The simulation revolution: past, present, and future in IR

Episode Transcript

Recorded live from the Cook booth at SIR 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.

Well, welcome to another episode of Cook@ SIR, coming to you live from the Cook booth here in Nashville. I’m your host, Andrew Kesselman from Stanford University. Today, we’re diving into an exciting and transformative topic: simulation training in interventional radiology. I’m thrilled to be joined by my colleague and good friend here in the field, Dr. Amanda Rigas, who has pioneered and integrated simulation into her practices. We’ll be exploring how this technology is reshaping the way we train and refine our skills in IR. So, let’s just jump right into it. Amanda, how did you first get into simulation? How do you utilize it in your daily practice now?

That’s a really great question, and it’s interesting because we both work together on simulation, but there’s really never been an opportunity for us to talk about it in this way, so I think that’s really cool that we have the space and time to do this today. For me, I’ve been interested in simulation for quite a long time. I was a piano player growing up, and so the way that one becomes skilled in piano is, you have a teacher, you maybe have a 30-minute lesson per week, and then you go home and you practice on your own. You practice and practice and practice. And then as you have a recital coming up, you start to change the way you practice to prep for that specific event. Maybe you memorize a song that you’re going to play, maybe eventually you scope out the place that you’re going to perform at. You maybe practice in the room on that piano, and then comes the event.

So, for me, simulation feels a lot like that: the opportunity to practice on your own time in a scenario that is hopefully somewhat true to real life but can be varying degrees of that. Throughout my residency and fellowship, I had various opportunities to work on simulation projects and be benefited from simulation as a trainee, and so as an attending, I was interested in integrating that, and there really wasn’t anyone doing that at the VA Palo Alto and Stanford Radiology at the time. So, the first forays were really on the diagnostic radiology side, where I led sessions working on contrast-reaction simulations in the CT scanner and emergencies in the MR scanner, so how does the team work together to keep the patient safe in those situations that were not quite full-on codes but near-code situations? In the meantime, we started integrating more partial task trainers or basic task training-type work into both DR- and IR-side education with your help as well. That’s a little bit of what we’re doing now. What about you? How did you get into sim?

That’s a great question, and it’s great hearing your perspective. My intro to simulation is a bit different, actually. I actually got introduced to it when I was doing my global outreach work, actually, in particular. It was very helpful to have another way to provide IR education when we go on these trips, and something that was first really easy to utilize was some of these more basic simulations, the low-fidelity simulators that we can make. Basically, ballistic gels, we would bring them and be able to do ultrasound-guided procedures on there, like biopsies, to show them what kind of things we can do in IR and let them practice.

But later on, when I got introduced to, through one of the courses I took, actually, about high-fidelity simulators and what they could do, I thought it would be a great fit if we can get one of these to do international work, because there’s a lot of pluses to using these in resource-strained settings. That’s how my interest bore out. And then at Cornell, we started a simulation program there for IR, and when I came to Stanford, you had already built something, which was great, and we just expanded it since then.

Yeah, that was super awesome. That’s really interesting, thinking about the different ways that simulation can be utilized. We think about it commonly for trainees, but there is also definitely benefit to even fully trained physicians. Maybe there’s a new procedure that one hasn’t done before, or something rare that occurs, so it can be helpful to use simulation in those scenarios to be more prepared for the real thing.

Yeah, I agree. I feel like I’ve seen the same thing come about more recently, not just for new users, like you said, for medical students in terms of gaining interest in interventional radiology, but also for building new skill sets, like you said, for the new procedures and new devices that are coming out. It could be extremely helpful to practice these beforehand before doing it live, even if you have experience from prior using something similar.

Yeah, absolutely. I think that it’s great how IR is adopting this more and more. Really, simulation field in medicine started in anesthesia, and it was really something that came from the airline industry. They’re very big into safety, rightfully so, and they heavily use simulation to educate pilots, and so, there’s an anesthesiologist at Stanford and the Palo Alto VA who really championed medical simulation back in the ’80s. It’s very cool to be a part of that now,j to be at the same institution that he’s at. But anesthesia and emergency medicine have really adopted this even much more so than we have in some surgical fields too, even to the point where simulation is even part of their board exams for some fields. And so, there can even be, in addition to a training component, even like an evaluative component, which can be very important as well.

