Use of Simulation –
The Pros (& Cons)
Prof K.R. Sethuraman
Dean – Faculty of Medicine &
Deputy VC – Academic/International Affairs
AIMST University
Viewpoints From
•
•
•
•
•
Students’ perspective
Educators’
,,
Pedagogy support
Research
,,
Patient safety & rights
How Learning Used to be…
•
•
•
•
•
No Computer
No Internet
No TV
No Video
No Mobile Phone
• Less Diversions!
Net Geners Learn Differently
• By 21 years of age,
– 10,000 hours playing
video games
– 20,000 hours on email – chat – blog
– 20,000 hours watching
TV
– 10,000 hours on cell
phones, and
– under 5,000 hours
reading
• They need:
– fast paced, highly
stimulating
presentations
– increased interactivity
with content & each
other
– information that relates
to the learner’s world
– multiple options for
obtaining knowledge.
Susan El-Shamy. Training for the new and emerging generations.
Quoted in http://scope.lidc.sfu.ca/mod/forum/discuss.php?d=521
Parenting Net Generation!
Educating the Next-Generation
• Medical education has responded by
increasing the amount of :
– multimodal content (visual, auditory, kinesthetic
“hands on” practice)
– active learning (read, write, discuss)
– experiential/contextual learning (job shadowing,
simulation labs)
– problem based learning, team projects.
Simulation for Residents with
Kinesthetic Learning Style
• An individual’s preferred
way of learning:
– Auditory (listening – lecture),
– visual text (reading print textbook),
– visual picture (seeing images,
diagrams),
– tactile kinesthetic (learning by
doing, hands-on),
– verbal internal kinesthetic
(learning by putting into own
words)
• A study of learning styles
of 20 anaesthesia
residents:
– strongly (90.0%) or
moderately (10.0%)
tactile kinesthetic
• Medical simulation will be
a valuable Hands-On
teaching modality,
– especially for students with
a strong tactual kinesthetic
learning preference.
Linda M. et al. Value of Medical Simulation for Residents with Tactual/Kinesthetic Learning
Styles [State University of New York] in ANESTH ANALG 2005;101;S1-S90
The CanMEDS initiative –
Royal College of Physicians and Surgeons of Canada
1.
2.
3.
4.
5.
6.
7.
Specialist roles for the
future specialist:
medical expert/decision
maker,
communicator,
collaborator,
health care advocate,
manager,
scholar
professional
CanMEDS initiative focuses
on those ignored in
resident training:
– communicator,
– collaborator,
– manager and
– Professional
Simulation has been
advocated to train
residents in these
roles
Ref - Brown & Finucane. “7 roles…” in ANESTH ANALG 2005;101;S1-S90
The CanMEDS initiative – RCPSC
• Residents’ experience
with real critical events is
unsatisfactory.
– The frequency of these is
unpredictable
– Staff take over managing
critical events when they
occur
– Poor pre-planning and
inadequate debriefing.
– Traditional teaching by
clinical work, rounds,
anesthesia conferences,
etc do not deliver
substantive learning
• Resident rated
simulation based
learning high
– learning was powerful and
experiential
– Simulator learning
allowed for deep
integration of book
knowledge with practical
skills,
– especially in the areas of
communication,
collaboration, teamwork
and leadership.
Bottom line: “Simulation use must be strongly endorsed at an institutional
and university level.” – RCPSC
End-Of-Life Communication –
Usefulness Report of Simulation
• high-fidelity
simulation with
professional actors;
• observation of other
trainees engaged in
simulation;
• debriefing with the
learning team;
• Supporting learning
activities and material
• Most helpful items – Direct participation &
interaction with “realistic”
actors
– Observation of other trainees
– hearing other trainees
discuss difficult
conversations
– Debriefing and discussion
with the learning team
– Feedback provided by the
proxy patients and –parents
What Components of an End-Of-Life Communication Simulation Program are Most Helpful To Trainees?
[Boston and Harvard Medical School] Elaine C. Meyer, et al in ANESTH ANALG 2005;101;S1-S90
End-Of-Life Communication –
Feedback on ‘what was learnt’
• Communication skills
– value of speaking
honestly,
– allowing for silence,
and
– individualizing their
language and
approach
– based on the family’s
needs and
preferences
• Relational skills
– listening,
– showing concern, and
– bringing their own
humanity to bear
during difficult
conversations
– are highly valued and
long-remembered by
families
How hazardous is health care?
REGULATED
DANGEROUS
(>1/1000)
Health Care
100,000
ULTRA-SAFE
(<1/100K)
Total lives lost per year
Driving
10,000
1,000
Chartered
Flights
100
Mountain
Climbing
10
Bungee
Jumping
Scheduled
Airlines
Chemical
Manufacturing
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
1,000,000 10,000,000
Number of encounters for each fatality
Note: both dimensions are logarithmic scales
Swiss Cheese Model of Accident Causation
Goal Conflicts
and Double Binds
Incomplete
Procedures
Triggers
Mixed
Messages
Workload
Pressures
Regulatory
Responsibility
Narrowness
Shifting
Inadequate
Training
Attention
Distractions
Deferred
Maintenance
Clumsy
Technology LATENT
FAILURES
The World
Accident
DEFENSES
Modified from Reason, 1991 © 1991, James Reason
SBME is Now Becoming a Vital Need
• Bristol Case of high mortality in Paed Card
– The training of doctors in advanced
procedures
– How to approach the so called learning curve
of doctors for standard procedures
– How clinical competence and technical
expertise are assessed and evaluated
– How doctors explain risks to patients
• GMC inquiry raised several such issues
Editorial - All changed, changed utterly. BMJ 1998;316:1917-1918
An Ethical Mandate for All
• Patients are to be
protected from all
avoidable harm
• They are not
commodities to be
used as
conveniences of
training
Amitai Ziv, et al. Simulation-Based Medical Education: An Ethical Imperative.
Acad. Med. 2003;78:783–788.
Barriers to Student Access to Patients
• Bedside teaching is in steady decline
– Only about 50% were accessible
– 35% (70% of above) agreed to give history
– 34% agreed to be examined
– Assessed by repeated cross-sectional audit
– too few to provide current student population
with extensive clinical experience
• We must use Simulated Patient
encounters
Leslie G Olson et al. Barriers to student access to patients in
a group of teaching hospitals. MJA 2005; 183 (9): 461-463
SBME (Simulation-Based Medical
Education) is an Ethical Imperative
• Medical training must
use live patients to
hone the skills of health
professionals.
• But we have an
obligation to ensure
patients’ safety and
well-being by providing
optimal treatment.
• Balancing these two
creates ethical tension in
medical education.
• SBME can mitigate this
tension by taking care of
– best standards of care and
training,
– error management and
patient safety,
– patient autonomy, &
– social justice
Simulation of Vaginal Birth for Third Year
Harvard Medical Students
• it is not unusual for
students to complete their
labor rotation without
conducting a normal
vaginal delivery.
• The goal of this pilot
program was to provide a
realistic simulation of a
normal & abnormal
vaginal deliveries to
students of 3rd year.
• Post-course evaluations
were uniformly positive.
• Sample comments
include:
– “Wonderful way to learn”;
– “I forgot it was Friday
evening”; and
– “Great combo of didactics
and teaching”
Roxane Gardner et al. in ANESTH ANALG 2005;101;S1-S90
Simulations may be effective if
used wisely
• Evidence of the
effectiveness of carefully
implemented simulations:
• A review of 109 studies
looked at whether
medical simulations
actually facilitate learning.
• The best available
evidence shows a benefit
for simulations when four
conditions are met:
1. educational feedback
is provided,
2. learners are given the
opportunity for
repetitive practice
3. exercises based on
the simulation are
integrated with the
curriculum, &
4. tasks range in
difficulty.
Editorial – Med Teacher 2005;27: 10-28
Cynic is one who • Knows the Cost of Everything…
but the Value of Nothing
– Oscar Wilde
The Future of Simulation
The IOM report made strong recommendations
with regard to medical simulation:

