Since 1550, the famous adage “Usus promptos facit”, commonly known as “practice makes perfect” has formed the basis of learning. Our magical brain termed plastic has the capacity to respond and adapt to environmental demands. Brain training allows extraordinary growth of new pathways, which enable the brain to develop more connections to provide a heightened learning ability. To achieve this, the brain is put through mentally challenging situations and trained. Research has shown that trained brains perform much better than untrained ones. The achieved skills are detectable even after 10 years.

Intelligence Quotient, IQ, obtained from the ratio of mental age to chronological age multiplied by 100, has always been used to gauge a person’s intelligence. It is calculated after making an individual take a standardized test which includes scientific and non scientific portions. It tests arithmetic, reading, vocabulary, general knowledge, abstract reasoning, visual and verbal aspects. One of the brightest minds belonged to Albert Einstein whose IQ score reached 160-190, a score of superior intelligence, genius even. To help understand this exceptional person’s mind and IQ, we will take a look at important milestones in his life.

As a child, Einstein was a late talker and very shy. At 7 yrs, he was heard repeating his sentences softly to himself, giving an impression that he was dull. Growing up in Germany, he studied Calculus at the age of 12, 3 years earlier than his peers. In 1895, he sat for the entrance examination for the prestigious Swiss Polytechnic School while he was 2 years younger than his fellow participants. That was the only test Einstein failed in his entire life. In the test, he did exceedingly well in Physics and Mathematics but failed in non-scientific subjects, especially French. His background German education did not train him in History, Language, Music and Geography. Yet, not crestfallen, he immediately joined the Cantonal School of Aargau for training and gave a second successful attempt for the entrance exam later the same year. In 1905, aged only 26, Einstein published 5 brilliant papers in Annalen der Physik in a row, the most revolutionary being the September issue carrying the explosive E=mc2. Modern studies have diagnosed this enigmatic man with Autism or rather Asperger’s syndrome, its milder form. He was often aloof, keeping away from society, describing himself as a lone wolf and his German academic learning as a military drill often giving him a psychological block.

What we take note from the above is that Einstein’s brain has been trained prematurely, ahead of others. To test this theory, he succeeded well above average in matters that he studied for long back, but failed helplessly in those that he ignored. Brain training himself led to him rising to the entrance exam challenge. Ultimately what we do conclude from this is, to achieve excellent results the brain has to be trained and exposed to new situations beforehand. Exposure once builds new synapses. Repeated exposure wires the brain and becomes etched in memory. Subsequent exposure just triggers memory with an automated response. Any exposure after this refines our automation to a level of pure perfection. There is no better way to expose the brain to repetitive stimuli than through simulation. It is fast, flexible and safe. Today, to make the most of these resources, why don’t we apply them to Surgery where mistakes hang us between life and death?

The traditional Halstedian training method allowed the student to learn surgery through direct observation and imitation of a mentor’s skills. This apprenticeship model bequeathed to us has become anachronistic in the 21st century with the growing complexity of surgical illness and the expectation to acquire the best skills in the least possible time. Thankfully, an enlightening alternative has been training through immersive surgical simulation.

The riveting experience of immersion, akin to being submerged in water, has not left surgical simulation untouched. Today, immersive surgical simulation brings us to a totally engrossing environment with loss of physical awareness. This technique uses immersive virtual reality, iVR. The more realistic and interactive the virtual world, the more engulfed we become in it. To develop a surgical simulator, the following steps are involved: generation of 3D anatomical models, measurement of soft-tissue material properties, their integration, development of collision detection and response techniques for interaction, merging of hardware and software and ultimately, system validation [1]. iVR perfects each step. An ideal surgical simulator should have the following components:

