JGIM

INNOVATIONS IN EDUCATION

Simulation Technology for Skills Training and Competency

Gordon Center for Research in Medical Education, University of Miami Miller School of Medicine, P.O. Box 016960 (D-41), Miami, FL 33101, USA.

Medical education during the past decade has witnessed widespread use of medical information technology across the
a significant increase in the use of simulation technology continuum of lifelong learning: medical students now view
for teaching and assessment. Contributing factors in- lectures online or via podcasts; residents consult resources
clude: changes in health care delivery and academic stored in personal digital assistants (PDAs) to help make
environments that limit patient availability as education- patient management decisions at the point of care; practi-
al opportunities; worldwide attention focused on the tioners receive continuing education credits by attending
problem of medical errors and the need to improve patient teleconferences broadcast over the internet. Simulations rep-
safety; and the paradigm shift to outcomes-based educa- resent another form of technology that medical education has
tion with its requirements for assessment and demon- increasingly employed in recent years, and this article aims to
stration of competence. The use of simulators addresses provide a general overview of these educational innovations
many of these issues: they can be readily available at any and their uses for training and assessment.
time and can reproduce a wide variety of clinical condi- Medical simulations, in general, aim to imitate real patients,
tions on demand. In lieu of the customary (and arguably anatomic regions, or clinical tasks, and/or to mirror the real-
unethical) system, whereby novices carry out the practice life circumstances in which medical services are rendered. Our
required to master various techniques—including inva- discussion here may use the term simulation, which in its
sive procedures—on real patients, simulation-based ed- broad sense includes any approximation of actual clinical
ucation allows trainees to hone their skills in a risk-free situations (such as mass casualty exercises or standardized
environment. Evaluators can also use simulators for patient [SP] encounters), but in keeping with the technology
reliable assessments of competence in multiple domains. theme (and space limitations) of this special supplement, we
For those readers less familiar with medical simulators, will focus more narrowly on simulators, referring to particular
this article aims to provide a brief overview of these simulation devices. These can take many forms and span the
educational innovations and their uses; for decision range from low to high fidelity, and from devices for individual
makers in medical education, we hope to broaden users to simulations for groups of trainees. A convenient
awareness of the significant potential of these new classification scheme groups these various simulators into 3
technologies for improving physician training and assess- categories: part task trainers, computer-enhanced manne-
ment, with a resultant positive impact on patient safety quins, and virtual reality simulators.1
and health care outcomes.
KEY WORDS: medical education; simulation technology;
competency assessment.
J Gen Intern Med 23(Suppl 1):46–9 SIMULATOR TYPES AND FEATURES
DOI: 10.1007/s11606-007-0283-4
© Society of General Internal Medicine 2007 Part task trainers consist of 3-D representations of body parts/
regions with functional anatomy for teaching and evaluating
particular skills, such as plastic arms for venipuncture or
suturing. In most cases, the interface with the user is passive
(i.e., the device is examined, or procedures are performed on it,
INTRODUCTION
with little more than rudimentary responses from the simula-
Irrespective of our clinical specialty or health care profession, tor). Although more sophisticated part task trainers may
we encounter new medical technologies in nearly every facet of contain computerized components, we nonetheless distinguish
modern practice, from diagnostic imaging and laboratory them from computer-enhanced mannequins (CEMs) because
testing techniques to therapeutic devices. The potential for the latter reproduce not only the anatomy, but also normal and
these technologies to improve health care delivery and patient pathophysiologic functions. With CEMs the interface with the
outcomes—as well as the disappointments or failures to deliver user is more often active or even interactive: in the latter case,
these benefits—frequently captures attention in the scientific the simulator response will vary according to user actions (for
literature (not to mention the lay press). Perhaps less recog- example, heart rate and blood pressure will change appropri-
nized, however, are the ways that technological advances ately depending on the dose of a particular drug administered
impact on the fundamental process underlying all clinical intravenously). Training and assessment using these simula-
practice, that of medical education. Simply witness the tors can focus on individual skills (e.g., ability of a resident to

