AAMC Reporter: January 2008

Simulators Come to Life in Resident Training

Internal medicine residents Dwight Mosely, M.D., Nicholas Honda, M.D., and Kimberly Sommers, M.D., at the Center for Medical Education and Innovation at Ohio's Riverside Methodist Hospital.

For teaching hospitals, striking a balance between an enriching educational environment and an exceptional patient care facility can be difficult. One new methodology, however, is attempting to do just that—by removing patients from the training equation, at least initially. Many programs are using computer-based simulators to hone the skills of young doctors.

"Simulation provides a controlled environment for surgical residents to learn skills starting with the most basic components and then putting those together into more complicated procedures," said Jane Shellum, administrator of the Mayo Clinic Multidisciplinary Simulation Center. "There are obvious patient safety benefits. Residents are allowed not only to repeat things, but to make mistakes they cannot make in a patient care setting."

Several surgical residency programs employ simulators to teach technical, cognitive, and behavioral skills. Most programs use one or a combination of three types of simulators: computerized mannequins that realistically re-create anatomy and clinical functionalities such as respiration, "part task" simulators intended to teach a variety of techniques, and "box" trainers typically geared toward surgical skills, particularly for minimally invasive surgeries.

Although simulation is an expensive venture and efficacy research is preliminary, anecdotal evidence points to improved clinical skills in residents for whom simulation is part of the curriculum. Although simulated surgeries do not count toward the 750 surgeries that residents are required to perform, proponents claim this technology is an important educational tool.

The University of Michigan Health System's nearly four-year-old Clinical Simulation Center houses a variety of "part task" simulators that help surgical residents acquire psycho-motor techniques, including the skill sets necessary for laparoscopic procedures. Mastering basics with a trainer, said Pamela Andreatta, Ed.D., M.A., M.F.A., director of Michigan's center, frees up clinical time to learn more complicated aspects of patient care, such as critical thinking and communication among surgical team members.

But the simulators are not used solely for memorizing medical procedures. The center uses simulators to drive home the more nuanced lessons as well, as mannequin simulators help teach team coordination and emergency protocols.

"These tools are a very effective way to get at the more complicated interactions that occur between professionals around a crisis—how well they communicate and manage decisions," Andreatta said.

Edward P. Dominguez, M.D., an associate surgical professor at the Grant-Riverside Methodist Hospitals in Ohio, said simulators can indeed teach cultural as well as clinical competencies.

"We use these simulators to teach cognitive aspects of surgery, and how well our residents think through these types of situations," he said.

According to David R. Farley, M.D., professor of surgery at Mayo, simulators can introduce residents to certain situations or unusual conditions that they may not observe during residency. Some mannequin simulators can be programmed to mimic the systems of an extremely broad range of disease and conditions, some of which a resident may never encounter in a living, breathing patient.

"There are things we can do with mannequins that we couldn't do with real patients, like program them with a rare tumor type," he said. "Residents would probably never get to see this patient care situation before simulators."

Of course, these benefits come with a hefty price tag. A "part task" trainer can cost from $15,000 to more than $100,000, and human patient mannequins can run as high as $350,000. Michigan's center spends $500,000 annually on equipment alone. At Riverside, it took $3.1 million to purchase simulators, audio-visual equipment, and related infrastructures. Riverside's center has an annual budget of $1 million.

Help may be possible for institutions that cannot purchase simulators outright, said Pamela Boyers, Ph.D., director of medical education at Riverside. Her institution found grant funding through the Agency for Health care Research and Quality (AHRQ) and other entities. Kerm Henriksen, Ph.D., AHRQ's human factors advisor for patient safety, said the agency is interested in simulation programs and the quality benefits they can provide.

"The place to practice your skills is on a simulator, not a real patient," Henriksen said. "We now know that there are many ways to avoid mistakes in medicine. One way is to have people learn it on a simulator first."

"Simulation is the wave of the future," said Linda DeWolf, president of the VHA Health Foundation, which funds and helps promote new models of health and health care. "It provides a safe environment for people to learn important skills. That is a great thing."

Although simulation is currently used only for more informal assessments, experts predict this technology could take on a more official evaluation role as its validity becomes further established.

"I have no doubt that some day expansion of practice and maintenance of competency-based decision will involve simulation and simulation based assessments," said Paul G. Gauger, M.D., associate professor of surgery at University of Michigan Health System.

Simulation centers also can become cost-saving mechanisms. "We are anticipating there might be reductions in liability costs," Boyers said. "Insurance companies are interested in what we are doing."

With the capabilities of technology expanding at such a high rate, rapid depreciations in the value of the machines is an issue with which facilities must contend.

"There are always better and more durable models coming out," Shellum said. "Our center is looking at five-year depreciation for the simulators, although potentially they would even be obsolete before then."

Regardless of cost, the key question remains of whether simulation training actually translates into improved patient care. Anecdotal evidence says yes. Faculty at Mayo, Michigan, and Riverside report that residents who have used simulators seem more comfortable with surgical procedures. Boyers credited simulation training with contributing to a recent decrease in central line infection rates at Riverside.

At Michigan, investigators did find some clinical improvements among surgical interns who had trained on a laparoscopic simulator. These interns were quicker and more accurate than a control group when performing surgery on live pig models.

Overall, however, the field is still in its relative infancy. "There isn't a lot of data [on efficacy] yet," Farley said. "But for those of us who do it, we see the benefits. We see it's worth the effort."

—By Elissa Fuchs

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