Chapters Outline
- Simulation in Various Medical Fields
- Advantages of Simulation Learning
- Freedom to Error and Learn from Mistakes
- Learning can be Customized
- Simulation Provides Detailed Feedback and Evaluation
- Simulation in Health Care
- To Summarize about Simulation in Education
- Objectives of Simulation
- Activities of the Simulation Society
- Modern Medical Simulation
- Advantages of Mannequin-based Computer Simulators
- Transesophageal Echocardiography Simulation
- Importance of Transesophageal Echocardiography Simulation
INTRODUCTION
One of the most important steps in curriculum development is the introduction of simulation-based medical teaching and learning. Simulation is a generic term that refers to an artificial representation of a real world process to achieve educational goals through experiential learning. Simulation based medical education is defined as any educational activity that utilizes simulation aides to replicate clinical scenarios. Although medical simulation is relatively new, simulation has been used for a long time in other high risk professions such as aviation. Medical simulation allows the acquisition of clinical skills through deliberate practice rather than an apprentice style of learning. Simulation tools serve as an alternative to real patients. A trainee can make mistakes and learn from them without the fear of harming the patient. There are different types and classification of simulators and their cost vary according to the degree of their resemblance to the reality, or ‘fidelity’. Simulation-based learning is expensive. However, it is cost-effective if utilized properly. Medical simulation has been found to enhance clinical competence at the undergraduate and postgraduate levels. It has also been found to have many advantages that can improve patient safety and reduce health care costs through the improvement of the medical provider's competencies. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method in undergraduate and postgraduate education.
Simulation technology (Figure 1) has been used successfully to advance medical training, especially in4 the last 10 years.1
Recently, the emphasis has been on scenarios when the skill involved is critical to patient safety and/or the number of procedures required to achieve proficiency is impractical.2,3 Simulation technology can be complemented with parallel three-dimensional (3D) models that improve the spatial perception of the procedure (reality-enhanced simulators) or with devices that allow visual feedback and kinesthetic interactions between an operator and the simulator (haptic technology).
DEFINITION
The dictionary meaning of simulation is “the representation of the behavior or characteristics of one system through the use of another system, especially using a computer”. One can learn in a particular zone of development by what vygotsky called the “Lure to learn” (Figure 2). Particular zones of development can be referred to as the domain where people are acting a particular scenario. For a simulation procedure (SP), it would be within the constraints of a simulated patient examining room. For a construction scene, the constraints will be at work site. Being able to successfully improvise within the particular zone of learning and engaging with the other members of the interaction will allow a fluid dynamic in interaction.
Medical simulation is a branch of simulation technology related to education and training in medical fields of various industries. It can involve simulated human patients, educational documents with detailed simulated animations, casualty assessment in homeland security and military situations, and emergency response. Its main purpose is to train medical professionals to reduce accidents during surgery, prescription, and general practice. However, it now has been extended in its use for training students in anatomy and physiology during their clinical training as allied health professionals. These professions include nursing, sonography, pharmacy assistants and physical therapy. Advances in technology are advancing geometrically and a McGraw Hill textbook, Medical Simulation, by VanCura and Bisset interfaces the simulator technology with any medically related course of study.
Many medical professionals are skeptical about simulation, saying that medicine, surgery, and general healing skills are too complex to simulate accurately. But technological advances in the past two decades have made it possible to simulate practices from yearly family doctor visits to complex operations such as heart surgery.
SIMULATION IN VARIOUS MEDICAL FIELDS
The utility of simulation is widely recognized and becoming a greater part of medical education across fields. Each major specialty in medicine has worked to shape and optimize the use of simulation in ways that not only address common medical challenges but also specifically address competencies unique to a given specialty. To better understand simulation as a changing entity across medical fields, we briefly survey key components of the use of simulation in each of five major medical specialties outside neurosurgery: anesthesiology, emergency medicine, surgery, obstetrics and pediatrics.
The nature of certain medical fields in which spontaneous emergent intervention is required5 (e.g. anesthesiology, surgery and emergency medicine) is such that learning opportunities in critical cases may be sporadic and somewhat limited given the rapidity with which intervention must be implemented. Unacceptable consequences may occur should care be delayed or errors take place during training.
Procedural simulation has been demonstrated to improve clinical implementation of advanced cardiac life support protocols.4 Therefore, given the often high-acuity environments of anesthesiology, simulations have provided a natural supplement to clinical anesthesia training, with 70% of medical schools using some form of simulation for teaching.5
ADVANTAGES OF SIMULATION LEARNING
Simulation Learning Provides the Following Opportunities
Learning in healthcare is too frequently in an apprenticeship model. In many disciplines, as opportunities to learn and practice come along, it is hoped that learners encounter enough situations to insure that they become competent. This is ultimately a haphazard way to learn, and puts learners and patients at a disadvantage. Simulation offers scheduled, valuable learning experiences that are difficult to obtain in real life. Learners address hands-on and thinking skills, including knowledge-in-action, procedures, decision making, and effective communication. Critical team work behaviors such as managing high workload, trapping errors, and coordinating under stress can be taught and practiced (Figure 3). Training runs the gamut from preventive care to invasive surgery. Because any clinical situation can be portrayed at will, these learning opportunities can be scheduled at convenient times and locations and repeated as often as necessary.