Yeah, I think we spoke about that before, me and you, actually: How could it be worked into credentialing or even boards for interventional radiology similar to how it is in—and you said some other surgical specialties are doing that, even.

Yeah, no, absolutely. I’m curious, with your global outreach work, was getting the funding for the high-fidelity simulator an issue, or what was the path for that?

Yeah, I would say that was probably the biggest hurdle. I should circle back, maybe. One of my early experiences with the high-fidelity simulators—because the simulators themselves have come a long way, these newer endovascular simulators that are high fidelity are pretty much a big game changer for us in terms of the international outreach stuff that we do—I was actually doing a course on prostate artery embolization when it was first starting up as a procedure for interventional radiology. I think it was one of the very early courses for that. And it was great. It was led by Dr. Bhatia, and at the time, they gave a bunch of didactics, and then the last day, they told us, “Oh, we’re going to be doing some hands-on.” I was like, “Oh, this is interesting. I didn’t know we were going to go to the lab or anything.” When we got to the room that they brought us to, it was like three of these Mentice simulators.

Oh, okay.

And I hadn’t seen them before. I’d seen them maybe remotely before, but I didn’t know how they worked. And yeah, we did it both radial and femoral prostate artery embolization on the machine, and it was very realistic. So, at that point, I was like, “I really got to get in touch with the people who make this machine to see if I can bring it on my global outreach trips.” That’s kind of where I got the idea. I reached out to Mentice, which is one of the companies that makes one of these high-fidelity simulators, and we worked on a collaboration and partnership where they lease us, basically, the simulator to take to other countries with us. And the nice part about theirs, it’s pretty portable, so it packs into two flight cases, and we bring it with us on our deployment trip. And our deployment teams usually involve some MDs, so they attending, some trainees, fellows, but also nurses and techs. So, we bring the simulator with us and we get a good experience there, setting up, usually, symposiums and things like that.

Yeah, no, that’s super awesome. I think that setting up a program can feel a little challenging sometimes, but I think that if people are passionate about it, then it really just seems to be something that speaks to people. Practice makes perfect. We all can intuitively understand the value of practicing, and in this environment, where there’s no harm to the patient, there’s no cost time-wise, there’s a lot of benefits to it, for sure.

Yeah, no, I definitely agree. I wanted to touch on what has been the most eye-opening simulation procedures you’ve experienced, and why?

That’s a good question. For me, again, circling back to these team-based simulation trainings, I think, have been the most interesting to me in terms both of planning out the procedures or the simulation and then executing them. You almost feel like you’re the director of a movie, a little bit. You’re like, “Okay, I’m going to make up a little bit of a script. These are the teaching points I want people to understand. I want them to know how to respond in this scenario, what should you do? A, B and C, for example.” And then you tell people their roles and you just see what happens, what they do. And then you give feedback after, and there’s a whole art to debriefing and giving feedback, of course. But those have been really awesome to see. It’s been really great team building to help make sure that the team is communicating well in these emergency-type simulations.

It’s been really valuable for the trainees. I ran one, and a short time after, there was a contrast-reaction situation in the emergency room and the resident knew exactly what to do and was very confident in doing, and instead of rifling through and finding the card that has all the epi doses on it, they just knew exactly what to do, and they said that the session was super helpful for that. To me, that just stands out as one situation that really showed me the power of simulation in these various ways. What about you?

