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Most training is sold on confidence. Show Me The Evidence is built on data.
In every episode we take a single study, clinical trial, or systematic review and work through what it found, how it was designed, and what it means for the way we teach and assess skill. We focus on metrics-based training and proficiency-based progression, the approach that asks learners to demonstrate measurable competence before moving on, and we trace its results across surgical, medical, and professional education.
This is a podcast for learning professionals and medical educators who want more than opinion. Expect plain-language breakdowns of the research, honest discussion of what the evidence does and does not support, and conversations with the people behind the studies.
If you make decisions about how people are trained, we think you deserve to see the evidence first.
Göran you started with Mentice
in 2008, you
have an engineering background
and you came
really from the high-tech
sector from
automotive and industrial markets.
So you came from that
background into virtual
reality simulation
in medicine, was that really
a very big jump?
I wouldn't say so Tony,
I mean I've always
been working with high-tech
or technology and
selling advanced technology
into a B2B
environment, so that's pretty much
the same and the main focus
is to understand how can
new technology
solve problems for the client
and that's the same
regardless of what you sell
really. So from that
perspective it was known to
me, obviously you had
to learn a new area, application
area, so that
was all new but the basic thing
was fairly similar.
I would say.
So what did you make of this
newish industry?
I mean, because back in
the early 2000s,
like virtual reality simulation
in medicine
was relatively new, medicine,
the Swedish company,
I'm sorry, Mentice Swedish company
was fairly much
at the forefront of where
things were going.
So what did you make of it
and what did you think the
challenges were?
I mean, I think my first
impression was really,
I was amazed by the passion among,
I mean, among our people
obviously,
but also among physicians
and the nurses
that their dedication to provide
care for patient
and to try to make things right.
I think that that was probably
what I first sort of noticed.
But from a challenge
point of view,
I would say that the difficult
thing,
I mean, we always talked about
the big opportunities
obviously in hospitals and provide
structured training
for doctors, for physicians.
But what I faced very early
on is the fact that
training is not really connected
to return on investment
or to value.
In a lot of cases, training
is just the cost item.
So it's really hard to
find a structure
to allocate the right resources,
both financial
and people resources to
provide training
in a structured way.
And in many situations, I would
say that training worked
just because you had physicians
and others
being passionate about training
and they investing their own time.
But in a continuum that
just doesn't work.
So I think that that's one of
my biggest challenges
early on, but in a lot of cases,
that's still the same really.
And in 2026, do you think,
so that was in 2008 there,
that was a big issue and today,
do you still think that's
a big issue?
Yeah, yeah, I would say so.
I mean, of course in
a lot of cases,
simulation is tied to training
of fellows in residence
or a graduate medical education.
And that's still the same really.
Obviously we, both you and
me believe that
simulation should be used for
practicing physician
in the continuum and that's
different.
But yeah, I say largely the same.
I think from an industry
point of view,
simulation has come a long way
where we, 20 years ago,
we're focusing on more basic,
basic learning, imaging,
Catheter & wire techniques
things like that.
Why today, I mean, the simulation
can provide
way more advanced training on
a complicated device
that's in complicated kind
of procedures.
So from that point, I mean,
simulation have improved
quite a bit.
There was a recent article, I
think it was a Jama
in the New England Journal
of Medicine
where they were complaining that
academic medical centres
in the past were seen as the leaders
in education & training
and now more and more profit.
And the business ethos is
moving into it.
And the trainees, the residents
are really seen as service
providers.
But the problem is, okay, they're
service providers,
but the primary duty of the
hospital or the university
is the training of the resident
and keeping the skills up
of the experience
and attending physicians.
And the pace of change with
medical devices
is just astonishing.
I mean, we developed the metrics
for a cryo-oblation device
and it's now in less
than two years,
it's been superseded by
another device.
And physics-based simulation
would seem to me
to be the ideal solution.
So is the return, the business
attitude
and the return on investment
by the hospitals,
by the training organisations,
do you think is that distracting
from the point of the primary
business that they should be involved
in that's training?
No, I don't see that as
a main problem.
I think it's actually
ultimately good
to have a commercial drive
and a commercial push to
become better.
So I think that that should help.
So I don't think that's an issue.
But I mean, if it interferes
with the training
and the insistence on the
quality assurance
of the people that work for
the organization,
where training and quality
assurance of performance
is pushed to the side, surely
that is an issue.
I agree with you about
the business.
Okay, it's a harsh world out there
and organisations do have
to make a profit.
I really don't have an
issue with that.
But what I do have an issue is
if you've got a responsibility
to do something
such as training, such as quality
assurance of performance,
that has to fit into the
scenario somewhere
and that's gonna cost money, that
doesn't come for nothing.
Yeah, no, I can hear you.
I can see that.
So my research has shown that any
simulation without metrics
is a suboptimal tool for procedure-based
training.
What's your view on that
conclusion?
No, I completely agree with that.
I mean, I would say there
are more use cases
and scenarios for use
of simulation
than learning a specific device
or procedure.
But if we talk about structural
learning
to reach a defined level
of skills,
clearly metrics-based or proficiency-based
progression
is the way to go.
So with that, I completely agree.
And so what's the major challenge
for simulation companies
to implement performance metrics?
Because we've had this conversation
many times
and we've gone all the way from
characterisation to procedure
to building the metrics into one
of your simulations.
