Implications for the wider issue of simulation in surgery

The vocational training of anyone whose work involves clinically invasive procedures requires the best from that individual with regards to decision-making and psychomotor skills Thus the development and monitoring of these is vital. Ultimately simulator-based skills training will become integrated within the framework of clinical governance (thequality assuranceof clinical service delivery). The methodology of the

1st prototype simulationtask analysis for this trial was based upon the practical limits of what can be achieved with current available equipment, and also the expert analysis of tasks (61;139). The results of the1st prototype simulationtrials were inconclusive with a small number of trainees, as would be anticipated in a hypothesis-generating study with a small population. A larger number of trial candidates are required. This led to the Virtual University supported approach in the VOU3 trials.

The tutorial system needed refinement as well as the simulation system, and so parallel development of the different domains (library, virtual classroom, discussion groups and the dynamic review process) meant that by VOU3 the user population and the tutorials were supported by a fundamentally different infrastructure from the original Exeter Virtual University of Orthopaedics1 (EVOU) shoulder arthroscopy tutorial system developed forThe 1st prototype simulation.

6.13.1 Process of evaluation evolution

The pilot study results led to further Design Team Group Discussions. These were similar to Focus Group Discussions, but included involvement of the interdisciplinary design team of engineers and medical personnel. Design Team Group Discussions lead to further design modifications to both the methodologies for the software and theUser-based evaluation. This involved plans for the controlled testing

of the system while it is being used for specific tasks of the procedure. The

Questionnaires for collecting the user’s experience supplemented by interviews and other discussion methods were thus improved and updated as a consequence of the evaluation. Such a process for evolution of the Questionnaire A methodology (Chapter 8) usability group runs in parallel with the iterative design process for simulation products.

6.13.2 Review of the use of Java as an interface.

The primary purpose of the Java code was to provide a channel of communication between the two platforms of the tutorial and the simulation achieving integration (in the form of embedding), providing different parts of the system to the end-user. Use of this should not require skills beyond the basic information technology skills of an average surgeon. The level of this was confined to the user profile analysis in the 1st prototype simulation. The assertion that the interface can be built into the conventional User Interface (UI) is aimed to assist the uptake of the technology. The development of the user interface is likely to progress in two directions:

1. Improved communication between machines using the developing agent technologies (often referred to as software robots (autonomous software applications), which is yet to be implemented.

2. Increased complexity of the interface through improved functionality. This has been implemented in the VOU3 using XML It should, where possible, abide by standards being evolved for this domain by the international organisation Health Level Seven (www.HL7.org). This will ensure greater compatibility between the interfaces that are used for the control of surgical procedural trainers (simulators).

There were potential pitfalls using Java that precipitated the change of approach with respect to tutorial design and integration. The most significant of these are:

Security:Although the system is stable and likely to display good survivability characteristics (140), the open nature of the language and its potential application for providing communication portals between the machines can provide a vehicle for corrupting software (viruses) also. This application was designed only for operation between trusted machines.Remote Method Invocation (RMI) may help to overcome this problem using Java. Custom socket factories (software tools that assign the connecting sockets between computers) can allow a remote object to specify the protocol that RMI will use for remote calls to that object. RMI over a secure transport (such as SSL) can

be supported using custom socket factories. However the bigger picture calls for robust secure extranet services and so a platform was developed to meet this demand.

This in fact runs JavaScript over http using the

href="javascript:open_movie('shflick1_u.mov',360,288,280500)" command inside the secure extranet area – a command invoked from;

http://voeu.ecs.soton.ac.uk/voeu/library/doc.aspx?docid=13.

Speed of processing: the 1st prototype simulation pilot study user group highlighted this in subjective comments. There are certain applications for which the Java interface is not the most appropriate tool. For the development of complex simulations, C and C++ provide a fast and effective language for coding. Designers need to keep this fact in mind when considering multi-user environments where critical action sequences must be maintained in the simulated environment. Java has a role for the control process at present but not for the simulation engine itself. This was indicated by the pilot study assessment. By changing the VOU3 model that limits interactivity it is possible to greatly improve access, and by adopting video streaming technology it is possible to ensure that this runs upon lower specification platforms, as is likely to be found in most hospitals.