Yeah, no, I can see that. I appreciate you sharing that. I think for me, one story in particular that comes to mind is related to our work in Kenya. There, we were able to actually get a simulator donated to the hospital there and the training program there because they have a new IR fellowship there at the University of Nairobi. And it’s a partnership with RAD International, which is the nonprofit that does IR outreach that I work with, and the hospital and the IRs there. We have fellows there that are training, obviously, and for them, consumables are very costly, so they save these microcatheters, microwires, and things like that for when they really have important procedures to do, like a trauma comes in, or something like that. There’s not a lot of elective cases being done as much there with the microcatheter work, so the simulator is helpful to them practice elective cases. And an example is, one of our fellows, he went out to do one of his electives at one of the smaller hospitals that does more of the elective endovascular procedures, and his first case there with one of the attendings who we know pretty well was a UAE, a uterine artery embolization, for fibroids, and he gets in the procedure, he’s working with this new attending, and the attending actually reached back out to us and let us know that this guy did fantastic. The fellow let us know that he was asking him, “How many of these cases have you done? This is really great, you did it from start to finish.” And he told them that he hadn’t done any of them, actually, beforehand on a live person. He said he has actually been just working on the simulator for the past two to three weeks. So, I think that showed me that doing these things, you can build really good proficiency and competency in doing some of these procedures that can actually show when you’re doing live cases.

Yeah, no, absolutely. I think, to your earlier point, that the high-fidelity simulators have come quite a long way, to the point where the haptic feedback feels pretty good. There’s lots of benefits in terms of understanding and planning out the steps of the procedure, like, “Okay, I do this step, I have to do this step. What’s the best tool for it?” In a simulation setting, you can even try a tool you don’t normally use, like “Can I get up and over it with this random catheter? Maybe, maybe not.” But it’s nice that the feedback of the wire feels pretty true and that if you’re in a small vessel, you’ll feel resistance.

A lot of the simulators, they’re very nice. They can take you through step-by-step if you want, or you can turn off the guidance so you’re just doing it more realistically, kind of “on your own.” It will warn you if you’re doing nontarget embolization, for example. So, I think that the fact that technology has come such a far way really has enabled us to have experiences like the one you just said with that trainee, where it was close enough to real life where it really translated in his experience to the point where the attending really felt like he actually knew what he was doing, so that’s awesome.

Yeah, exactly. I think it’s really nice for them to be able to practice—trainees in particular—in an environment that’s safe. You’re not going to injure patients, but you can also make mistakes there and learn from them. I think that’s been great to see get better and better with these high-fidelity simulators.

Yeah, no, absolutely.

I know you built the program that we have here at Stanford. What was your journey there at the VA, getting the simulator and the program that we have now?

That’s a great question. It was a lot of luck, to be honest with you. As I mentioned before, I started doing some group-type contrast reaction and MR emergency simulation through diagnostic radiology, and I’d started carving out a little bit of time in the interventional radiology didactic as well. I had started doing that, and then I knew about these high-fidelity simulators and I really thought it’d be great to have one, so I had set up a meeting with some people in the department who had access to that funding. And cost is definitely an issue that various groups will run into in terms of these simulators. So, I went and I was really excited and probably a little green. I was like, “This is great. We should do this!” And there were two other people in the meeting, and one person was like, “Well, I heard that they’re not actually really that great,” and then it was clear that basically, the funding was not going to be there at the time, and it was actually sort of discouraging. So, I was like, I actually think they’re really great and super helpful. And that person’s comment was probably based on earlier generations that they had encountered years ago. But the advice that was given to me at the end was good advice, even though in the moment, I was discouraged overall. The advice was just “Start small. Just do something. Just do what you can.” So, I circle back to what you described before, the low-fidelity basic task trainer-type simulators, like the gel molds and the grapes and tofu or blueberries, or the chicken breast, and starting with that, so kind of building a program with the tools that you have—your own time and resources, mostly—and then getting people to buy in. Getting trainees excited, getting program directors excited.

