UKSH in Germany enhanced neuroradiology training with Mentice simulators to address the shortage of INRs and meet rising patient demand.
The University Hospital Schleswig-Holstein (UKSH) is one of Europe’s largest medical care centers, with the Department of Neuroradiology at Campus Lübeck providing neuroradiology services to outpatient clinics, clinics and institutes of the University Medical Center Schleswig-Holstein, as well as to numerous external referring clinics conducting both diagnostic and therapeutic neuroradiological examinations and interventions.
As an accredited training center of the German Society for Neuroradiology and the German Society for Interventional Radiology, the Department offers a wide range of diagnostic and therapeutic neuroradiological services. This includes interventions on supra-aortic and spinal vessels, such as stroke therapies, treatment of vascular stenoses, and embolization for intracranial aneurysms, intracranial and spinal vascular malformations, tumors, and fistula.
Like many such institutions, the Department of Neuroradiology at UKSH has invested in a simulation-based solution as part of its training of new INRs. In the case of UKSH, the hospital chose a Mentice simulator, acquiring the system about three years ago. And like other hospitals, the reasons for investing in simulation training hinge ultimately on one basic fact: a shortage of trained INRs to meet rising demand.
“It’s really that simple,” says Professor Peter Schramm, Chair of UKSH’s Department of Neuroradiology. “On one hand, we have ageing populations, with increasing numbers of patients presenting with conditions that can be addressed by interventional radiology. But on the other hand, we have fewer live-training opportunities. Further, the number of purely diagnostic invasive catheter angiographies has been decreasing for years due to the continuous improvement of CT- and MR-based angiographies. As far as I can see, simulation is the only way to remove this training bottleneck.”
When applying for a grant to invest in simulation-based training, Schramm based his application on three key points. The first dealt with the fact that highly realistic simulation training attracts highly motivated students. As it turned out, this argument proved to be the decisive reason for the grant’s approval. The second argument had to do with the implementation of sustainable innovation technology supporting shorter training times enabled by simulation. This comes partly from the fact that trainees can get directly to the core of the advanced aspects of intervention without dealing with preparing patients, tables, liquids, etc. – in a day, they can do and face many different patients and challenges. No alternative has nearly as quick a turn-around as the virtual simulation. The third argument had to do with risk reduction. As Schramm explains: “Highly realistic simulation training obviously reduces risk for patients. But it also reduces risk for novice INRs. Beginning INRs naturally take longer to perform procedures, thus increasing their and their teams’ exposure. Simulation training in a radiation-free environment brings new INRs up to speed safely.”
Acquiring simulation-based training, however, was not a quick fix for Schramm’s training bottleneck. The necessity of having a proctor present at all simulation training sessions limited the utilization of the simulator. “We,” says Schramm, “simply lacked the manpower to assign a proctor to each session.” This presented Schramm and his team with a classic ‘catch-22’ situation: the need to use simulation training to produce more INRs, while not having enough manpower to fully utilize the simulator.
Fortunately, Mentice made available its Neurovascular Essentials (NVE) procedural training module. Put simply, NVE is a software module that enables independent training. Its cloud-based curriculum guides trainees through initial anatomical steps, device selection and critical maneuvers—in effect offering virtual proctoring. The addition of NVE has had a positive impact on Schramm’s training plans. “I’m now able to introduce trainees to the interventional part of neuroradiology much earlier than previously. Before NVE, a trainee had to be accompanied at the simulator by a proctor. But now, fellows can train independently on the simulator—they are guided step-by-step by NVE’s detailed curriculum.”
However, the adoption of NVE has done more than facilitate independent learning. According to Schramm, NVE brings with it extremely realistic simulation. “Take the way the catheters and wires behave,” says Schramm. “In NVE, it is very realistic. And the software has improved drastically over the past few years. I mean, compare today’s simulation capabilities with the first simulators, which essentially were limited to carotid stenting only.”
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Some might argue that although NVE enables independent training, it cannot provide truly fine-grained haptic and tactile feedback. But Schramm insists that such feedback is not a mandatory condition—at least not above a certain base level of competency. He illustrates his point by highlighting the fact that insisting on haptic feedback would rule out robots performing neuro interventions. “And clearly,” he adds, “this is not the case. The endovascular robotics for neurovascular procedures, for example, lack haptic feedback, yet that does not rule it out.”
Moreover, Schramm adds, once a trainee has acquired the basics, it is vision that is the INR’s most valuable guide.
“At the beginning of one’s training, it is necessary to combine what one sees with what one feels. Images alone are inadequate. But with experience, one learns to see if there has been too much pressure or tension on the catheter tip or if excessive friction has moved a vessel. And this is where the NVE module is valuable—because it makes it possible to see very subtle movements and stress situations on the monitor. For me, this level of visual accuracy and realism is an impressive achievement.”
From the outset, Schramm has been clear that simulation training at UKSH would benefit both trainees and experienced INRs. “New and complex procedures are constantly emerging and evolving; just look at stent-assisted coiling or intravascular flow-disruptors. This is a dynamic field. So even the most experienced INRs can benefit from lifelong training in a safe, realistic environment.”
Schramm is also keen to underline the intangible benefits of simulation-based training, such as the confidence and psychological resilience that fellows develop as a result of training with simulators. “Don’t forget, we are doing more than imparting the technical skills needed for interventions. Simulation training is a risk-free, and frankly quite efficient, way of preparing fellows for every imaginable situation and eventuality. And calm, confident physicians help foster calm, comfortable patients.”
Another benefit of simulation training has to do with the fact that in Germany, many trainee INRs come from a diagnostic background. As such, they have been trained to detect subtle changes on MRI and CT images. But once under Schramm’s guidance, these trainees have to start performing invasive and potentially risky procedures on sometimes fully conscious patients. It is a major transition that Schramm agrees can be very stressful for fellows—at least in the beginning. And it is here, as Schramm adds, that simulation-based training can be “an invaluable tool in helping them negotiate this transition.”
The University Hospital Schleswig-Holstein (UKSH) in Germany, faced with a shortage of Interventional Neuroradiologists (INRs), successfully leveraged Mentice simulators to enhance their neuroradiology training. The integration of the Neurovascular Essentials (NVE) module allowed for independent, realistic training, reducing the need for proctors and enabling trainees to learn complex procedures safely. This approach not only addressed training bottlenecks but also benefited experienced INRs by providing ongoing education in a risk-free environment. Simulation training also fostered psychological resilience in trainees, helping them transition from diagnostic to interventional roles more smoothly.
Professor Peter Schramm, highlighted three key benefits:
This approach effectively addresses training bottlenecks, enhances procedural proficiency, and maintains high patient care standards.
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