Conclusions regarding the value of AIPES

The overall aim of a simulated learning environment is to provide a rich source of information that effectively supports the learner through the adaptive features and allows users to engage with material more effectively. This is achieved through careful simulation (complex multidimensional hypermedia) authoring while maintaining a constant awareness of users’ needs. The main strategies for developing an effective simulation were to:

 Provide simulation adapted to the specific surgical task.

 Design a simple practical system that provides for upgrading as technologies and databases improve.

 Increase maintainability of the application through the distributed architecture.

 Increase the usability and accessibility of information through simple human computer interface adoption.

Using the AIPES system comprehensive evaluation of the features was initiated to scrutinize the effectiveness of the simulation to achieve its goals. This evaluation process will give some insight as to what simulation-based learning in surgery actually benefits the trainees. Continuous review of future users and evaluation of their perception of the value of the various qualities of the surgical simulations will be supported by the client server architecture using a DRJ. This allows users to express their perspective managing the user administration issues for contributing to future trials.

The results of the usability trials of an integrated web-based surgical training tool represent a start upon a road leading to closure of the audit loop, where surgical

simulators are assessed accurately with respect to whether they actually will deliver the educational goals for which they are intended. These have been subdivided to reflect the main areas of the trials, which consider the simulation and the environment in which it is situated. The ‘pre-study’ provided feedback for the design of the final study and its proposed methods for data collection. It emphasized the need for greater integration of end-users into the design process. It was therefore necessary to focus upon testing a web-based simulation package in light of the results of the pre-study detailing the testing of the educational infrastructurei.e.:

 Assessment methodology

 Internal structure and content

 Multimedia Educational Orthopaedic Module

All of this is based around an interactive course and the assessment methodology employed which considers the conduct assessment of trainee performance. The results demonstrate the iterative design and development process has benefited from users’ participation in the development process. By setting and attaining quantitative usability goals during the design process of EVW prototype 3, it was possible to engineer usability into products that may be derived from this research project as part of a rollout plan for technology implementation. The ease of testing using VOEU DRJ technologies recommends the system implicitly.

Testing versions with users early and continuously supports design iterations. By identifying users who are able to develop the system, running trials and analysing tasks, it is possible to set usability specifications for the developing prototypes of the simulation system. By testing prototypes a Usability Test Report is generated, which can be managed by the DRJ. It will therefore be possible in future developments to see if there have been significant improvements in design by comparing datasets. More importantly from the user’s perspective, it will be possible to distil the questionnaires to only use the questions that are truly discriminatory and so minimise the effort required for feedback and thus decrease the incidence of user fatigue with the analysis method. The difficult part is selecting and organising tasks to test, creating task scenarios that are realistic. The Zeltzer cube analysis partly demonstrates the future path of development based upon results so far, but as a system for analysis of integrated simulation it remains limited, and the proposed revision of this AIPES scoring for the EVW Prototype 3 has demonstrated a workable alternative.

Preparing other material for the test, as the AIPES scoring system demands, also depends upon preparing the test environment. It is necessary to study task analysis and quantitative usability goals so that timely issues based upon the earlier tests of this system answer the questions that remained. From the pilot study it was clear that a usability engineering approach and an iterative design approach was needed. This was borne out in the main studies. By developing user profiles, it is possible to select and organise tasks to test and create task scenarios (cases) that are suitable to the training grade of the trainee. The question is now how to progress from ‘results’ to ‘use’.

The initial results argue the way forward, considering the process of integration into the conventional pre-digital surgical educational world, and the implications for surgery and surgeons. The move from embedded systems to integrated systems requires consideration as it has implications for surgical education. The key is how to ensure that the quality improves as a result of the implementation. Proof the simulation actually improves training would require cohorts of surgeons to potentially be subjected to inferior training and therefore it is developed as an adjunct to conventional training. Its benefit can however be demonstrated.

4.16.1 Metaphysics of VR for surgical simulation

As part of the introduction of VR to readers, it is necessary to define the boundaries, the potential limitations upon simulation, and the aims of simulation. This includes the potential limitations of the human ability to perceive the performance parameters by which they operate. The human performance aspects are detailed in Chapter 3. First it is necessary to discover what the user wants to perceive.

The traditional definition of virtual reality implies that the operator should be induced to perceive a risk of consequence associated with failure to achieve an acceptable standard of performance, where in fact no actual risk exists. The particular training environment in which the trainee is learning and demonstrating their skills can to some extent generate this. For example should the trainee be using such a simulator as part of the regular professionally supervised training schedule, then the validity of their performance would necessitate their attempting to achieve the best possible results. Anything less would be playing a game. Due to modelling limitations, scenarios will remain simpler than the clinical world exposes users to. There is no reason to believe that this poses an ultimate limitation, especially if networked systems are employed.

Ultimately one would hope that such simulations become the types of machines that pass an analogue of the Turing test. By this I mean that it is possible to interact in such a way with the virtual environment that the end user would be unable to distinguish between the virtual environment and the real one.

Environment: It may be important to consider other aspects of the simulation, such as a similar physical environment to the operating theatre. A draped mannequin is used to provide the shape of the shoulder, in order to produce some semblance of a physical simulation of the operating environment. The physical environment in which the simulation is conducted may contribute significantly to the scenario generated in certain situations, but exploring this is beyond the scope of this thesis, which focuses upon the approach to the visual display component of the simulation. Such principles were originally described in the early 1960s, the most notable example of which would be the "Sensorama simulator" (102).

Since the human mind is adept at "filling in the blanks", making up for the shortfalls in certain areas of the simulation, this attribute has been used to good effect by concentrating upon such interactivity as the ability to exercise control over the apparent direction of the vehicle (e.g. a motorcycle). By various means, the operator can have enough "studio/artificial reality markers" to be able to maintain the willing suspense of disbelief.

Clearly in an operating environment there are certain reality markers which people use, such as types of clothing to demarcate who is able to perform sterile tasks and thus able to work within the operating field, or (something which is not yet possible to take into account) the recognition of other people within the surgical team.

This last matter is something which is often overlooked but which in any real operating environment is a significant factor in the smooth running of a procedure, with regard to both safety and the satisfaction of all those who participate. Although this is not fundamental within the actual simulator itself, it has to be emphasised within the tutorial part of a training package in an attempt to achieve a degree of compromise.

Where the operator obtains a view of the operating environment indirectly via a monitor, the environment is already immersed. This is one area where terminology becomes a little hazy since the definition of immersion defines the relationship between experience and representation, in effect eliminating the syntax-semantics barrier.

Therefore such a system for shoulder arthroscopy need only be "semi- immersive" since the operator is in effect already immersed within the appropriate operating environment. There are of course other areas that need to be considered in this interface and these are detailed in the equipment section below.