And the mechanical thrombectomy
for acute stroke
is probably one of the
best examples
where mentors were pushed to build
and subsequently patent
a new device because the
clinicians were unhappy
with part of the simulation.
I mean, that was almost
a perfect example.
So what's the issue for
the challenges
for the simulation company
to build the metrics
into the simulation?
I mean, there are a couple of
things connected there,
but I would say to simplify it,
I would say that the biggest
issue for us
is the process of defining and
validating the metrics.
I mean, we as a technology
provider,
solutions provider have a hard
time pushing that
onto the device companies.
So I think that is a fairly
complicated process
to require the device companies
really think that through
properly.
And if that's not done before
we get engaged,
that I think is the heart
of the issue.
And in a lot of cases
when we do that,
we don't have time enough to,
or the company doesn't have time
enough to make that happen
or to get taken back by the effort
or the cost of that process.
I would say that that is for me
probably the biggest hurdle.
But surely it shouldn't just be
the medical device manufacturers,
surely it should be professional
medicine,
maybe the departments of health,
because the evidence shows that
somebody that trains
on a simulation with validated
metrics
with performance benchmarks,
they perform about 60% better in
the clinical environment.
Surely professional medicine and
departments of health
should have a significant
chunk of that cake
unless they want the industry
to own the metrics.
I absolutely agree with you.
But if you look at the view
of this right now,
at least if you if you ask me and
if you go to US and ask
hospital and physicians, who do you
think is responsible for
the training?
They would in my mind
at least link it
to the device and then
to say it's the
company's responsibility.
So I think it's the question of
who owns that responsibility.
And I agree with you it should be the
hospital and the providers of
of health care.
But right now, in my mind,
it's not the case.
Yeah, I mean, I agree with you.
And a lot of medicine complains
that the medical device
manufacturers own the metrics
and so on.
I said to them, OK, if you
want the metrics,
you're going to have to develop
and validate them
and own them and own
the benchmarks.
Otherwise, I think professional
medicine
going to end up being controlled from
outside their organisation.
And that's not a good position
to be in.
But there seems to be a naive
understanding of,
like you just described, about
the development
and who owns it and so on.
I mean, I think probably
we need something
of an equivalent effort as
the genome program,
where the medicine, professional
medicine
has to develop validate the
metrics at the benchmarks
and then go to the simulation
companies and say, OK,
these are our metrics.
Can you build these into
your simulation?
And there needs to be some
sort of negotiation.
The negotiation, similar to what
we had for the mechanical
thrombectomy that worked out
almost perfectly.
It wasn't 100% perfect, but
it was pretty good.
So many of my clinical device
manufacturer colleagues
seem to have a very naive understanding
of why physics
based virtual reality simulations
are so expensive.
Why do you think that is?
I think that there are more and
more companies that really
understand what you're
talking about.
And obviously, I mean, you
and your team,
I've been working with this now
for many, many years.
And I think there is more and more
people that really get it
and understand the value.
But I think my simple view of this
is that if you get to the training
responsibility
or the marketing department right
now with industry,
it's not in their body.
It is not in the scope,
but maybe not
in their responsibility to
provide training
in the way you provide.
I think if I take a bit of a
different approach to that,
it is also not only for fellows
and residents,
because a lot of the training
that we work with
is related to more advanced
devices like heart valves
and things like that, where you
typically start using them
past your specialisation or maybe
in your two, three,
or four, or five year term after
you have graduated
as a specialist.
So it's not only really for the
graduate medical education
training.
It's really much, much longer.
So I think it's a question really
what you relate to.
I think in hospitals, to
relate back to yourself
initially, they don't
really have right now
a process to define training
programs like that.
We have very few, if any,
development initiatives
with hospitals or with health
care providers.
I mean, all of our discussions on
developing new modalities
or functionalities related
to device industry.
So it just doesn't seem like that
have come to that point
where hospitals actually
define a program,
to define a program specific task.
Well, actually, your honour,
I wasn't actually
thinking of the residents.
I was actually thinking of the
consultants learning to use
a new device or a modification of
a device because I mean,
I mean, OK, I do hospitals, but I
also do quite a bit of work
with industry.
And they complained to me about
the price of a physics based
virtual reality simulation.
I said, hold on a second.
This can be used anywhere
in this country
with the same standards,
with the same--
this can be used anywhere in the
world with the same metrics.
And they seem to have a view that
a physics based virtual reality
simulation is something
like a video game.
You just switch the video
and that's it.
They don't seem to understand that
it takes programmers
and engineers like months and
months on hours of work.
That's never mind the physical
engineering
to actually build the simulation,
the simulator,
the mechanical or electromechanical.
They don't seem to understand
that you just
don't do this in five minutes.
Yeah, but I also might think--
sorry, I interrupted.
I also think, Tony, that it's
a question of what
is the scope for simulation?
What is the ambition you have?
How do you calculate that value
or the alternative cost
of not using simulation?
So I think there's more to that.
I think if you really look at what
you could use simulation for,
if you have the program
you talk about,
if you have a structured training
to provide a defined skill
set of a group of physicians and
you can calculate the value
or compare with the alternative
cost of having people go
through real cases with proctors over
a three or six month period,
you can easily see that the value
of what you provide
with simulation is very,
very high.
But I don't think we do that
comparison in a fair way.
And so why is that not being done?
I mean, Stefano Puliati published
a paper a few months ago
that basically demonstrated that
with a relatively large group,
about 500 group trainees, I
mean, whatever level,
that proficiency based progression
simulation training
costs about a third of what it
would normally cost.
