Approval of virtual reality training for carotid stenting: what this means for procedural-based medicine.

PERCUTANEOUS ENDOVASCULAR PROCEDURES CONFER benefits to patients similar to those seen with minimally invasive surgery, such as minimal invasion of the body cavity, reduced pain, shortened recovery time, and more rapid return to work. However, minimally invasive surgery and endovascular procedures also share similar problems. As with minimally invasive surgery, endovascular procedures require physicians to perform invasive procedures guided by 2-dimensional video images while using and manipulating tools with limited degrees of freedom. Endovascular procedures also require the operator to adapt to significantly decreased tactile sensation and overcome similar proprioceptive-visual conflict issues from manipulating long wires or instruments that can fulcrum against the body wall. These hurdles combine to create substantial challenges for physicians training to acquire these skills. The challenge of training physicians for performance of endovascular procedures has been brought to the forefront because of the rapidly expanding application of carotid stenting for treatment of carotid artery stenosis into the broader medical marketplace. Currently, few physicians are experienced in the carotid stenting technique. However, with the recent US Food and Drug Administration (FDA) approval of cartoid stents, many physicians from multiple specialties will want to learn the carotid stenting technique. Traditional training methods for new procedures include performing the procedure on animals, cadavers, or mechanical models or supervised performance of the procedure on patients. Inherent problems with these traditional training strategies include the ethical and anatomical problems of training on animals, risks posed with repeated exposure to radiation, and the expense of consuming real medical devices. However, the majority of procedural training in the United States still occurs on patients with direct mentoring by experienced physicians during an actual clinical procedure. This tradition of training on patients has raised concern among the profession and the public about how physicians will acquire sufficient skill to safely perform new, potentially high-risk, endovascular procedures such as carotid stenting. Because the carotid arteries are the primary blood vessels to the brain, if an embolus of thrombotic plaque dislodges and enters the brain during a carotid stent procedure, the patient could have a stroke or die on the operating table. As with other procedures, carotid stenting has a definite learning curve. However, unlike many other procedures, the risk conferred to the patient in this procedure from the physicians’ learning curve is unacceptably high. Traditionally, it was assumed that if a physician performed a procedure a certain number of times or trained for a period of time then that physician became proficient in the procedure. However, essentially no mechanism for measuring posttraining skill has been used. Both number of procedures and duration of training are, at best, crude surrogate measures of skill and fail to factor in the variability in individual rates of learning. This approach to training produces physicians with considerably variable skills that have been only subjectively assessed by those who trained them. This variation is particularly important with carotid stenting because this procedure crosses multiple clinical specialties with each bringing a different skill set to the training table. For example, a vascular surgeon has a thorough cognitive understanding of vascular anatomy and management of carotid disease but may lack some of the psychomotor technical skills of wire and catheter manipulation and may be unfamiliar with management of the fluoroscope. Conversely, an interventional cardiologist will have the technical skill with catheter-based