Reset button required: how simulation is revolutionizing IR training and patient safety

Episode Transcript

The content, information, opinions, and viewpoints contained in this webinar are for educational purposes only, and speakers are paid consultants for Cook Medical. Some opinions expressed may represent those of the speaker and are based on their own clinical experience in their practice. This information is not meant or intended to serve as a substitute for a healthcare professional’s clinical training, experience, or judgment. Always refer to the instructions for use, IFU, for complete prescribing information, including indications for use, warnings, precautions, adverse events, and deployment/use instruction. Enjoy the podcast.

Recorded live from Cook Medical and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics, this is the Cook@ SIR podcast series.

All right. Hi, everyone. Welcome to Cook@ SIR. I’m Andrew Kesselman, and today we’re exploring how simulation is transforming the way IR physicians learn embolization procedures. There’s a reset button in simulation, but not in patient care. As embolization therapies continue to grow, how can simulation help us master complex procedures, mitigate complications, and improve access to these life-changing treatments? Joining me today are my esteemed colleagues, Gloria Salazar and Jessie Stewart. All right, let’s get started. Why don’t we start with firsts, first experiences in simulation. Gloria, do you mind starting us off?

My first experience with simulation really comes from my own training in simulation. I took over the simulation program at Mass General, I don’t know, 15 years ago when I was there, and then I had to go to the Center for Medical Simulation training at Harvard, and we had to go and do our simulation. We have to be part of the simulation and they will film you. And you think you’re great and everything and you’re going to save the patient, and you don’t save the patient. And then they show you the video and that’s it. So, I learned a lot about self-awareness. So, of course, that was my own sort of experience with simulation, but throughout the years that I’ve taught simulation, I really saw how it engages participants and how the knowledge retention is much better than just watching a lecture on a video.

Yeah, that makes a lot of sense. Jessie, how about you?

So my first experience with simulation was actually when me and you were working together, Andrew, in Kenya. I think it was 2019 or something like that, where we did a symposium there with some of the residents in the radiology residency program there at the University of Nairobi. Since then, that’s where most of my experience with simulation has been, has been working with our trainees there through the RAD-AID collaboration at the University of Nairobi as we’ve helped get the IR fellowship there at the university off the ground.

Yeah, I agree. That’s been a great experience and definitely seen a lot of firsts there as well. For me, my first experience in simulation, particularly the endovascular simulators from Mentice, was a little bit before that. I took a prostate artery embolization, or PAE, course and a bunch of days of didactics. And then the final day we were going to do a hands-on, and I think I mentioned this before, I thought we’re going to see a real patient case, but they actually had a room full of simulators. And at first, I was disappointed, but then actually when we started using them, I was like, “Wow, this is really impressive, and this is a great way to learn.” So, from that point I was pursuing it a lot for trainee experience, but also like you said, for outreach, Jessie, I thought it was a great idea. So, that’s great to hear from you guys.

I think there’s a lot I’ve learned. Based on our experiences now, how do you guys teach simulation now when it comes to the trainees? Jessie, how about you?

Yeah, so as I mentioned, most of it has been through the outreach with RAD-AID that we do with University of Nairobi. And I think it’s a really useful tool, especially not only in residency programs and for students in the US, which I think helps them get reps and just get more comfortable with things, but especially in a resource-limited setting like that, I think it’s really important for them because the simulators not only can simulate cases and issues you encounter with cases, but just getting them familiar with devices, device selection, wire selection, things like that that we might take for granted in the US that we have all these different shapes of catheters that they might come across. Really, this is getting them familiar with the toolkits, things they could ask for, things they might need in different procedures. So, I think just getting them familiar with what a well-stocked IR suite might have and what things might be useful in different kinds of situations.

And then just letting them run through it, see what kind of trouble they can get into on the simulators sometimes. I was talking with one of our recent graduates from the University of Nairobi fellowship program who’s just finishing and starting her IR practice down in the city of Mombasa. She was saying that she felt like the simulator, her time with working on the Mentice, has really helped her be able to recognize problems specifically with respect to uterine fibroid embolization, watching out for cervicovaginal branches, watching out for reflux, things like that. So, there’s been some specific things that getting repetition on the simulator has really helped her with. I also think in a resource-limited setting, sometimes there are issues with their actual machines. We’ve encountered this on our trips there. So, sometimes the fluoroscopy machine is down or the AC is down and they can’t run the machine.