  • A graphical interface which displays real-time, detailed, stereoscopic, high-fidelity models[2] while reflecting anatomical variability with multiresolution techniques. The latest GPUs (Graphics Processing Units) have superseded CPUs, providing a peak performance of 1600 Gflops [3] through parallel processing of instructions with thousands of cores. Better still, Intel® Phi TM provides 1.2 teraflops of performance.
  • A refined acoustic interface that can be programmed to generate operating room sounds like the buzzing of diathermy, the patient’s breathing, heartbeat and the hustle and bustle of anaesthetists, OR nurses, technicians and interns in surround sound acoustics for emotional engagement. Recently, the LISTEN [4] and the 3D Audio Projects by Microsoft [5] have utilised sound with motion tracking for better immersion.
  • A haptic interface with force feedback mechanism to provide precise kinesthetic and tactile impressions[6]. Tactile semiconductor sensors detect a wider range of tactile stimuli to approximate the human touch. Geomagic Touch point-based devices now give precise feedback at a single point and allow for 6 degrees of freedom of rotation [7]. Exoskeletons worn on the outside of the body generate a higher range of force feedback from numerous joints. Carter et Al has created ground-breaking non-mechanical, non-contact UltraHaptics [8].
  • An olfactory interface that replicates the foul smell of Fournier gangrene, the roasted scent of diathermy or the feculent odour of perforated bowel. Soft tissue simulation of as many different tissue textures as possible using an improved mass-spring model [9] to mimic non-linear elastic behavior of human organs will produce realistic features.
  • Another feature is the use of Augmented Reality displays to superimpose virtual pre-operative plans directly onto the patient. In the theatre, contours will show cut paths, tumours or delineate boundaries of interest using operative microscopes, VR loupes or laser technology. Better still, software such as Argonaute 3D allows professionals in various locations to simultaneously view, analyse and discuss cases with stereoscopic reconstructions of the patients’ entire systems [10].
  • An innovative teaching concept is a simulator with a huge database of simulated pathologies, feasible therapies, clinical cases and perplexing 3D reconstructions of all possible anatomical variations such as the Phrygian cap of the gallbladder or the tortuous caterpillar turn of the hepatic artery. This should be made readily available to users for reference and comparison.
  • Better immersion is achieved by establishing presence. Distractions in the form of cumbersome equipment need to be discarded. Hence, induction of sensations can be implanted directly into the body’s nervous system. Hypothetically, Brain-Computer Interfaces in the form of nanorobots connected to the brain wiring can tap artificially generated nerve impulses while shutting out natural ones. Very powerful systems, using perhaps quantum computing techniques, to process such complex VR inputs/outputs would be needed. Moreover creating a realistic avatar [11] of oneself in the virtual environment will increase one’s presence.
  • Immersive experiential simulation needs to be highly versatile providing flexibility. The surgeon should be free to manipulate the program to go back to any specific step and repeat it at any time. He should also be allowed to carry out complex manoeuvres which are normally prohibited with a simulation of the immediate consequences of his error, thereby increasing his surgical realisation and exposing him to all possibilities. The goal is to achieve professional automaticity with very little conscious effort.
  • Based on the user’s learning method, both virtual companionship and autonomous mode can be provided. We will be surprised how a virtual teacher can help. He can be very encouraging after the initial simulation excitement has worn off and boredom sets in with repetitive manoeuvres. He can co-pilot with a student, taking control of certain parts of the operation to teach.
  • Recognition and reward also stimulate immersion. Simulation needs a validation system. An internal validation checks if the correct task has been performed. An external validation, however, checks the application of the acquired skills on a new situation. Both have to measure skill, precision, progress, number of attempts, ambidexterity, decision-making as well as identify foibles. Scoring and ranking would spice up competition, with surgeons attempting to break their last records to reach excellent standards.

Surgical simulation is nonetheless double-edged. Challenges include cognitive overload [12] and simulator sickness amongst others. The key is to make the virtual transition as subtle as possible. Eliminating superfluous media and focusing only on goal-relevant information improve concentration and performance. Simulator sickness arising from sensory conflict or postural instability theories mostly presents with nausea, disorientation and oculomotor disturbances [13]. Some advise habituation while others advocate limiting simulation sessions to only few hours per day as a coping mechanism.

Discovering the brain’s secrets, getting it exposed to the best conditions to unleash its full potential is what we hope for to follow in Albert Einstein’s footsteps. Being immersed in rich, challenging experiences is particularly favourable for learning and developing insights to work with complexities. In this era, immersive surgical simulation is fundamental to gain mastery and will revolutionise future training and skills acquisition to pursue excellence. The day the training surgeon no longer discriminates between a simulation and a real operation will be the day immersion would have reached perfection. Till then why don’t we create as many brain synapses as possible?


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