I mean, so this wasn't super
difficult to collect
the information and the data.
So why is medicine not doing that?
Because we know that suboptimal performance
leads to worse outcomes
and worse outcomes cost money in
terms of hospital stay.
And so why do you think
medicine has not,
the business of medicine has not been
collating this information?
I mean, it's a it's a big
question, I think.
But I mean, my view is what we
touched upon earlier on here.
It's an unclear responsibility,
really.
Who's who's responsible for this?
I mean, if you look at industry,
it's it's obviously very
hard for industry.
It's a sensitivity in in measuring
the connection
between providing training
and the sales of a clinical
device, as
you know, that that's one
one sensitivity.
But but it's also unclear
if it's the
if it's the industry's
responsibility.
And I know you say it's not to to tell
a doctor or a group of doctors
that they are not ready to perform
that procedure with that
with that device.
But the question is, who who have
that responsibility?
Is it the the regulatory bodies?
Is it the society's?
Is it the health, the hospital
health providers or is it?
I mean, I think it's a lot
of things there
in terms of the stakeholder
responsibility
that is not clear.
So I think that that in my
mind need need to be,
I mean, it needs to be worked out
in order for this to be clear.
How should this be done? You know, but
but it hasn't been worked out.
And we've sort of I mean,
even if we
go back to the Berkman
study in 2013,
we've known that suboptimal performance
of experienced clinicians.
We knew that we're probably going
to have bad outcomes.
What we didn't anticipate was the
magnitude of the difference.
I mean, it was like something
like 50 to
80 percent difference in
terms of that.
I mean, like we're talking
more than a decade
later and it doesn't sound like
much has happened.
Yeah, no, it's it's frustrating.
I completely agree.
But I think it's a question of and
I probably should have said that
for the challenge I faced
initially.
But I think that that's
really one of the
challenges that if you come
into the group
group, the hospital or a group of
physicians or whatever,
it's really hard to understand
who who have
the authority to determine
who can do what
or who's who's ready to perform
a procedure or not.
To me, that's that's not clear.
I think a lot of that is is
and needs to be worked out and
it's clearly not, you know.
Yeah, I mean, 20 odd years ago,
the the device manufacturer
suspected
that a lot of their device
failures
wasn't really to do with
the device because,
I mean, for example, the
explanted had
like a pacemaker or CRT
that had failed
and they'd get it back to the production
facility to dismantle it.
There's nothing wrong
with the device.
And they sort of suspected that
maybe it was to do with the
clinician, but they couldn't
say that.
Today, they actually have
the metrics to
say, OK, that procedure
wasn't done well.
I mean, one of the interesting
examples was
Yorio Macheroni published a study in
JAMA Open a couple of years ago
where the training he did proficiency
based progression,
virtual reality simulation in Metronics
headquarters in Switzerland,
and he compared it to the best
example of what they would
normally do.
Nobody in the their normal
training,
their controlled or their standard
training group,
nobody demonstrated the
proficiency benchmark.
But in the PBP group, it
was 93 percent.
That was a very hard message
for Metronic takes.
I mean, I think they accepted, but
it was a very hard message
for them
that basically nobody
in their best
example of training that
they often,
nobody demonstrated the
proficiency benchmark.
And I think they get
that the skills
of the operator impacts
on outcomes.
And I think their grappling was,
OK, what do we do with that?
I, as I said, I think
the evidence is
utterly clear that volume
and skill
set have a massive impact
on outcome.
And I think I mean, my view is
that I think right now,
I would probably think that
in the industry,
leaders in the industry need
to take the step.
And I think if you have
one or two of
the of the large medical
device companies
taking the step or providing
structured
training and really providing
training
to to to define skill set, that that
will change the perspective.
And everyone else need to follow.
You know, that that to me is
probably the most logical
path right now,
because I don't see any any clear
next step for me.
Yeah, I mean, the device industry,
they're legally mandated to supply
instruction for use.
There was a I was in Leuven
yesterday,
you know, for PhD, and
the Viva was on
proficiency based progression
training
for a circular stapler
circular stapler
is about 500 euro.
It has about 27 percent leak
and complication rate.
And a third of the patients that
have a leak will die.
This is a 500 euro device.
And we had the device manufactured
train according to the instruction
for use.
The the best trainers
that they had in
comparison to proficiency
based progression,
the standard training,
the industry
training had a one third
leak rate.
The proficiency based progression
trained group had none.
And this is not physics based
virtual reality simulation.
This is simulation on a circular stapler
with an animal model tissue.
And the industry is looking at this
and going, her IFU doesn't work.
And I think they don't know what to
do with that level of evidence.
But I think it's as I said before,
it's very sensitive for
for a device company or their representative
to to make the judgment
or tell physicians that might be
their friends or at least
their clients
that they are not ready.
You know, so I think
there's there's
a large degree of sensitivity
there.
So I think that that need to be
worked out in a proper way.
What I've been trying to
say to them is
they're not saying to them that
they're not ready.
What they're saying is you're
not ready yet.
Yeah, the metric, the metrics
aren't the
simulation companies metrics or
the device manufacturer.
They are the metrics that are
developed by developed from
clinicians who are good
at the procedure.
They're validated with clinicians
who are good at the procedure.
So it's not really the device manufacturers
saying it's the metrics
from their peers that are saying
they're not ready yet.
You know, I would agree.