A lot of it is analogous to practice-building, actually. There’s a lot of very common things in terms of start small, celebrate your successes, advertise them to people who can help you—in a nonobnoxious way, of course. But really trying to just get that awareness out there that this is something that people really like that’s very helpful. So, I was doing all of that. In the meantime, was trying to secure funds for a high-fidelity simulator. And the VA has an interesting process that happens every year. Essentially, if there’s excess funds, you can put in bids yearly to potentially get awarded towards random equipment, so you just put in bids. I was working on that process, and we had brought out a few high-fidelity simulators to show as demos—and even that is great, just again, continuing to build that interest level.

But we hadn’t been successful thus far, but I had gotten the word out. People knew I was interested. People heard “simulation” and thought about me, and so fortunately, one day, there was another VA that had one of these high-fidelity simulators, it was in cardiology, and they decided they didn’t want it anymore. No one was using it, it was gathering dust, which is a separate issue we can circle back to. Luckily, people knew that I’d be interested, so someone reached out to me and was like, “Hey, Southern VA is getting rid of this. Do you want it?” And I was like, “Yeah, absolutely.” And so, we were able to secure that simulator just with the cost of shipping, and fortunately, we brought it over and—fortunately, we had a space for it that was convenient and close to the hospital. It’s in a separate building, but on the same campus. And then we were able to eventually get the software modules that we needed, which was a cost as well, but a much lower cost than the equipment itself. Over time, it was both persistence but also luck and being in the right place at the right time that helped it be successful.

That’s amazing. I think that story is good to hear because it’s good to think you did outside the box for alternative funding sources for it, because, like you said, it could be expensive and you never know. Your specific interests brought it to your table, so that’s great.

Yeah. Another thing we were exploring, which I think can be helpful, is potentially allying with other departments. We think about interventional radiology. Are there other departments? Would vascular surgery also potentially use it with you and then you can combine funding sources? So, that can be helpful too.

With these high-fidelity simulators you’re right, there’s different types of procedure sets now, even neurointerventional radiology, interventional cardiology, so there’s a couple different departments you can partner with, like you said. And it also brings to mind to me, you can also partner with vendors as well because they actually have simulators that they have for their sales and their training, so it’s a good avenue to reach out to them as well to see if you can collaborate, maybe have them come in and do some demo sessions with your staff.

Right, exactly, and a lot of what I saw in my fellowship was just that exactly: people bringing in so you could learn how to deploy their specific aortic stent graft, for example. All that building-up is really important, both to secure funding, but then also on the back end, to make sure the simulator is utilized. I’m sure people have stories about that. You have to make sure that the technology is easily accessible, convenient for people to use, and that they have access to it. For us, the simulator is in a nearby building on the VA campus. We put it specifically in a certain room where trainees can get card access, so they can go 24/7. They just get a quick orientation with me. They have their own account, so they can log in, track their own cases, track their own progress, and they can go during the day if there’s downtime, or again, during the evening time, whenever is convenient for them, which is really nice. They can bring someone with them, they can do it on their own, whatever’s easiest.

It’s really nice because the simulator tracks certain metrics. That’s another piece that we hadn’t touched on yet. We touched on it a little bit, that evaluative component in terms of the boards, but there is also data that the simulator is collecting that can help trainees as well, like “How fast did I do this procedure, or how many times did I…?” I think it even tracks—and you probably know, as well—I think it tracks numbers of hand motions with certain devices, and things like that, so I think all of that can be really useful in learning.

Yeah, no, I agree. I think the metrics that it tracks have grown as we’ve seen the simulators getting better and better. But the amount of contrast given, time for procedure, those are things that are definitely tracked on most of them that I think can be very helpful for trainees to keep looking at as benchmarks.

Right. And one that we haven’t specifically stated before, but fluoro dose, obviously, is a big one that’s a risk both to the patient but also to the trainee. And that’s another thing that can be tracked in a simulated setting. And you can try to have a target fluoro time, that one does a procedure and work towards that and hopefully maintain that with a real patient.

Yeah, no, that gets me thinking about certain things we could do in the future. I think radiation safety is super important and we could probably create a skill set there for younger trainees to show us that they can do things like collimate, raise the table appropriately, mag in, mag out, things like that that would be helpful for them to learn early on.

