Modeling and Simulation in the Medical and Health Sciences E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Wissenschaft und neue Technologien
• Sprache: Englisch

Seitenzahl: 370

Veröffentlichungsjahr: 2012

Beschreibung

This edited book is divided into three parts: Fundamentals of Medical and Health Sciences Modeling and Simulation introduces modeling and simulation in the medical and health sciences; Medical and Health Sciences Models provides the theoretical underpinnings of medical and health sciences modeling; and Modeling and Simulation Applications in Medical and Health Sciences focuses on teaching, training, and research applications.  The book begins with a general discussion of modeling and simulation from the modeling and simulation discipline perspective. This discussion grounds the reader in common terminology.  It also relates this terminology to concepts found in the medical and health care (MHC) area to help bridge the gap between developers and MHC practitioners. Three distinct modes of modeling and simulation are described: live, constructive, and virtual.  The live approach explains the concept of using real (live) people employing real equipment for training purposes.  The constructive mode is a means of engaging medical modeling and simulation.  In constructive simulation, simulated people and simulated equipment are developed to augment real-world conditions for training or experimentation purposes.  The virtual mode is perhaps the most fascinating as virtual operating rooms and synthetic training environments are being produced for practitioners and educators at break-neck speed.  In this mode, real people are employing simulated equipment to improve physical skills and decision-making ability.

Leseprobe

Contents

Cover

Half Title page

Title page

Copyright page

Dedication

Contributors

Foreword

Preface

Part One: Fundamentals of Medical and Health Sciences Modeling and Simulation

Chapter 1: Introduction to Modeling and Simulation in the Medical and Health Sciences

Introduction

Modeling and Simulation in the Medical and Health Sciences

Research and Development of Medical and Health Sciences M&S

The Question of Ethics in Medical and Health Sciences M&S

Conclusion

Key Terms

References

Chapter 2: The Practice of Modeling and Simulation: Tools of the Trade

Introduction

Modeling and Simulation Terms and Definitions

Modeling and Simulation Paradigms

Conclusion

Key Terms

References

Part Two: Modeling for the Medical and Health Sciences

Chapter 3: Mathematical Models of Tumor Growth and Wound Healing

Introduction

Other Basic Models of Tumor Cell Population Growth: Multicellular Spheroids

Diffusion of Growth Inhibitor

Time-Evolutionary Diffusion Models

Tumor Angiogenesis

Conclusion

Key Terms

References

Further Reading

Chapter 4: Physical Modeling

Introduction

Tangible Physical Models

Cadaver-Based Models

Animal Models

Computational Physical Models

Conclusion

Key Terms

References

Part Three: Modeling and Simulation Applications

Chapter 5: Humans as Models

Introduction

Cadavers and Wax Models

Standardized Patients

Plastination

Human Data Sets

Conclusion

Key Terms

References

Chapter 6: Modeling the Human System

Introduction

Organ Modeling

Modeling of Muscular Electrophysiology

Conclusion

Key Terms

References

Chapter 7: Robotics

Introduction

Robotics Technology

Using Robotics: Advantages and Disadvantages

Conclusion

Key Terms

Chapter 8: Training

Introduction

Types of Training

Creating Successful Simulations in Health Care

Training programs and student levels

Simulation-Based Training

Barriers to Simulation Training in Health Care

Key Terms

References

Further Reading

Chapter 9: Patient Care

Introduction

Related Work

Team Performance

Surgical Intent Inferencing

Empirical Study

Conclusion

Key Terms

References

Chapter 10: Future of Modeling and Simulation in the Medical and Health Sciences

Introduction

Future Processes for Modeling and Simulation

Future Technologies and Applications

Conclusion

Key Terms

References

Appendix: Modeling Human Behavior, Modeling Human Systems: Addressing the Skepticism, Responding to the Reservations

Introduction

A Code of Ethics Within the M&S Community

Skepticism in the Social Sciences

Reservations in the Medical and Health Sciences

Making It Real: Addressing the Skepticism, Responding to the Reservations

Conclusion

References

Index

MODELING AND SIMULATION IN THE MEDICAL AND HEALTH SCIENCES

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data Is Available

Modeling and simulation in the medical and health sciences / edited by John A. Sokolowski and Catherine M. Banks

Includes bibliographical references and index.