I think it would be logical
that you have.
I mean, I think more and
more, if you
look at in in the US, you
both, you and me,
have spent quite a bit of time
on US hospitals.
I mean, they move there
to more and
more clinical leadership
and hospitals.
To me, would make it probably more
simple to find a way where
you have a CMO,
Chief Medical Officer, so able
to control that more
as a team leader and say that
this is a structure.
Here's what we're going to do.
Here's the requirement.
You need to get to this point before
you start doing the procedure.
And then you can work
together with
a device company to make
that happen.
I think that's more logical, where
maybe in other situations
where you have a
have a clinical leadership
and then you
have a financial leadership
of a hospital
and those who never sort
of work together
and it's and you have a group
of physicians
that everyone makes their
own decisions.
And I think I think I think
there's a way
to get there where you
can work together
between industry and hospitals.
But that I still think
that's today
still is the is the largest issue.
That is there is no clear
structure there.
Who who makes those those calls?
Yeah, I agree with you.
And I think that article
that I mentioned
earlier on about about the
business ethos
in academic medical centres,
I think
that's attempting to confront
that problem
that you've just characterised.
Yeah.
I mean, I work a fair bit
with industry,
particularly about the rollout
in new devices.
And industry gets that
they're going to
have to, you know, have a
simulation for it.
But the issue that I see is
they approach the
clinical education division
about six months
before they go to market
and they say,
OK, we want you to build
a curriculum now
and get ready for going. I've
been very explicit.
I think that's wrong. I think
it's the wrong approach.
I think that as soon as the device
manufacturer knows that they're
going to market,
they should go to the education
division and
say, right, I want you to construct
us a curriculum.
I think that the the education
division should build the
metrics and so on.
And that probably should be about
two years in advance.
How long would Mentice how long
would you like to be able
to, you know,
build the metrics for a new device
into the physics based
VR simulation?
I mean, first of all, to say, I think
if if there were a structure where
the device company started much earlier
and they created a metrics,
defined metrics and and validated
them prior coming to us,
I think that will be fantastic,
because that
means that we have clients
that is way more
prepared and have a clear understanding
for what you want to achieve.
And I think at that point,
if we are there,
I think the extra effort for us to
implement the metrics
was not significantly delayed
the project.
I mean, I would say typically
depends on
depending on the complexity
of the device
and the procedure, it will
take us three
to six, maybe sometimes
up to nine months
to to to create the program based
on specification.
And I think if if a customer
comes to us
with already defined metrics,
validated metrics,
I don't think it's going to delay
that process significantly.
We're going to do it in
principle in the
same maybe it's a lay of
amounts and so on.
So I think think to me most important
change would be what you said
that the company take
responsibility
for the definition and
the validation
or the metrics prior to coming to
us. That would be fantastic.
Yeah, I mean, I've had this
conversation with some of the
device manufacturers
and they're complaining about
the simulation company.
I said, hold on a second.
What are you complaining about
the simulator?
I mean, your conversation with
them is imprecise.
What you need to do is
you need to go
to the company, the simulation
companies.
These are our metrics. Can you build
them into your simulation?
But if you can't build them in,
we're not interested.
And then it's a negotiation. Which
ones can you build them?
And the device manufacturer
needs to have.
They're not doing that.
I mean, like I don't think it's
the education division.
I don't think it's necessarily
that
they're given much too short
a period of time.
And they seem to be more wanting the
simulation for a marketing tool
rather than actually, you know, an
effective simulation tool.
I don't think they have
they have got
that it's not not a task they
have got initially.
I mean, they have got the task
to define a program
to provide initial training
for advice and so on.
So I think that if you have have
the approach that you
are suggesting,
it probably would require people
from development
and other parts of the company
to be involved as well,
because you probably need way more
technical understanding for the
details of the procedure and the
requirement for the device
and so forth.
And I think that we would have a different
dialogue with the client.
And in a lot of cases
today, I mean,
a lot of our clients
are super smart
and very, very skilled.
But still, we see many, many situations
where the perspective
or the scope of the of the of a project
changes multiple times during
during the project because
they have just
haven't done that work prior
coming to us.
We are redefining the program as
as as we starting the project,
which I don't think is
the right way.
I mean, but the irony
is that the the
manufacturer has a lot of
this information
inside the company anyway, I mean,
with the human factors people.
I mean, when we met with a
manufacturer that was producing
a new robot,
we had to have a conversation
with the human factor
and they were uncomfortable with our
metrics because they thought
we were trying to change
the human factors,
you know, benchmarks and information
that they did.
And once they understood we weren't
all we were trying to do
was operationalise it to build
into a simulation, they were fine.
But they have this information anyway,
so I'm not really sure why
they're not actually using this
information to help build
the metrics.
To go to slightly different
tack, I
mean, everybody's buzzing
about A.I.
at the minute, basically
the amount
of money that's that's
been spent on it
is astronomical. I mean, will A.I.
in your opinion and do you think it's
going to help with metric
based scoring
in real time to give feedback on the
VR simulation to the trainee?
And if if it is, is what sort of
time frame are you going
to put on it?
I think it's probably
a bit premature.
And I'm maybe not the right person
to answer that question.
I certainly think that A.I.
would have have a big
play also there.
I mean, I can say that
I already have
an important role in our
development.
I mean, we use it for in a speed
up code generation.
We we use it to improve
segmentation.