Yeah, no, that’s very true. Yeah, these simulators can take different oblique views, which is helpful in terms of lying out certain vessels but also add some consideration in terms of radiation dose. All those things can be learned in this setting, which is really, really great.

I think as a trainee, when you’re in the room, sometimes your attending expects you to already know how to use all those features, so I think especially early on, it might be helpful to get a taste of that on a simulator {inaudible} for that. Yeah.

Yeah, no, absolutely. They expect you to know, like, “We’re going to do AP view first and then RAO,” and the trainee may or may not know, but again, if they’ve run through it, that’s a great thing about some of these high-fidelity simulators: They have that mode where they take you through and they tell you exactly what to do. And I think especially for the junior trainees, they love that because it’s almost like they’re reading the text. It’s like an attending next to them basically telling them, “Okay, now we’re going to select this catheter and go up and over,” so they actually really like using it. And again, I think it being a low-stress environment where they’re not able to hurt anybody is really great for them.

That’s great. We set it up so we do quarterly sessions with our trainees, and then we tend to couple that with a didactic. Do you feel like that’s been working out well for us in terms of building a simulation program?

I think so. I think that frequency is good. I think when people talk about simulation and talk to simulation enthusiasts, sometimes people start to get worried that we think that simulation is going to supplant everything else, but it’s really complementary to other learning strategies. We were probably trained more in a master-apprentice–type model, where you learn mostly standing next to someone and watching them and eventually doing some parts of a procedure with guidance and eventually more and more, and it was a graduated-autonomy situation. That’s probably true for most of medical education. And of course, we talked about the benefits of simulation. It’s really a blend of both of those approaches that can be super useful, so I think for us, having these simulation sessions integrated into our didactics—which some are more formal didactics, some have become more interactive over time—I think it’s a really nice blend. I think if you just had simulation, that would be potentially very focused on the procedural aspect of training, but obviously, in IR we’re very clinical, and so we need to also know a lot about the pre- and post-procedure care and the pathologies that we’re dealing with and how IR fits into all the other things, so I think simulation is a piece of a larger puzzle, but one that can really enrich the training.

Yeah.

What do you think? Do you think it’s been working out well?

I do, I do. I agree with everything that you said. I think the quarterly sessions we’ve been doing have been great. It’s really been engaging the trainees at all levels, coupling with didactics, like you mentioned, bringing those clinical aspects that you don’t touch on, just doing the procedural aspects on the high-fidelity simulator. And I think the other thing that you touched on is giving them access outside those hours to practice on their own, I think, which is really helpful. So, we do provide them, like you said, that access there to use a simulator throughout the day if they have downtime, because, again, you don’t want it sitting idle, as well. Like you said, you should get full use out of it.

Right, exactly. I also do simulation sessions with our clinical team, which is great too. We’ve talked a little bit about the spectrum of learners. For us, we’ve had patients start to become hypotensive on the table after an arterial access, for example, and what does a team do? Again, going back to that sort of pericode situation—like it’s not quite a code, but what do I do in this moment?—and that’s been really great too. And these are very experienced techs, nurses, physicians, but again, these emergency scenarios come up only every so often. They’re rare, and so, being able to practice those emergencies—rare situations—and be more ready to act in the real moment is very helpful too, so that’s something else. We do regular sessions as part of that team education too. So even places that don’t have physician learners or trainees, there’s still benefits to using simulation in regular education in some way or other.

Yeah, that makes a lot of sense. I also think there’s another way we use it, actually, to gauge interest in IR, actually, because we do work with medical students, and I think having them at the medical student sessions—the symposiums, actually—is very helpful for us because it can be really hard to know what we do in our field and explain it well, I would say, and having the simulators there that they can play with and see what we do, I think, is extremely helpful to them, particularly if they can’t come out and shadow in IR from the get-go early in their medical student career.