So, this is a great way to supplement those times where they’re still able to get reps on their training during their time instead of having that time be wasted.

Yeah, that’s a lot of good points. And I see a lot of parallels in what I’m doing with the trainees as well. Gloria, what about you? Similar kind of aspects?

Yeah, no, I think that’s a great description of the value of simulation when you have limited resources to teach. One thing that I like to focus on a lot in simulation is the multidisciplinary team training. We are specialty of multidisciplinary. We work with other specialties and one of the things that we’re trying to incorporate is the value of proper communication in emergency settings. I trained a lot of teams on how to communicate, not only amongst physicians, but also nurse technologists and physicians. And what I think, aside from the technical aspects and troubleshooting and understanding the procedure, the communication during the procedure, particularly when you have a trauma case or when you have— For example, at UNC, we have a placenta accreta team. I know Jessie is somewhat familiar because she started it before I came here, and now we evolve to a level of communication that is unheard of.

So, I think simulation, even when you are not at the simulator, but just simulating a patient that comes for a very difficult procedure and you have to have 10 different moving parts, it’s extremely important to practice that, so that when there’s a real patient, then you’re ready to go. Then it’s sort of like you know what to do. It’s common because you’ve done it before with the simulation and team training, and I guess you get less nervous because you’re familiar with the protocols and also in how do you make sure that the technical aspects as well as the patient care is being delivered properly with the different teams in a hospital.

Yeah, no, those are great points. I think it is very helpful now that we’re being more and more included in these response teams because we can offer some really lifesaving therapies. I think our participation in that is helpful to run things through with simulation, like you said, so that it’s not a really difficult situation when the time arises. And I think particularly for trauma embolizations, things like that, so if you have a trauma response team or a postpartum response team, the cases may not come up every week. So, having a simulation session every so often, just so everybody’s refreshed on the communication pathways, like you said, I think is very important in making sure things move smoothly every time.

There’s another thing too, Andrew, and I want to hear from you guys because there are a lot of metrics that are being measured now for hospitals for the trauma response. So, I think that simulation is a great tool also to improve that turnaround time. Not that we want to rush to it, but understand what are the things that are going to get in the way for us to provide care. So, at our hospital, and I’m sure it had evolved, and now we have a 30-minute from the time we call, I guess 30-minute, 45-minute, I have to ask, but it’s sort of like a time limit set from the time we get called, from the time we puncture, and we’re measuring that very closely.

Yeah, we’re following it in my hospital, too.

Yeah, we’re doing that as well. I think ours is, well, I think we’re shooting for 60 minutes for trauma, but I agree. I think the simulation for multidisciplinary teams, I think, is the standard way that things have been done for other specialties. And I think it’s time that IR is on board with that kind of a program as well.

Yeah, I agree. I think we can build into that simulation session, not just communication, but then follow it up with the endovascular cases as well, and that just makes it more comprehensive. So, that’s great. And I think that’s some really great points. We wanted to talk about how simulation can shorten learning curves, improve procedural efficiency and look at some metrics if we could. I did participate in a study when I was at my prior institution, and we looked at an IR curriculum and how that could improve trainees’ confidence. And it was interesting; we did find that it did make the trainees themselves feel that the sessions improve their confidence in the IR procedural room, which makes sense because they can make complications in the simulation. They can ask questions that they may be too afraid to ask during the actual procedure room and be more confident when they actually are in the procedure room.

And then about 75% of them believe that the curriculum should be incorporated actually into the IR residency program. And anecdotally, during that experience and a little bit before that when we were dealing with COVID, I had a junior trainee during COVID and we had shut down elective procedures, so there wasn’t a lot of opportunity for her to get microcatheter work. The seniors were taking all the microcatheter embolization procedures. So, I was running sessions on the simulator down in our IR suite in between things, and she was able to participate in that. And she said that was really great hands-on for her, allowed her to get feedback from me directly when I was in the room, maybe preoccupied with other things. So, anecdotally, she said that helped her a lot, especially— Now later, when I talked to her later as a senior trainee, she said that she think that experience was very valuable.

I don’t know how you guys feel if you’ve seen similar things and if you have any questions regarding metrics or anything like that.

