This is the history of simulation in medicine and surgery. It may surprise you…

In 1927, when Edwin Link first pitched the idea of a flight simulator that could be used to train new pilots on the ground – a device he dubbed the “Link trainer” – the US Army Air Force flatly rejected it.  The device was conceived in earnest.  Link, an electrician and amateur pilot, was unimpressed with the amount of real-life flight training available to him.  Fueled by his dissatisfaction, he built a ground-based simulator, which featured a pneumatic motion platform, an electric motor, and a fully functioning replica cockpit.   Despite the novelty of such a device in 1927, Link couldn’t convince anyone in the industry – not just the military, but also private aviation schools – that the simulator would ever serve a meaningful purpose in pilot training.


But in 1934, something changed.  The US Army Air Force won a contract to deliver mail by aircraft, a duty that required pilots to fly daily, rain or shine, in optimal conditions or dangerous ones.  After dozens of pilots were killed in the first few weeks of the contract, the Air Force remembered Link and his flight simulator.  Seven years later, they understood the value of the Link trainer: It was an opportunity for pilots to practice life-saving skills in a low-stakes, ground-based model before venturing into often threatening skies.

The rest, of course, is history.  The Link trainer became a cornerstone of pilot training in World War II, and in 1954, United Airlines became the first commercial aviation company to invest in a flight simulator.   Although the no randomized control trial has ever been conducted (for fairly obvious reasons), the modern use of flight simulators in pilot training is estimated to save millions of dollars and prevent countless human casualties.

After the dawn of the patient safety movement, medicine began taking cues from the aviation industry in hopes of improving organizations, processes and, ultimately, patient outcomes.  Many may assume simulation was one of the many lessons learned from the world of aerospace.  In reality, when it comes to simulation, medicine has historically been far, far ahead of aviation.

In the broadest definition of the term, medical simulation has been established for centuries.  Cadaveric dissection has been a paradigm of anatomic and procedural training since the 16th century.  In 1784, prominent midwife Madame du Coudray developed a mannequin from leather and bone to teach clinicians how to deliver a vaginal birth.   Almost 200 years later, in the 1960s, the idea of simulation in medical training was reawakened with the release of Resource Anne, a mannequin intended for CPR training.


But in creating the type of medical simulation we know today, innovations in flight simulation, computer technology, and advanced materials were necessary predecessors.   So it wasn’t until the 1990’s when an explosion of advancement in medical simulation technologies began, after the completion of the Visible Human Project, which used images from real human cadavers to develop anatomic models that allow for 3D viewing and manipulation.  These models have served as the chassis for a broad spattering of modern surgical simulation technology, from the Laparoscopic Training Box to the REMIS VR trainer for cholecystectomy to, of course, Touch Surgery.
Today, we know that simulation is good for surgeons in training.  Gallbladder resection, for instance, is up to 30% faster in simulator-trained residents.  Residents trained on a virtual-reality arthroscopic knee show significantly greater skill level in the operating room compared to non-VR trained residents.  And when compared with the simulator- trained residents, those without simulation training are up to 5 times more likely to burn non-target tissue.  Unsurprisingly, in 2006, the Residency Review Committee for Surgery voted unanimously to mandate simulation training in surgery residency programs.

But more importantly, we’re also learning that simulation training is good for patients.   As physicians armed with the power of the randomized clinical trial, we have the ability to measure the direct benefit to patients from simulation technology.  Through this process, we’ve seen that simulator training in ophthalmology significantly reduces adverse events in cataract operations, that a hernia repair simulator leads to fewer perioperative complications as well as decreased the length of stay, and that the implementation of a simulator-based central line placement training, slashes rates of catheter-associated bloodstream infections (CLABSIs).

Perhaps one of the best benchmarks of the success of medical simulation, however, is the answer you might expect when posing a simple question to a patient:  Would you prefer a surgeon who, in addition to real-life experience, trained extensively on a surgical simulator…or one who didn’t?

By Nicole Van Groningen