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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 59-65

The expanding use of simulation for undergraduate preclinical medical education

Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA

Date of Web Publication7-Jul-2017

Correspondence Address:
Jonathan A Lipps
Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_40_17

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Simulation as a tool for medical student education has long been valued for its ability to provide realistic standardized experiences to learners in a controlled environment without exposing patients to harm. Consequently, the use of simulation-based medical education (SBME) has greatly expanded over the last decade. While traditional simulation for medical education has been limited to procedural training, increasingly its scope has expanded to include instruction for preclinical curricular elements. Technological advances in health-care simulation have allowed for activities that can enhance or even replace traditional basic science content. This has coincided with a shift in medical school curricula to include early clinical experiences, which only further increases the demand for medical student simulation. This article is the result of both the authors' experiences as well a synopsis of a literature search of both reviews as well as original research related to SBME for preclinical medical students. Different simulation modalities including partial task trainers, standardized patients, virtual patient, and high-fidelity simulation are all discussed.
The following core competencies are addressed in this article: Patient care, Medical knowledge, Practice-based learning and improvement, and Interpersonal and communication skills.

Keywords: High-fidelity simulation, simulation, simulation-based medical education, standardized patients, undergraduate medical education

How to cite this article:
Lipps JA, Bhandary SP, Meyers LD. The expanding use of simulation for undergraduate preclinical medical education. Int J Acad Med 2017;3:59-65

How to cite this URL:
Lipps JA, Bhandary SP, Meyers LD. The expanding use of simulation for undergraduate preclinical medical education. Int J Acad Med [serial online] 2017 [cited 2023 Jan 29];3:59-65. Available from: https://www.ijam-web.org/text.asp?2017/3/1/59/209843

  Introduction Top

Over the last two decades, simulation-based medical education (SBME) has increasingly become a common component of undergraduate medical education.[1] The benefits of SBME are well documented, but perhaps the most commonly cited are its ability to provide medical students with repeatable clinical experiences without exposing real patients to any harm.[2] The use of simulation as a tool for undergraduate medical education is often thought to be particularly useful toward the later years of medical school when instructional content is weighted more heavily toward clinical encounters. During the 3rd and 4th year of medical school, students rotate through various clerkships during which they are expected to learn a diverse set of clinical procedures. Partial-task trainers are often used to allow students to rehearse these procedures in a low stress, controlled environment before performing them on an actual patient. On an anesthesiology rotation, for example, a student might be given the opportunity to learn and demonstrate mask-ventilation and endotracheal intubation on an airway trainer before being allowed to perform the same on an actual patient. Other procedures amenable to instruction with task trainers include peripheral intravenous placement, suturing, and central line insertion. Although partial-task trainers are one of the most well-known components of SBME, it is actually just one modality in the simulation toolbox. In an effort to better meet the instructional needs of a new generation of students with a diverse set of learning styles, instructors are increasingly using simulation-based techniques to enhance (and in some cases replace) the traditional didactic content. Physiology, pharmacology, anatomy, and introduction to clinical skills (CSs) are all subject areas ripe for enhancement through simulation. This article is the result of both the authors' experiences as well a synopsis of a literature search of both reviews as well as original research related to SBME for preclinical medical students. We will explore the ways in which SBME has now moved beyond being designated solely to procedural training and is quickly becoming a fixture of undergraduate curriculum in the preclinical years.

  Curriculum Changes Top

A part of this shift toward increasing use of SBME may be due to an increasing recognition that using simulation educators can create immersive experiences that other more traditional didactic modalities cannot provide. Recently, there has been a focus on refining medical school curricula to provide better clinical correlation and achieve vertical curriculum integration. Vertical curriculum integration is, in short, the blending of basic science principles with practical clinical applications. This serves the purpose of providing learners with a clinical context for the basic science concepts they are learning. These curricular changes have presented a unique opportunity for the greater use of SBME in the preclinical years.[3] While learning in situ (the hands-on learning of basic science concepts in the clinical setting) is the most direct path to achieving vertical curriculum integration, this would not be practical, ethical, or even safe for novice students with little to no clinical experience.[4] However, by simulating the clinical context, educators are able to provide their students with a realistic experience within a safe, controlled environment.