46
JGIM Scalese et al.: Simulation Technology in Medical Education 47

intubate) or the effectiveness of teams (e.g., a “code blue” invasive or endovascular techniques), often follows a steep
resuscitation scenario). learning curve; this has obvious implications for patient safety,
Virtual reality (VR) simulations are even newer innovations particularly when novices are performing invasive procedures
in which a computer display simulates the physical world, and on real patients. Recent reports6,7 have highlighted the
user interactions are with the computer within that simulated problem of medical errors and the need not only to prevent
(virtual) world. Existing technologies now allow for very high- mistakes by individuals, but also to correct faults in the
fidelity simulations, ranging from desktop computer-generated systems of care.8
environments (much like those in 3-D computer games) to Other professions with high-risk performance environments
highly immersive VR (e.g., CAVE simulations where the user already have successfully incorporated simulation technology
wears goggles and sensor-containing gloves and sits within a into their training and assessment programs. Examples
specially designed display). Sound and visual feedback are include flight simulators for pilots and astronauts, war games
often highly realistic in these simulations, with recent progress and training exercises for military personnel, and technical
in “haptic” (touch and pressure feedback) technology improv- operations scenarios for nuclear power plant personnel.9–11
ing the tactile experience as well. Employed most commonly for Simulations such as these improve skills acquisition by
examination, surgical, and endoscopic procedures training placing trainees in lifelike situations and by providing imme-
and assessment, we can use VR simulations (like CEMs) to diate feedback about decisions and actions.3 Such simulation-
evaluate both individual and collaborative skills. based programs enhance not only the development and
In all of these examples, the learner is required to react to evaluation of individual skills, but also effective collaboration
the simulation as he or she would under real-life circum- in teams and the building of a safety-oriented culture.
stances; of course, we realize that the fidelity of a simulation is Adopting these models in medical education, specialties
never completely identical to “the real thing”. Some reasons are such as anesthesiology, critical care, and emergency medicine
obvious: engineering limitations, psychometric requirements, have led the way in using simulation modalities, especially for
cost and time constraints.2 Nonetheless, technological ad- teaching and testing the skills needed to manage rare and/or
vancement leading to higher fidelity and increasingly realistic critical incidents. Examples of the effectiveness of such
simulators has been a significant contributor to the recent rise simulation-based training include the mastery of advanced
in the use of this technology throughout medical education. cardiac life support skills by Internal Medicine residents,12 and
a systematic literature review details other features and uses of
high-fidelity medical simulations that lead to improved educa-
tional outcomes in multiple domains.13
FACTORS INFLUENCING USE OF SIMULATION-BASED Closely related to these safety issues are important ethical
questions about the appropriateness of “using” real (even
EDUCATION
standardized) patients as training or assessment resources.
This shift to simulation-based training and assessment con- Such debate often centers on instructional or evaluation
stitutes a significant departure from the traditional “see one, settings that involve sensitive tasks (e.g., pelvic examination)
do one” approach and the customary reliance on real patients or risk of harm to patients (e.g., endotracheal intubation). Use
for education. In addition to developments in simulator of patient substitutes, such as cadavers or animals, raises
technology per se, other factors have influenced this evolution. ethical concerns of its own and faces additional challenges
Changes in health care delivery (e.g., outpatient management (such as availability, cost, and maintaining an adequately
of many conditions for which inpatient treatment was previ- realistic clinical environment). Use of simulators, conversely,
ously indicated, higher acuity of illnesses and shorter hospital circumvents most of these ethical obstacles: trainees can make
stays for patients who are admitted) have reduced patient mistakes and learn to recognize and correct them in the
availability as learning opportunities at academic medical forgiving environment of the simulation, without fear of
centers; at the same time, resident work hour reforms and punishment or harm to real patients. At the same time, the
changes in staff compensation make it increasingly difficult for educational experience becomes truly learner-centered, in-
both trainees and clinical faculty to balance their service stead of focused on the patient, as is appropriate in actual
obligations with time for education and evaluation.3,4 Many clinical settings.
simulators, by contrast, are ideally suited for independent
learning and, thus, can save faculty time. Moreover, unlike real
patients who are frequently “off the ward” when instructors
SIMULATION FOR OUTCOMES-BASED EDUCATION
and learners arrive to perform their assessments, simulators
can be readily available at any time and can reproduce a wide Finally, to understand fully all the influences driving the
variety of clinical conditions and situations on demand. This increased use of simulation in medical training today, we must
transforms curricular planning from an ad hoc process consider them within a broader new context: “While student
(dependent on finding real patients with specific conditions of learning is clearly the goal of education, there is a pressing
interest) to a proactive scheme with great flexibility for need to provide evidence that learning or mastery actually
educators. In addition, simulators do not become tired or occurs.”14 This statement reflects a recent worldwide shift in
embarrassed or behave unpredictably (as might real, especially focus toward outcomes-based education throughout the
ill, patients), and therefore they provide a standardized health care professions. This paradigm change derives in part
experience for all.5 from attempts by academic institutions and professional
Mastery of clinical tasks involving innovative diagnostic and organizations to self-regulate and set quality benchmarks,
therapeutic technologies, such as those featured in this issue but chiefly it represents a response to public demand for
(for example, deployment of medical devices via minimally assurance that doctors are competent.15 Accordingly, medical
48 Scalese et al.: Simulation Technology in Medical Education JGIM

