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Agnes Ryzynski in the Simulation Centre with Dr. Daniel Kagedan.

Tim Fraser

Simulated medical procedures are a key component of teaching the next generation of health-care professionals

Practice makes perfect. And countless physicians, nurses and other health-care providers are receiving the repeated practice they need to excel in patient care, thanks to the Sunnybrook Canadian Simulation Centre.

Education is in the DNA of Sunnybrook Health Sciences Centre. The Simulation Centre, which opened in 1995, helped more than 1,250 health-care professionals hone their craft last year alone.

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Dr. Shady Ashamalla, a surgical oncologist at Sunnybrook, says the Simulation Centre is a good way to teach scenarios that are either too rare to practice repeatedly – such as a trauma team's treatment of victims of a multiple shooting – or "very reproducible," meaning something that doctors do over and over again in a similar way. One example of a reproducible procedure is laparoscopic abdominal surgery for removing cancer of the rectum, colon, spleen, pancreas, and liver. Laparoscopic surgery is often described as "minimally invasive" because it is done using tiny, keyhole incisions, and patients usually feel well enough to go home the same day.

Oncologist Dr. Shady Ashamalla teaches laparoscopic
surgery to colleagues of all levels of experience.
photo by Tim Fraser

Dr. Ashamalla teaches this very precise and relatively new surgical technique in the Simulation Centre. Surgical students, as well as practicing surgeons who had trained before this technique was commonplace, practice the procedure on realistic synthetic bowel tissue. They are videotaped and monitored from behind one-way mirrors, and receive feedback on things like the fluidity of their hand movements and whether they held the instruments at the correct angle. "Eventually learners move to the operating room, bringing individual skill sets, so they are starting with a much higher threshold," he says.

"There is good evidence this creates better technical surgeons. It's the 10,000-hour theory," he adds. "Time spent in simulation is designed to enhance the time in the OR, not replace it."

Simulation as a way of training medical personnel is definitely here to stay. In 2013, the University of Toronto became the first medical school to integrate simulation into its core curriculum. "Simulation is not terribly novel. What's novel is how we are implementing it into surgical training," says Dr. Ashamalla. "Implementation is embraced by the University of Toronto more than any other training program".

Besides surgical training, the simulation centre is used for orientation for nurses, code-blue training for senior medical residents, anesthesia learning, and sedation training for oral surgeons. The centre collaborates with others across Canada and around the world, so that education techniques are always evidence-based and ahead of the curve. "Every so often something comes along that can completely revolutionize health-care education and therefore care delivery. Simulation is exactly that opportunity," says Dr. Joshua Tepper, vice-president of education at Sunnybrook.

Simulation is all about "creating situations," says Agnes Ryzynski, the centre's coordinator. Situations can be low-tech or extremely high tech, from using synthetic tubing for suturing practice to deploying virtual reality to create life-like emergency scenarios.  There may also be hybrid combinations, such as during obstetrical training, when Ryzynski manipulates a baby simulator to create a difficult birth. Situations are made to seem as real as possible, even using simulated vomit, stool, and siren sounds. "It's like immersing in the real situation," she says. "It makes the learning stick that much more."

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One of the Simulation Centre's newer innovations, thanks to cardiac surgeon Dr. Fuad Moussa, is surgical training in a procedure called Off Pump Coronary Artery Bypass. Surgeons learn – in progressive stages – how to do surgery on a beating heart. In the first session, they stitch vessels together using two pieces of tubing on a board. Next, the tubes are put in a heart model, which requires surgeons to articulate their hands differently. Then, the heart is placed in a simulated chest cavity, so now surgeons are doing the operation in an even tighter space. Then, a compressor is turned on so that the heart is beating. In the next stage, the procedure is performed in a virtual operating room. Finally, the full team is brought in, mimicking what a real artery-bypass surgery would be like.

"When a learner says, 'I had this happen and I didn't freeze. I felt calm and relaxed because I had practiced it six times in the Simulation Centre,' that is nice to hear," says Ryzynski. "Think of the pilot who landed on the Hudson River. He couldn't have been that calm if he hadn't simulated. They are able to perform at a higher level because it is already coded in their brain."

The Sunnybrook Canadian Simulation Centre is now embarking on an exciting multi-phase expansion plan. In order to grow its global impact in simulation research, the centre will develop new technologies, collaborate with other institutions and continue to assess and improve programs.

Specifically, there are plans for an Advanced Surgical Skills Simulation Program, which will contain six state-of-the-art, mobile laparoscopic stations and a central station that can project the instructor's laparoscopic trainer onto a large central screen. In addition, Sunnybrook is hoping to become a regional hub for simulation in cardiac surgery.

"The range of learning at the Simulation Centre is already incredible," says Dr. Tepper. "And the potential has only begun to be realized."

This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.

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