Medical education has traditionally relied on the concept of ”see one, do one, teach one” to educate learners. However, with increasing numbers of trainees and reduced training hours, there are fewer real patient opportunities for learners to be exposed to less common medical conditions.
Following release of the Institute of Medicine’s report, To Err is Human: Building a Safer Health System, patient safety has become a major focus in healthcare, and educators are emphasizing the need for more hands-on learning before medical trainees have contact with real patients. Therefore, new approaches to medical education are required, and simulation using realistic mannequins and scenarios helps provide needed training opportunities.
What is Simulation?
Simulations “scenarios” are cases designed to closely approximate real-world situations for the purposes of training and evaluation. Modern-day simulation finds
its roots in commercial aviation, nuclear power and the military, where inherent risks of catastrophic error exist on a daily basis and where training in the real world would be too costly or dangerous.
The era of modern medical simulation began with the first “high-fidelity” simulator designed by Denson and Abrahamson(1). Fidelity is the extent to which the appearance and behavior of the simulator or simulation match the appearance and behavior of the simulated system. High-fidelity simulators facilitate student interaction by providing direct feedback in the form of physical findings such as heart sounds, breath sounds, palpable pulses, blinking eyes and even speech. Patient responses, generated by the mannequin’s operator through a computer-driven model, allow vital signs to change in response to administered medications or interventions.
Because of their extensive life-like capabilities, simulators can be quite expensive, approximately $40,000 to $50,000. Nonetheless, developing simulation programs that teach a variety of health care providers the cognitive, technical and behavioral aspects of managing a wide array of medical conditions is a wise investment.
Although simulation experiences are designed to be as real as possible in order to facilitate experiential learning, there are many challenges inherent in achieving this realism. This underscores the tremendous advantage of using high-fidelity simulation in which the simulator is able to mimic real physical findings and real physiological responses. However, the cost and limited availability of high-fidelity simulators means that they cannot be used in all areas of medical training – yet. To maximize their value and potential, medical educators aim to match the amount of realism to the desired educational objectives of the simulation session.
For simulations in which a high degree of realism is desired, the primary goal of the simulation-based educator should be to “suspend disbelief,” allowing students to immerse themselves in learning experiences that most closely match those encountered in real life. Realism can be created in a number ways, such as replicating the environment, documentation, patient monitors, addition of multidisciplinary team members, using actors, limiting instructor involvement during the scenario and requiring the utilization of normal resources (i.e. drawing code drugs and requiring them to be given through an IV to the mannequin).
Benefits of Simulation
With few opportunities for hands-on practice with real patients, certain skills are taught didactically. Limited opportunities to practice skills, especially in pediatrics, impair learner proficiency and performance, erodes provider confidence and increases the chances of medical errors or adverse outcomes.
Incorporating David Kolb’s Experiential Learning Model2, simulation can provide a learning experience that incorporates key elements to make the experience realistic (the simulation) with immediate “real-world” relevance. A major benefit of simulation education in pediatrics is that it increases exposure to acutely ill or injured children in an immersive environment. Simulation provides additional and ongoing opportunities for experience and practice in the assessment and management of children and also enhances the capability for reflection, generalization and application.
Using simulation for team training, with the incorporation of human factors that contribute to medical errors, may have even greater benefits. The quality of team behavior has been shown to improve following simulation training and may lead to a subsequent reduction in the number of medical errors.
Pediatric Simulationin Atlanta
Over the last several years, there has been a dramatic increase in simulation-based pediatric training and education in greater Atlanta. In July 2009, Emory and
Children’s Healthcare of Atlanta developed the Pediatric Education, Safety and Quality Development Through Simulation (PEDSIM) program to enhance education of residents and other trainees.
PEDSIM facilitates team building and communication in a safe and controlled environment and helps residents and fellows learn to function as team leaders, applying physiologic principles in real time – before actually taking care of children. The Emory Center for Experiential Learning (ExCEL) provides a state-of-the-art facility for residents and fellows to receive task- and scenario-based training.
Simulation experiences also take place in patient rooms at Children’s Healthcare of Atlanta hospitals, where medical teams are called upon to manage and care for a child without any forewarning (i.e. mock codes). This “in situ” simulation adds the highest degree of fidelity to any scenario. Additionally, the program helps interns become proficient at performing lumbar punctures by implementing “just in time training.” Interns practice on a mannequin with supervision “just” prior to performing the procedure on a “real” patient. (PEDSIM link: http://med.emory.edu/excel/pedsim/)
This year, the Children’s Training, Excellence and Mastery through Simulation (TEAMS) Center was created. With a dedicated group of simulation experts and specialists, the TEAMS center will aim to embed key elements of crisis resource management (CRM), such as role clarity, team building concepts and enhanced communication skills with healthcare providers. These CRM principles are of paramount importance to high-quality and safe healthcare delivery.
Using portable high-fidelity mannequins, we simulate a variety of clinical situations in an effort to standardize workflow and provide staff and physicians experience in managing infrequent but critical events. Thanks to the generous support of Neal and Joan Allen, a simulation room equipped with video-recording capabilities is being constructed at Scottish Rite that will provide a dedicated area within the children’s hospital for medical staff to train.
These are just the beginnings of a vision to have simulation play a key role in education, quality and safety for the children of Atlanta. In the future we will
be conducting continuing medical education (CME) programs, expanding to satellite outpatient care clinics and developing community outreach programs for local healthcare providers to increase exposure to pediatric- based procedures and patient management.
By incorporating simulation into routine medical training at Emory and Children’s Healthcare of Atlanta, we hope to use this novel educational vehicle to continually improve safety and quality of care to pediatric patients throughout our community. We are also working to become a model program nationally for use of simulation in graduate and continuing medical education.
1. Denson JS, Abrahamson S. A computer-controlled patient simulator. JAMA 1969; 208:504-8.
2. Kolb D. Experiential Learning: Experience as a Source of Learning and Development. Englewood Cliffs: Prentice Hall, 1984.
Kiran Hebbar, M.D., F.A.A.P. is Assistant Professor of Pediatrics, Emory University School of Medicine. He is Pediatric Critical Care Medicine, Medical Director Children’s TEAMS Center for Simulation, Medical Director Egleston, Technology-Dependent ICU Children’s Healthcare of Atlanta at Egleston.