I mean, the process to
convert CT scans
into 3D graphical models
or anatomies.
I believe we can use A.I.
much more effectively to create
new content like new anatomies
and areas, things like that.
So I think it's just a
matter of time
before we can do what
you're saying.
But I can't say if it's one
year or three years.
I don't think it's significant
longer than three years.
Yeah. Yeah. I mean, I
agree with you.
I'm not too sure about
the three years.
I think it might be longer.
What worries me is that the A.I.
research that I read
in the leading
journals, unless there's
something going on
in the background, but
the the A.I.
research I read in the leading
journals, they're making all
the same mistakes
that were made in the laparoscopic
generation where they're using
they're trying to measure
process rather
than actually the quality
of performance.
And I think they're going to have
to develop some sort of alphabet
that allows them or tools that allows
them, you know, to to measure
the actual quality of performance,
which
really means they've got to
measure the errors.
And I don't see anything
approximating that.
And it's certainly not
in real time.
So I agree with you. It's
a few years off.
You say three. I say more
like five to ten.
And that's that's assuming the
bubble doesn't burst.
Yeah, I think it's a question what
you expect, though, because
in my mind,
you still need to have
the underlying
functionality created in
the simulation.
I mean, both I mean, first, the hardware
needs to be able to measure
what you want to measure
in a realistic way.
But then you have in the software,
you need to have the software
capability
from the stock. But if
you have that,
then I think I think you
can have AI to to
make it to sort of evaluate
it to to
to assess it and and
a lot of that.
But I think the underlying functionality
still need to be created
and if you say to make
it faster, that's
one thing, but it's still
going to be made
by by man, so to say,
you know. Yeah.
Yeah. And the irony is,
I think, I mean,
the time, the effort that it takes
to actually label things
and then the effort to
train it is huge.
And the quality of the
labelling that I
see in a lot of situations
is very poor.
But if you if you can get something,
for example, for the mechanical
thrombectomy that Mentice built, I
mean, I think that a lot
of the cases
for training the AI will
probably be on a
simulation because it's
more controllable,
it's more standardized,
it's more precise.
You have the mathematics there and
there seems to be very few groups
actually using the simulation
for training the AI,
which I think probably is the direction
that they should travel.
So the device manufacturers
seem to be comfortable
with using virtual reality
simulation for marketing.
They seem less comfortable
with using
virtual reality simulation
as a training tool.
You've been in the industry for a
long time and in different
contexts.
So why do you think they're more
comfortable with marketing
rather than
metric based physics based virtual
reality simulation for training?
I touched upon it before.
And I think I mean, I think there's
there's quite a bit of value
in what we call marketing tools.
It's not only marketing, just
marketing tools.
I mean, it's a lot of the work that
we do today where we provide
relevant understanding for a
complication or the behaviour
of the device and so.
But so there are a lot of use
cases, as I said before,
where you can use simulation with
without the metrics
for the proficiency based
progression structure.
But I really think that
it's a mix.
The reason why it's not more structured,
I think it's the mix of
probably lack of understanding, coupled
with what I said before,
the sensitivity of really
assessing
skills of doctors and
clinical staff.
That's still, I think, in discussion
I've had with companies.
They they tip toeing around that is
it really our responsibility?
Should we really do that?
What will happen if we do that?
So I think that that and
then maybe a
third point is what you
mentioned before,
the actual cost and effort of
defining that program.
So those those three would
be the reason.
Really, because I really
think, sorry,
going back to what we talked
about before
I think you need to have a force
shaming that perspective.
Either you have a couple of device
company taking the lead
and demonstrating
by example the effect
of that, or you
need to have a regulatory
change or a
or a regulatory body of some kind
saying that stop with this.
Now, now we have a different
structure.
Here's the requirement and then
you have to live up to that.
Yeah, I mean, I don't have a
problem with marketing.
I mean, I know that industry they've
got to make a profit.
I really don't have an
issue with that.
But coupled with that, you've
got to train
people to effectively and safely
use your device.
And one of the uncomfortable
messages
that a lot of the manufacturers
receiving,
and this is in published
evidence that
some of the clinicians that
they're using
for their faculty and have
been for the
last 10 years are really
not very good
at what they do when you objectively
assess the performance.
And this has come as a shock
to them because
the irony is if you ask if
you want to know
whether a surgeon's good or not,
ask the theatre sister.
Yeah. If you want to know whether
somebody's good at training
or whatnot,
ask the device manufacturers
professional training staff,
they know this.
So I'm not too sure why
the hierarchy
is having difficulty
to accept this.
Because if you have somebody that's
not good at doing the procedure,
they're not going to do good
skills training.
And it seems to me that the device
manufacturers, they know it,
but they really don't want
to know it and
they certainly don't want
it quantified.
But an impact on the
sales of their
device, I think if you train
somebody properly,
they're confident in their
capacity to use that.
You're going to have less
complications.
You're going to have
somebody that's
safer and better at using
the device.
And I think they're going to purchase
more devices to implant.
That's always been, I mean,
both you and me
see many examples of the negative
side of that.
If you run into issues, several
of the devices
both you may work with have had
those kind of issues
and you see the negative impact on
sales of something like
that happening.
And I think it's clear, I mean, I
always talk about the
speed to volume.
I mean, in order for you to get a
device to sell in volume,
you need to have a large
group of physicians
properly trained in order to
use that device safely.
And only then you're going to have
the sales number going up.
So it's very clearly
linked to that.