ISBN 978-0-470-76947-8

oBook ISBN: 9781118003206

ePDF ISBN: 9781118003183

ePub ISBN: 9781118003190

My wife, Marsha, and my daughters, Amy and Whitney, for all your love and support

—John A. Sokolowski

My husband, James, the love of my life

—Catherine M. Banks

CONTRIBUTORS

JOHN A. ADAM, Department of Mathematics and Statistics, Old Dominion University, Norfolk, Virginia

CATHERINE M. BANKS, Virginia Modeling, Analysis and Simulation Center, Old Dominion University, Suffolk, Virginia

C. DONALD COMBS, Eastern Virginia Medical School, Norfolk, Virginia

MOHAMMED FERDJALLAH, Virginia Modeling, Analysis and Simulation Center, Old Dominion University, Suffolk, Virginia

ELIZABETH A. JACOB, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire

LINDSAY B. KATONA, Hitchcock Medical Center, Dartmouth College, Hanover, New Hampshire

GYUTAE KIM, Department of Electrical and Computer Engineering, Old Dominion University, Norfolk, Virginia

KEUM JOO KIM, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire

RICHARD LEE, Department of Robotics Surgery, Englewood Hospital and Medical Center, Englewood, New Jersey

DEQING LI, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire

PAUL E. PHRAMPUS, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania

STACIE I. RINGLEB, Department of Mechanical Engineering, Old Dominion University, Norfolk, Virginia

JOSEPH M. ROSEN, Hitchcock Medical Center, Dartmouth College, Hanover, New Hampshire

EUGENE SANTOS, JR., Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire

RICHARD M. SATAVA, Department of Surgery, University of Washington, Seattle, Washington

JOHN A. SOKOLOWSKI, Virginia Modeling, Analysis and Simulation Center, Old Dominion University, Suffolk, Virginia

FEI YU, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire

FOREWORD

Advances in the medical and health sciences are partly the result of the variety of modeling and simulation tools available to professionals in these fields. The technology now facilitates accurate representations of the body that serve as baseline models for assessing and prescribing courses of actions for disturbances to the human system. To fully engage this capability, medical professionals – users – need to be trained to use this technology. They must also participate in the development of this technology to ensure that these tools meet their standards.

Modeling and Simulation in the Medical and Health Sciences introduces this modeling and simulation application domain from both the engineer's and medical professional's perspective to provide just that – a better understanding of simulation development for medical applications.

Throughout the chapters an underlying theme is presented: the call for greater collaboration between simulation developers and users.

The discussion purposely introduces a broad review of simulation in the medical and health sciences. First, it presents the necessary introductory material in the field of modeling and simulation, then it progresses to modeling itself such as mathematical representations of human elements and the employment of several modeling techniques designed to replicate humans and human systems. The concluding chapters address a variety of uses of simulation in training and patient care.

Medical professionals are keenly aware of the need to broaden medical simulation applications with a view to expedited and effective training of healthcare providers.

Significant also to medical simulation applications is its ability to facilitate better informed decision-making during critical junctures in patient care – as the text calls it, facilitating a seamless mode of information transmission. To develop effective training tools and application tools, effort is needed to bring together multidisciplinary expertise. Modeling and Simulation in the Medical and Health Sciences is the right place to start.

ARYEH SHANDER, MD, FCCM, FCCP

Englewood Hospital and Medical CenterMount Sinai School of MedicineNovember 2010

PREFACE

With the technology boom of the 1990s came varied approaches to modeling, varying degrees of simulation, and sophisticated methods of visual representation—essentially an informal introduction to what would eventually comprise the discipline of modeling and simulation (M&S). Students in the engineering and computer science disciplines were the first beneficiaries of these technological advancements, and it wasn't long before that technology, coupled with an expanding body of knowledge on modeling and simulation, fast-tracked across the disciplines. This placed M&S at the forefront of a multidisciplinary effort to integrate quantitative and qualitative research methods and diverse modeling paradigms. What is more, M&S now possesses a variety of modeling tools that can represent many aspects of life, including life itself. The medical and health sciences are proof of that.

M&S is providing practitioners in these fields with the capability to better understand some of the fundamental aspects of health care, such as human behavior, human systems, medical treatment, and disease proliferation. Whether live, virtual, or constructive modes of M&S are used, nurse educators and physicians are trained in a variety of applied areas through simulations developed from mathematical, physical, computer, and human models. Thus, it can be said that medical and health sciences M&S is an evolutionary, interdisciplinary process of model development and simulation design requiring the expertise of developers (M&S experts) and users (medical and health care trainers and practitioners) to facilitate a seamless mode of information transmission. This book provides a venue to do just that, as it is designed to educate future members of the medical M&S community toward developing and perfecting a seamless mode of information transmission in the health care domain.

