The Role of Simulation Training in Cardiac Electrophysiology

Podcast discussion with Stephan P. Seslar, MD, PhD, and Ashkan Ehdaie, MD

In this episode of The EP Edit, we are highlighting a discussion on simulation training in cardiac electrophysiology (EP). Stephan P. Seslar, MD, PhD, is an attending pediatric cardiologist and electrophysiologist at Seattle Children’s Hospital and assistant professor at the University of Washington School of Medicine. Ashkan Ehdaie, MD, is an assistant professor of cardiology and associate director of the Clinical Cardiac EP Fellowship Training Program at Cedars-Sinai.

You can also listen to this episode on Spotify and Apple Podcasts!

Stephan Seslar: My name is Steve Seslar. I am a electrophysiologist at the University of Washington and Seattle Children's Hospital, and I am excited to talk today about simulation training in EP.

Ashkan Ehdaie: Hi, I am Dr Ashkan Ehdaie. I go by Ash. I am one of the faculty members in cardiac EP at Cedars-Sinai Medical Center in Los Angeles, California, and I am the course director of the Cardiac EP Advanced Simulation Program. I am excited to talk about our simulation program, what we are planning to do in the future, and some of the gaps in our knowledge for this purpose.

Seslar: Great! I am glad you are here. I called you last fall to reach out and try to understand where the simulation field was in EP, like where had we gotten to. I called around the United States and talked to program directors, and your name came up quite early in that conversation as somebody who I should talk to. So this is going to be exciting. For me, this started about 5 or 6 years ago when I was heading up the adult congenital program at the University of Washington. As you know, all those patients are unique. Everyone is a little different and their cases are challenging. As a trained and reasonably seasoned electrophysiologist, I was looking for ways to do simulation to try and learn more about how to approach those patients without them having to be in a procedure. That is how my interest got started in this, and it has been a long and interesting journey. How did you get started in simulation training?

Ehdaie: Believe it or not, when I was a trainee, I stumbled onto some of the resources we had at Cedars-Sinai. It was out of my own interest in practicing these procedures off hours, getting repetition, understanding what I am looking at, and advancing my own techniques throughout the fellowship. We had an understanding that there was a simulation center in our hospital, but I did not understand to what extent that meant as far as hardware and software and what we could use. So, it started from there. Once I understood what resources we had and what I could do with the system, it transitioned into using this to teach and learn as well as explore and complement what we do in the lab, so that we not only get the benefit from that, but also the fellowship program at our hospital.

Seslar: One of the things that I found, and I spoke to probably more than 20 program directors around the country, is that there was very little simulation training going on, and what did go on was mostly industry bringing in specific simulators to show people their products more than anything else.

Ehdaie: Right.

Seslar: So, Cedars-Sinai represents a unique approach to this, where they have actually integrated it into their training program. Can you talk a little about the challenges in doing this and why Cedars-Sinai is able to make this happen in so many programs? My own has struggled to bring simulation training in.

Ehdaie: I think you have to start with awareness, just like myself. I did not even know that existed at our hospital until I stepped in and explored. So if you do not have awareness or you have not explored the resources or what you have in front of you, it is hard to imagine that you could use it and have it incorporated into some kind of program. So, it is nice that we are doing this, because I think this helps with awareness, for you and I and everybody else that are part of the team to be able to explore with what we have and raise awareness for this useful educational resource. The other thing is that I think the resources are limited in that sense. For example, it costs money to buy a machine that has high fidelity that requires service, upkeep, and software. When I explored some of the other programs and looked at what they have, they do not have what we have, for example, that has been bought by the Cedars-Sinai Foundation and the money that has been put into the simulation center. So, the second limitation is having the resources.

Seslar: Yes, I see. What I found was that when we go down the ladder a little, simulation has really made inroads with medical school trainees. But as they get farther out on a branch, you may have one or two trainees at a given center. It is hard to justify tens of thousands of dollars for some of these simulators when you are talking about a low number of simulation trainees. That has certainly been one of the challenges that I have seen reflected back as I have talked to different program directors. The other thing I would like you to comment on is what do we know about simulation training in terms of how effective it is, where the data is that shows that we are improving outcomes and improving on the apprenticeship model, and how do we start filling some of those gaps?

Ehdaie: I think that is an important point, especially moving forward. We want to be able to objectify how this program works and how simulation can impact patient care, whether it is efficacy or safety outcomes. It is difficult, to be honest. We have talked about this topic within simulation a lot. How do you objectify an outcome with simulation? If you look at the data, for example, a lot of it comes from small series of students that have done certain things such as a transseptal puncture in the EP or interventional lab. After the transeptal puncture, they are graded and it is determined they did well after a certain amount of simulation. When they take that to the lab, they are graded based on their abilities to do certain techniques. That is difficult to standardize. That is our biggest gap in knowledge of how simulation is going to be used to improve care and how to prove that. Everyone has their subjective assessment. For example, this fellow did much better when they went through simulation for the first month compared to the other fellows in the past. That is not going to hold any water and we need to objectify that to see how we can improve the outcome.

