User Centered Design

Background
Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation.

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The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

This review paper discusses the role of haptics within virtual medical training applications, particularly, where it can be used to aid a practitioner to learn and practice a task. The review summarizes aspects to be considered in the deployment of haptics technologies in medical training. First, both force/torque and tactile feedback hardware solutions that are currently produced commercially and in academia are reviewed, followed by the available haptics-related software and then an in-depth analysis of medical training simulations that include haptic feedback. The review is summarized with scrutiny of emerging technologies and discusses future directions in the field.

The Role of Haptics in Medical Training Simulators: A Survey of the State of the Art

Objectives Despite the broad range of continuing medical education (CME) offerings aimed at educating practicing physicians through the provision of up-to-date clinical information, physicians commonly overuse, under-use, and misuse therapeutic and diagnostic interventions. It has been suggested that the ineffective nature of CME either accounts for the discrepancy between evidence and practice or at a minimum contributes to this gap. Understanding what CME tools and techniques are most effective in disseminating and retaining medical knowledge is critical to improving CME and thus diminishing the gap between evidence and practice. The purpose of this review was to comprehensively and systematically synthesize evidence regarding the effectiveness of CME and differing instructional designs in terms of knowledge, attitudes, skills, practice behavior, and clinical practice outcomes. Review methods We formulated specific questions with input from external experts and representatives of the Agency for Healthcare Research and Quality (AHRQ) and the American College of Chest Physicians (ACCP) which nominated this topic. We systematically searched the literature using specific eligibility criteria, hand searching of selected journals, and electronic databases including: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Abstracts of Reviews of Effects (DARE), PsycINFO, and the Educational Resource Information Center (ERIC). Two independent reviewers conducted title scans, abstract reviews, and then full article reviews to identify eligible articles. Each eligible article underwent double review for data abstraction and assessment of study quality. Results Of the 68,000 citations identified by literature searching, 136 articles and 9 systematic reviews ultimately met our eligibility criteria. The overall quality of the literature was low and consequently firm conclusions were not possible. Despite this, the literature overall supported the concept that CME was effective, at least to some degree, in achieving and maintaining the objectives studied, including knowledge (22 of 28 studies), attitudes (22 of 26), skills (12 of 15), practice behavior (61 of 105), and clinical practice outcomes (14 of 33). Common themes included that live media was more effective than print, multimedia was more effective than single media interventions, and multiple exposures were more effective than a single exposure. The number of articles that addressed internal and/or external characteristics of CME activities was too small and the studies too heterogeneous to determine if any of these are crucial for CME success. Evidence was limited on the reliability and validity of the tools that have been used to assess CME effectiveness. Based on previous reviews, the evidence indicates that simulation methods in medical education are effective in the dissemination of psychomotor and procedural skills. Conclusions Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors and clinical outcomes. More research is needed to determine with any degree of certainty which types of media, techniques, and exposure volumes as well as what internal and external audience characteristics are associated with improvements in outcomes.

Effectiveness of continuing medical education.

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Bringing user experience to healthcare improvement: the concepts, methods and practices of experience-based design.

Previous investigation of a cost-effective virtual reality arthroscopic training system, the Sheffield Knee Arthroscopy Training System (SKATS), indicated the desirability of including haptic feedback. A formal task analysis confirmed the importance of knee positioning as a core skill for trainees learning to navigate the knee arthroscopically. The system cost and existing limb interface, which permits knee positioning, would be compromised by the addition of commercial active haptic devices available currently. The validation results obtained when passive haptic feedback (resistance provided by physical structures) is provided indicate that SKATS has construct, predictive and face validity for navigation and triangulation training. When tested using SKATS, experienced surgeons (n = 11) performed significantly faster, located significantly more pathologies, and showed significantly shorter arthroscope path lengths than a less experienced surgeon cohort (n = 12). After SKATS training sessions, novices (n = 3) showed significant improvements in: task completion time, shorter arthroscope path lengths, shorter probe path lengths, and fewer arthroscope tip contacts. Main improvements occurred after the first two practice sessions, indicating rapid familiarization and a training effect. Feedback from questionnaires completed by orthopaedic surgeons indicates that the system has face validity for its remit of basic arthroscopic training.

Passive haptics in a knee arthroscopy simulator: is it valid for core skills training?

Previous investigation of a cost-effective virtual reality arthroscopic training system, the Sheffield Knee Arthroscopy Training System (SKATS), indicated the desirability of including haptic feedback. A formal task analysis con firmed the importance of knee positioning as a core skill for trainees learning to navigate the knee arthroscopically. The system cost and existing limb interface, which permits knee positioning, would be compromised by the addition of commercial active haptic devices available currently. The validation results obtained when passive haptic feedback (resistance provided by physical structures) is provided indicate that SKATS has construct, predictive and face va lidity for navigation and triangulation training. When tested using SKATS, experienced surgeons (n = 11) performed significantly faster, located significantly more pathologies, and showed significantly shorter arthroscope path lengths than a less experienced surgeon cohort (n = 12). After SKATS training sessions, novices (n = 3) showed significant improvements in: task completion time, shorter arthroscope path lengths, shorter probe path lengths, and fewer arthroscope tip contacts. Main improvements occurred after the first two practice sessions, indicating rapid familiarization and a training effect. Feedback from questionnaires completed by orthopaedic surgeons indicates that the system has face validity for its remit of basic arthroscopic training.

Passive haptics in a knee arthroscopy simulator : Is it valid for core skills training? : Virtual reality symposium

In order to develop effective virtual reality training systems for surgery there is a need to provide appropriate sensory and performance feedback to the user. This paper aims to demonstrate a method by which performance data can be collected. This is used to investigate the effect of haptic feedback on performance. A PHANTOM desktop device was used in conjunction with a suturing simulation A pair of needle-holders was instrumented with strain gauges and attached to the stylus of the PHANTOM allowing the measurement of force application and time. Suturing performance was evaluated in terms of stitch completion time, peak force application, and the length and straightness of the stitch. The effect of the level of force feedback provided by the simulation and performance over time was considered. The results indicate that the presence of force feedback affected task completion time, peak force application and the straightness of the stitch. Task completion time was shown to increase with the level of force feedback provided. Performance was seen to improve over time in terms of task completion time and the accuracy ofthe stitch. The work has examined how the presence and level of force feedback affects performance of a simple task. The accuracy of haptic feedback is important in the design of surgical simulation systems to ensure effective training transfer. A data collection method by which objective performance evaluation can be made is demonstrated. The method can be applied to training using bench models, simulations and potentially in the operating theatre.

Objective surgical performance evaluation based on haptic feedback.

Telemedicine in Middle Eastern countries: Progress, barriers, and policy recommendations.

The Sheffield knee arthroscopy training system (SKATS) was originally a visual-based virtual environment without haptic feedback, but has been further developed as a mixed reality-training environment through the use of tactile augmentation (or passive haptics). The design of the new system is outlined and then tested. In the first experiment described, the effect of tactile augmentation on performance is considered by comparing novice performance using the original and mixed reality system. In the second experiment the mixed reality system is assessed in terms of construct validity by comparing the performance of users with differing levels of surgical expertise. The results are discussed in terms of the validity of a mixed reality environment for training knee arthroscopy.

Louise Moody

Papers

Passive haptics in a knee arthroscopy simulator: is it valid for core skills training?

Passive haptics in a knee arthroscopy simulator : Is it valid for core skills training? : Virtual reality symposium

Objective surgical performance evaluation based on haptic feedback.

Telemedicine in Middle Eastern countries: Progress, barriers, and policy recommendations.

The feasibility of a mixed reality surgical training environment