No, I thought your article was really interesting, and I really thought you raised some great points about just the limitations of residency training and how this can— There’s just increasing pressure from all sides. There’s duty-hour restrictions, there’s turnaround time, trying to get more patients through in a day that limits our time and ability to let residents really take their time and learn their skills on actual patients. And it’s just limitations left and right. So, I think that was an interesting point of your study there. And it’s good that it found that they increased confidence. I think that lines up with what we’ve seen anecdotally working with trainees as well.

Andrew, I have to congratulate you because in doing the team training and the simulation work now for, I don’t know, 15 years, there were very little papers on IR. And so, congratulations on publishing this. It’s hard to publish in simulation for those of us who are doing research and how to capture the outcome metrics. So, thank you for bringing that.

I have a question for you because I think that that whole paper is very interesting, not only for our country, but also obviously for even medical schools. I think particularly in South America, we have a lot of medical schools that are building simulation hospitals. I know my mom called me the other day, she’s in Chile. She’s like, “Oh, they’re building a simulation hospital right here.” And she was excited. I don’t know why, but that’s cool. That cute that she was excited. But jokes aside, I think—

So, share with the audience and with us, too, how do you convince people that simulation is important for the hospital administrators and for your chair, for example?

Yeah, no, that’s a great question because if we look at outcomes, it’s hard to translate what we’re doing in the simulation to the procedural suite and show that that leads to better outcomes and track that. What we have shown, and there’s actually a 2025 meta-analysis that included almost 8,000 patients from nine studies, did show that the comparison of procedural time and fluoroscopy time were shorter for those that did do the angiographic simulator training. So, I think we do have those papers to fall back on. There’s other things published outside of IR looking at EVARs and procedure time as well as neuro IR procedures, which also have shown similar things in terms of reducing fluoroscopy time and procedure time. So, I think those are things we can lean on, and everybody’s focused on good patient care, good safety outcomes, and I think we definitely can advocate that these can help with safety, I think, making procedures safer and avoiding some complications.

I do think there is a void, though. I think we still need to publish more on if we can get to that outcomes-based information for IR specific. I think that’d be really helpful for us. So, I think that’s a goal for us, particularly at our simulation program here to see if we can get some of that data. Sometimes it can be hard to randomize trainees, but I think it’d be valuable in the long run. What do you guys think?

No, I think a lot of the metrics that you’re mentioning make a lot of sense. I think there’s a lot of different ways you would want to measure this, but just in terms of getting residents more comfortable, it could be something as simple as knowing what angle of the II you want to use and saving time that way or saving time, knowing exactly what power injection rate you might want and things like that. So, I think it’ll bear out in the data once we get this more established.

Yeah, I think metrics for simulation papers and research is very hard, but one of the things that I know that the simulation literature in general does for the team training aspect is how much the teams adhere to the protocols after simulation. I think that’s a great outcome metric. It’s not specifically measuring the patient outcome, but it’s sort of assuming that if we have less variation in the care, we have better quality of care. And we did that at our simulation program was for emergency managements, and we wanting to check how often we were following our protocols. But it’s extremely hard, and like I said, I congratulate you for completing and for doing this for our community because I think it’s extremely important for the future of our specialty and also for the trainees to feel confident and comfortable and superstars when they go and become attendings.

Yeah, I appreciate that. I think that’s a really good point. If I think about the PAE procedure, PAE was my first exposure, and Jessie, we did a lot on UAE, UFE at our global work. These are pretty challenging procedures to learn. How do you think these similarities help in terms of not only improving the trainee education, but also patient access at all if you think it’s possible?

Well, I think the confidence comes through. I think the confidence will show for our trainees that when they’re going out, like our recent trainee that’s going out there, she feels confident now in offering UFE something she can feel good about offering to patients out in her community. So, I think just having that confidence behind you will help you with your outreach efforts, with speaking with clinicians, that they can tell that you’re well-trained and that you’ve had the experience necessary to treat patients in your community.

Yeah, I think in Kenya in specific, it’s helping the confidence in those IRs that are graduating from that fellowship that we’re participating in. I think it’s giving access to— because some of those, correct me if I’m wrong, but some of those trainees go out to remote places within Kenya to practice. So, I think it’s giving that confidence to do that, even though their reps may be lower on live cases, it could be pretty high on simulated cases.

