|Year : 2017 | Volume
| Issue : 1 | Page : 1-4
What's new in academic medicine? Simulation in medical education: An imperative for efficient learning, patient safety, and interprofessional collaboration
2ndDepartment of Anesthesiology, University of Athens Medical School, “Attikon” University Hospital, Athens, Greece; Department of Anesthesiology, Centre Hospitalier Du Cotentin, Cherbourg, France
|Date of Web Publication||7-Jul-2017|
2ndDepartment of Anesthesiology, University of Athens Medical School, “Attikon” University Hospital, Athens; Department of Anesthesiology, Centre Hospitalier Du Cotentin, Cherbourg
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Stroumpoulis K. What's new in academic medicine? Simulation in medical education: An imperative for efficient learning, patient safety, and interprofessional collaboration. Int J Acad Med 2017;3:1-4
|How to cite this URL:|
Stroumpoulis K. What's new in academic medicine? Simulation in medical education: An imperative for efficient learning, patient safety, and interprofessional collaboration. Int J Acad Med [serial online] 2017 [cited 2019 Jul 23];3:1-4. Available from: http://www.ijam-web.org/text.asp?2017/3/1/1/209853
Like aviation, medicine is a high-risk industry where errors can be fatal and extremely expensive. The need for creating a controlled and safe environment where doctors (both juniors and seniors) can be exposed in high-risk conditions that could rarely be encountered in the clinical setting has been widely understood particularly over the past two decades. However, errors do not only occur in difficult or rare clinical settings. It has been found that errors occur in our everyday clinical practice and they involve mostly nontechnical skills. Furthermore, whereas medical simulation training at its early beginnings focused on training in following algorithms and procedures, it was rapidly recognized that it should also focus on human factors and teamwork.,
Simulation is a standardized process that enables trainers to reproduce clinical settings of infinite variety and complexity so as to allow to health-care professionals of with different skills and background to achieve clinical competency as a team.
In a practice that tolerates zero margin of error, and where error is poorly dealt and accepted by physicians, simulation has a paramount role to play in a paradigm shift to our current practice by promoting feedback, debriefing, and discussion. Of all medical specialties, anesthesiologists and surgeons have been the pioneers in simulation training over the past three decades. Since 2010, the “Helsinki Declaration for Safety in Anaesthesiology” by the European Board of Anesthesiology and the European Society of Anaesthesiology has been disseminated and adopted or supported from numerous countries worldwide.
The declaration recognizes that human factors are of primordial importance in the delivery of safe patient care to. Therefore, operating room teams (anesthetists, surgeons, nurses, as well as all other clinical partners involved), should work in close cooperation to effectively and reliably provide this. The text emphasizes the role of education's key role in improving patient safety and stresses the need of “development, dissemination, and delivery of patient safety training” stipulating thus that team training should become part of the curricula.
Furthermore, in 2014, the Accreditation Council for Graduate Medical Education (ACGME) in the United States implemented the “Next Accreditation System” for anesthesiology, emphasizing on “competency-based” learning in residency. Among the ACGME core competencies, we can find knowledge, patient care, professionalism, communication and interpersonal skills, practice-based learning and improvement, and systems-based practice. The same applies for several other national anesthesiology societies as in Israel, UK, Canada, and Australia.,,
Traditional training inside a single specialty resulted in enhancing bonds, communication and perhaps performance between health-care professionals of the same specialty (e.g., anesthetists and nurse anesthetists) but at the same time, it could lead to the creation of barriers between them and practitioners coming from other specialties (surgeons). One could say that an anesthetic team may be perfectly aware of and capable of perfectly following hemorrhage management algorithms but without correct communication with the surgical team and vice versa the outcome could be detrimental for the patient. However, there is a fundamental misconception in that statement: there are no different teams! The health-care professionals taking in charge a patient should constitute a unique team using the same communication codes. This topic of multidisciplinary simulation is analyzed in detail by Stroud et al., in the present issue.
Current research indicates that simulation training not only enhances technical skills acquisition (central venous line insertion, lumbar puncture fiber-optic intubation, and advanced cardiac life support ,,) but it also enhances teamwork, leadership, decision-making, and critical thinking.,, In addition to the above, simulation has been proven useful in developing clinical decision support systems (CDSSs) not only in anesthesiology and surgery but also in geriatrics, emergency department, Intensive Care Unit (ICU), decision-making in end of life ICU use, policy making in stroke prevention, and management of in-hospital cardiac arrest.,,,,,,,,, However, creating CDSSs is an extremely complex task to undertake as it necessitates an analysis not only of the clinical requirements and of the cognitive processes that take place during a given medical activity, but they also have to provide and present an information in an optimal context that fits the receptor's (i.e., the health-care professional) processing activities so that they can achieve situation awareness and be accurately guided through their decision-making process. Pappada and Papadimos describe how CDSSs embody the principles of medical simulation and allow their transfer to clinical practice.
