Simulation-Based Medical Education

The future is bright for this rapidly evolving technology

In the early 1960s, task trainers and manikins were used as a regular part of medical education, and in 2004, standardized patient encounters became part of the national licensing process for physicians.2 Simulation technology has expanded, and today more than 90% of emergency medicine programs utilize medical simulation technology to train medical residents.2

Modern simulation-based medical education (SBME) is rapidly evolving to meet the growing need for effective methods of instruction in medical settings. This article explores SBME including current use, strengths, weaknesses, barriers to adoption, and the future of simulation technology for medical education.

Medical Simulation Technology

Simulation technology has been in use for decades in many areas outside medicine. For example, the aviation industry used flight simulation technology as early as the 1930s.2 The technology expanded to encompass other industries, including the military, engineering, astrophysics and mathematics.

Simulation technology is ideal for practicing high-risk situations.3 Simulation is generally used both for training and as an assessment tool. It also reduces the need for experimenting on animals or human subjects.4 A wide range of simulators are available, including standardized patients, simple task simulators, electromechanical clinical manikins and computer-based virtual simulators.5

Many schools and hospitals use a combination of tools to simulate multiple aspects of patient care. For example, standardized patients reinforce interpersonal communication and help students understand disclosure of error, communication of a difficult diagnosis, and grief counseling.5 An interesting benefit of using standardized patients is that medical students can be taught how to appropriately challenge authority. For example, simulation scenarios can be built in which clinicians in authority can intentionally give medical orders that would harm a simulated patient. In this scenario, students are assessed on their willingness to intervene on behalf of the patient and block harmful medical orders.6

SBME is an ideal solution for the growing demands of medical education.7 First, medical students, interns and residents are required to learn massive amounts of information, and the volume of it is increasing as advances in medical knowledge continue. Second, residents are limited in the number of duty hours they can practice and learn new clinical procedures. Third, in a litigious society, technical proficiency is constantly challenged, thereby raising the required level of knowledge for clinicians. Finally, productivity constraints continually challenge clinicians to perform at the highest level of technical capacity. These factors are causing medical educators to reevaluate teaching methods and seek more effective educational tools.

Strengths of Medical Simulation

One of the most significant benefits of SBME is reduced risk to patients, because it provides the opportunity to practice procedures before performing them on real patients.8,9 Many procedures, such as chest tube placement, central line placement and cardiac catheterization, involve significant risk to the patient. Utilizing computer-based simulation equipment lowers patient risk and improves outcomes.10 Large medical centers, including military hospitals such as Walter Reed National Military Medical Center, are successfully using medical simulation technology.8

There are many advantages to simulation. First, students receive immediate and consistent performance statistics, thereby allowing them to increase their levels of performance.

Second, educators can track performance of both individuals and groups of students. Therefore, in an educational setting, faculty has clear performance metrics that can be incorporated in the curriculum design to enhance student experiences.

Third, SBME is superior to traditional clinical education in many areas.11 For example, in a quantitative meta-analysis spanning 20 years, the authors found:11 “There is no doubt that SBME is superior to traditional clinical education for acquisition of a wide range of medical skills . A growing body of evidence shows that clinical skills acquired in medical simulation laboratory settings transfer directly to improved patient care practices and better patient outcomes.”

Fourth, SBME allows just-in-time refresher education for clinicians who previously mastered a clinical skill but need a refresher prior to a patient encounter.12

Fifth, simulation can be utilized to prepare for specific surgical procedures. For example, 3D Systems in Cleveland has designed high-fidelity simulation training systems. The company’s product line, Simbionix, provides visual modeling and haptic (tactile) feedback, offering realistic immersion in performing clinical procedures. The company’s procedure rehearsal studio technology provides three-dimensional models of a specific patient CT scan that simulates preoperative endovascular surgical treatments specific to an individual patient. With these powerful tools, surgeons can virtually rehearse a patient’s surgery.

