The Application Of Virtual Reality Endoscopic Simulator In Digestive Endoscopy Training

BackgroundDigestive Endoscopy is an important means for diagnosis of digestive diseases. With the progress of science and technology as well as the continuous improvement of endoscopy attachments, the digestive endoscopy is not only for the digestive system diagnosis, but also used in the treatment of some digestive system diseases, which has emerged as one of the essential skills in the department of gastroenterology. The development of endoscopy has gone through five stages:rigid endoscopy stage, semiflexion endoscopic stage, endoscopy stage, the electronic endoscopy stage, and more recently, capsule endoscopy stage. Hospitals are mainly in the electronic endoscope stage in China, and some of the third-grade hospitals have been carried out capsule endoscopy. In recent years, medical condition in China continues to improve that the third-grade hospitals were routinely carried out the electronic endoscope, and the majority of primary hospitals gradually carry out the project too.With the endoscopists increasing, the training of endoscopists becomes one of the focuses of clinical education in recent years. Previous training of digestive endoscopy always uses the approach of "one professor teaches one students by hand-to-hand method". The students exercise in patients as soon as studying the digestive system anatomy, digestive endoscopic operation principle, and theoretical knowledge, so the training approach has medical risks certainly. In addition, participants brought pain and discomfort to the patient because of the unskilled operation. As the medical situation changing, the possibility of learning procedures in patients reduced gradually. How will a doctor trained to be an endoscopists is a very challenging task. The education and training of digestive endoscopy in China still don’t get uniform standards or guidelines, and needs further exploration and summary.Virtual reality endoscopic simulator is new training equipment in the medical simulation education in recent years. By simulating the operating environment, it makes the study process of digestive endoscopy visualized, and the students can participate in, so that students can learn the digest endoscopic skills better. In order to verify the effectiveness of virtual reality endoscopic simulator for the digestive endoscopic training, scholars from various countries did a series of studies. In2004,Di Giulio E had shown that virtual reality endoscopic simulator helped novice physicians learning gastroscopy better. In2008, Shirai Y-and had shown that virtual reality endoscopic simulator could significantly improve the students’endoscopy skills in real patients. In2004, A. Eversbusch reported the virtual reality endoscopic simulator could improve the efficiency of colonoscopy study significantly. And in2005, G. Ahlberg also reported that students who using virtual reality endoscopic simulator operated in real patients with the shorter operation time and the patients felt less discomfort. In addition, there were different results. In2007, Robert E Sedlack regarded that simulator training could not be able to improve the work of gastroscope in real patients effectively. Roy Phitayakorn in2009reported that the ability of the evaluation standard of operator in virtual reality simulator was not so perfect, and the effectiveness of the evaluation system was questionable. Because the study period of virtual reality endoscopic simulator in digestive endoscopy is not so long, there are still many controversial and unresolved issues problems to be studied.Operating digestive endoscopy is a motor skill, and joining the sports psychology methods in the process of training may support the study. The imagery training is an important movement training methods of contemporary sport psychology, which is symbolic rehearsal of the action in mind without the actual muscle movement. With the development and perfection of the theory and practice, imagery training gradually began to be used in the high cognitive motor skills training, initially in sports training. In recent years, it began to be used in clinical skills teaching. In2004, Charles used the imagery training in the surgical suturing skills training, and found the rehearsal may be effective. Subsequently, Charles added the rehearsal to the training of surgical skills, found the students acquiring skills more effectively. Rachel Bramsonand had shown that the imagery training seems to be an effective training method to teach students learning lumbar puncture. However, using the imagery training in the training of digestive endoscopy process has not been reported.Our group carried out a series study of virtual reality endoscopic simulator in the endoscopic teaching practice early, and the results suggested that virtual reality simulators improved the operation of the students in actual patients, but there are still many issues to be resolved, such as:which mode could be better in the training with the simulator? Whether the psychological method improves simulator training effectiveness? Are the Degree of simulation, calibrated degree and the reliability of virtual reality endoscopic simulator good enough? How is the retention of skills after virtual reality simulator training?This research aims to optimize the simulator learning methods, evaluate the reliability of virtual reality endoscopic simulator, and study retention of skills after virtual reality simulator training.Objective1. In the process of virtual reality endoscopic simulator training, using three different training methods:the key anatomical segmented training, the whole training, and the combination of the whole training and the key anatomical segmented training. To investigate that the role of the different of virtual reality simulator training methods during the forming of the gastroscopy skills, and optimize the training mode.2. Using the imagery training in the gastroscopy training with virtual reality endoscopic simulator, in order to study the role of the imagery training which is a kind of psychological skills training methods in gastroscopy skill acquisition, and provides a theoretical basis for the establishment the gastroscopy teaching model combined with the psychological training.3. To evaluate the reliability of the simulator by comparing the score of physicians with difference colonoscopy operating experience in a virtual reality colonoscopy simulator.4. To investigate whether the colonoscopy novices