In our view, the phrase seamless mode of information transmission has meaning on two levels. First and foremost is the sole objective of medical and health sciences M&S: to create environments whereby precise information transfers directly to or is discovered by the health care provider. Academicians and commercial developers of medical and health sciences M&S products are working on this crucial goal by creating the ideal virtual operating room, the perfect prosthesis, and the best diagnostic imaging apparatus for users. Essentially, for medical and health sciences M&S to have any significant impact in health care, a seamless mode of information transmission via models and simulations must take place. The second meaning, and one that serves as the impetus for this book, is that M&S developes and users must share expertise, requirements, and criticisms while recognizing limitations and expectations regarding model development and simulation design. Modeling is not easy, and the human body is one of the most complex systems for modelers to attempt. Similarly, medical trainers and practitioners recognize the dynamism of the body; therefore, they cannot always provide discrete, static portraits of the anatomy or quantitatively convey degrees of pain. Understanding the parameters and the tasks that both audiences address in their work is critical if the goal of a seamless mode of information transmission is to be accomplished. This publication facilitates that understanding by providing an interdisciplinary study for future members of the health care M&S community toward a greater capacity for collaboration with M&S developers.

This book is intended for engineering graduate students focusing their research on the development of medical and health sciences M&S and for medical and health care students who will be engaging M&S as practitioners or trainers. The content is an orientation to the theory and applications of M&S in the medical and health sciences. The book can also serve as a valuable resource for medical and health sciences majors who desire a technical understanding of modeling and simulation as they might function as future consultants to M&S developers. All readers of this book will no doubt benefit from the incisive analysis of the key concepts, body of knowledge, and M&S applications in medical and health sciences provided by the scholars and expert practitioners who will have contributed to the book.

Note, in particular, that the discussion has been set within the reasonable bounds of a graduate course in medical and health sciences modeling and simulation by introducing key concepts, citing the body of knowledge, elaborating on theoretical modeling underpinnings, and referencing M&S applications in research and education. Thus, we make no claims that it is an exhaustive study of model development, simulation design, and applications of M&S in the medical and health sciences. Plainly omitted from this discussion are a number of subsets: adaptive seriousgames (training and rehabilitation), E-health, clinical lab maintenance, insurance systems modeling, medical informatics (hospital information systems, computer-based patient records), clinical engineering (such as risk factors, safety, and management of medical equipment), quality improvement and team building, hospital design, open standards for medical M&S, and ethical issues associated with use of medical technology.

Students studying disciplines in the sciences (e.g., computer science, mathematics, biology) and engineering (e.g., mechanical, bioengineering, electrical, systems, M&S) are grounded in the fundamentals of M&S but lack an understanding of the medical applications, such as the human body as a system, disease proliferation, and even gait analysis. These students need to become versed in understanding the human system, in understanding what takes place as training in the medical and health sciences, and in advancing the three modes of M&S: live, virtual, and constructive. We focus on that necessary M&S education via a multidisciplinary approach, with chapter contributions from faculty across the disciplines as well as medical experts possessing both Ph.D. and medical degrees.

With the M&S student as developer in mind, we approach the topic of medical and health sciences M&S in three phases as a way to introduce approach, theory, and application in a methodical manner. Thus, we start by introducing the fundamental modes of M&S, progress to explaining the theoretical origins of the model, and conclude by highlighting M&S treatment in research and in education and utilization.

The book is divided into three parts, beginning with a general discussion of M&S as a discipline. In Part One, “Fundamentals of Medical and Health Sciences M&S,” we ground the student in common terminology. We also relate this terminology to concepts employed in the medical and health care area to help bridge the gap between developers and practitioners. Three distinct modes of M&S are described: live, constructive, and virtual. The live approach explains the concept of using real (live) people employing real equipment for training purposes. The constructive mode is a means of engaging medical M&S. In constructive simulation, simulated people and simulated equipment are developed to augment real-world conditions for training or experimentation purposes. The virtual mode is perhaps the most fascinating, as virtual operating rooms and synthetic training environments are being produced for practitioners and educators at breakneck speed. In this mode, real people employ simulated equipment to improve physical skills and decision-making ability.

The development of any model takes its form from a theoretical perspective. In Part Two, “Modeling for the Medical and Health Sciences,'' we discuss both computational and physical models. Computational models exist in either a purely mathematical form such as a series of equations or in an algorithmic form implemented in a digital computer. Physical models can be manikins that contain representations of human anatomy for the purpose of practicing surgical or diagnostic procedures. Computational and physical models directly support the modes of M&S described above. Computational models are most closely associated with the constructive mode; physical models are used from a virtual mode perspective. These linkages are explored in the introductory chapters of the book.

Part Three, “Modeling and Simulation Applications,'' covers two general areas: (1) medical and health sciences M&S research, such as the use of humans as models and human systems modeling, and (2) medical and health sciences M&S education, such as in the areas of robotics, training, and patient care.

There is a wide range of medical and health sciences M&S research. We look first at humans as models and then at the challenge and manner of modeling the human system. Humans as models makes use of real people, who may be asked to do things such as portray or mimic particular disease symptoms to provide an interactive diagnosis training experience for medical and health sciences students and professionals. This type of modeling is included in the live mode. Human systems modeling introduces analytical and computational methods to model and simulate medical principles as a way of understanding how the organ systems control the functions of the body. This type of modeling integrates expertise from numerous disciplines, including biology, mathematics, and computer science.

