The last few years have witnessed tremendous growth in simulation-based medical education (Issenberg 203) possibly due to availability of computerized whole-body mannequins which are moderately priced and heightened patient safety awareness. Simulation is argued to be the most important innovation to have happened in medical education (Passiment, Heather and Grace 1). It connotes a teaching technique which not only endeavors to provide as realistic environment as possible but also an opportunity for directed feedback. This technique has found unprecedented popularity especially in medical and engineering fields. In medical environment, the clinical situations are virtually simulated for learning purposes thereby providing the students with opportunities to practice newly taught skills without use of real patients. Simulation-based education ranges from the use of screen-based interactive computer software to virtual yet realistic environments. Thus, it may assume many forms from simple to complex computerized models. But despite simulation having grown rather rapidly, its use in many learning centers is biased towards a particular professional discipline or medical specialty. For instance, some medical school may have a laboratory for teaching its students physiology or acute resuscitation procedures using virtual patients while another nursing school may have a mannequin for teaching hemodynamic procedural skills.
Today, many healthcare systems are increasingly recognizing simulation-based medical education as an integral part in enhancing patient safety – knowledge that is expected to continue promoting safety agenda and culture of healthcare institutions. Moreover, institutions that appreciate this potential have well trained personnel focused on patient safety particularly reduction of clinical errors (Weller et al. 2). Success of such efforts depends principally on healthcare leadership and can have profound influence on advancing comprehensive application of virtual simulation in medical training in line with changes in modern health care delivery.
Although simulation-based education is an emerging interest in research, numerous studies have been published supporting the value of simulation in teaching and learning process. Hamstra and Philibert detailed the uses and benefits of simulation in graduate medical school. While simulation can be a costly project for a medical school, it has the potential to enhance student learning process while also standardizing clinical assessments (Hamstra and Philibert 539). Accordingly, it is important for leaders of medical centers to have good knowledge of simulation techniques available in the market today in order to extrapolate their relevance in medical curriculum delivery and patient safety. This is in agreement with Weller et al. argument that simulation-based medical education provides both safe and effective learning environments for medical students (Weller et al. 1). The primary advantage of virtual simulation in medical education is to provide realistic learning experience without any risk of causing harm to a real patient (“Medical Education Through Simulation”). In the past, medical schools solely relied on training their students using actual patients. In such a kind of experiential training, the students are likely to make mistakes which pose a serious risk of harm to patients. As technology continues to affect many spheres of our lives, better and quality care for patients has become essential. The students also enjoy using simulations as they can practice their skills, repeat procedures – as often as necessary – without the pressure of a real patient’s health being at stake. Institute of Medicine report shows that since 1999, 44,000 to 98,000 deaths have occurred annually possibly due to medical errors which could reduce substantially with use of simulation in resident education (Hamstra and Philibert 539). Other studies have highlighted medical errors as the eighth leading cause of death in the United States although the exact figure remains uncertain (Michaels et al. 1664). Hence, if simulation is appropriately integrated in medical training, it has huge potential to reduce medical errors in clinical setting.
Apart from enhancing patient safety, simulation-based education in itself provides students with better learning experience as it provides a bridge between the theory of medicine and clinical practice. The medical students can easily identify gaps in their knowledge (Weller et al. 2-3), boost their self-confidence and hence reduce their anxiety when dealing with actual patients. Simulations further helps not only in the assessment but also in improving student’s communication skills and competencies in application of medical theory to lifelike clinical situations (Hamstra and Philibert 539). For example, critical thinking; which is facilitated by experiential learning, greatly improves through simulation. The students also have better retention of newly acquired knowledge compared to traditional lectures. This is underscored by Khan, Tim and Morgan who argue that simulation offers an enabling environment for critical thought and focused reflection (p.1-2). As such, medical simulation holds the promise of transforming medical education and enhancing current curriculum through integration of basic and complex concepts through reflective practice. The simulators help the students to integrate basic medical knowledge and clinical situations thereby effectively preparing them for residency.