Another advantage of SBME is the ability to deliver content in such a way that students with different learning styles can receive it. There are several different learning types, and the educator should acknowledge that students learn best in different ways. Three commonly described learning types are visual, auditory, and kinesthetic. Simulation-based teaching can appeal to each. Unlike much traditional didactic, content simulation also allows the student to be actively involved – an important aspect for kinesthetic learners. Simulation-based teaching can package many different learning styles into one lesson thereby allowing more students to learn and retain the information presented.[5] Beyond appreciation for different learning types, the educator should also acknowledge that the medical student is an adult learner. As such he or she should be familiar with the five key principles of adult learning theory or andragogy.

  1. Adults need to know why they are learning
  2. Adults are motivated to learn by a need to solve problems
  3. Adults' previous experience must be respected and built upon
  4. Adults need learning approaches that match their background and diversity
  5. Adults need to be actively involved in the learning process.

SBME, when used as an enhancement to traditional didactic content, incorporates principles of andragogy by building upon and enriching content that the students have already experienced. Further, it allows them to see the practical applications to abstract concepts and solve problems that occur clinically in a safe environment. Finally, SBME can add an emotional component to learning. Immersive exercises can frame basic sciences within a clinical environment thereby creating an “affective anchor” which can, in turn, promote memory retention.[6] Recent work in cognitive load theory has examined ways in which stress, a common component of realistic simulated exercises, can help consolidate working memory into long-term memory.[7] SBME, by replicating real-life patient interactions, can appeal to emotions and enhance learning and memory retention in ways that traditional lecture-based didactic techniques simply cannot.

  Standardized Patients Top

A 2011 survey by the AAMC showed the use of SBME as high as 84% and 91% of medical schools in the 1st and 2nd year, respectively.[8] Although there has been no more recent survey performed, given the trend toward increased use of simulation it is likely that the current prevalence in the preclinical years is nearly ubiquitous. In the same survey, those portions of the preclinical curriculum that were reported to be the most commonly taught using simulation were in the domains of CSs, introduction to clinical medicine, and physical diagnosis. On the other hand, in the preclinical years, procedural training is usually only a small component of the curriculum. If the prevalence of simulation for the instruction of preclinical students is nearly universal, this is in large part due to the widespread use of standardized patients (SPs). SPs likely represent the most common modality for simulation instruction during the first 2 years of medical school.

The use of SPs in the United States dates back to the 1960s when they were first proposed by Barrows and Abrahamson for the assessment of CSs.[9] Barrows described the primary benefits of what he called the “programmed patient” as being repeatability and reliability. Barrows initially used his “programmed patients” or what we now refer to as SPs to replicate neurologic signs and symptoms such as paraplegia and hyperalgesia. Since that time, the use of SPs has expanded beyond the realm of neurology and into the mainstream. In the 2011 AAMC survey on SBME, 94% of medical schools and 65% of teaching hospitals reported using SPs.[8] In addition to the benefit of repeatability which Barrows noted in his original report on “programmed patients,” SPs as with other simulation modalities offer students an opportunity to learn in a safe, controlled environment.

Simulated patient encounters using SP actors comprise a large portion of a medical student's earliest doctoring experience.[10] Interpersonal communication, professionalism, and the basic physical examination are all skills that are common elements in the preclinical curriculum. Simulated experiences with SPs give students the opportunity practice each of these skills in a controlled, low-stress setting. After careful observation and feedback on their performance by medical school faculty, the students may be better prepared to interact with actual patients in the clinical years.

While exposure to SPs often begins early in the 1st year, interactions continue throughout all 4 years of medical school where many schools incorporate these encounters into their objective structured clinical examination (OSCE). Inherent in the name, SP encounters are standardized to allow for reproducible experiences. This quality can be useful for the purposes of assessment. SPs are most useful for assessment in those CSs or competencies that deal with interpersonal and communication skills and professionalism. In addition to eliciting a particular history and set of symptoms, actors portraying the patients can be trained to produce an emotional tone that reflects the diverse temperaments and emotions that students can expect to see in real patients. The interactions are prescripted such that SPs can be played both by faculty and nonphysician actors alike. Since initially proposed for student assessment by Barrows in the 1960s, numerous educators have examined and validated the use of SPs for the assessment.[9] The near universal adoption of SPs and OSCEs for training students may be attributed in part to the adoption of the United States Medical Licensing Examination Step 2 CS examination by the National Board of Medical Examiners. This exam, implemented in 2004, is required of all graduating medical students and is comprised a series of SP encounters where students are assessed on the merits of communication and interpersonal skills, spoken English proficiency, and data gathering/interpretation.[11] While this examination is most commonly taken in the final year of medical school, the topics that are assessed are some of the first that students are taught in their preclinical years.