It was at late 1980's when David Gaba identified the existence of gaps concerning nontechnical skills in the curriculum of anesthesia training programs. Since then it has been well clear that to effectively close these gaps nontechnical skills should perhaps be taught earlier than in residency but during medical studies.,
Many medical school curricula are now incorporating simulation technology into their undergraduate and postgraduate programs, recognizing the ability of all levels of simulation to provide students with hands-on training in practically every clinical aspect even the rarest ones.,, Direct hands-on learning and the classical “see one, do one, teach one” approach has disadvantages (patient discomfort, preventable errors) and raises important issues from the ethical viewpoint. As Jenkins et al. point out, high-fidelity simulation has probably an important role to play at that point, as it enables students at different academic levels to learn, apply and test their knowledge in a realistic environment simulating any given clinical field with limitless possibilities. Furthermore, no patient is put at risk, and the process can be repeated as many times as deemed necessary. What is most important is that not only medical students but practically all health-care students can be involved early in their academic life in simulation and “initiated” in the principles of communication and teamwork as depicted by Lipps et al. in the present issue.
However, when coming to developing scenarios in simulation, an important question arises: Does one size fits all? For example, when preparing an obstetric airway scenario does a consultant anesthetist have the same didactic and training needs as a 3rd year resident in obstetric airway management? And even more, does a senior consultant have the same training needs as a junior consultant? Or, how will an experienced or team will respond under a junior anesthetist and vice versa? When developing a simulation scenario educational needs and goals have to be assessed and clearly defined by the educators, and team task analysis has to be undertaken. Bandhary et al. elaborate on this intriguing process of scenario development strategies.
Another medical specialty that requires extensive hands-on training and teamwork skills development is certainly surgery. Vanderbilt et al. and Strosberg et al. analyze the role of medical simulation in this field of medical education. Data suggest that psychomotor performance when assessed in a virtual environment can correlate with technical skills in the operating room. Furthermore, there is evidence that the skills acquired during simulation training (using predefined proficiency levels inside a structured program) are transferable in the operating room.,,, Data coming from meta-analyses support these findings, however, the impact on patient outcome is yet unclear.,
Almost two decades after admitting that to “err is human,” we are still struggling to find the optimal educational method for minimizing medical errors. Research for objective measures of competence and for appropriate assessment tools is constant, and simulation has certainly an important role to play in that process. As abovementioned, simulation has been proven to improve learner's technical skills but also teamwork and communication skills. However, its effect on patient outcome has yet to be proven in large, adequately powered studies (there are nevertheless encouraging data).,,
Learning cannot be guaranteed by simulation only, but simulation has to be considered as an important and indispensable tool in modern teacher's armamentarium, integrated in the traditional curriculum.
But do only the clinicians/trainees/learners commit errors? Teachers/educators also do. The most common mistake in simulation training is that it focuses on realism instead of learning objectives. A faculty of competent educators/tutors should be the primary concern of any simulation center, to be able to identify and to successfully adapt to each particular learning group's needs. Continuous education and evaluation of these educators are strongly warranted. A triadic assessment (assessment from the students, peer- and self-assessment) seems necessary for tutors in the modern era. Motivated tutors, constantly reflecting on the philosophical questions of teachers' role, applying the principles of adult learning, and inspiring others to become like them, are the mentors required for a successful health-care system. Simulation has a certainly a primordial role to play in modern medical education to ensure Hippocrates' dictate: “Regarding disease, do two things: (Act) in patient's benefit or
The author wishes to thank Prof. Tom Papadimos for his editorial support and for his valuable feedback.
| References|| |
Koetsier E, Boer C, Loer SA. Complaints and incident reports related to anaesthesia service are foremost attributed to nontechnical skills. Eur J Anaesthesiol 2011;28:29-33.
Gaba D, Howard S, Fish K. Crisis Management in Anesthesiology. New York: Churchill Livingstone Publishers; 1994.
Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol 2010;27:592-7.
Isaak R, Chen F, Hobbs G, Martinelli SM, Stiegler M, Arora H. Standardized mixed-fidelity simulation for ACGME milestones competency assessment and objective structured clinical exam preparation. Med Sci Educ 2016;26:437-41.
Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system – Rationale and benefits. N Engl J Med 2012;366:1051-6.
Sidi A, Gravenstein N, Lampotang S. Construct validity and generalizability of simulation-based objective structured clinical examination scenarios. J Grad Med Educ 2014;6:489-94.
Chandra DB, Savoldelli GL, Joo HS, Weiss ID, Naik VN. Fiberoptic oral intubation: The effect of model fidelity on training for transfer to patient care. Anesthesiology 2008;109:1007-13.
Friedman Z, Siddiqui N, Katznelson R, Devito I, Bould MD, Naik V. Clinical impact of epidural anesthesia simulation on short- and long-term learning curve: High- versus low-fidelity model training. Reg Anesth Pain Med 2009;34:229-32.