But as I said before, that also
makes it a bit sensitive
because then you can argue
that the device
company only provides training
to sell more.
which is not really the only
thing they do.
You also make sure that when
you provide a device,
you also provide safe care for
your saving patients.
And your experience globally,
not just in Europe,
but in the US, because you spent
a long time in the US,
you think that's an uncomfortable
issue
for the device manufacturers to
deal with, to embrace,
to think about?
Yeah.
You do?
Yeah, yeah.
Yeah, it's a sensitivity,
absolutely.
I mean, I face that, regardless
if it's Europe or US
or even Asia, but I think
in a lot of cases,
either US or Europe, but no,
I really see that
as one of the big issues.
Okay, if we move away from
industry for a second,
do you think teaching hospitals
should have
their own simulation suite
for trainees to use?
And what, in your view, would
be the optimal approach
for those hospitals?
Is it every hospital?
Is it only teaching hospitals?
Is it index hospitals?
What do you think?
Well, obviously I have to say,
every hospital should have
a Mentice device.
You know I would say that.
Okay, let's be sensible now.
No, but I actually, I've seen
since I started
20 years ago, so that,
I mean, we're coming from
a situation
where you create big multi-discipline
skill centres,
things like that.
I mean, you had the US,
the Kennedy bill,
the Kennedy bill back in
05 or 06 or 07,
that way a lot of hospital got
government funding
to build training centre.
And you build these massive
buildings
with all kinds of simulation
and training equipment.
And that might have worked
for some specialties,
but if I look to what we work
with endovascular space,
I mean, there's a fairly focused
group of people.
There's four or five or six
different specialties
or groups of physicians
that have the different
requirement.
So I've really seen all the
years that it seemed
to be way more effective to move
the simulation activity
out to the departments
and really make sure that
you have a structure
where it's not only, as we
talked about before,
fellows and residents or trainees
using simulation,
maybe just, then it's maybe only
a couple of times a year,
but really find a way to
get it integrated
in their weekly structure.
I mean, use it for, you know,
what are the interesting cases
during this week?
I mean, what are we training for?
What are the new devices procedure
we need to train on?
Really get it integrated so
everyone can get used
as a daily use tool rather,
because if it's delegated back
to something you use
a couple of times a year,
eventually it's gonna fade out
and it's not gonna be used
in a structured way.
So I think that the most effective
way we're seeing
is that it's close to
the cath lab.
It's available, easy to set up.
You can use it when you have an
hour off between cases.
You have the proctors close
that can help you.
And, you know, that's the
way it should be.
It should be, you should be
able to start it up
in a matter of minutes and you
can run a case or two
or run a session in a
structured way
with a proctor or a mentor
close by.
That is my way, the best way.
And then I think all these
different specialities
should really have access
to a simulator
with the proper program and
the proper structure
to make that work.
The endovascular simulators in
my view are the best.
The physics-based endovascular
simulators
are the best virtual reality
simulators in medicine.
That's my, and I've long
held that view.
I mean, I also think, I would
pick teaching hospitals
that, you know, have, you know,
a bulk of trainees
for those disciplines.
But I also think that physics-based
virtual reality
simulation should be mandatory.
It should be a non-negotiable part
of part of the residency's
training
and that they demonstrate the
benchmarks and so on.
I think that should be
centrally funded
because a lot of the hospitals
are finding it tight
and they use that as an excuse
to not fund those.
So I think it needs to be funded
either by the European Commission
or Departments of Health.
And the hospitals, you know, they
would have to compete for it
but it would also be
quality assured
what they're actually doing.
Would this, you know, centrally
funded simulation units
in hospitals funded by the
Department of Health,
I'm thinking of Ireland in
the UK and in Europe,
funded by the Departments
of Health
or the European Commission,
would this be a good investment
and why do you think it would
be a good investment?
I'm not just thinking, I'm not
just thinking residents.
Okay, I'm thinking primarily
residents
but I'm not just thinking
residents.
No, I think it needs to be,
I mean, go back to what
you just said.
I think it's important that this
is continuous training.
That this is lifelong training.
I mean, you keep holding
on your skills.
I mean, you know what
you said before.
It's so much new technology
coming out
and new devices every single year.
And I mean, everyone
needs to train
throughout the entire career.
So that's why it needs to be there
and people need to change
their mindset
that this is just, I train
in my other days
and then I'm done, you know?
So I think that that's
the first point.
But to answer your question,
if there would be value for money,
I certainly think so.
But I think in order to put
that structure,
you need to have a very clear view
on who has the responsibility
and who can make the call of
what you're gonna do.
What is the, I mean,
if you talk about certification
or whatever it is,
I think that structure is
just not in place.
I mean, I think right
now there are,
as I said initially,
there are a number of different
stakeholders
between societies, regulatory
bodies,
industry, hospitals and the
position organisation.
And it's not just clear who owns
that responsibility.
So there's been, as you know,
there've been multiple attempts.
I worked with American Board
of Internal Medicine
in the US some 10 years ago
that have a very ambitious program
for cardiologists
to certify them and re-certify
them
and they are implementing
a simulation.
They got massive pushback
from multiple different directions
on why they did that
and how they can impose requirements
like that on doctors.
So I think it just needs to be
thought through carefully
and it should be implemented,
but I think you need to work
out the structure.
I think just getting the
resources or money
obviously would not help.
I think there's more things you
need to figure out first.