An overview of medical and health sciences M&S education as a general application area is useful in assessing the current tools available and the need to refine or expand that toolbox. The use of robotics for invasive surgical procedures is making inroads in many hospitals. Surgeons trained to use these tools are observing significant decreases in patient recovery. Robotics is one among numerous M&S applications being used for training. All aspects of care taking can be taught in a fully immersive virtual operating room fitted with a simulated patient and both real and simulated equipment. The system is designed to provide training in judgment and decision making for members of surgical teams using both real and virtual team members. M&S technology is also being used to augment training with standardized patients: persons who are used to portray patients realistically, to teach and assess communication and other clinical skills. Stethoscopes allow the learner to hear abnormal heart and lung sounds when placed on a normal, healthy standardized patient. Another medical and health sciences M&S application area, much more explicit, is patient care, which is the culmination of medical and health sciences M&S research, development, and training.

Although the illustrations are not printed in color, some chapters have figures that are described using color. The color representations of these figures may be downloaded from the following site: ftp://ftp.wiley.com/public/sci_tech_med/modeling_simulation.

JOHN A. SOKOLOWSKICATHERINE M. BANKS

PART ONE

Fundamentals of Medical and Health Sciences Modeling and Simulation

Chapter 1

Introduction to Modeling and Simulation in the Medical and Health Sciences

CATHERINE M. BANKS

INTRODUCTION

Technological advancements have paved the way for new approaches to modeling, simulation, and visualization. Modeling now encompasses high degrees of complexity and holistic methods of data representation. Various levels of simulation capability allow for improved outputs and analysis of discrete and continuous events, and state-of-the-art visualization allows for graphics that can represent details within a single shaft of hair [1]. These technological developments were first exploited among the engineering and computer science disciplines; however, the expanding body of knowledge and user-friendly applications of modeling and simulation (M&S) have resulted in applications across the disciplines. As such, M&S is at the forefront of multidisciplinary collaboration that integrates quantitative and qualitative research methods and diverse modeling paradigms. Significantly, these modeling tools are capable of representing many aspects of life, including life itself. Case in point: the use of M&S in the medical and health sciences (MHSs).

Practitioners in the MHSs are engaging M&S to explore and understand some fundamental aspects of health care, such as human behavior, human systems, medical treatment, and disease proliferation. The training tools available to people in these fields include the three primary modes of M&S: live, virtual, and constructive. These modes facilitate the development of mathematical, physical, computer, and human models. Thus, it can be said that medical and health sciences is an evolutionary, interdisciplinary process of model development and simulation design requiring the expertise of developers (M&S experts) and users (medical and health care trainers and practitioners) to facilitate a seamless mode of information transmission. The information discussed in this book is designed to educate future members of the MHS M&S community toward developing and perfecting a seamless mode of information transmission in the health care domain via M&S.

Consider this seamless mode of information transmission as having two interrelated meanings. The first is a focus on basic M&S as it pertains to the MHSs, in which the objective is to create environments whereby precise information transfers directly to or is discovered by the health care provider. The second meaning, and one that serves as the impetus for this book, is that M&S developers and users must share expertise, requirements, and criticisms while recognizing limitations and expectations regarding model development and simulation design. Any expert modeler will freely admit that modeling is not easy: The more complex the system or entity to be represented or characterized, the more difficult the task of modeling it. Added to that is the difficulty of modeling the organic, dynamic nature of the human body. Similarly, medical trainers and practitioners recognize the dynamism of the body; therefore, they cannot always provide discrete, static portraits of the anatomy or quantitatively convey degrees of pain. Therefore, both developers and users must appreciate the parameters and the tasks that each one encounters to best facilitate a seamless mode of information transmission. In this chapter we introduce the current challenges of developing and engaging M&S in the MHSs. We present the role of M&S as two complementary activities in health care studies: the development of tools and the training and use of those tools. An introductory overview of these concepts is a good place to start.

MODELING AND SIMULATION IN THE MEDICAL AND HEALTH SCIENCES

The M&S body of knowledge is expanding as interest in the discipline and application of models and simulations increases. The academic programs in which the core curriculum of M&S is taught are found in the engineering and computer science departments. These disciplines dominate the body of literature, which is grounded in mathematics, engineering, and computer science. As M&S applications and user friendliness increases, so will student (and user) interest. For many students M&S serves as a way to explore hypotheses and serves as a training tool. This has also been the case with students studying medicine and health sciences; the long history of medical modeling is proof of that.

There is, however, a growing concern that a lack of understanding exists on the part of the MHS student when using M&S solely as a training tool. This deficiency creates a void in understanding the theoretical underpinnings of the M&S. Conversely, engineering students as M&S developers must appreciate the fact that acceptance of medical applications of M&S depends on such issues as performance, robustness, and accuracy—attributes that require medical expertise and/or input at the development stage. A cursory review of the MHS M&S literature sheds light on the fact that a gap exists in the scholarship that disconnects developer and user.