Exactly. Yeah.

Gloria, what do you think?

Yeah, no, I think that’s a great value of simulation when you have a very complex case that is very rare. And I think, again, going in parallel with the surgeons and the vascular surgeons with the aortic stuff, it’s so much stuff right now that I cannot even keep up. And the training is very important and using simulation for essentially bridging the gap of the volume that you may have. The other aspect of it I think is really when we’re talking about innovation, IR is innovation and IR is magic. So, the patients are always going to think that we are doing better because we are not doing surgery. However, to Jessie’s point, we want to train people well because that will determine the experience they have. Of course, complications can happen to any of us, but the level of confidence thing has everything to do with how we represent our specialty in this country, in the world.

And I think the more you do, the better you get that’s outside of the simulation, that’s just what we know of. So, I think public awareness is just all of us represented in our trainee that we train and how the simulation can help it. It’s really important for the patients to see that benefit, particularly with new procedures that are coming up now, everybody wants to learn those and what a better way to do it with simulation.

I think that’s so true. Yeah. I mean, especially with things like PAE, too. With PAE, there’s so many potential complications that can arise, and I think simulation can help expose them to those complications so they know exactly what they’re seeing, and so they can help avoid complications as they’re getting their practices off the ground, which is so important for building those practices and getting patients in the door, too.

Yeah. And be able to identify that anatomy very quickly and seeing a lot of that I think is the variable anatomy I think is going to be helpful. So, you did mention some new procedures. I think that’s a good segue. Where do you see simulation have the biggest impact in the future? What kind of procedures do you think it could be influencing in the future that are coming down the pipeline?

I can just get started with a little bit of a joke because I don’t know that whoever’s doing the most procedures in genicular artery cannot travel all over the world to teach everybody. I mean, they may be able to, but I think that the simulation is critically important in this setting because you just create a module and then people can learn. Even remote, we know that telesimulation is used in the army and in some surgical procedure, orthopedic procedures like with robots, and they can do something here and then do it remotely in another country. So, I think for me personally, of course the PAE already is sort of not new, but the genicular artery embolization, I think it’s very interesting because it’s such a small vessel and I don’t know, but how you do not cause a spasm, it’s my question, but we’ll leave it up to the simulator to teach me when I get there.

No, I agree, Gloria. Honestly, I know that it takes a lot of work to make these simulation modules on the Mentice and other simulators, but my wish would be for these really esoteric brand-new procedures that are pretty technically challenging, not just GAE, but all these different MSK embolization procedures that are coming down the pipeline, embolization of the elbow for tennis elbow, plantar fasciitis embolization, you name it. So, there’s so many new emboli therapies coming down the line, and it’s tough to get reps on these and to even see these kind of cases because they’re not very commonly done. So, I know that’s a lot of work for the team at Mentice. Maybe AI can help somehow, but some of these more rare new emboli therapy procedures I think would be perfect for simulation.

Yeah, I agree. I think there’s going to be explosion with MSK embolization procedures, and I think that’s something to learn. And then like you mentioned, Gloria, the anatomy, the complications, spasm, things like that are going to be important to mitigate, and I think learning on the simulator will really help. My practice, and I think Jessie, you do these two, hemorrhoid embolization, thyroid embolization, those might also be interesting ones to pursue because it may not be something that they get a lot of exposure to in their training, but maybe more so in practice, and it may be partnering with vendors who are creating these modules to really get access to them in terms of being helpful.

I agree. I think those are two great examples, Andrew, because thyroid’s an example of one where like prostate where there can be devastating complications with failure to recognize certain anatomies, so I think that’s an important one. And then hemorrhoids, it’s just decision making, and I think you could show them a lot of different anatomical variants to help build confidence there more so than the technical aspects or from a complication standpoint. So, I think there’s a number of different reasons why simulation could be useful in some of these up-and-coming procedures.

For a thyroid, the risk of stroke and non-target embolization with the particles I think is high. So, if we had a simulation of it, I’d definitely let the fellow stroke them out during the simulation so they can get a feel for an overembolization.

That’s what it’s for.