Simulation is valid instructional tool relevant in several different medical settings. Training in surgical simulators arguably reduces the time required to realize proficiency in a certain surgical skill (Clausen and Schmitz-Rixen). As this discussion would certainly show, most literature on high-fidelity simulation is primarily descriptive in nature with just a few investigating the utility of complex simulators as educational tools. Nonetheless, there is emerging evidence on success of simulations in specific medical disciplines. Deering, Tamika, and Ernest focused their study on obstetric simulation for different education levels right from a student to a fellow. Obstetrics and gynecology stands to benefit enormously from simulations as the specialty requires wide range of both operative and clinical skills. While a general Obstetrician is tasked with many routine medical responsibilities similar to those of a family medicine practitioner, they in addition, ought to be competent surgeons with expert knowledge of managing pregnancy, labor, and delivery. They are tasked with managing two lives at the same time –the mother and the fetus. This requires intellectual and technical knowhow which makes simulation-based education imperative for obstetrics. A report by the Association of Maerican Medical Colleges (AAMC) shows that 81% of obstetrics simulation is used to provide formal feedback, 56% for individual evaluation, 37% for remediation, and 19% for validation and certification (Deering et al. 143). Using simulation to acquire and assess the surgical skills critical in gynecology specialty in addition to the routine and emergent procedures characteristic of labor and delivery room is not only possible but a necessity to guarantee best outcomes possible.
The need for virtual simulations in obstetrics is today nationally and internationally acclaimed. For instance, organizations such as the Society for Maternal Fetal Medicine (SMFM) and the American College of Obstetricians and Gynecologists (ACOG) both have established simulation committees for facilitating full integration of simulation in the specialty (Deering et al. 144). And while obstetric simulators are still being developed, some studies have already described their use and utility. For example, there are simulators for studying amniocentesis – a common procedure in obstetrics for evaluating fetal lung maturity. Another procedure named breech vaginal delivery has also been simulated. Increasingly, more evidence is being published to demonstrate the benefits of obstetric simulation in medical education. One study evaluated the use of simulation-based training on breech vaginal delivery and reported performance results before and after training. In this study, Deering and Auguste report that a total of 20 students recruited from two institutions completed the protocol in which results showed significantly higher scores for completion of critical delivery components after training with overall improved performance as it regards the safety of delivery (Deering and Auguste 438). Another study demonstrated that students who performed simulated deliveries showed more confidence of performing most procedures of a vaginal delivery independently or with minimal supervision compared to students lacking simulation training (Deering et al. 143). These results are in agreement with the findings of Barsuk et al. In addition to being comfortable to perform delivery procedures, the students on simulation group scored higher in both oral and written examinations (Deering et al. 143). Furthermore, the students performed better in skills evaluation and exemplified readiness to embark on obstetric house jobs.
Simulation has been demonstrated to be a valuable technique for teaching ultrasound skills. Clausen and Schmitz-Rizen investigated the impact of ultrasound simulation on medical student’s education by recruiting 48 students without experience in ultrasound for a one day crash program on ultrasound simulated training. The study showed that compared to the control group without ultrasound simulator, the group that underwent ultrasound simulated training had higher subjective confidence in diagnosis and were at better position to identify pathological features. In essence, this study demonstrates that regardless of the crash-day program, the participants acquired in-depth knowledge and skills important for performing and interpreting basic ultrasound examination and results. There is also overwhelming evidence showing that the use of ultrasound simulators in central line placements increases success rate and leads to less complications (Gayle and Kaye 2). Due to the complicated applications of ultrasound such as in peripheral venous access in both adults and children, ultrasound simulation models are especially essential for initial training. Also, ultrasound has become a very critical diagnostic tool for most life-threatening conditions hence its routine use makes it an evolving standard of care and important component for residency training. Onward training in ultrasound will most certainly rely on simulators and complex computer-based systems.
Anesthesia simulators have widely been used in role-play and experiential learning and evaluation. These have caused a significant change in the role and image of today’s anesthesiologists; a fact that can easily be noticed in work practices in which there has been a decline in opportunities for anesthetic students to acquire skills on technical procedures in supervised practice. Introduction of simulators for training technical procedures in anesthesia has been part of joint efforts in mitigating medical errors and promoting patient safety (Gayle and Kaye 2-3). Despite the fact that simulation has been extensively used in anesthesia for crisis management training, very few studies have documented its use for technical skills training in medical schools. Nonetheless, simulation in anesthesia is theoretically justified by virtue of aiding in acquisition of psychomotor skills and expertise. Practical frameworks for this theory have been developed and applied in other specialties such as obstetrics.