I mean, I think simulation
centres,
however it's worked out,
certain index centres
in the country
or in academic medical centres
whether in Europe and the US,
I think that's inevitable.
In the European Commission,
I'm assuming you know what
they're pushing now
for micro-credentials,
for technical skilled performance
and for robotics for endovascular
procedures and so on.
And they don't just want to hear
that somebody's gone on a course.
They want to know actually
what they can do
at the end of the course.
And the fact that the
micro-credentials
are delivered by the universities
means that there's an agreement
across Europe
that if I get micro-credentials
in Germany,
they'll be accepted in Ireland
or in Belgium.
And I think that's a good,
but it's gonna have to have teeth
and it's gonna need money
because the hospitals that
I work with,
they use that as an excuse not to
purchase the simulations.
But it's more than that.
And I suppose that leads on
to my next question.
Suppose these centres were funded
and the simulations were available
for the trainees.
Would you be happy for
the trainees
just to go and play on
the simulators
or would you be hoping that they
did something more than that?
Would that be a trick
question, Tony?
That's not really a trick
question.
No, I know what you're getting.
No, of course not.
I think that if you don't
provide a structure
for how the simulation
should be used,
people will lose interest rapidly
and you will not create any value.
So obviously it needs to
be a structure
and a required learning
and all of that.
So, I mean, there are
some obviously,
if you go back to the residents
and fellows,
there's some value in sort
of market the field
and make young physicians
interested in an area,
but that's just a small
part of it.
If you're talking about really
getting the value
out of the technology,
you need to have a really
defined structure
and provide the structure.
Yeah, I totally agree.
Well, it wasn't a trick question,
but I'm curious what
you would say.
I mean, ERIS is a European robotic
simulation centre
for cardiovascular procedures
and we've just started running
our courses.
And there's two important things
have happened.
One is the European Heart
Rhythm Association
has released a scientific statement
from the society
and the European Society
of Cardiology
that basically says,
"Okay, simulation is a fundamental
part of training."
And that basically what
they've said is,
it's gotta be proficiency based progression
simulation training,
which is a big deal.
And the more applied end,
we've started running the courses
where I think
we're on our third or fourth
course now.
And the trainees, the thing that
we're discovering,
well, I'm not discovering, I was
saying it for a while.
The thing that we're,
the trainees want more simulation
based training.
And what I'm saying to the faculty
is we've got to move
more of the didactics online
and we've got to give them the
maximum amount of time
on the simulator.
Because the trainees understand
the value of the simulation.
It allows them to train on
a good simulator
in a safe space away from
the patient.
And it's safe for them
to make mistakes
because they can learn more
from the mistakes
than they can actually from
getting it right.
But I think that simulation
centres in hospitals,
whether it's probably academic
training centres,
university hospitals,
I think that's going to
be inevitable.
But I also think you're
quite right
that it's gotta be something
structured.
They can't go, a trainee or faculty
who says in front of me,
well, I'm gonna play on the
simulator for a while.
And I say, no, you're not.
You're gonna train on the
simulator for a while.
There's no playing on the simulators
on this course
because it's a very significant
part of how we train people.
But I mean, you have every
speciality,
every faculty is their own
entity sort of.
So I think, I mean, if you're
gonna work it procedure
for a procedure or faculty or
speciality per speciality,
it's gonna take a long time.
So the question is how do
you approach it?
If you manage to do it
in one area,
how do you make it move
to the next one?
So I think that there is a structural
element of this here
you need to figure out.
Yeah, but I think you as industry
and me as an academic,
I think we're partly at
fault as well
because a young colleague
of mine said to me,
he says, "Tony," he says,
"proficiency-based progression
simulation training."
He said, "It's not that the
evidence is not there."
He says, "You haven't sold it
or we haven't sold it
to the clinical community."
And I think he was quite right.
You look at the amount of evidence
there is on simulation,
the effectiveness of simulation-based
training.
And I mean, I'm still hearing
colleagues
talking about how expensive physics-based
simulation is.
And you match that up
against the cost
or the consequences of the
death of our patient.
I don't know.
I mean, I think you told
me this before,
but maybe this is the thing,
that we will lack that evidence,
that actual evidence to, as you
usually say, body count.
I mean, you need that ultimate
study then maybe.
I'm not sure if that is the case,
but if you need that
study to prove
that if you use simulation
structurally
with a professional-based
progression,
this is the outcome you're
gonna get.
If you don't do, this is the
outcome you're gonna get.
And maybe that's what needed,
but I'm just skeptical.
I mean, obviously we have
not been able
for financial reason to
do that study
because that's a very costly
thing to do.
Then the question, if that would
be done in one area,
how would that be transferred
to other areas?
Would it have to repeat that
in every single faculty
or every single speciality?
No, I don't think so.
I mean, I agree with
you that that,
and it's always been my ambition
in that study.
But I mean, the person who told me
about not selling proficiency-based
progress,
I think he was right
at resonated.
I mean, I don't think it's
gonna be one thing
that's actually gonna get a
simulation over the line.
I think it's gonna be multiple
factors.
And over the last five
years or so,
I think the evidence has
been accumulating.
Industry, I mean, the fact
that they have,
they have their own published
prospect
of randomised blinded studies
published in the leading
medical that demonstrates their
simulation-based training.
They have the simulators,
but they're not using
them properly.
And I think there's almost like
a cascade building up,
but you're quite right.