As a whole, the MHS M&S body of knowledge is comprised of books, journals, and conference proceedings that span both the development and application sides of the domain. Probably the most complete MHS M&S subarea in the literature is the technical–developer community responsible for visualization and imaging. Academic training for visualization and imaging is generally found in the electrical and computer engineering and/or computer science disciplines, both of which have been perfecting the development of visualization and imaging technology. In fact, there is a long tradition of scientists and engineers who illustrate their work with graphics that include anatomical illustrations and computer images to provide representations to store three-dimensional geometry and efficient algorithms that render these representations. Other developer-side contributions to the body of literature include subareas such as biomedical and devices and systems: technology and informatics, which speak to computational intelligence and medical simulation as well as to developing next-generation tools for medical education and patient care.

Biomedical engineering is the application of engineering concepts and techniques to problems in medicine and health care. This is a relatively new domain with typical applications in prosthetics, medical instruments, diagnostic software, and imaging equipment. Computational intelligence techniques consist of computing algorithms and learning machines, including neural networks, fuzzy logic, and genetic algorithms. One such study designed for graduate-level students is the 2008 Begg et al. text discussing state-of-the-art applications of computational intelligence in cardiology, electromyography, electrocephalography, movement science, and biomechanics [2]. Numerous biomedical handbooks are available. A notable text is Medical Devices and Systems edited by Bronzino [3], which introduces the term clinical engineer. These engineers are closely aligned with biomedical engineers, whose primary focus areas include the development of biocompatible prostheses; various diagnostic and therapeutic medical devices such as clinical equipment to microimplants; common imaging equipment such as MRIs and EEGs; biotechnologies such as regenerative tissue growth; and pharmaceutical drugs and biopharmaceuticals. Clinical engineers also apply electrical, mechanical, chemical, optical, and engineering principles to understand, modify, or control biologic systems; and they assist in diagnosis and treatment.

Also found on the user–educator side of the body of knowledge is a significant series entitled Medicine Meets Virtual Reality [4–6]. These edited volumes of short papers present different approaches to and uses of simulation. As a whole the series is committed to knowledge sharing and building bridges via breakthrough applications in simulation, visualization, robotics, and informatics as well as experiences between physicians in all specialties, scientists in various disciplines, educators, and even commercial entities that serve as retailers of this technology. This bridge building is significant and necessary. Additionally, the series includes cognitive and behavioral assessments derived from simulation trials used for examining a variety of scenarios, ranging from enhancing dental treatment processes to examining schizophrenia.

Among the numerous essays in the Westwood et al. volumes is one of special interest to M&S educators, as it explains the need to develop body of knowledge repositories and commonly agreed upon definitions for the medical M&S vocabulary. In “Visualizing the Medical Modeling and Simulation Database: Trends in the Research Literature,” the authors, Combs and Walia, present a structured categorization of the literature (choosing to bin it into eight categories) as well as general terminology that can serve as a baseline for a common lexicon, such as procedural simulation and telemedicine [4].

All students of MHS M&S need to stay current with this expanding body of literature to understand the basic theoretical underpinnings of M&S technology and the new tools available to practitioners. These tools include engineered devices such as the cochlear implant, the defibrillator, and the pacemaker, as well as novel applications stemming from the field of biomechatronics, which merges humans with machines. Robotics is also providing innovative approaches to the human–machine interface as well as in clinical procedures. Computer-based M&S has led the development of training simulations where medical practitioners can hone their skills and expand their experience through the use of haptic devices, digital models, and imaging capability.

The body of literature draws attention to the divide or gap that exists between the technical engineer who develops M&S tools and the practitioner who applies the methods. Therein lies the challenge: to balance of both worlds. Students who master the challenge will have accomplished a necessary, meaningful, and useful contribution to these disciplines. A good place to start that mastery is a basic understanding of the terminology and concepts relevant to the study of M&S in the MHSs.

Definition of Basic Terms and Concepts

Throughout this book the reader will be introduced to a number of terms and concepts in the MHS domain. Appropriate for this chapter is a brief introduction to some of these terms and concepts, beginning with the fundamental modes of M&S and the general nature of the model itself. (See Chapter 2 for a detailed review of this information.)