“Establish interdisciplinary team training
programs, such as simulation...”

Use procedures to mitigate injury through
simulation training.

Create a learning environment. “Use
simulations whenever possible.”
 (IOM Report: To Err Is Human: Building a Safer Health System,
Institute of Medicine. National Academy of Sciences. 1999)
Simulation & Transformation of
Medical Education
• Three pillars of a major
transformation occurring in
medical training today:
– Patient centered care with an
emphasis on quality and
safety;
– new training models,
including standardized
clinical encounters and
simulations; and
– competency-and milestonebased education, training,
and credentialing.
• We must accept the
primacy of patient welfare
and embrace our
commitment to
professional competence
• In future, medical
education, residency
training, CME/CPD and
clinical privileges in
practice will bear little
resemblance to the past
Gary J. Becker, Simulation and the Coming Transformation of Medical Education and Training.
Radiology 2007; 245:7–9
Future Vision of Simulation in Healthcare
• Systematic training and
assessment – a major
priority.
• Simulation training will be
applied to individuals,
teams, work units, and
organisations.
• Simulation will be an
important "bottom up" tool
for
– creating a culture of
safety and
– for fostering changes in
work procedures and
systems.
• Facilitate competency
focussed clinical training and
practice.
• Costs of simulation based
training will vary depending
on its complexity.
• Benefits of simulation may be
hard to measure.
• Key drivers of simulation
include public, insurers,
professional societies,
accrediting organisations, &
regulatory agencies.
D M Gaba. The future vision of simulation in health care. Qual Saf Health Care 2004;13:i2-i10
Vote for Simulation !