Weaknesses of Medical Simulation

SBME has two significant weaknesses. First, it is not clear if the cost of the simulation training exceeds the benefit. Empirically, it may appear that utilizing SBME is efficient and cost effective. In one small study of 26 internal medicine interns, 97% reported improved ability to function as an intern.13 However, Bewley and O’Neil14 observed that “great promise and impressive technical capability are not sufficient to conclude effectiveness.” In an analysis of nearly 1,000 studies evaluating medical simulation training, Zendejas9 noted that “Cost reporting in SBME research is infrequent and incomplete.” Only 59 studies reported any costs associated with SBME, and fewer than 2% reported any comparative analysis between SBME and other medical education tools.9 One study documented that while more than 90% of emergency medicine residency programs use simulation technology, definitive evidence is lacking to determine if the simulation affects behaviors, performance or clinical skills.2

Some studies have documented improvements in medical knowledge, especially for specialties such as pediatrics.15 Similar benefits have been shown in the preparation of internal medicine residents to work in a medical intensive care unit as well as in trauma units.16 Barsuk et al17 documented similar results for acquisition of task-specific skills such as central venous catheter insertion. Therefore, although the technology appears to be effective and cost efficient, more research needs to be completed to validate this assumption.

Second, the measurement of learning outcomes is historically insufficient. Upon completion of tasks using SBME, participants may feel they improved their technical skills. However, until recently, few quantifiable models have been available to measure performance. Wayne and McGaghie18 suggested 12 measurable essential features of SBME: deliberate practice; feedback; curriculum integration; rigorous outcome measurement; simulation fidelity; skill acquisition and maintenance; mastery learning; transfer to practice; team training; high stakes testing; instructor training; and attention to educational and professional context.

Another model for measurement is the Kirkpatrick Model.14 In this model, student performance is measured at multiple levels, including reaction time, level of skill, behavioral changes, patient outcome, and organizational benefits. One of the challenges is that although medical schools provide formal education in basic skills, many fail to use simulation technology to teach advanced clinical skills.19 Berg et al19 reported that 46% of schools used basic simulation and only 23% used advanced procedure training with simulators. This further complicates performing analysis or performing cost-benefit analysis to determine the effectiveness of SBME.

Barriers to Adoption

Several barriers exist to the adoption of simulation technology. First, the high cost of simulation technology is a significant barrier for many organizations. Institutions must factor in the total cost, including equipment, training, maintenance and specialized facilities. Colleges and hospitals are challenged to obtain funds to acquire simulation equipment.

Second, retaining faculty and staff familiar with the technology is challenging. These skills are limited, and employees are frequently offered new positions at higher pay by other organizations, thereby making retention difficult.

Third, simulation labs may be underutilized, and this is especially challenging for expensive equipment. Students may utilize SBME for a particular task, and when the task is mastered with sufficient proficiency, the equipment may not be utilized again for several months.

Future of Medical Simulation

Improvements in automated scoring based on standardized measurements are needed for SBME systems.14 Many systems have limited capabilities to score and track performance. However, more advanced systems with large storage repositories could score and track performance over large numbers of clinicians. This is important so that clinical skills can be assessed, but also for consideration in curriculum design and SBME improvements. For example, if patterns of common errors appear, SBME designers can reevaluate simulations to ensure they are appropriately designed. Errors could be design flaws, and improvements could bring more realistic simulation to the classroom. However, errors could be due to ineffective preparation in the didactic portion of the education. Therefore, the curriculum could be modified to support the clinical simulations and to improvement performance.

Another future area is expansion on systems such as those by Simbionix for individual patient simulations. Enhancement in importing radiographic imaging such as CT into simulation environments can significantly enhance simulation and presumably, patient outcome. Development of predictive-based modeling can be linked to this expansion area to predict patient success with various medical interventions. For example, simulation of radiographic treatment versus surgical treatment of a cancerous tumor could provide guidance about treatment options.

Finally, more studies need to be performed to determine the cost effectiveness of simulation tools. This will require specialized techniques to capture all expenses and benefits. For example, patient outcomes and success can be difficult metrics to capture. However, measuring and tracking this information is important for the future of SBME. Although more research needs to be conducted to quantify the financial benefits, SBME is a powerful tool to enhance medical education. As technology becomes more powerful, it is likely that SBME will play a dominant role.


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