We do need that ultimate study
that's prospective randomised,
it's squeaky clean,
and it basically shows
a body count,
where there's no ambiguity, this
is the cause and effect.
So in your opinion, how should
VR simulation be used
and is not currently in the
medical device sector
and in healthcare?
I mean, it's always, I mean,
regardless if we come
from industry or go directly
to hospitals,
it's always the training
of physicians
that is the end goal here.
So, I mean, I think that the
reason why industry
has been driving this is because
there you have the link
to value and the ability to
actually fund simulation
that ultimately provided
to doctors.
But if I look at what we do
now in hospitals,
I mean, it's always been said
that hospital for us
is the ultimate opportunity
or ultimate target.
I think that right now we
probably target,
I don't know, less than 5%,
less than 3% of the opportunity
in hospitals,
since it's just part of a TELOS
residency program
that is used for simulation.
It's not really providing the
structure all the way
to training them to a
specific goal,
but even less so for the
practitioners
used in their continuum for certification
on new devices,
new procedures also.
I think that we can use simulation
way more,
way broader.
I mean, if you look at the process
of teaching a practicing
physician,
a new procedure like heart valves
or a section heart
and then helping them to use
a new complex device,
like a micro valve or something
like that,
that's today a six to nine
months process,
maybe more in some cases,
but simulations are only used for
the first part of that.
And I think that if you
have a program
that you're talking about,
you can use the simulation
much, much further
and in a very cost effective way
and reduce the time to proficiency
for those trainees significantly,
which would obviously lead
to better outcome,
lower cost by industry.
So I think that there is a
lot of opportunities
to really extend where simulation
is used.
I also see that too,
if we provide,
I mean, we continuously improve
the realists of what we do
and we also work a lot,
have been working a lot
with structures
to provide a unique patient
information
or a unique cases that we say,
all the way up to patient
specific situation.
I think that if we can continue
to improve that,
we can provide way more learning
capability
or ability for physicians
to really practice
and learn on every single
situation,
up to a point where you can train
before and after a procedure.
I mean, you can prepare
for a procedure,
you can warm up in a proper way,
but you can also after
the procedure,
work on what went right,
what went wrong
and how can I improve to
the next round.
You can also bring up situations
from the week
as we talked about before
and train the entire
group of people
on making sure that we always
come together,
improve on what we do.
If you do all of that,
I mean, the opportunity for use
of simulation in our area,
could be, I mean, 50,
100 times larger
and we can provide significant
value to healthcare.
I mean, you know, there's so
much challenges around,
cost are increasing, we're
all getting older,
you can provide very advanced,
complicated care,
you're not getting older, but
the rest of us are.
And you provide very
high cost care
way up in the age spectrum.
So I think it's just important
to use technologies
like simulation to help improve
productivity,
reduce cost and make sure we
provide better care really.
So it's a lot of opportunities.
I know I totally agree with you.
I mean, unfortunately, I think
a lot of medicine
and healthcare looks at simulation
as some sort of magic bullet
and it's not,
it's a tool, but it's a very
powerful tool.
I mean, there was a friend of mine
many, many years ago,
he'd just come back from three
weeks in France
and I met him in the evening
and he said to me
that he had been operating
that day
and he had felt very de-skilled.
He'd been away for three weeks
and that led to a subsequent study
that we published in Annals
of Surgery
that shows once you're away from
the job for about two weeks,
you significantly decrease.
And so I use simulation primarily
for training,
for residents or fellows or
for a new device,
but that surgeon could have
gone to the simulator
and could have got their skills
back up to a level again.
I mean, there's so many uses, I
totally agree with you.
So what do you think the
future holds
for physics-based VR simulation
in medicine
and in healthcare?
Where do you see it going?
We will be able to provide
a situation
or an environment where clients
in hospital
can create their own content
and in a much faster and
effective way
to make the information relevant
for all kinds of situation.
And if you couple that with
structures for metrics
and the proficiency-based
learning,
I think we can provide very
relevant training
for all levels of expertise
of physicians,
but also other clinical staff
like nurses and techs.
So, you know, but it needs
to be integrated
in the daily clinical practice
and be a natural part
of your work.
And people need to get paid
to use simulation.
They need to be part of
the requirement.
That's not the case.
So it's a lot of things that
need to be changed
in the structure and how people
are reimbursed
and paid for what to do.
Because today, I mean,
the people have to use their
own private time
sort of in other cases to
go on a simulator,
which is not right.
Yeah, no, I totally agree
with you.
I mean, I think I've always
valued simulation
particularly the endovascular
Simulations.
I mean, I think I bought
the first one
that you produced in Europe.
And I mean, in comparison today,
there's a significant,
but even back then I saw
the value of it.
And I look around at some of my colleagues
in clinical medicine and
in industry and they see it's some
sort of magic, but it's not.
It's a tool, but it's a very, very
powerful tool that can be used
in many contexts.
And unfortunately at the minute
that it's not.
But I'm also cognisant
that part of
that may be my fault that
I haven't really.
I just assumed people would
understand and get it.
And unfortunately, not as many of
them have got it as they
would like.
Yeah, I don't think you should
take responsibility for that.
I think you have helped a lot.
And we all have tried
to move this,
the development of this
over the years.
And I think we come a fair
bit on the way there,
but certainly a lot, lot
more we can do.
So, yeah.
All right, Göran.
Thanks very much.
Always good to talk to
you as usual.
Thank you, sir.
All right.
Yeah, sure.