Cheng A, Lockey A, Bhanji F, Lin Y, Hunt EA, Lang E. The use of high-fidelity manikins for advanced life support training – A systematic review and meta-analysis. Resuscitation 2015;93:142-9.
Hughes KM, Benenson RS, Krichten AE, Clancy KD, Ryan JP, Hammond C. A crew resource management program tailored to trauma resuscitation improves team behavior and communication. J Am Coll Surg 2014;219:545-51.
Steinemann S, Berg B, Skinner A, DiTulio A, Anzelon K, Terada K, et al. In situ
, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ 2011;68:472-7.
Miller D, Crandall C, Washington C 3rd
, McLaughlin S. Improving teamwork and communication in trauma care through in situ
simulations. Acad Emerg Med 2012;19:608-12.
Broomé M, Donker DW. Individualized real-time clinical decision support to monitor cardiac loading during venoarterial ECMO. J Transl Med 2016;14:4.
Genes N, Kim MS, Thum FL, Rivera L, Beato R, Song C, et al.
Usability evaluation of a clinical decision support system for geriatric ED pain treatment. Appl Clin Inform 2016;7:128-42.
Evans KH, Daines W, Tsui J, Strehlow M, Maggio P, Shieh L. Septris: A novel, mobile, online, simulation game that improves sepsis recognition and management. Acad Med 2015;90:180-4.
Russ AL, Zillich AJ, Melton BL, Russell SA, Chen S, Spina JR, et al.
Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation. J Am Med Inform Assoc 2014;21:e287-96.
Webb K, Bullock A, Dimond R, Stacey M. Can a mobile app improve the quality of patient care provided by trainee doctors? Analysis of trainees' case reports. BMJ Open 2016;6:e013075.
Press A, McCullagh L, Khan S, Schachter A, Pardo S, McGinn T. Usability testing of a complex clinical decision support tool in the emergency department: Lessons learned. JMIR Hum Factors 2015;2:e14.
Khan S, McCullagh L, Press A, Kharche M, Schachter A, Pardo S, et al.
Formative assessment and design of a complex clinical decision support tool for pulmonary embolism. Evid Based Med 2016;21:7-13.
McEvoy MD, Hand WR, Stoll WD, Furse CM, Nietert PJ. Adherence to guidelines for the management of local anesthetic systemic toxicity is improved by an electronic decision support tool and designated “Reader”. Reg Anesth Pain Med 2014;39:299-305.
Lich KH, Tian Y, Beadles CA, Williams LS, Bravata DM, Cheng EM, et al.
Strategic planning to reduce the burden of stroke among veterans: Using simulation modeling to inform decision making. Stroke 2014;45:2078-84.
Field LC, McEvoy MD, Smalley JC, Clark CA, McEvoy MB, Rieke H, et al.
Use of an electronic decision support tool improves management of simulated in-hospital cardiac arrest. Resuscitation 2014;85:138-42.
Gaba DM, DeAnda A. The response of anesthesia trainees to simulated critical incidents. Anesth Analg 1989;68:444-51.
Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simul Gaming 2001;32:175-93.
Harris DM, Ryan K, Rabuck C. Using a high-fidelity patient simulator with first-year medical students to facilitate learning of cardiovascular function curves. Adv Physiol Educ 2012;36:213-9.
Candler C, Andrews MD. Technology in medical education: How the OU College of Medicine has used technology to enhance the medical education experience. J Okla State Med Assoc 2004;97:8-10.
Kundhal PS, Grantcharov TP. Psychomotor performance measured in a virtual environment correlates with technical skills in the operating room. Surg Endosc 2009;23:645-9.
Boet S, Bould MD, Sharma B, Revees S, Naik VN, Triby E, et al.
Within-team debriefing versus instructor-led debriefing for simulation-based education: A randomized controlled trial. Ann Surg 2013;258:53-8.
Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91:146-50.
Gallagher AG, Cates CU. Approval of virtual reality training for carotid stenting: What this means for procedural-based medicine. JAMA 2004;292:3024-6.
Gallagher AG, Cates CU. Virtual reality training for the operating room and cardiac catheterisation laboratory. Lancet 2004;364:1538-40.
Nagendran M, Toon CD, Davidson BR, Gurusamy KS. Laparoscopic surgical box training for surgical trainees with limited prior laparoscopic experience. Cochrane Database Syst Rev 2014; Mar 1;(3):CD010478. doi: 10.1002/14651858.CD010478.pub2. Review.
Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev 2013 Aug 27;(8):CD006575. doi: 10.1002/14651858.CD006575.pub3. Review.
Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med 2011;12:33-8.
Cohen ER, Feinglass J, Barsuk JH, Barnard C, O'Donnell A, McGaghie WC, et al.
Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical Intensive Care Unit. Simul Healthc 2010;5:98-102.
Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest 2008;133:56-61.