FREEDOM TO ERROR AND LEARN FROM MISTAKES
Working in a simulated environment allows learners to make mistakes without the need for intervention by experts to stop patient harm. By seeing the outcome of their mistakes, learners gain powerful insight into the consequences of their actions and the need to “get it right”.
LEARNING CAN BE CUSTOMIZED
Simulation can accommodate a range of learners from novices to experts. Beginners can gain confidence and “muscle memory” for tasks that then allow them to focus on the more demanding parts of care. Experts can better master the continuously growing array of new technologies from minimally invasive surgery and catheter-based therapies to robotics without putting the first groups of patients at undue risk. Some complex procedures and rare diseases simply do not present enough opportunities for practice, even to established clinicians. Examples include treating a severe allergic reaction or heart attack in an outpatient clinic setting, or handling a case of malignant hyperthermia in the operating room. This is a gap that simulation training methods can help fill (Figure 4).6
SIMULATION PROVIDES DETAILED FEEDBACK AND EVALUATION
Real events and the pace of actual healthcare operations do not allow for the best review and learning about why things took place, or how to improve performance. Controlled simulations can be immediately followed by videotape-supported or after-action reviews that richly detail what happened. Advanced surgical and task simulators gather much data about what the learner is actually doing. These performance maps and logs provide a solid and necessary feedback mechanism to learners and help instructors target necessary improvements.
SIMULATION IN HEALTH CARE
Health care simulation is coming of age, and has begun to share much with established methods in aviation, spaceflight, nuclear power, shipping and the military. The rapid advance of computer science, bioengineering, and design has met demands from all stakeholders for safer, more effective and efficient ethical healthcare. When the stakes are high and real settings do not lend themselves to artificial handling for other purposes, simulation methods will find applications.
TO SUMMARIZE ABOUT SIMULATION IN EDUCATION
- Simulation-based education (SBE) is a rapidly developing method of supplementing and enhancing the clinical education of medical students.
- Clinical situations are simulated for teaching and learning purposes, creating opportunities for deliberate practice of new skills without involving real patients.
Experts can better master the continuously growing array of new technologies from minimally invasive surgery and catheter-based therapies to robotics without putting the first groups of patients at undue risk.
- Simulation takes many forms, from simple skills training models to computerized full-body mannequins, so that the needs of learners at each stage of their education can be targeted.
- Emerging evidence supports the value of simulation as an educational technique; to be effective it needs to be integrated into the curriculum in a way that promotes transfer of the skills learnt in clinical practice.
- Currently, SBE initiatives in India are fragmented and depend on local enthusiasts; Health Workforce Australia is driving initiatives to develop a more coordinated national approach to optimize the benefits of simulation.
OBJECTIVES OF SIMULATION
- To develop standards of practice regarding the key applications of simulation including education, research and patient care.
- To foster a network of professionals working within the simulation field.
- To advocate for continued development and availability of simulation-based modalities for key applications including education, research and patient care.
- To form affiliations with societies and groups having common goals in relation to simulation and safety and quality in health care.
- To promote the professional development of individuals working in the simulation field.
- To advise on legislation related to the use of simulation in health care.
- To be recognized as the official representative of these groups in the national and international scenarios.
ACTIVITIES OF THE SIMULATION SOCIETY
The Simulation Society (TSS) from India formulated in August 2014 by, the authors of this chapter conducts workshop on simulation regularly. Simulation in cardiac critical care is in the curriculum of medical7 education which is essential to promote technical skills in clinical practice.
- Conducting conferences, seminars and workshops including the SimHealth conference.
- Sponsoring student scholarships.
- Contributing to the development of Indian and international standards of simulation.
- Liaising with international simulation organizations.
- Encouraging research.
- Information dissemination via newsletters and the website.
- Running a college and a journal to enhance simulation based education and learning in medical sciences.
- Providing certification courses and fellowship examinations in simulation based teaching in medicine and cardiac critical care on a regular basis.
MODERN MEDICAL SIMULATION
The American Board of Emergency Medicine employs the use of medical simulation technology in order to accurately judge students by using “patient scenarios” during oral board examinations.6 However, these forms of simulation are a far cry from high fidelity models that have surfaced since the 1990s (Figure 5).7
Due to the fact that computer simulation technology is still relatively new relative to flight and military simulators, there is still much research to be done about the best way to approach medical training through simulation. That said, successful strides are being made in terms of medical education and training. A thorough amount of studies has shown that students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means.
The Council of Residency Directors (CORD) has established the following recommendations for simulation.
Students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means.
- Simulation is a useful tool for training residents and in ascertaining competency. The core competencies most conducive to simulation-based training are patient care, interpersonal skills, and systems based practice.
