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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
I was at a meeting with our Dean recently when, while discussing a new medical education building for students, he emphasized the role of simulated instruction. In fact, a considerable part of the new building was dedicated to simulated learning. I was vaguely aware of the increasing role that simulation was playing at all levels of medical education, but the enthusiasm and passion with which it was presented prompted me to delve further into the topic. Flight simulators have, of course, been used very effectively in aviation for many years and have been proposed as a model for medicine. It seems quite clear that the replication of clinical scenarios in a controlled laboratory setting will similarly be of increasing importance not only in the training of physicians, but also in assessing their capabilities and improving the quality of care.
Medical education has traditionally utilized the mentorship method. The student observes the teacher and then gradually assumes a greater role in delivering care as experience is gained. The process has sometimes been likened to the training of artisans and referred to as an apprenticeship. It has also been often characterized by the well-known cliché of “see one, do one, teach one.” Although it has been very effective over the years, this mentorship approach can provoke some anxiety, especially when considering the first attempt of a trainee to perform a delicate surgical procedure.
A number of changes within our medical system are presenting challenges to the conventional mentor approach to education. The number of skills and procedures that physicians must master is increasing rapidly, resulting in an expanding pool of those to be trained. At the same time, the teachers are increasingly distracted by administrative tasks and the requirement to generate clinical revenues. Hospital stays for patients are continuously decreasing, and the demands of cost efficiency are minimizing both time and opportunity for instruction. For their part, patients continue to harbor some discomfort with the prospect of being the subject of someone's education. Finally, recognition of the prevalence and consequences of medical errors has resulted in increasing urgency to eliminate iatrogenic events. Simulation laboratories are seen as the solution to many of these challenges.
A spectrum of models can be used in simulated medical education. Computers can be applied to reproduce clinical situations and allow for rapid feedback. Manikins have been used for years; newer generations can emit physiological responses appropriate for the clinical condition and are well suited to teach invasive procedures. An important development has been the use of actors as patients. These pseudo-patients are often well schooled in the signs and symptoms of disease and the response to management, and may have scripts the size of textbooks. Finally, clinical scenarios can be created in which a group of physicians, nurses, and other providers are made to work together to teach and assess not only their individual skills but also the effectiveness of their interaction.
Although simulation was initially employed for education, and is still primarily used in this role, the technique has expanded to other applications. A natural extension of the teaching function is evaluation, and the same imitation clinical setting can be used to both train and test for proficiency. Such a system lends itself very well to instruction and evaluation of catheterization skills. Finally, clinical scenarios can be created to define potential problems in group behavior, such as lack of communication, that can be rectified to enhance quality of care. ACLS is a classic example that comes to mind.
For a medical simulation to be valuable, two characteristics are requisite. First, the replication must have fidelity, or accurately reproduce the clinical findings that would be encountered. An unrealistic simulation would clearly be of little value. Second, the model must have validity. That is, the simulation must result in knowledge and ability that can be applied in a clinical setting to improve outcome. There are obviously limits on how accurately specific clinical conditions can be reproduced. As for the ability to be effectively applied in a true patient care situation, data validating the methods are increasingly available. However, additional validation in larger datasets is needed.
The advocates of medical simulation have long pointed to the effective use of this technique in aviation. Aviation replicators can very accurately reproduce not only instrument settings but also the position and movement of a plane in any situation. Simulators can expose aviators to circumstances that they would (hopefully) almost never encounter, such as complete engine failure. Pilots not only use simulated lessons to learn to fly planes, but periodically undergo repeat sessions to maintain proficiency. Simulation training is credited in large part for the ability of Captain Sullenberger to land his engineless jet in the Hudson River without the loss of life. Not surprisingly, therefore, proponents of simulated medical education believe that the method would be equally effective both in enabling physicians to master new skills without patient risk, and in preparing them to deal with rarely encountered medical emergencies.
While I have become a believer in the value of simulation, I see important differences between its application in aviation and medicine. The circumstances encountered in flying a plane, including instrument settings and position of the cockpit in space, can be very accurately reproduced in a model. The visual and motion sensations experienced can be precisely replicated. In addition, all aircraft of a given type will respond similarly. However, the variables present in any individual clinical situation are almost infinite; it is impossible to predict with certainty how a given patient will respond to a disorder or its treatment. Moreover, clinicians learn to detect and interpret subtle signs such as the color, temperature, and behavior of the patient in coming to a diagnostic assessment and treatment plan. Even the most expert actor cannot be expected to imitate these findings perfectly. Therefore, although a pilot might become competent to fly a plane based upon simulator training, real-life clinical experience is necessary to be an excellent physician. In my opinion, simulation can supplement clinical training, but it cannot replace it.
There is one other aspect of simulated instruction that I believe is important. The experience of performing in a risk-free environment without the possibility of morbidity or mortality is very different from being involved in a true clinical situation. The stress and tension inherent in a serious medical encounter certainly have the ability to affect performance. Anyone who has stood before a putt on the 18th green to win a tournament knows that shot is quite different from the one on a practice day. The same can be said for a foul shot in the closing seconds of a championship game. When there is much on the line, everything seems just a bit more difficult. Again, while simulation can imitate the clinical setting, it can never fully reproduce it.
I am certainly glad that the university has invested significantly in simulated education. It will almost certainly be of great value in a large number of clinical situations, and it will overcome many of the challenges currently encountered in the traditional mentor approach to training. As time goes by simulation will surely get better and more refined, and I can envision a time when physicians retrain periodically similar to pilots. However, I do not think that simulation will ever replace clinical experience. The instincts and judgment that come from seeing a number of patients in the midst of their disorders represent a skill set that cannot yet be reproduced in any other way.
- American College of Cardiology Foundation