The discipline of M&S and the use of M&S applications is grounded primarily on analysis, experimentation, and training. Analysis refers to the investigation of a model’s behavior. Experimentation occurs when the behavior of the model changes under conditions that exceed the design boundaries of the model. Training is the development of knowledge, skills, and abilities obtained as one operates the system represented by the model. There are three modes of M&S—live, virtual, and constructive—and they are the same no matter what discipline makes use of M&S. Any discussion of these modes should originate from the discipline of the M&S perspective. This facilitates the establishment of a common terminology. It also relates this terminology to concepts found in the MHS domains to help bridge the gap between developers and MHS practitioners. First, there is the live mode approach, the concept of using real (live) people employing real equipment for training purposes. Next, the virtual mode, which is perhaps the most fascinating, as virtual operating rooms and synthetic training environments are being produced for practitioners and educators at breakneck speed. In this mode, real people are employing simulated equipment to improve physical skills and decision-making ability. Finally, there is the constructive mode, used as a means of engaging MHS M&S. In constructive simulation, simulated people and simulated equipment are developed to augment real-world conditions for training or experimentation purposes.

All modeling originates from a theoretical perspective, and it evolves from a conceptual model. The nature of the model can be computational or physical. Computational models exist in a purely mathematical form such as a series of equations, or in an algorithmic form implemented in a digital computer. Physical models can be manikins that contain representations of human anatomy used for the purpose of practicing surgical or diagnostic procedures. Computational and physical models directly support the three modes of M&S. However, computational models are most closely associated with the constructive mode, whereas physical models are commonly engaged in a virtual mode. (These modeling natures are discussed in detail in Chapters 3 and 4.)

It is important that developers of MHS M&S understand the modes and the nature (or origin) of a model. This information is necessary in determining what type of model would best serve for MHS training or as a practitioner’s tool. Training and tools are the two primary categories in which many MHS applications of M&S can be found.

Modeling and Simulation Applications

Generally speaking, the application of models and simulations are found in two broad areas. The first area is research, which encompasses such things as humans as models, human systems modeling, and disease modeling. Humans as models makes use of real people so that they can portray or mimic particular disease symptoms to provide an interactive diagnosis training experience for MHS students and professionals. Naturally, this type of modeling is included in the live mode. (This type of modeling is discussed in detail in Chapter 5). Conversely, human systems modeling introduces analytical and computational methods to model and simulate medical principles as a way of understanding how the organ systems control functions of the body. This type of modeling is interdisciplinary, as it makes use of expertise from numerous disciplines, such as biology, mathematics, and computer science. (This topic is reviewed in detail in Chapter 6.)

The second area is usage and education, such as in training and patient care. The use of mechanical means to facilitate less invasive surgical procedures—robotics—is discussed in Chapter 7. Much of the M&S education in an MHS relies on current tools that are used primarily as training applications: for example, a fully immersive virtual operating room fitted with a simulated patient and both real and simulated equipment. The operating room is designed to provide training in judgment and decision making for members of surgical teams using both real and virtual team members. M&S technology is also engaged to augment training with standardized patients (i.e., people who realistically portray patients—used to teach and assess communication and other clinical skills). Modified stethoscopes allow the learner to hear abnormal heart and lung sounds when placed on a normal, healthy, standardized patient. (The topic of training is addressed in Chapter 8).

Patient care deals with using simulation to improve or contribute directly to a patient’s overall health and well-being. Simulation makes it possible to test new protocols and to design new products to achieve an improved level of health. (See Chapter 9 for a discussion of patient care.)

RESEARCH AND DEVELOPMENT OF MEDICAL AND HEALTH SCIENCES M&S

As M&S educators, the editors of this book found it interesting that the MHS M&S community, a subset of the M&S community at large, would refer to the science of simulation as a separate entity or discipline. This encouraged the editors to conduct an analysis of M&S in the MHSs in an attempt to bring together under one umbrella a shared lexicon. Frankly, until researching the resources for this textbook study, neither editor had heard the term science of simulation (and Dr. Sokolowski has a Ph.D. in modeling and simulation!). As such, a book by Kyle and Murray, Clinical Simulation: Operations, Engineering, and Management, drew attention [7]. That text addresses simulation as a core element of training in medicine, surgery, clinical care, biomedical engineering, and the medical sciences. Specific to this study was an enlightening essay by Richard M. Satava of the University of Washington.

Satava speaks of the collective support for using simulation as a medical educational tool on the part of the Residency Review Committee of the Accreditation Council on Graduate Medical Education. The council now requires that residency programs have simulation as an integral part of their training programs. The American College of Surgeons has also recognized this transformation and is certifying training centers to ensure the quality of simulation training provided. For medical professionals serving as educators, simulation has become what Satava calls a training environment with permission to fail, where students are taught by errors. Thus, as part of a broader M&S education program, this book is designed to encourage the M&S developer community to take hold of the science of simulation subset and integrate it into the M&S body of research and development. To separate the two is confusing and nonproductive, and it perpetuates a disconnect between developer and user. Only recently have the challenges posed by this dichotomy been realized.