Just as the advent of SPs more than 50 years ago revolutionized medical education, advances in technology may allow us to further expand the capability of SBME to target the specific needs of a diverse set of learners. Virtual patients (VPs) are interactive computer-based correlates to the SP that allow for even greater flexibility than SPs. VPs unlike their actor-based counterparts require less human resources, are more standardized, and can be programmed to contain a vast library of cases.[12] Perhaps most importantly, VPs allow for the collection of large amounts of data on student performance, which can clarify which educational strategies are most effective and adapt accordingly. Already VP use is gaining traction in clerkship education. Pediatric-based virtual case simulations as a part of the Computer-Assisted Learning Program for the Pediatrics Clerkship Project were developed from 2000 to 2003 and are now used by over fifty medical schools.[13] Although VPs are currently being used in a limited capacity for training undergraduates in communication skills, it remains to be seen whether they will ever be able to match the training provided by interaction with an actual human.[14] It is likely that much of the skepticism on the utility of VPs resembles the same skepticism Barrows faced when he proposed SPs be used in place actual patients for training purposes. As the realism of artificial improves, it is not hard to imagine that VPs will be more mainstream in training preclinical students.

  Physiology and Basic Science Top

While the use of SPs makes curricular areas such as CSs and interpersonal communication easy targets for SBME, the basic sciences are also ripe for an instructor looking to enhance the curriculum with simulation-based teaching. It might seem at first that simulation would not be the best fit for demonstrating abstract topics such as pharmacology and physiology, but several educators have successfully utilized high-fidelity simulation (HFS) to do just that. High fidelity as it pertains to simulation is loosely defined as a simulated experience characterized by a high level of realism such that the conditions of the simulator closely resemble a real patient or task.[15] Several commercially available mannequin-based simulators can be described as high fidelity in that they can be used to demonstrate complex human physiology. Physiology is traditionally a challenging topic for medical students and one that is most commonly taught in the confines of a large lecture hall. The recent shift toward system-based curricula with early clinical experiences has made it difficult to find time to properly teach physiology.[16] Laboratory experiences that utilize high-fidelity mannequin-based simulations to demonstrate basic human physiology principles allow for that opportunity. Several studies have shown that students generally prefer simulation-enhanced physiology experiences to the traditional didactic counterparts. It is not surprising then that several educators have also demonstrated simulation-based instruction to be superior with respect to knowledge acquisition. In one of the earliest examples, Euliano in 2000 introduced simulation-based physiology demonstrations to replace animal-based physiology instruction. She used a mannequin-based simulator to demonstrate pulmonary physiology concepts such as ventilation/perfusion mismatch, pulmonary compliance, and the oxyhemoglobin dissociation curve.[17],[18] Gordon et al. in 2006 similarly used high-fidelity mannequin-based simulation to teach cardiac physiology. He demonstrated improved understanding of the topic in a small sample of 1st year medical students immediately after a simulated encounter of a patient with a myocardial infarction.[19] As compared to controls that only received a traditional case discussion, retention of knowledge was also improved at 1 year after the session. Others have successfully implemented similar mannequin-based HFS experiences to teach shock physiology and pharmacology.[20],[21],[22],[23]

At our institution, we have implemented small group interactive laboratory experiences to teach 1st year students both cardiac and pulmonary physiology. In each session, a group of no more than ten students is led by an instructor to interact directly with a high-fidelity mannequin through different progressive phases of clinical care.[23] In our pulmonary physiology laboratory, the students first encounter the mannequin in a simulated trauma scene where they are asked to perform basic components of the physical examination including auscultation. Next, the student follows the patient into the emergency department where the instructor leads the students through the clinical management of a life-threatening tension pneumothorax. The instructor will frequently pause the simulation to discuss and demonstrate principles of pulmonary physiology. Each of the students is encouraged to participate in patient care in some whether it is placing monitors, applying oxygen, or performing a needle decompression. Finally, the students follow the mannequin into the simulated Intensive Care Unit where the instructor leads a discussion of ventilation, dead space, and West zones of the lung [Table 1] and [Figure 1].
Table 1: Example of mannequin-based pulmonary physiology laboratory

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Figure 1: Patient simulator in the Intensive Care Unit setting (original by author)

