Evaluating Simulations in Medical Education

By: Serena Zaccagnini

Simulations in medical training are a realistic cross-disciplinary method of training and feedback. In simulation-based learning learners can repeatedly practice and review tasks in lifelike circumstances using physical or virtual reality models to identify and understand the factors that affect systems and the problems that can arise. Simulation-based medical education (SMBE) allows students the chance to refine their skills in a safe and controlled environment where they can increase their skills and reduce their margins of error. SMBE creates a safe and controlled environment that exposes trainees to dangerous conditions.

The State of Medical Education

Research by Jones, Passos-Neto and Braghiroli indicates that, despite advances in technology, teaching strategies and learning theories, it is not uncommon for medical students to be taught with decades-old syllabi. The current model of medical training has been in use for at least a hundred years, but a developing movement for patient safety has forced institutes to revise the medical education system.

Several external factors are driving the movement for medical education reform:

  • Increased awareness of information overload and stress on medical students.
  • Recognition of the need for students to be effective junior doctors after undergraduate studies, not during residency; students are often ill-prepared for their roles.
  • The need for continuing education for higher specialist training, coupled with the drive to revalidate.
  • New interest in outcomes-based education, focusing on the student’s ability to perform what they have learned, rather than the typical goal-based education, which focuses on student satisfaction.

Some institutions have already adopted simulations for use in examinations. For example, Scalese, Obeso and Issenberg indicate that the Royal College of Physicians and Surgeons in Canada uses simulations with computers and mannequins alongside patient participants in their Internal Medicine certification exams.

Simulations, Past and Present

Any person attempting to determine the origins of simulation-based education would find themselves mired in information dating back millennia. While the first dedicated use of simulations in medical training took place in the USA in the 1960s, use of simulations in medical training can be found across cultures and ancient civilizations. In the past, these simulations used active participants or mannequins as the test subject. Over the last several decades, the educational tools shifted from the real-world to the virtual.

A Shift toward the Virtual

Medical education is one of many disciplines experiencing a significant increase in the use of simulation technology for teaching and assessment. From the military and aviation industries training pilots on flight simulators to construction workers training on virtual cranes, simulation-based education has seen a boom in trust and satisfaction.

The shift to virtual education for medicine follows the trends of society. Many medical students and practitioners have adapted their methods to better fit the 21st century:

  • Many medical students view lectures online or listen via podcasts.
  • Residents consult information stored in Personal Digital Assistants (PDAs) to make patient management more efficient.
  • Practitioners can receive continuing education credits by attending teleconferences.

Much of the movement toward simulations occurred in the 1980s and 1990s, when sophisticated computers and software capable of reproducing and mimicking physiologic responses and feedback were produced. The first wave of simulated patients combined a Macintosh computer with a mannequin and waveform generator to mimic a patient during anaesthesia. Specialties such as anesthesiology, critical care and emergency medicine have long been at the forefront of the push toward SMBE.

Technological innovations have paved the way for a wide range of simulators that can facilitate and supplement learning in numerous medical disciplines.

The Limits of SMBE

Primary concerns regarding simulation use in medicine involve cost, efficiency and simulation quality.

  • Cost: The best medical simulations are available at considerable costs. Machines require maintenance and updating, which continually adds to the initial purchase price.
  • Efficiency: Incorporating time into current medical curriculums is problematic and would require the medical curriculum to be updated. Dedicated and exclusive resources are seldom available. For simulations, an instructor-to-learner ratio of 1:3 or 1:4 is ideal, where the current ratio is between 1:10 and 1:15.
  • Simulation Quality: Human systems are complicated and varied, thus models and instruments can never completely mimic each iteration. Poorly designed simulations can inhibit learning, such as causing students to neglect checking for physical signs because they are absent in the simulation. Participants will naturally approach simulations differently than they would real life. Students will either be hypervigilant or negligent.

Long-term studies must be conducted to analyse the effects of SMBE on patient care and general effectiveness as a teaching tool. It is only after the impact of SMBE has been evaluated that simulations can begin to replace all outdated teaching materials.

Where To, Next?

The current model of medical education has changed little over the last hundred years, but an increase in demand for experienced doctors has pushed educational institutions to reconsider the system. Simulation on its own cannot guarantee learning, but it is a game-changer.

Future studies should be conducted regarding the effects of SMBE on improving patient outcome. Without strong evidence, a field as costly and vital as medical education cannot be altered with any severity. At best, simulations will be a periphery in medical education and training. The potential growth for SMBE alongside technological advances is unmeasurable and may be the key to training medical professionals in the future. However, institutions and practitioners must analyse the current education system and the validity of SMBE research to determine if the jump can be made now or later.

The shift toward heavy technology use is unavoidable; medical professionals, as other professions, have started to rely on computer- and cloud-based materials to improve their patient care. What remains to be seen is if they will fully accept this paradigm shift and trust simulations to train the next generation of doctors.

Resources

Bradley, Paul. "The History of Simulation in Medical Education and Possible Future Directions." Medical Education 40, no. 3 (March 2006): 254-62. doi:10.1111/j.1365-2929.2006.02394.x.

James, John T. "A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care." Journal of Patient Safety 9, no. 3 (September 2013): 122-28. doi:10.1097/PTS.0b013e3182948a69.

Jones, Felipe, Carlos Eduardo Passos-Neto, and Oddone Freitas Melro Braghiroli. "Simulation in Medical Education: Brief History and Methodology." Principles and Practice of Clinical Research 1, no. 2 (July/August 2015): 56-63.

Krishnan, Divya G., Anukesh Vasu Keloth, and Shaikh Ubedulla. "Pros and Cons of Simulation in Medical Education: A Review." International Journal of Medical and Health Research 3, no. 6 (June 2017): 84-87.

Scalese, Ross J., Vivian T. Obeso, and S. Barry Issenberg. "Simulation Technology for Skills Training and Competency Assessment in Medical Education." Journal of General Internal Medicine 23, no. Suppl 1 (January 2008): 46-49. doi: 10.1007/s11606-007-0283-4.


Serena Zaccagnini is a student at Seneca College in Toronto, Ontario studying Technical Communication. She is looking forward to a career in the Technical Communication field. I have a Specialized Honours Bachelor of Arts in English and Professional Writing with emphasis on Digital and Institutional Communication from York University. In my spare time, I enjoy reading and baking.

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