AAMC Reporter: April 2005

"Annie" Grows Up: Medical Schools Praise Educational Value of Simulators

By Donna Coffman, Special to the Reporter

David J. Murray teaches general anesthesia techniques to medical students from the Washington University School of Medicine in St. Louis

While supervising medical students using simulators at Barnes-Jewish Hospital in St. Louis, Bernard Henrichs, M.D., discovered that the training often becomes so intense that if the simulator "dies" during a practice scenario the students get upset, feeling as if they had lost a patient.

Even though the simulator is only a mannequin, not a real patient, but Henrichs now intervenes before a "death" occurs if the students do not take the appropriate steps.

Henrichs, director of the nurse anesthesia program at Barnes-Jewish Hospital, believes the simulator to be an effective tool when teaching a student how to react in a stressful situation. Some students "focus on a little thing and they miss the whole idea," she said. Learning crisis management by practicing it hands-on made students more comfortable in crisis situations.

More than just a training vehicle for medical students and residents, simulators are becoming an effective training tool for all allied professions. Educators at Barnes-Jewish Hospital with Washington University in St. Louis use a simulator regularly in the anesthesia department for training nurse anesthetists. While the simulator was initially used exclusively for the anesthesia department, it is now used for medical students, nurses and paramedics.

Medical simulation has made great strides since "Annie" was used for CPR instruction. Now computer-driven simulators can replicate the signs and symptoms of many diseases and respond to interventions. Medical school students can work in a hospital setting without the pressure of treating a live patient. Both students and teachers give strong endorsement to the method.

Full-body simulators have heart and lung sounds that can be modified to mimic various diseases, blood pressure, heart rate and pulse. Various diagnostic procedures, such as cardiac monitoring and electrocardiogram can be done. Chest tubes, central lines and intravenous catheters can be inserted. The more advanced simulators even have bowel sounds and changes in pupillary response.

Reality Education

Medical school officials praise simulators for their high degree of realism and flexibility. Now an instructor can design a curriculum without having to wait for a patient to arrive with similar symptoms.

"The problem is that crisis situations are infrequent, and you can't guarantee the student will be around," said Paul Rogers, M.D., vice chair for education in the critical medicine department at the University of Pittsburgh School of Medicine. "The simulator provides a safe environment where the student can learn and where if they don't do something correctly, no one is hurt."

Rogers teaches simulation at the school's Peter M. Winter Institute for Simulation, Education and Research. With 19 full-scale simulators, four airway simulators and computer programs for advanced cardiac life support, the University of Pittsburgh has one of the nation's largest simulation programs. Rogers tailors the training to fit the needs of students and residents. For third year medical students, his goal is to teach them basic first line interventions.

"All I want the third year students to be able to do is recognize someone who's in respiratory distress, call for help, learn how to start oxygen, bring the crash cart in the room and learn bag and mask ventilation," he said.

During the fourth year, Rogers expands the curriculum to cover what the students will encounter in their first year of residency. Rogers is encouraged by the transformation he sees in his students. By the end of a month of training on simulators, they are quickly acting to stabilize and resuscitate the patient with appropriate interventions.

"At the beginning of the course they're presented with someone who's in respiratory distress," he said. "They do what fourth year medical students do: take a long history and physical."

Initially students are worried about making the right decisions. To ease the anxiety, Rogers delivers a pep talk to encourage them to take advantage of the environment without fear of mistakes.

"So much of medical school is showing people what you know," he said. "For the next month I want them to show me what they don't know."

The value of simulators is not lost on students who value the opportunity to learn in a low risk setting.

"We have a chance to be active learners and apply material in a way that allows us to think through problems and stumble through mistakes," said Ryan LeVasseur, a fourth year medical student at the University of Pittsburgh. "We come out with a better understanding of not only physiology but the applications in different disease states."

Clinical Skills

Gordon Mandell, M.D., instructs students at the University of Pittsburgh

At George Washington University's Clinical Learning and Skills Simulation Center (CLASS) there are two sections reflecting two different approaches to learning patient care. One area is devoted to clinical skills training complete with standardized patients. The students build patient interaction skills, such as taking a medical history or physical exam and delivering difficult news. The center also uses patient simulators.

"The realism makes a major difference in terms of how well the students and residents learn," said Claudia Ranniger, M.D., medical faculty associate at George Washington University, who teaches in the simulation center. She points out that students learn the most from patient cases that do not go well.

In a real-life emergency room setting, it would be too risky to wait for a resident to deliberate over needed treatment. However, with a simulator Ranniger can stand back and let the students work their way through the case. If they do not manage the situation quickly enough, she can then discuss with them what could have been done to prevent that outcome.

"We can do things that the residents and students see rarely and we can do things that require critical intervention without having to jump in," Ranniger said. "If there's a patient in the ER who needs a nitro drip, I can't let the residents sit there and try to figure out when to use the nitro drip, I need to step in and do something."

In addition to the full-body simulators, there are simulators for a wide range of specialties such as pediatrics, airway management and surgical fields such as hysteroscopy, gynecology and arthroscopy. The available software covers medical problems from routine physical exams to bioterrorism scenarios.

While the largest simulators, such as "Stan" by Medical Education Technology, cost $200,000, smaller simulators, such as SimMan are more affordable. Ranniger said the cost per SimMan is $25,000 to $30,000. Schools must shoulder additional maintenance costs such as a technician to keep the simulator functioning and providing the necessary teaching space. School officials with simulation labs agree that the expense is well worth the price.

Intense Training

Critics of simulation point out that no matter how much the instructor tries to create a real life scenario, the simulators are not the same as live patients. Rogers said that his experience of learning difficult intubation techniques on a manikin proved incredibly valuable when performing the same procedure on a live patient with a difficult airway. Many of Rogers' former students at the University of Pittsburgh describe how the training helped them manage specific patient problems.

Another criticism is that the programs require a major financial commitment. Rogers argues that there is no similar method for introducing a multitude of case scenarios in a short time frame.

"In one hour I can show 14 students several crisis situations that you would be lucky to see during the course of several months of training," he said.

Medical school officials involved with simulator training believe it should become part of the curriculum at every school. The ultimate goal is to provide better training for doctors.

"If you step back and think about the overall goal of simulation training it's obviously to turn out better physicians in the end," Ranniger said. "There is a lot of push in this country towards reducing risk and improving patient outcome and if we can show that simulation training improves patient outcomes in the end, that's where it needs to take us."

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