In the 2005 report by the National Academy of Engineering, the call for engineering and health care partnerships rang out loudly. By February 2009, medical simulation legislation had been enacted. Appropriately called SIMULATION (Safety In Medicine Utilizing Leading Advanced Simulation Technologies to Improve Outcomes Now), this legislation extends the benefits of advanced medical simulation technology to the civilian health care system and calls for the establishment of simulation technology in medical, nursing, allied health, podiatric, osteopathic, and dental education and training protocols.

M&S has been grappling with accurately characterizing or representing human behavior in models developed from real-world case studies. This is a challenge because human behavior is difficult to evaluate (as it is unpredictable and dynamic) and to quantify. The human body is equally unpredictable and dynamic; thus, it is difficult to model from a developer side. The inherent uncertainty within the model and/or the simulation tools calls to question user confidence. Yet, one must ask: What is the alternative? Simply refuse to model, or attempt to model, human systems or case studies that reflect degrees of uncertainty? No. M&S educators are compelled to press forward with enhancing modeling capability in an effort that best represents the human factors and the human system while fully recognizing the limitations of M&S and the fluidity of the entity being modeled. A multidisciplinary approach to MHS M&S research and development fosters ongoing enhancement and improvement in the applications and tools available for the user community. As the MHS M&S toolbox expands and becomes more sophisticated, a training environment with permission to fail will yield both a desired seamless mode of information transmission and proficient medical practitioners.

MHS Research Centers

M&S is now an established research and development domain that is supported at all levels of government. In July 2007 the U.S. House of Representatives unanimously passed House Resolution 487, declaring M&S a national critical technology that can provide unparalleled advancements in American competitiveness, develop new and innovative ways to protect the homeland, and bring high-tech jobs and economic prosperity to our communities. Among the numerous descriptors found in the resolution is one specific to MHS: “acknowledges the significant impacts of M&S on a breadth of fields including defense, space, national disaster response, medicine, transportation, and construction.” The same 2009 House and Senate resolutions that introduced SIMULATION (HR.855/S.616) focused further attention on the fact that M&S expertise would be needed at all levels: development, assessment (verification and validation), and usability.

From an engineering perspective, there is now, more than ever, a need for partnership between engineers and health care professionals; this is so if engineers as developers and medical professionals as users are to meet the six goals outlined by the Institute of Medicine in Washington, DC and its focus on 21st Century Health-Care. The report by the institute calls for the health care system to be safe, effective, patient-centered, timely, efficient, and equitable. This is a challenge because the health care system is experiencing overwhelming advances and threatening declines. While the changes in medical technology and practice are advancing and improving training and patient care, shortages of skilled health care professionals are becoming severe.

Throughout the United States there are numerous institutes and centers whose research and development focus on user MHS M&S. The Advanced Initiatives in Medical Simulation—AIMS—is a coalition of professionals and organizations intent on promoting medical simulation to improve patient safety, reduce medical errors, train, and reduce health care costs. This collaborative body endeavors to engage the MHS M&S community, articulate a community-wide message to foster a uniform community, and secure resources necessary for future research and development. The Center for Integration of Medicine and Innovative Technology—CIMIT—is another leader in the MHS M&S community. Its aim is to initiate and accelerate translational medical research in the domain of devices, procedures, and clinical systems engineering. Harvard’s Center for Medical Simulation—CMS—provides simulation training for health care providers through high-fidelity scenarios. (There are numerous other centers worthy of note, including Computer Aided Surgery, CAS; Image Sciences Institute, ISS; Computer Assisted Radiology and Surgery, CARS; and the Society in Europe of Simulation Applied to Medicine, SESAM.) Conversely, modeling and simulation research and development centers, such as the Virginia Modeling, Analysis, and Simulation Center—VMASC—also support various MHS M&S application areas and domains.

At VMASC, faculty among numerous disciplines (engineering, mathematics, health sciences, sciences) work in four areas of research and development: (1) training, (2) treatment, (3) disease modeling, and (4) management of health care systems. In the area of training, VMASC researchers developed a fully immersive virtual operating room outfitted with a simulated patient and both real and simulated instruments. In the domain of treatment, M&S is engaged for rehabilitation, to improve the diagnosis and treatment of orthopedic injuries and disorders, and to optimize physical performance. Mathematical models and computer simulations covering a variety of diseases are used for disease modeling. In the subset management of health care systems, researchers are using M&S to understand the effects of bioterrorism on the health care system in conjunction with a mass casualty model.

Meeting the growing demands of MHS M&S effectively and efficiently requires that the education of the M&S developer include explicit input from the user community—the MHS practitioner. A solid foundation for that type of education has its roots in a multidisciplinary approach: developers and users in the same classroom. As technology and application improve, simulation will no doubt find a permanent home in the MHSs. For many developers this is a grand accomplishment; for many users this is an opportunity to provide highly sophisticated patient care. But for some, these advancements give rise to the ethical question of using simulation, inanimate technology, to represent animate behavior and human systems.