Yeah, no, absolutely. I think there’s a lot of parallels in some ways between our field and vascular surgery, like when vascular surgery became integrated some years ago. Similarly, they use simulation for recruitment as well, and I think that makes a lot of sense to show people what we do. I believe I saw an abstract or a presentation at SIR a few years ago where a medical student had put together, actually, quite an impressive program using simulators to teach med students about IR and showed that their knowledge and understanding of the field really increased, which was really cool to see. It’s another good opportunity, for sure—and even for IRs to show other physicians what we do, because certainly, I think that there’s an opportunity for increased understanding there as well.

Yeah, and I think that some of us have experienced, actually, using it throughout our career, so I think if you start them as a medical student, if they’ve had some experience using simulators then, it may carry out throughout the rest of their career.

Yeah, no, that’s absolutely very true.

There’s a particular situation I wanted to bring up, actually, that was interesting and it opened my eyes more to what simulation could do for us as well in training. During COVID, I was working back in New York City, and I can tell you that we were hit pretty hard during COVID, particularly in elective procedures. For a brief period of time, we actually had to shut down a lot of our IR elective procedures due to COVID. So, you can imagine, that was a big hit to the training program. Fellows were definitely worried that they’d lose certain skill sets during those couple weeks where we wouldn’t be able to do certain elective cases, so at that point, we leaned on simulation there.

We brought our high-fidelity simulators down to where our IR suites were, set them up so it’d be really easy access for the fellows, and then had them practicing the other microcatheter skills, things like that, on our elective procedures that we weren’t doing live, but now doing simulated. And the feedback I got for that was great. I think when we picked back up doing elective procedures shortly after that, they felt like they didn’t miss a beat, that they were able to still keep that skill set and know the steps of the procedure. So, you never know. It’s been kind of a whirlwind recently. You never know what’s going to happen—the next pandemic, or resources might be constrained—so it’s good to have this as a supplement or, like you said, a complement to what we’ve been doing traditionally.

Yeah, no, absolutely. That’s a great example. And, knock on wood, hopefully, no near situations like that will come soon, but you never know, like you said, and it’s such a nice tool to have in the tool kit, there’s no question.

Yeah. Have you been seeing it used by people who are out in their training to build—already attending level and beyond—to build new skill sets and things like that?

I’ve heard about it a little bit, and I think it’s great, especially—we’re seeing new modules being developed, like for example, prostate artery embo, which has now become more common, or genicular artery embo, newer procedures where experienced attendings may have that skill set already—that fine microcatheter, microwire skill set—but may be less comfortable with the anatomy, so the things that they’re learning and getting from the simulation may be slightly different than a junior trainee who’s just trying to get the technical or manual skills, but it’s still very helpful. And overall, many studies have shown that operators have increased confidence after doing these simulations. And that’s probably the key thing that’s been shown the most robustly, is that people after simulation training are much more confident in their ability to do the procedure. That applies both to trainees and experienced attendings with new procedures, like GAE, for example. What about you? Have you seen people use it in that setting?

Yeah, I think so. More so more recently, but I think as we continue to innovate, new procedures coming out, I think I agree with you, the anatomy would be something that they really want to look at, and particulars of the procedure. Maybe not so much, like you said, the micro-catheter skills that they may already have, but the unique things, so maybe the product that they’re using or things like that, those aspects.

I think also, we’ve been talking a lot about high-fidelity simulators that are commercially available, and there’s plenty of commercially available products. It’s also a space where people can get really creative and build something themselves and test it themselves, if they’re an expert in that procedure, and try to develop something that’s really true to the tactile feedback that one would get during the procedure. I believe one of our colleagues did something like that a few years back. There’s a lot of opportunity in the space. There’s so much opportunity to explore and really create something meaningful or execute something meaningful for all learners.

Yeah, and I have to tip my hat off to vendors like Cook that are investing in getting these modules made and using these simulators and getting access to IRs for them.

Oh, yeah, absolutely. No, very much so.

You touched a little bit on the evidence there in that last little bit. Like you said, I am aware of some evidence, not a ton. Do you think there’s a lot more we need to do in the future in terms of getting evidence for how simulators work and how they impact clinical care?