retain the skills from the endoscopy simulator colonoscopy training so that to found a basis for course setting.Methods and materials1. By stratified sampling method to extract30male students from the First and Second Clinical Medical College of our university. The participants were divided into three groups randomly. After learning the gastroscopy basic knowledge, the group A accepted the key anatomical segmented training, group B accepted the whole training, and group C accepted the combination of the key anatomical segmented training and the whole training. After finishing the training, compared the total score, comfort degree score(overinsufflation score, patient pain index score), operating time score, safety score, accuracy score, to determine which kind of training mode is most effective between three groups.2. By stratified sampling method to extract30male students from the First and Second Clinical Medical College of our university. The participants were divided into three groups randomly. All participants received the psychological evaluation using State-Trait Anxiety Inventory (STAI) and Movement Imagery Questionnaire (MIQ). After learning the gastroscopy basic knowledge, group A accepted the combination of the conventional practice and the imagery training in simulator, group B exercises conventionally, and group C didn’t accept any practice. All participants operated in the case1of virtual reality endoscopic simulator, recorded score. All participants received the STAI Questionnaire test again and recorded the results. After finishing the training, the scores were compared between three groups to determine which kind of training mode was most effective. The STAI and MIQ score was compared between three groups and STAI score before and after training were also compared.3. Basing on operating experience of colonoscopy, divided endoscopists into three groups:the novice group (5<the number of colonoscopy operation cases<10), the physician group (50<the number of colonoscopy operation cases<100), the expert group (the number of colonoscopy operation cases>500). After learning the basics knowledge of virtual reality endoscopic simulator and watching the operation demonstration, each endoscopists operated the cases I1、I6of virtual reality endoscopic simulator. The total score, comfort degree score, operating time score, safety score, and accuracy score between three groups were compared.4.14trainees accepted virtual reality simulator colonoscopy training and performed a standardized virtual reality colonoscopy at the end of training (post training), and performed again after6months without practice (retention).The scores between two performances were compared.Results1. The basic data of three groups including the age, the performance of internal medicine and sports had no significant difference by balance test. The significant difference existed in the total score between three groups. The group C is better than the other two groups, but no significant differences existed between group B and group C. There were no significant differences between three groups in terms of safety and accuracy score. The significant difference existed in overinsufflation score, patient pain index score and operating time score. The group C is better than the other two groups.2. The basic data of three groups including the age, the performance of internal medicine and sports had no significant difference by balance test. There were no significant differences between three groups in terms of STAI and the MIQ score. Paired t-test results showed that there were no significant differences between STAI score before and after the training in each group. The significant difference existed in the total score between three groups. The group A is better than the other two groups, group B is better than group C. The significant difference existed in safety score, accuracy score, overinsufflation score, patient pain index score and operating time score between three groups. 3. Analyzing Operation score of case I1showed:The significant difference existed in total score between three groups, and group B as well as group C were significantly higher than group A, but there were no significant differences between group B and group C. There were no significant differences between three groups in terms of safety and accuracy score, but the significant difference existed in overinsufflation score, intestinal loop forming score and operating time score. Analyzing Operation score of case16showed:The significant difference existed in total score between three groups. The total score of group B and group C were significantly higher than group A, and group C was significantly higher than group B. No significant differences existed in terms of safety and accuracy score between three groups, but the significant difference existed in overinsufflation score, intestinal loop forming score and operating time score too.4. There were significant differences between the training end and the retention for six months. The significant differences existed in the overinsufflation and intestinal loop forming and speed score. The score at the training end was better than6months later without practice (retention).Conclusion1. The combination of whole training and anatomical segmented training was suitable for gastroscopy beginners training. Although there were no significant differences in safety and accuracy score between three groups, the significant difference existed in operating time and patient pain index score between three groups, and these indexes played an important role in improving the quality of digestive Endoscopy. The combination of the key anatomic training and the whole training should be recommended.2. Imagery training significantly improved the effect of virtual reality endoscopic simulator in training gastroscopy skills. The method was simple and feasible, easy to grasp by students, and provided a new idea for the training with the simulator.3. The simple case in simulator could differentiate novice from skilled physician only, but couldn’t distinguish between skilled physicians and specialists. In complex cases could differentiate novice, skilled physicians, and the experts. Therefore, the results suggest that reliability of simulator’s colonoscopy module was medium.4. Some skills about accuracy and safety acquired using the Endoscopy Simulator could be retained well The results of this trial clearly support the plan to integrate simulator training into colonoscopic education curricula.