Yeah, no, I think the thyroid is a great one. And also because some people do neuro IR, right? Some IRs are trained IR and they have to cover neuro IR, and I learned this from the paucity of neuro IRs in Central America. So, there’s one IR, and they do everything, so it will be very interesting. I think the thyroid is a very interesting one for sure.

Well, just neuro IR in general, I think a lot of IRs in the US are going out to their practices and finding that they need to take stroke call. It’s not uncommon for sure. So, I think simulation can fill that gap because that’s not how our training programs are established in the US. You’re not really training in stroke if you’re a peripheral IR fellow. So, another great gap that it helps fill.

Yeah, that’s an interesting point you bring up. I think our training programs and adopting simulation into those training programs is lagging for sure. I think we try to build a curriculum with the two programs I’m at, but I don’t think that’s the standard or the norm for sure. I think somewhere where simulation can really be helpful is knowing how somebody’s doing in terms of our boards. We don’t integrate in our boards actually any kind of hands-on.

It’s mostly oral questions and running through a case, which is good for thought process, but we don’t really judge technical skills really well currently with our board’s practice. And it’d be nice to see if that’s ever built out in the future with endovascular simulation, seeing if there’s technical skills we can actually judge prior to signing off on people.

That’d be very interesting.

We did an attempt of that at SIR. Remember, Andrew, with Ron and your team, we did a competition at SIR when I think— I forgot which year, and then I don’t know who won also; I forgot because I don’t think my team won, and I didn’t participate. But it’s interesting to talk about that because I think when we’re talking about trainees is great, and everybody sees the value. But I think when you are an established attending and you have to learn something new, I think there’s still a bit of resistance in simulation. And I hope that people can see the benefit of you doing your case as an attending and evaluating yourself, like somebody to coach you and tell you, “Hey, maybe you can do this better.”

That’s a great point. I think that’s a great point. I think that’s definitely something we should look at in the future. And maybe even if we’re certifying on another procedure or something like that, we use simulation to either tailor remediation or even to sign off and use it for competency. So yeah, I think those are great points.

All right. Well, I think it’s been a great discussion so far. I think let’s look at maybe a lightning round here where what is one action every IR trainee or healthcare system should take to improve awareness training and patient access for these disease states? So, one practical takeaway you think would be good if you had to endear it to another IR physician or trainee?

I mean, I would say with respect to simulation, to just embrace it as best you can within the constraints of your institution. Think creatively about how it could be implemented, whether that’s a curriculum for trainees or maybe it’s even helping onboard new techs, or nurses sometimes on our teams don’t completely fully understand what’s going on in some of our procedures. You can get really creative about how this could really positively impact your whole team or multidisciplinary teams as Gloria mentioned earlier. So, I think it’s easy to think about it as just benefiting your own trainees and limited to that, but I think it really can benefit patients’ care and also our teams as a whole. So, maybe that value proposition could be a little bit more appealing given obviously these are expensive systems, but there could be benefits for more than just trainees.

Yeah, I completely agree with Jessie, and I would advocate for the future of IR for us to work, incorporate simulation with the other teams. I think that a lot of information is lost and sometimes the other teams don’t know what we do. So yes, trauma response and PE response, et cetera, et cetera. But I think we could do much more with that and really engage the other stakeholders in our hospital and your system to make sure that simulation is part of it. My dream would be what I saw at Vince Vidal’s hospital. I was actually learning how to do hemorrhoid embolization, the “hemborrhoid,” and they had a simulation when I was there. The whole hospital stopped, and it was a simulation about a mass casualty, like a bombing, a terrorist attack—and of course it was all simulation—and they were doing it and I was there.

I was like, “I can’t believe you guys are doing this.” Everybody stopped and they had to go through. So, I think there’s a lot to learn and hopefully to look forward in the future of how we can do better with our healthcare system as interventional radiologists or radiology in general using simulation with other teams.

Yeah, I think I have a similar sentiment. I really want everybody to advocate for simulation to be more readily incorporated into our training programs and our practice. So, for me, I think if we could partner with either vendors or the societies to get that simulation experiences available, trainees and also practicing physicians, I think that’s something that access to that I think will improve everything across the board. All right. Well, I think that was great. I think a lot of great points, a lot of things for us to digest, and I really appreciate all your guys’ experiences here in simulation and in IR in general. Thank you.

Thank you.

Thanks, guys.