Simulators use in Osteopathic medicine in the United States has been on rapid growth. For instance, Campbell University School of Osteopathic Medicine has adopted various simulation models for training its students. Maddox and Schmid particularly underscore the use of simulators in imparting new skills in a controlled environment and in providing a modality for testing their skills using a wide range of clinical conditions otherwise impossible in a traditional medical training. The university has 9,600-square-foot high fidelity simulation center whose primary task is to provide a replica of patient care environments so that students can learn, practice and evaluate their skills on wide range of clinical conditions. The simulator is complete with operation room, birthing suite, emergency department, clinical examination rooms, interview rooms, computer room, and a 75-capacity classroom (Maddox and Schmid 59). The unit also has a virtual hospital in which the students use the high-fidelity mannequins for patient assessment, intervention, and monitoring. Maddox and Schmid conclusively shows that best outcomes are realized when simulation exercises are integrated with the standard curriculum rather than when treated as separate unit.
Emergency skill training has reaped positively from simulators. Successful performance of complex tasks in the emergency department such as resuscitation requires both the proficiency in each of the skill and ability to prioritize the skills. The possibilities of training and attaining proficiency in these emergency clinical skills largely depends on a functioning simulation program in which the medical students are exposed to simulated scenarios and the ability to use such advanced patient simulators. While is possible for individual clinical skills to be attained in non-simulated environment, integration of those skills can only be attained by students exposed to advanced simulations.
In the view of the above discussion, simulation-based training has been shown to be superior to dependence on patients for procedure training. The later is seen as problematic because of two major reasons. First, some of the clinical procedures are rarely performed and may take long period of time before the students attain proficiency for the clinical procedure. Simulators on the contrary provide the medical students with opportunity to perform many repeats of a procedure on different mannequins before they attempt it on an actual patient. Even though simulators may appear to be limited in the anatomical features represented, the process of learning and perfecting a new procedural skill is greatly heightened. According to Deering and Auguste, perfecting the new skill in a realistic laboratory environment confers familiarity with the equipment and the student develops good memory of the procedure which is essential for achievement of efficient and effective skill performance (p.238-239). This is not the case when dealing with actual patients for training. Secondly, procedure training on patients has setbacks in that some procedures performed on the patients for example in the emergency department may be potentially harmful and painful. Availability of simulators allows the medical student to commit an error without consequence; an advantage that is lacking in clinical setting. The trainees can actually go too far with procedures on the mannequins beyond where they would be allowed if they were training on real patients. Thus, they can gain more knowledge and maneuver their way beyond the bounds allowed on a real patient for safety of all especially the patient.
In order for a medical school to practical benefits from simulation Hamstra and Philibert proposes four main areas for consideration: identification of clinical situations that can benefit from simulation, identification of specific learning objective, designing appropriate learning resources and lastly, establishing criteria for assessment and debriefing (539-540). Lastly, simulation programs require huge capital to implement and operate. A combination of stable internal and external funding is necessary for success of the project.
Conclusion
The above discussion has detailed the benefits of virtual simulation in medical education in which learning is facilitated through experience prior to clinical practice. Simulation holds great potential to provide this learning experience if well integrated with the basic principles of curriculum delivery. In a medical set up, simulation has been shown to provide an effective modality for integration of basic theories with clinical situations. Prior to introduction of simulators, medical students primarily acquired their skills during a real-life clinical experience. However, increased focus on patient safety marked with the realization of increasingly complex modern clinical procedures, simulation-based training has become imperative. It has also become difficult for a novice to gain clinical proficiency solely on clinical environment training. Consequently, interest in simulation as a critical component of medical training has grown. Conclusively, systematic reviews of simulation-based medical education suggest great potential in reducing medical errors, patient discomfort and litigation by ensuring that medical students first learn in the safe setting of a simulation laboratory.
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