Seslar: Yes, we can definitely feel the difference, but demonstrating and scientifically is challenging for all those reasons. We can look to our surgery partners, who I think have done more in this realm and have a lot of standardized observational scoring methods. The Objective Structured Assessment of Technical Skills (OSATS) score comes to mind, and I think that we have to take the time to validate some scoring systems and put them into place. We need to have systems that are high enough fidelity, but also reflect the cost sensitivity of the programs that are trying to do this. That is a challenge and what we have been facing.

Ehdaie: On that topic, do you think there should be some kind of a committee, in a sense, to say that these are people that have explored simulation and these are people that have used simulation? Should we develop a curriculum that can be used and referenced to help other EP communities or programs? I think that is something that we brought up before.

Seslar: Yes, this is a great example of where sharing resources could have a dramatically positive effect on what we can do. We all do not have to go and reinvent the wheel in our own programs. In fact, there would be strength in putting things together as a group where it would give it buy-in. There is a relatively small number of training programs and some are more interested in simulation training than others, so I feel like we could get a core group together to at least get something moving in the right direction.

Ehdaie: The other thing you mentioned is how to expand simulation and virtual reality. It does take away some of the hardware resources that are the limitation. For example, my system is different than what you envision to be a system for training. What are your thoughts on that? How, if cost and resources are barriers, how do you use virtual reality to eliminate those barriers (for example, hardware and software barriers)?

Seslar: That is a great question. I think one of the problems is that if you have somebody bringing the hardware in, like a big company, or flying people someplace for a couple of days, I do not think that gets at the heart of what we are trying to do. What we want is something where people in your program have access to it on an ongoing basis and they continue to train on it over and over again. Virtual reality solves that problem in a couple of ways. One of those ways is to group people in a virtual reality setting and allow them to interact with one another over distance. We have been able to bring together programs across the country to participate in virtual simulations. You also know that my bias on this is that I think the virtual means of simulating stuff that is tactile and moving things through what will be a physical heart when you are doing this in a clinical procedure, is challenging. I am not crazy about the idea of pure virtual simulation, because I think it loses something when we have to mimic rather than feeling the physics. So, it is a challenge that we are working on and we have some ideas about it that have not yet been validated. On the one hand, having the resources to put a physical system in everybody's program seems unlikely. Flying people somewhere does not seem like a good long-term solution. So, how do we do this where we can keep everybody where they are and still have them interact in a way that is meaningful and feels like a real procedure? There is a lot of work going on with haptics in the robotics space, so I think there are avenues that we could explore if we had a group of interested people.

Ehdaie: I agree. I think that is trying to balance what you have as full virtual without the haptics or the tactile feedback that you need vs the resources that come with hardware and buying. That is difficult.

Seslar: The other thing that is interesting about the virtual world, one of the advantages, is we can display things in ways that you currently cannot in clinical procedures, but I think can add to trainees' 3-dimensional (3D) perception. So while I do lament the lack of the tactile feel, I love that we can immerse ourselves in the structures. As you know, we have done these sections that are purely anatomy based. We can literally crawl inside these hearts and give people a tour and introduce this to fellows in a way that is quite unique compared to how we all learned anatomy in our days of training.

Ehdaie: Yes, it is surreal. Being able to go inside a normal or congenitally defective heart and understanding where the structures are and the color coding, including everything else that you can do with the software, is just amazing. You cannot get that in real anatomy.

Seslar: Yes. You can also translate these images that give a full 3D perspective of what is happening and then we can also render them back in a 2-dimensional (2D) format. So this is what is really happening and what it looks like inside there, and now we are going to show what the view is that you would actually be seeing to help people make that transition. When I started, there was no Carto system (Biosense Webster, Inc, a Johnson & Johnson company). We used fluoroscopy and we got used to looking at gray scale 2D, and we learned how to make what we saw into a 3D object in our head. I think we can shorten that learning curve by immersing people in a virtual environment, but also showing them the 2D version as well. So I think it is time for a relook as to what is possible in EP simulation. I do not think anybody would disagree that if we can do it and have a way of assessing it, it would add value to the training programs that are out there.

Ehdaie: I agree. There is so much to be learned from repetition, the amount of hours you put in, and the teaching process. I think there was a book written about the 10,000-hour rule. If you want to be skilled at something, you need to practice. That has a lot of limitations in the real-life lab, but it also has to do with who teaches that aspect as well. So it is good for the student, but it is also great for us that we are able to explore this and understand how should we teach simulation. You have models of hearts, I have catheter manipulation. There are certain things that we have to look at and assess how we are going to teach this to the trainees.

Seslar: Yes. So, if there was a call from this interaction, it is that we have talked about getting together at the Heart Rhythm conference with people who are interested in this and building a groundswell of people who think this is worth pursuing. You and I certainly do, and I think it would be exciting to take a step back and rethink this. Let's figure out where the barriers are and try to move something forward that we know will help with training and safety and all the things we know simulation training can do. We just have to take the time and put the effort in to make it work for EP.

Ehdaie: Absolutely. This was an amazing discussion. Thanks Steve, and thanks to everyone putting this podcast together. I think this was a great discussion about where simulation is and what we need to do. It is an amazing resource for our fellows, I can tell you that. I want to explore the options of moving forward and making this a nationwide or worldwide phenomenon where everybody can experience what we experience.

Seslar: Fantastic. Yes, I greatly enjoyed the discussion and look forward to working with you more on this as we go forward.