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These sessions were specifically designed to incorporate hands-on procedures and student-mannequin interaction. Both are considered essential to allow for multisensory engagement and kinesthetic learning. It is possible also that this exercise, which realistically demonstrates rapid pulmonary decompensation and respiratory failure, adds an element of emotional weight to the exercise. Although the students at this point in their training would not be expected to be proficient in many of the procedures performed during the exercise, the hands-on nature of the experience may lead to a better understanding of abstract physiology concepts by encouraging active learning. Another unique aspect of this method of teaching physiology is the fact that it can be taught almost exclusively by clinicians (i.e., anesthesiologists, intensivists, and pulmonologists) who are experts in the clinical applications of these concepts. At this point in medical school, most students have had limited or no exposure to the field of these fields, and this type of activity is ideal for demonstrating the scope of each.

It is worth mentioning that simulation-based physiology exercises must not always perform in the small group setting. Certainly, the model described above is very resource intensive. Other educators have described implementing a hybrid model whereby simulation-based physiology demonstrations are directed to large groups of students.[24],[25] Fitch in 2007, for example, describes simulation-based neuroscience large group demonstrations resulting in improved posttest performance.[24] This hybrid simulation-lecture model is able to engage preclinical students by demonstrating the clinical application of basic science concepts while also taking into account the reality of limited resources.

Another domain of medical education where simulation can enhance preclinical course content is anatomy. For medical students, human cadaveric dissection in the gross anatomy laboratory has traditionally been a rite of passage and has been an integral component of medical education for centuries. Even before interacting with SPs and mannequin-based patients, the cadaveric donor is likely a medical student's first “patient.” Increasingly, however, this course content is being supplemented or even replaced with simulated three-dimensional computer models as more computer-assisted learning packages become available. Educators have demonstrated that knowledge of human anatomy can be enhanced by supplementing traditional didactics with simulation.[26] While some might argue for replacing traditional cadaveric dissection courses on ethical grounds, there is currently insufficient evidence to support replacing anatomy education entirely with a simulation-based curriculum.[27] At the very least, there is good evidence to support the inclusion of computer-assisted supplements. In one study of 238 1st year medical students access to virtual dissection tables in conjunction with cadaveric computed tomography scans yielded 27% higher scores test scores over the content.[28] Much as the high-fidelity physiology simulation provided clinical correlates for the didactic content, incorporation or radiologic imaging in the 1st year achieves the same goal of vertical integration. As of 2011, just over 40% of medical schools use some type of simulation as a part of their anatomy instruction.[8] This is similar to the percentage using simulation to teach other basic science topics such as physiology and pharmacology. While it is presently underutilized, as medical schools strive for vertical curriculum integration and more opportunities to introduce clinical correlations of basic sciences to students, they may look increasingly to simulation to supplement their preclinical curriculum not only in physiology but also in anatomy as well.

  Conclusion Top

The use of simulation at the undergraduate level has grown to become almost universal at the US medical schools. The content that can be taught using SBME is diverse and includes those subjects typically covered in the preclinical curriculum. During the early years of medical school teaching through simulation helps achieve vertical curriculum integration by introducing clinical concepts early. High-fidelity mannequin-based physiology laboratories are just one example of how simulation can bridge the gap between the preclinical and clinical years. By creating a direct connection between theoretical concepts and practical clinical applications, vertical curriculum integration appeals to the adult learner. This model also creates a kinesthetic learning experience that appeals to different learning styles to supplement more traditional teaching methods. The repeatable controlled setting of the simulation laboratory allows students to gain confidence and improves their skills before moving on to the more high stakes clinical environment. As the pace of technological innovation accelerates so too will the applications for SBME. The 21st century will likely see more traditional classroom didactics either supplemented or eventually replaced with virtual correlates. The widespread of adoption of SPs to become nearly universal only 50 years later is an example of how quickly an educational innovation can spread. Most recently VPs, computer-based cases, and virtual cadavers are increasingly being used. Each can be programmed to dynamically adapt to provide feedback and meet learner-specific needs. As artificial intelligence improves, simulation-based technology may one day be suitable for teaching and assessing skills in interpersonal communication. While it is reasonable to base changes in educational strategies on sound evidence, educators must be open to new strategies available in the vast simulation toolbox to best meet their students' diverse learning needs.


Thanks to Dr. Thomas Papadimos for his support in preparing this manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1]


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