological simulations to enhance medical training and patient care. These simulations, covering not just basic procedures but also complex emergency care, incorporate the latest technology, including virtual reality.
"One of the Mayo brothers once said, 'There is no excuse today to learn on the patient.' That principle guides our simulation centers," says William D. Freeman, M.D., a neurologist at Mayo Clinic in Jacksonville, Florida. "Simulations allow trainees — residents, fellows or even medical students — to practice before they ever touch a patient."
Mayo Clinic was among the first centers in the United States to develop neurological simulations, which are less common than simulations in other medical specialties. All three Mayo campuses have multidisciplinary simulation centers that engage in neurological activities. Each facility can duplicate multiple settings, including emergency and operating rooms, an intensive care unit, and inpatient and outpatient care rooms.
"People often think of a simulation center as just a place to get CPR training. It's really much more than that," says Matthew T. Hoerth, M.D., a neurologist at Mayo Clinic in Phoenix/Scottsdale, Arizona, and co-chair of the simulation center there. "Our simulations are geared to accurate and detailed reproductions of real health care experiences."
Mayo's simulations utilize life-size high-fidelity patient manikins, trained medical actors and scenarios written by neurologists. Virtual reality headsets allow learners to interact with a "patient" controlled by a computer operator. This technology facilitates critical care simulations that go beyond the basics.
"Since neurologists operate in a primarily nonprocedural specialty, our simulations emphasize patient evaluation, recognition of a problem and initial management," says Sherri A. Braksick, M.D., a neurologist at Mayo Clinic in Rochester, Minnesota. "We develop scenarios to ensure that our trainees are exposed to uncommon but necessary situations, such as a brain death evaluation. That's a core competency in neurology residency education, but outside of simulation, it's difficult to ensure that all trainees will be exposed to this examination, let alone perform it during residency."
Our learners are changing
At Mayo Clinic, some postgraduate year 1 interns practice neurology simulations in May, before starting their residencies in neurology. "Our neurology residents have jumped through a big hoop before they actually see their first patients," Dr. Freeman says.
These experiential activities go beyond pedagogy to provide a higher level of learning appropriate for today. "Our learners are changing," Dr. Hoerth says. "Everyone walks around now with a computer in their pocket. Trainees are very attuned to retrieving information in their own time. Applying that knowledge in the safe environment of the simulation center deepens their understanding and helps them to better retain the information."
Simulation of neurological disease is difficult, as neurological signs can be challenging for actors to portray and manikins typically aren't designed to depict neurological findings. The subspecialty of neurocritical care poses particular challenges, as critical care trainees may have limited exposure to neurological disease. In a study published in the February 2017 issue of Neurocritical Care, Mayo Clinic researchers found that a neurological simulation course administered to critical care fellowship trainees improved the trainees' skill and confidence.
Under Mayo's critical care integrated medical practice, neurological simulations are delivered to pulmonary and anesthesia critical care fellows. "The simulation setting is the only way to guarantee that a consultant can directly observe trainee reactions and responses before the trainee sees similar patients, as residents are often the first neurologist to arrive at a patient's bedside," Dr. Braksick says. In a review published in the August 2018 issue of Seminars in Neurology, Mayo Clinic critical care neurologists outlined the opportunities for learning that simulations provide.
On the holodeck
Simulations have limitations. "It can be challenging for the manikins and actors to get it right," Dr. Hoerth says. "We can change the way the manikin appears to breathe or the heart rate. But it's nearly impossible to have a manikin simulate a stroke."
Virtual reality scenarios — a sort of holodeck for trainee physicians — can overcome those limitations. Mayo Clinic already has the capability to perform virtual reality scenarios in which the learner wears a headset and a moderator on a separate computer controls the virtual patient's responses. Now Mayo is working to develop simulations in which the learner interacts directly with the virtual patient, with haptic feedback allowing the trainee to "touch" the patient.
"The idea is that you would go into a virtual reality augmented environment and plug into a scenario. You'd be in that scenario, interacting freely with the virtual environment," Dr. Hoerth says. "We're not there yet. But we're working to line up partnerships that would allow us to incorporate artificial intelligence and voice recognition into these scenario technologies."
Mayo Clinic envisions a future in which a specific learning objective is matched to the simulation modality that can best achieve it. "All simulation modalities have some type of limitation," Dr. Hoerth says. "At least initially, virtual reality won't give us a tactile response. The ability to physically move the patient might work better with live actors who have been trained to simulate tone. But having multiple modalities will allow us to give our learners a very rich experience."
Simulations can also potentially provide data to further improve training and patient care. "We might graph what a learning curve actually looks like, and use that information to improve an individual neurologist's skills," Dr. Freeman says. "Simulation is a great vehicle for change."
For more information
Braksick SA, et al. Neurology education for critical care fellows using high-fidelity simulation. Neurocritical Care. 2017;26:96.
Wijdicks EFM, et al. A future for simulation in acute neurology. Seminars in Neurology. 2018;38:465.