THE QUESTION OF ETHICS IN MEDICAL AND HEALTH SCIENCES M&S

The advances made in computer capability (software, artificial intelligence, and software agents) facilitate the simulation of complex phenomena such as human behavior modeling and the modeling of human systems.† Modeling human systems encompasses the representation of the human body. This requires great technical skill, for with greater accuracy of human physiology comes higher-fidelity, more realistic simulation. For the most part, medical simulation is becoming an accepted methodology for educating future medical practitioners and for providing ongoing training and assessment for practicing professionals.

Juxtaposed with these technical advances is the ethical concern of representing human physiology via simulation. The concern emanates from academic disciplines that rely heavily on soft (or fuzzy) and evolving data such as the social sciences and medical and health sciences. Developers (both those producing the models and those creating the simulations) must address the credibility and ethical concern of modeling dynamic organic systems such as the human body to validate M&S as a MHS practitioners’ tool. Central to the ethical discussion are the questions: Should computer models premised on mathematics represent human action (behavior) and human physiology (systems)? Is simulation a valid and verifiable means of characterizing humans? Discussing these questions proffers a means to bridge developer and user understanding of M&S. It also serves to communicate both the constraints and the potential of M&S.

The multidimensional capability of M&S credits it with being an enabling technology. As such, subfields of MHS make wide use of simulation, such as training with manikins, to using haptic devices, to imaging devices and virtual operating rooms.‡ There is a plethora of applications with promise of even more as medical simulation is used in multiple corners: research, evidence-based outcomes, medical education, and performance assessment, to name a few. In the MHS community medical simulation takes on the term surrogacy, which refers to the three modes of simulation in a clinical setting as human (a.k.a live), virtual, and mechanical (a.k.a constructive) [8]. Recall that human (live) simulation uses a trained role-player to act the part of a patient with a specific medical condition. This has been problematic in that a major limitation of human simulation is the inability of students to perform invasive procedures and other therapeutic interventions that could be harmful to the role-player. Virtual simulation employs the latest advances in computer technology and visual interfaces to create acceptably realistic learning experiences.

Game-based medical simulation is proving to be an efficient and effective tool for teaching many clinical lessons without real patients and instructors. In game-based learning (GBL), realism is created in hybrid platforms that allow students to explore virtual environments with highly sophisticated mechanical interfaces. Additionally, there is simulated vision such as three-dimensional photorealism, which provides a sensation of realistic vision in virtual simulation. To create simulated touch, haptic devices are used to facilitate the sense of touch—students are able to feel what they are doing as well as to see it. This teaches the student how to gauge pressure application. Mechanical (constructive) simulation allows students to use mock or artificial parts to mimic the experience that would typically be gained from interacting with a real patient’s body, organs, or tissues. In augmented reality, an application of integrated technology simulation is used to enhance real therapeutic interventions. Those endorsing augmented reality believe that reality plus simulation produces a better outcome than reality alone. Still, professionals in the MHS view the implied trade-off between reality and simulation as insufficient proof that one is superior to the other [8]. So what role should simulation play in MHS?

In 2001, a simulation gaming symposium drafted an assessment of the current state of affairs in MHS M&S [9]. Included was the general concurrence that the bridges between medicine and simulation are many and varied. Coupled with that is the fact that medical simulation itself is in overlapping areas of medicine and health care. Practitioners across the large domain of health care for the most part consider medical simulation beneficial. They contend that as the population increases, awareness of health issues improves, society continues to age, and MHS research and development progresses, health care demands will increase exponentially. Thus, the symposium came to what it believed to be a logical conclusion: There is a need to exploit the benefits of simulation in both training and operation.

Pedagogically, many institutions are using M&S training tools specific to MHS. This is due to the fact there is a great need for doctors and health care providers to quickly gain and maintain competence and demonstrate proficiency in the use of these new technologies. Consider the following:

It is predicted that by 2020 there will be a 20% shortage of nurses.Medical residents training or operating within an 80-hour workweek have less opportunity to interact with instructors.It is estimated that deaths from medical errors range from 44,000 to 98,000 annually, with 1 million injuries attributed to medical error.Various threats (such as bioterrorism) call attention to the speed needed to train first responders (EMS personnel) to react to health crises.

One can speculate as to why these numbers are so high: lack of adequate training, overworked personnel, inadequate tools, and insufficient staffing, among others. A proponent of simulation training, S. B. Issenberg (Center for Research in Medical Education, University of Miami School of Medicine), has suggested a framework for thinking about how to use medical simulators. Issenberg emphasizes the use of repetition, measurement of performance, and feedback as a way to strengthen and to standardize important components of medical education [10]. Health care educational institutions are also aware of the need to provide students with simulated experiences that will enhance educational experience and improve patient safety [11]† Still, this type of education and training is not without its critics, who raise questions of validity and ethics.