1. Simulation in Medical Education
Nur-Ain Nadir. MD.
Director of Resident Simulation
King’s County Hospital Center
07/27/2011

2. Lecture Outline Context Introduction Simulation repertoire
What is the Evidence
Best Practices

3. Context
To err is human
Report 1990’s by US IOM – patients died/year – preventable medical errors*
“First do no harm” – Epidemics, Hippocrates
Culture of minimizing medical error increasing patient safety
Traditional practice “See one, do one, teach one”
Shift in paradigm to observe some, practice several, then perform
Team approach to patient care
Focus on psychology, behaviors of medical professionals under stressful medical situations
Medicatoin errors, Procedural errors, Identity errors, knowledge deficit /carless errors

4. “Simulation is the act of mimicking a real object, event or process.”
Introduction
“Simulation is the act of mimicking a real object, event or process.”

5. Introduction History First computer aided modeling of physiology
Link Trainer Rescusi Annie Harvey
Introduction
History
Timeline
Events
1928
1960
1968
1973
1975
1988
1989
1990
1993
1994
1997
1998
2000
2005
2006
Link Trainer
Rescuci Annie
Harvey Cardiology
First computer aided modeling of physiology
SP and OSCE’s
First full body, computerized mannequin, Stanford
ACRM – Anesthesia focus on patient safety movement
Term Virtual Reality and Screen Based Simulators Introduced
US IOM “To Err Is Human” report
First national/international simulation meetings MMVR
Boston Center for Medical Simulation
MIST VR Task Trainer
Introduction of simulation into specialties like EM
Current generation of full body mannequins introduced by METI,Laerdal
Society for Medical Simulation
Simulation in Healthcare Journal

6. Introduction Is simulation a valuable teaching tool?
Learners can learn without risk to patient
Learning can be focused without regard to patient care needs/safety/etc.
Opportunity to repeat lesson/skill to mastery.
Specific learning opportunities guaranteed.
Learning can be done at convenient times.
Performance can be observed/recorded.

7. Introduction Why is simulation important to medical education?
Problems with clinical teaching
New technologies for diagnosis/treatment
Assessing professional competence
Medical errors and patient safety
Deliberate practice

8. Introduction ACGME ‘Toolbox of Assessment Methods’
Simulation is ‘the best’, ‘second best’ tool for assessing:
Medical procedures
Ability to develop and carry out patient management plans
Investigative/analytical thinking
Knowledge/application of basic sciences
Ethically sound practice

9. Introduction Simulation is one tool in our educational repertoire.
(new, expensive and exciting)
in our educational repertoire.
(Similar to lecture, case discussion, skill lab, MCQ, SP, etc.)

10. Repertoire of SIM equipment
Standardized Patients
Improvised Technology
Screen Based Simulation
Task Trainers
Mannequins
Virtual Reality
BEME article

11. Standardized Patients
Individuals trained to portray specific illness or behavior for the purposes of teaching or assessment.
Assessment of Communications and professionalism competencies
Required Clinical Skills testing for all students
USMLE Part II CS exam

12. Standardized Patients
Pros
Can consistently reproduce clinical scenario for standardized testing
Ability to assess rare conditions not otherwise reliably seen
Patients trained to provide objective & accurate feedback
Can use in real settings office/ED for realistic environment)
Cons
Little research on effectiveness
Cost to pay & time to teach standardized patients
Quality of experience heavily dependent upon training of the patient

13. Improvised Technology
Biological or Synthetic models
Models made of easily available items
Closely mimic human tissue
Allow for near replica of actual procedural steps
Generally used for instruction of procedures
Commonly used examples
Slab of ribs to teach insertion of chest tubes
Animal feet or head for suturing practice

14. Improvised Technology
Animal models
Synthetic models

15. Improvised Technology – Educational Theory
Procedure cognition
Understanding of indications, contraindications & complications
Knowledge of equipment used
Step-by-step knowledge of technical details
Identifying anatomical landmarks and ‘tissue clues’

16. Improvised Technology
Cons
Almost no research on effectiveness
Less ‘real-life’ experience, therefore stress factor removed
Often does not duplicate most difficult aspect of procedure (E.g. obese patient)
Static devices , therefore useful for specific procedures only, not actively changing clinical scenarios
Pros
Cheap!!!
Easily available at all sites
Easy to duplicate for repetitive use or multiple users
Minimal instructor education needed
Ability to create models otherwise not available
Resuscitative Thoractomy

