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Association of American Medical Colleges Tomorrow's Doctors, Tomorrow's Cures®

Prepping for Performance: The Value of Simulation in Medical Education

AAMC Reporter: June 2012

—By Barbara A. Gabriel, special to the Reporter

Think “Residency Program Meets ‘American Idol.’”

Emergency medicine residents treat a heart attack patient as the patient’s wife weeps audibly in the background. Nurses are called in, medications are ordered, tests are performed. At one point, the patient crashes, and paddles are brought in to revive him.

And then the residents are interrupted by the emcee.

The residents stop and turn to a panel of “celebrity judges,” who critique their performance. The audience chimes in, voting on which of the several scenarios they just witnessed is the most clinically accurate. Through a series of single-elimination rounds, one team is declared the winner of “Sim Wars.”

The “patient” is a high-fidelity mannequin, the “wife” is an actor, and the vitals are pre-programmed. It’s medical simulation reality-show style.

The Foundation for Education and Research in Neurological Emergencies and the Emergency Medicine Residents’ Association sponsors Sim WARS each year as an innovative competition among emergency medicine residents. The contest is evidence of the growing popularity of simulation in medical education, which many medical educators believe will become standard across the continuum of medical education.

Simulation goes far beyond performing resuscitation on a mannequin.

“Simulation occurs whenever we use a synthetic environment to achieve learning outcomes,” said Deborah Sutherland, Ph.D., CEO of the Center for Advanced Medical Learning and Simulation (CAMLS) at the University of South Florida Health Morsani College of Medicine (USF Health). “It can be as straightforward as using standardized patients, basic task trainers, high-fidelity simulators, or a surgical environment where you are using animal or cadaveric tissue. Any time you are creating a scenario that simulates the real thing and allows deliberate practice and feedback, you have a simulated experience.”

CAMLS, which opened in March 2012, is an impressive example of where medical simulation is headed. The 90,000 square-foot, freestanding facility boasts 36 surgical stations; training in robotic, computer-assisted, and image-guided surgeries; a hybrid catheterization lab; on-site tissue bank; vivarium; a robotics suite; and sophisticated equipment including a 64-slice CT scanner.

The center’s interprofessional education model emphasizes team training. USF Health medical students train alongside students in nursing, pharmacy, and other disciplines. Practicing clinicians, including physicians, nurses, and respiratory therapists, among others, enact scenarios together, focusing on communication as well as procedural skills. Under a Department of Defense grant for combat casualty training, CAMLS also is training military entry-level paramedics before they deploy. One of the center’s surgical suites can mimic a battleground environment, distracting clinicians with the sounds of war. It’s impressive, but it’s also expensive. CAMLS’ total price tag came in at $38 million.

Return on investment

With the massive investment that some schools are making in medical simulation, they are anxious to know if their money is having an effect. Are students who train with simulation equipment less likely to make mistakes?

“That’s the question,” Sutherland said. “I don’t think that we have seen anything that would lead us to conclude on a broad scale that simulation reduces medical errors and improves patient safety. But simulation allows deliberate practice in a safe environment where you get an opportunity to learn procedures or team processes.”

Erica Bicker, a rising third-year medical student at Michigan State University College of Human Medicine, believes she is less likely to make mistakes because of simulation training. “It’s a great opportunity to identify the kind of things you may overlook, the kind of things you don’t even know you don’t know.”

Ryan Southworth, M.D., an emergency medicine resident and chief resident in charge of simulation at Lehigh Valley Health Network in Allentown, Pa., said he “absolutely” is less likely to make errors as a result of his work with simulation.

“Simulation is the way to learn where the rubber hits the road when it comes to the actual practice of medicine,” he said. “Especially in specialties where you’re going to need to deal with the emergently ill patient. You need to have the procedure flow down before you go in and practice on a real human being.”

In a simulated environment, mistakes become learning opportunities rather than potential tragedies. Marsha Rappley, M.D., dean at Michigan State, where students experience simulated learning at the Learning and Assessment Center, said mistakes are an important part of learning.

“In a really well-done simulated environment, it feels so real, that a mistake is very powerful at shaping behavior, attitude, and learning,” she said.

The ability to repeat a given task until it is hardwired is another gift of simulation. According to Southworth, the traditional teaching model of “see one, do one, teach one” is obsolete. “The new model is ‘see it simulated, do it simulated 100 times until you get it right, and then do it under guidance on a real patient.’”

And, when the result of the traditional teaching model could be a mistake or complication, simulation becomes even more attractive, said William Bond, M.D., medical director for educational technology at Lehigh’s Interdisciplinary Simulation Center.

“In complex endeavors, do humans ever truly master anything or perform at high levels without practice?” Bond asked. “For something such as central-line-associated bloodstream infections, I would argue we can pay for the training or we can pay for the complications. Personally, I’d rather pay for the training.”

Simulation in the curricula

As more medical schools and teaching hospitals add simulation to their curricula, it is becoming a mainstay in medical education. In 2010, the AAMC surveyed medical schools and teaching hospitals to assess their use of simulation. According to the results, reported in 2011, all 90 medical schools and 64 teaching hospitals that responded indicated that they use simulation during medical school.

Paul Phrampus, M.D., director of the University of Pittsburgh Peter M. Winter Institute for Simulation Education and Research (WISER), said classes that incorporate simulation training are among the most popular at his institution. One of those classes is a rotation in the intensive care unit (ICU).

“Every day students do rounds on real patients in the ICU, and then they come to WISER for two hours in the afternoon for a simulation session,” said Phrampus, who serves as president-elect of the Society for Simulation in Healthcare. “It gradually builds up their confidence over a four-week immersion to where they are being assessed at the end to handle a decompensating patient in the ICU.”

WISER, which is associated with the University of Pittsburgh Medical Center Health System, also uses simulation in assessments of students and residents. At the graduate level, residents must successfully place a central line in a simulated patient before they can do so on actual patients.

The University of Minnesota Medical School offers simulation training to fourth-year medical students.Incoming residents who have matched in a surgical program can sign up for a six-week course to prepare for surgical study.

“It prepares our students well for that first night on the ward, when they have to put in a central line, in a way that medical school doesn’t prepare them,” said Robert Sweet, M.D., director of Minnesota’s Center for Research in Education and Simulation Technologies.

Sweet said simulation training is well-received by Minnesota students. “They love it. They want more; that’s all I hear,” he said, adding that he believes student enthusiasm for simulation-based learning will drive its expansion in medical education. “When most residents come in, they’re most excited about the sim center. It’s putting the pressure on schools to offer this type of learning.”

June 2012 Home

students perform and observe an examination on a simulated patient

Students at the University of Pittsburgh Peter M. Winter Institute for Simulation Education and Research learn to identify heart rhythms on “Harvey,” a cardiac rhythm simulator. Photo credit: Max Leake

medical students work with a simulated patient

Medical students at the University of Pittsburgh run a simulation scenario. Photo credit: Max Leake

medical students in scrubs work with a simulated patient

Medical students at the University of South Florida Health Center for Advanced Medical Learning and Simulation practice ultrasound-guided central venous catheter placement on a simulator. Photo credit: Eric Younghans/University of South Florida

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