- It is appropriate for performance assessment but there is a scarcity of evidence that supports the validity of simulation in the use for promotion or certification.
- There is a need for standardization and definition in using simulation to evaluate performance.
- Scenarios and tools should also be formatted and standardized such that simulation educators can use the data and count on it for reproducibility, reliability and validity (Figures 6A and B).
ADVANTAGES OF MANNEQUIN-BASED COMPUTER SIMULATORS
- Students can refine and apply their skills in realistic health care situations
- Learning tailored to the educational needs of students
- Allows unlimited creation of situations that might be too dangerous or expensive to perform live
- Allows students repeated practice of procedures to reach proficiency
- Allows adherence to standard guidelines by reinforcement
- Allows evaluation of individual or group performance
- Scenarios can be halted at any time to allow for discussion of management strategies
- No issues of patient safety or confidentiality.
TRANSESOPHAGEAL ECHOCARDIOGRAPHY SIMULATION
A perfect example of high fidelity simulation.
Transesophageal echocardiography (TEE) is a widely-used technique in the cardiovascular assessment of patients undergoing complex surgery or those that are critically ill.8
It is recognized as an important element that impacts surgical technique, especially in patients undergoing mitral valve surgery (Figure 7).8,9 Image acquisition and interpretation using TEE can also be subject to variability depending on experience and skill of the operator. The National Board of Echocardiography and the Society of Cardiovascular Anesthesiologists (SCA) have therefore established training guidelines that define expectations of competency in TEE during the training period for perioperative physicians.10 Acquiring minimal proficiency in perioperative TEE can also be challenging for trainees and teaching faculty, as the number of cases required learn TEE is considerable as is the time for acquiring the cognitive skills through didactic education.10
A TEE simulator is capable of displaying two images—one that shows a three-dimensional representation of cardiac anatomy, while the other shows the simultaneous echo correlate (Figures 8A and B). The location of the TEE probe with the esophagus removed is an added advantage that helps the user visually with anatomical relationships. The manipulation of the echocardiographic scan plane can be accomplished using a keyboard or a connected mannequin.
IMPORTANCE OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY SIMULATION
This technology can also be used by trainees in several disciplines such as anesthesiology, cardiology, cardiac surgery and critical care to improve proficiency in basic TEE image acquisition and interpretation. At the present time, exposure to intraoperative TEE is challenging for trainees outside the operating room environment (Figure 9).9
The development of cardiac pathology will greatly help trainees develop the interpretative skills in areas either too complex or infrequent in occurrence to permit enough time for education in the clinical environment. This technology can be used for helping physicians maintain competency in situations where clinical case volume may be insufficient to support current competency requirements.
Significance of Simulation Training
The availability of reality-enhanced TEE simulation is a significant departure from traditional training models that rely on a combination of didactics and real time clinical teaching. While more ‘real world’ in application, the challenges of simultaneous clinical management may place additional burden on educators in the operating room. Simulation in TEE provides a more controlled environment in which to assess the efficacy of this training methodology over conventional approaches while also providing objective data to justify its routine use.
Limitations of Simulation Training
Simulation technology is expensive and TEE simulators are not immune to this phenomenon. A TEE simulator can cost from US$ 22,000 up to US$100,000. Maintenance expenses add to the overall cost of a simulator. A simulator also needs to be placed in a dedicated training area and this cost should also be accounted for. Other echo modalities such as M-mode, spectral Doppler and color flow are challenging to reproduce and are not currently available. Similarly simulation of transducer functions, such as gain, compression and depth are not available. Simulation of pathologic states is the next frontier in TEE simulation when the touch of a button can produce mitral valve prolapse, aortic stenosis, or a regional wall motion abnormality.
CONCLUSION
Simulation patients are the issues, learning gaps, and needs that are required to improve simulation patient education. Simulation based education are requiring for the concept of virtual humans, embodied conversational agents, fundamentals of acting, clinical play, virtual humans, and future immersive technologies. A fresh look is needed into looking at standardized patient education. Improvization is essential in simulation in which there is a need to show and simulation can get us to a better level of quality when educating these essential medical role players.
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- Ahmed K, Jawad M, Abboudi M, Gavazzi A, Darzi A, Athanasiou T, et al. Effectiveness of procedural simulation in urology: A systematic review. J Urol. 2011 May 13. PMID 21571338.
- Practice guidelines for perioperative transesophageal echocardiography. A report by the american society of anesthesiologists and the society of cardiovascular anesthesiologists task force on transesophageal echocardiography. Anesthesiology. 1996;84:986–1006.
- Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: Summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (ACC/AHA/ASE committee to update the 1997 guidelines for the clinical application of echocardiography). J Am Soc Echocardiogr. 2003;16:1091–110.
- Cahalan MK, Abel M, Goldman M, Pearlman A, Sears-Rogan P, Russell I, et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Anesth Analg. 2002;94:1384–8.