schools, postgraduate training programs, hospital and health student “knows”. Conversely, it makes little sense (despite
system credentialing committees, and licensing and specialty longstanding custom) to test the ability to perform a procedure
boards are all placing greater emphasis on using simulation by writing about it. Rather, for evaluation of those outcomes
modalities for the evaluation of competence across multiple that require trainees to demonstrate or “show how” they are
domains.16–23 Thus, beyond its scope for teaching and learn- competent to perform various skills, the ACGME Toolbox of
ing, simulation technology offers potential advantages in the Assessment Methods27 suggests that simulations are the most
realm of clinical assessment. appropriate instruments.
The new outcomes-based educational paradigm serves as a In the patient care domain, for example, the toolbox ranks
suitable framework for considering the best applications of simulations among “the most desirable” methods for assessing
simulation technology for testing purposes. The Accreditation ability to perform medical procedures and “the next best
Council for Graduate Medical Education (ACGME) in the US method” for demonstrating how to develop and carry out
describes 6 domains of clinical competence: 1) patient care, 2) patient management plans. Within the medical knowledge
medical knowledge, 3) practice-based learning and improve- competency, examiners can devise simulations to judge train-
ment, 4) interpersonal and communication skills, 5) profes- ees’ investigatory/analytic thinking or knowledge/application
sionalism, and 6) systems-based practice.24 Evaluators may of basic sciences. Simulations are “a potentially applicable
use simulations to assess various knowledge, skills, and method” to evaluate how practitioners analyze their own
attitudes within these domains. practice for needed improvements (practice-based learning
During a ward rotation for Internal Medicine residents, for and improvement) and, in the realm of professionalism, simula-
example, faculty can test aspects of trainees’ patient care: tions are among the methods listed for assessing ethically
using a cardiology patient simulator, demonstrate the ability to sound practice.27
perform a focused cardiac examination and identify a fourth One of the strengths of simulators for testing purposes is
heart sound or a murmur. We can evaluate medical knowl- their generally high degree of reliability: because of their pro-
edge: using a full-body simulator during a simulated cardiac gramming, simulators consistently present evaluation pro-
arrest, verbalize the correct steps in the algorithm for treat- blems in the same manner for every examinee and minimize
ment of pulseless electrical activity. We can assess interper- the variability inherent in actual clinical encounters. This
sonal and communication skills and professionalism: during a reproducibility becomes especially important when high-
simulation integrating an SP with a plastic mannequin arm, stakes decisions (e.g., certification and licensure) hinge on
demonstrate how to draw blood cultures while explaining to these assessments. Use of simulators for such examinations
the patient the indications for the procedure. is already occurring in several disciplines: for instance,
This last example highlights the reality that actual clinical the Royal College of Physicians and Surgeons of Canada is
encounters often require practitioners to bring to bear their utilizing computer-based and mannequin simulations in
abilities in multiple domains simultaneously. Formal assess- addition to SPs for their national Internal Medicine certifica-
ments have traditionally focused on isolated clinical skills: tion (oral) exams,23 and the American Board of Internal
e.g., perform a procedure on a simulator at 1 station in an Medicine employs similar simulations in the Clinical Skills
Objective Structured Clinical Examination (OSCE), obtain a Module that is part of their Maintenance of Certification
history or deliver bad news with an SP at another station. Program.28
More recently, very innovative work features evaluations more Numerous published studies offer evidence of validity
reflective of real clinical practice by combining simulation (usually “face”, “construct”, or “content validity”) for various
modalities—for instance, a trainee must interact (gather some medical simulators, but whereas determination of these
history, obtain consent, explain the procedure) with a female psychometric properties is important, research often has not
SP, who is draped below the waist, while performing a addressed the perhaps more important question of “predictive
bimanual exam on a pelvic simulator placed beneath the validity” (i.e., will performance on a given assessment predict
drape—for simultaneous assessment of both technical and future performance in actual practice?). Only recently have
communication skills.25 reports of newer simulation devices for testing (e.g., virtual
reality systems for minimally invasive surgery 29,30) spoken to
these considerations that are fundamental to the competency-
based education model.
SIMULATION FOR COMPETENCY ASSESSMENT
Additionally, within any of the domains of competence, we can
assess learners at 4 different levels, according to the pyramid
CONCLUSION
model conceptualized by Miller.26 These levels are: a) knows
(knowledge)—recall of basic facts, principles, and theories; b) Spanning the continuum of educational levels and bridging
knows how (applied knowledge)—ability to solve problems, multiple health care professions, medical simulations are
make decisions, and describe procedures; c) shows how increasingly finding a place among our tools for teaching and
(performance)—demonstration of skills in a controlled setting; assessment. Technological advances have created a diverse
and d) does (action)—behavior in real practice. range of simulators that can facilitate learning and evaluation
Various assessment methods are more or less well suited to in numerous areas of medical education. Simulation technol-
evaluation at these different levels of competence; for example, ogy holds great promise to improve physician training and,
written instruments, such as exams consisting of multiple- thereby, to impact patient safety and health care outcomes in a
choice questions, are efficient tools for assessing what a positive and significant way.
JGIM Scalese et al.: Simulation Technology in Medical Education 49

12. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced
Acknowledgments: The authors gratefully acknowledge the men- cardiac life support skills by internal medicine residents using simula-
torship and support over many years of Michael S. Gordon, M.D., tion technology and deliberate practice. J Gen Intern Med 2006;21
Ph.D., and the Gordon Center for Research in Medical Education at (3):251–6.
the University of Miami Miller School of Medicine. 13. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ.
Features and uses of high-fidelity medical simulations that lead to
Conflict of Interest Disclosure: None disclosed. effective learning: a BEME systematic review. Med Teach 2005;27(1):
10–28.
Corresponding Author: Ross J. Scalese, MD; Gordon Center for 14. Kochevar DT. The critical role of outcomes assessment in veterinary
Research in Medical Education, University of Miami Miller School of medical accreditation. J Vet Med Educ 2004;31(2):116–9.
Medicine, P.O. Box 016960 (D-41), Miami, FL 33101, USA 15. Scalese RJ, Issenberg SB. Effective use of simulations for the teaching
(e-mail: [email protected]). and acquisition of veterinary professional and clinical skills. J Vet Med
Educ 2005;32(4):461–7.
16. Langsley DG. Medical competence and performance assessment. A new
era. JAMA 1991;266(7):977–80.
17. Norcini J. Computer-based testing will soon be a reality. Perspectives
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