17. Screen Based Simulation
Computer
programs
Desktop
Laerdal Microsim
ACLS
Critical Care
Anesthesia
Sedation
Neonatal

18. Screen Based Simulation
Pros - Low cost - Distance learning - Variety of cases - Improving realism - Self guided
Cons - No procedural skills - No teamwork skills

19. Task Trainers
Devices designed to simulate a specific task or procedure.
Examples:
Pericardiocentesis
Bronch simulator
Chest tube
Airway
Artificial knee
Central line

20. Task Trainers Pericardiocentesis Central line Intubation
Tube thoracostomy
Joint aspiration

21. Task Trainers Pros Weaknesses High fidelity Good research on efficacy
May have self guided teaching
Weaknesses
Expensive
Focus on single task
Not integrated into complete patient care

22. Mannequins
Low Fidelity
Mid Fidelity
High Fidelity

23. Low Fidelity Mannequins
Features:
Static airway
+/- rhythm generation
No/minimal programmed responses.
Pros: Low cost, reliable, easy to use, portable
Cons: Limited features, less interactive, instructor required

24. Mid Fidelity Mannequins
Relatively new class of mannequins, often used for ACLS training.
Features:
Active airways – ETT, LMA, Combitube
Breathing/pulses, rhythms
Basic procedures – pacing, defibrillation
Some automated response and programmed scenarios

25. Mid Fidelity Mannequins
Pros:
Active airways
Somewhat interactive
Moderate cost,
Moderate portability
Weaknesses:
Semiskilled instructor
Limited advanced procedures (lines, chest tubes)

26. High Fidelity Mannequins
Mannequin with electrical, pneumatic functions driven by a computer.
Laerdal, METI
Adult, child and newborn models
Features:
Dynamic airways, reactive pupils
Heart sounds, lung sounds, chest movement
Pulses, rhythms, vital signs
Abdominal sounds, voice
CO2 exhalation, cardiac output, invasive pressures
Bleeding, salivation, lacrimation

27. High Fidelity Mannequins
Procedures
O2, BVM, Oral/nasal airway, ETT, LMA, Cric
Pericardiocentesis, PIV
Defibrillation, Pacing, CPR
Needle or open thoracentesis
TOF, Internal gas analysis
Foley placement
Reacts to medications

28. Features

29. High Fidelity Mannequins
Pros
Many dynamic responses
Preprogrammed scenarios
Widest variety of procedures
Most immersive
Cons
Cost
Procedures not realistic
Lack of portability
Significant instructor training required

30. Virtual Reality Advanced form of human-computer interaction
Allow humans to work in the computer’s world
Experimental – mostly private sector
Types of VR applicable to medicine
Immersive VR
Desktop VR
Pseudo-VR
Augmented reality

31. Immersive VR (flight sim)

32. Desktop VR (software program)

33. Pseudo-VR (virtual anatomy)

34. Augmented Reality

35. Where is the Evidence ?

36. Where is the Evidence ?
Residents who participated in the screen based simulation out performed their counterparts

37. Where is the Evidence?
Comparing simulation to other teaching modalities demonstrates some slight advantages.

38. Where is the Evidence?
Simulation can be an effective replacement for live practice for some skills.

39. Where is the Evidence?
Team behavior can be effected by focused simulation experiences.

40. Where is the Evidence
”Softer” competencies like professionalism can be assessed with the aid of simulation technology.

41. Best Teaching Practices
Orientation
Introduction to session
Expectations
What is real/what is not
Self assessment
Debriefing
Evaluation

42. Best Teaching Practices
Determine what you want to assess.
Design a simulation that provokes this performance.
Observe/record the performance.
Analyze the performance using some type of rubric: checklist, GAS, etc.
Debriefing, feedback and teaching.

43. Best Teaching practices
Provide feedback
Give opportunities for repetitive practice
Integrate simulation into overall curriculum
Provide increasing levels of difficulty
Provide clinical variation in scenarios
Provide individual and team learning
Define outcomes

44. Simulation is one tool in our educational repertoire.
Summary
Simulation is one tool in our educational repertoire.

45. References
Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Issenberg, McGaghie, Petrusa, Gordon and Scalese. Medical Teacher, vol 27, 2005, p
Loyd GE, Lake CL, Greenberg RB. Practical Health Care Simulations. Philadelphia, PA. Elsevier-Mosby
Bond WF, Spillane L, for the CORD Core Competencies Simulation Group: The use of simulation for emergency medicine resident assessment. Acad Emerg Med 2002;9:
ACGME Resources

46. Additional References
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47. Additional References
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