Yeah, I think there’s definitely room for work there, for sure, especially if one is trying to come up with funding. There might be someone who you’re trying to pitch the idea to that’s looking for harder evidence, so to speak. And I think there are, again, a lot of studies that show that learners’ confidence is increased, that they’re able to do the procedure more quickly or more— whatever parameters you want better—so to speak, on the simulator itself. And then some studies show that that can translate into doing the procedure quicker or faster in a patient, but I think the piece, the holy grail that’s missing, is, Does it truly translate into safer patient care or more-efficient patient care? I don’t know that we’ve shown that conclusively.

Again, it feels intuitively true that that must be the case, based on, again, the paradigms that we use in our training, like practice makes perfect, for example. I know I said that before. But we haven’t quite proven it to that degree yet. And I think that if we were to do that, that would really enable simulation to totally take off. But that piece will be hard to prove, I think, because what we’re doing already is pretty good, I would say. There’s always room for improvement, but we’re already comparing something that has worked for many, many years. What are your thoughts on it?

I think very similar to yours. There’s good out there, like you mentioned, but what’s really lacking is, How does it affect clinical outcomes and safety? So, if we can get that, I feel like that would be great. I think those are the things that we should look into, try to get and collect in the future, but like you said, there’s a lot of difficulties in obtaining that data and showing that simulation really led to that.

Right. Yeah, exactly. It would be hard to design a study that was controlled enough to really show that outcome, for sure. And part of the issue, which simulation itself helps with, is that there’s variability in exposure to procedures and training, so accounting for those variables in a controlled way to really show that outcome will be tricky, I think, but something that’s worth pursuing, for sure.

I agree. And I think if we’re going to build it into things like our boards and things like that, they’re probably going to want to see that kind of information there.

Yeah, that is true. That is very true. That’s probably one of the bigger limitations of the simulation sphere, but are there other limitations that you can think of?

I think we touched on most of them, to be honest. I think the funding and then initially the access, but I think that’s been growing, like we’ve been talking about here, taking routes to get there. Your story about how you were able to obtain it at the VA, I think things like that are great to hear.

Right. Yeah, no, I agree with you. I think that the cost is probably the biggest limitation, but again, you can start with other lower-cost options and then work your way towards something bigger, hopefully.

Yeah. It’d be great to have a simulator to take to every country that we go visit for our outreach work. Thankfully, it’s pretty portable, so we can bring one to multiple countries. It’s got a lot of wear and tear on it, but it’s good to get that use out of it.

No, absolutely. I had heard of something really cool, actually. I’m curious if you had heard about it too, but I think a year or two ago, there was some talk about being able to actually practice a specific patient—on a specific patient’s anatomy. So let’s say you’re going to coil—you do a complex aneurysm coiling—that you would be able to load the patient’s imaging into the simulator and actually do the case with that anatomy before you did it on the patient. And that seems really, really interesting and innovative and could be very impactful as well.

Yeah, like you said, intuitively, that seems like it’d be extremely impactful and lead to better outcomes.

Yeah, it feels like it, for sure.

Yeah, definitely heard of case examples of that. So, I think that’s a huge way for things to advance in the future. All right, any other things you wanted to touch on about your simulation program at all?

I think it’s been really exciting talking about simulation, and I know we’ve been talking about it for a little while, but I think there’s a lot of room for even more integration of simulation practices across the country. That is one thing that the field probably doesn’t have a great handle on, how many programs are using simulation, even in education? And getting a better understanding of that would probably be really helpful in terms of, How can we use this tool to improve training and to improve practices across the country? So, I think that’s another direction that can be taken, as well. Yeah, no, it was great chatting with you. I really appreciate the time and thank Cook for picking such an impactful topic that we’re both really excited about.

Yeah, I definitely appreciate you coming out. It’s been great having you here, Amanda, and I really appreciate all your insight here on simulation.

Thanks so much, Andrew.