So what is simulated medical training? There are many different ways to practice health care including consultations with actors pretending to be sick or sick people asking each intern the same questions, hands-on case studies using simulated mannequins in realistic health-care settings, or practicing surgical skills in fully virtual environments and even computer games.

With all these different ways of simulating medical care it seems challenging to find a starting point for systemization. In this article we outline the benefits, challenges, and best practice for simulations in health-care training.

 

WHY PRETEND?

The opportunity to practice and master real-world skills has proven benefits:

 

Safety

Simulation training was pioneered early last century by the aviation and military industries because something had to change: Too many pilots were dying.

 

Due to the popular belief that great pilots were born rather than made, too many flew off unprepared—and paid the price. Flight simulators saved countless lives by giving pilots the chance to safely practice dangerous challenges like landing in a fog or flying through the eye of a storm repeatedly until they mastered the task.

 

Many of these early simulation strategies were crude, the storm being no more than a few assistants rocking the plane, but with practice they showed results. These successes made people rethink how to teach and inspired efforts to apply simulation training to equally life-threatening medical challenges.

 

In part, the growing emphasis on systematic practice in medical training is a response to the disturbing realization that an alarming number of patients have died due to medical errors. At the start of this century reportedly 98,000 deaths could have been prevented, more than those attributed to motor accidents, breast cancer, and AIDS [1].

 

Medical education has been redesigned in order to fix this problem. Although simulations might have historically focused on psychomotor skills, today they also emphasize on the contextual application of key safety skills such as strategic decision making under pressure or teamwork in a crisis.

 

Relevance

Written textbooks are excellent reference materials, but do not tell the full story. Patients have personalities. A patient's  recovery might be impaired due to their worries, or they might not notice their condition or ignore all advice until it is too late.

 

Administering health care to  actual people is very different from writing a test. Written scenarios may fail to reveal every challenge a surgeon might face and as a result students may not notice the small cues that give away what is really going on.

 

Systematic and objective

Simulations on the other hand can help to fine tune complex health care practices. The ability to target, provoke, and record a range of conditions, including (in some fields) standard tests for certified practitioners, helps educators objectively assess competency as well as teach procedure.

 

Identical scenarios can be repeated infinitely. They can also be reset to expose those taking part to all sorts of unforeseen circumstances. As a result, weaknesses can be identified that might otherwise have gone unrealized. Those weaknesses can then be diminished in a workshop by using increasingly difficult challenges until participants attain the required competency levels [2].

 

The opportunity to get ahead and master essential career skills

Assessment is an essential learning tool for this sort of training. Deliberate practice focuses on achieving clear goals and improving performance [2,3]. In order to be clear those goal posts might define relevant procedures, rather than outcomes per se. Nevertheless, studies show that students exposed to appropriate and relevant scenario-based training end up with more skills than those who do not have the same opportunities [2,3].

 

Accessibility

Educators have always been able to use surrogate patients as a way to safely teach medical care, but this works only to a certain point. Broken bones and surgical incisions cannot be practiced on real patients, regardless whether they are surrogates or not. Computer technologies open up a new chapter in medical training. They are also increasingly affordable.

 

In the late nineties state-of-the-art mannequins might have cost $250,000 or more. The release of the first SimMan in 2001 for under $50,000 marked the beginning of a new era in medical care. Today, as real patient surrogates become less available due to safety concerns and shorter hospital stays, computerized simulations are becoming more sophisticated and accessible.

 

 

CHALLENGES

 

Cost

Computerized simulation equipment may cost less today, but simulations are still time and work intensive. Unlike classes where one lecturer can teach 20, or even 100 students, in practice-based training it is more likely that three or four faculty are required to facilitate small teamwork scenarios.

 

Developing the necessary skills to support these activities is equally time intensive. Digital learning support materials need to be developed specifically for the diverse curricula, maintained over time, and kept up to date with changing medical technologies. This demands substantive resources.

 

One solution is to share costs. For example educators involved in the Computer-assisted Learning in Pediatrics Program (CLIPP) collaboratively develop e-learning case studies for pediatric training [4]. These case sessions are used by more than 100 training institutions across America and Canada [4,5].

 

Know how

The real challenge, however, is not money or even technology; the real challenge is how to use simulation technologies effectively to train future health care providers. Past experience shows that simulations need to be structured in specific ways.

 

Top ten features of effective simulations

 

1. Feedback: When assessment is also a learning tool, feedback is essential. Most of the learning occurs in debriefing sessions when students look at the recordings of simulated events and discuss the results. That feedback is most effective when it is provided on the spot and clearly points to what worked well, what needs to be changed, and how to change it.
2. Repetitive practice: Applying what has been learned in the next simulation helps to reinforce it. This is also known as deliberate practice: A repetitive, focused practice based on measurable results and rigorous feedback.
3. Curriculum integration: These outcomes need to be integrated into the overall curriculum so that they offer meaningful pathways for learning.
4. Range of difficulty: Being able to modify difficulty levels to match the abilities of the students concerned is optimal. On this basis, the level of difficulty can slowly be increased to offer new challenges and help master the tasks.
5. Multiple learning strategies: Blended learning strategies, including different ways of teaching and acquiring different complementary skill sets, build upon each other.
6. Clinical variation: Variety is the spice of life and trains participants to cope with a multitude of situations.
7. Monitored environments: A dedicated space where participants can learn by trial and error is vital.
8. Individualized learning: Simulations can be standardized but individual learners also need to be able to personalize those scenarios through active participation.
9. Defined outcomes: Simulated learning is more effective when students are given clearly defined goals and tangible outcome measures.
10. Simulation validity: Simulations should closely resemble real world challenges, in order to yield results that are useful for practice[3,6].

References

1. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.

2. Alinier G. A typology of educationally focused medical simulation tools. Med Teach. 2007 Oct;29(8):e243–e250.

3. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005 Jan;27(1):10–28.

4. Fall LH, Berman NB, Smith S, et al. Multi-institutional development and utilization of a computer-assisted learning program for the pediatrics clerkship: the CLIPP Project. Acad Med. 2005 Sep;80(9):847–855.

5. Berman NB, Fall LH, Chessman AW, et al. A collaborative model for developing and maintaining virtual patients for medical education. Med Teach. 2011;33(4):319–324.

6. Motola I, Devine LA, Chung HS, et al. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013 Oct;35(10):e1511–e1530.

7. Huwendiek S, Duncker C, Reichert F, et al. Learner preferences regarding integrating, sequencing and aligning virtual patients with other activities in the undergraduate medical curriculum: A focus group study. Med Teach. 2013 Nov;35(11):920–929.

8. Foster A, Shah M. PCaRD: A model for teachers to integrate games in their classrooms. Paper presented at: Society for Information Technology & Teacher Education International Conference; March 5, 2012; Austin.

9. Whitton N. Learning with Digital Games: A Practical Guide to Engaging Students in Higher Education. New York: Routledge; 2010.