Anyone with a video game console at home can simulate a variety of occupations: airplane pilot, race car driver, baseball player, Old West zombie hunter. As technology improves, the experience that can be created for these tasks grows ever more accurate and immersive, causing some experts to wonder whether simulation can be used for actual education as well as vicarious thrills. In the aeronautics field, this is old news – pilots have been trained on flight simulators for decades, gaining experience on high-risk, low-frequency tasks such as landing a damaged plane on a river. But in medicine, the use of simulation has only started picking up speed in the last decade, employing a mix of high-tech and low-tech to prepare doctors and nurses for both the usual and unusual.
In their Department of Medicine Grand Rounds presentation last week, Ernest Wang and Morris Kharasch from our partners at NorthShore University HealthSystem described the current state of simulation in medicine on the eve of their state-of-the-art simulation center’s grand opening. But while the idea might sound modern, it’s actually been around for more than 40 years, as Wang illustrated using a clip from the 1972 film Future Shock, narrated by Orson Welles.
Welles’ portentous warnings were a bit premature, it turned out. Never mind the leap from medical simulation dummy to humanoid robot, a generation would pass from when the first dummies were engineered in the late 1960’s before the broader field would accept simulators as a valid training tool for doctors.
“It looked pretty much what our current high-fidelity simulators look like, but didn’t have traction,” said Wang, a clinical associate professor at NorthShore. “There’s a Chinese saying: ‘When the student is ready the teacher will appear,’ and clearly they were too far ahead of their time and the conditions weren’t right.”
However, since 2000 the use of simulation in medicine has gathered momentum. A wide range of technologies are currently used for teaching sessions, from complex simulation environments that fully recreate the experience of being in an operating room to computer programs and table-top gadgets that rehearse medical decision-making and the performance of specific tasks. Medical simulation has grown to the point where a new specialty – the simulationist – may need to be created, Wang said.
“This would be a practitioner of simulation, who takes a recipe of clinically important cases, lessons learned from other industries, computer-driven full body simulators, realistic task trainers, and a dash of theater, to create a memorable learning experience that can be transferred directly to patient care,” Wang said. “In the end, that’s what this is about: education and patient care.”
Winning acceptance for medical simulation involves proving its success and determining its most effective uses. At the NorthShore center, educators have focused on designing simulation courses around “high-liability, low-frequency” events, said Kharasch, clinical director of the Center for Simulation Technology & Academic Research. The students in these courses might be residents encountering these situations for the first time, or older doctors who need a refresher on tasks they haven’t performed in many years before serving as an attending on the wards or in the emergency room.
“We’ve learned that as the years go on after you come out of residency, you are less able to do things that you once did as residents,” Kharasch said. “We spend a lot of time training on simple tasks that can be life-saving.”
The NorthShore courses cover a broad variety of subjects. A basic procedures course refreshes physicians on how to perform central line placement and chest tube insertion in pediatric patients; a neurology course (designed with the Medical Center’s Jeffrey Frank) uses a combination of table-top simulation and patient-actor interviews to practice the critical steps in the hours after a stroke. Another course is directed at teaching nurses what to do in the brief slice of time between when a patient crashes and the rapid response team arrives.
“The nurses have to do something in those first 5 minutes, and those are the most important five minutes,” Kharasch said. “We’ve learned people get better and better on the very common responses to each one of these things, and the times get better after the course in terms of responding and doing the basic things we want them to do in those first five minutes.”
When a simulation tool doesn’t exist, the center needs to invent it, and assembling these devices occasionally requires engineering skills more suited to horror movie special effects wizards. Kharasch talked about designing one training tool using lamb trachea (easily obtainable on the South Side he said) and synthetic skin that bleeds realistically when cut. The most memorable video was a rather graphic simulator of a sneakily difficult problem often seen in the ER: nosebleeds. “Obviously it doesn’t normally bleed like that…or at least I hope it doesn’t on my shift,” he joked.
Despite these innovations, simulation has much farther to go before it is fully integrated into the medical curriculum, both speakers said. The primary obstacle is a lack of data demonstrating that simulation does in fact improve patient safety and clinical care, numbers that are needed to justify the expense of establishing a simulation center and the use of scarce training hours on the tasks. Wang presented a sample of small studies that demonstrated improvements on cardiac resuscitation and pacemaker implantation, but Kharasch quoted the godfather of medical simulation, David Gaba, in saying that it wasn’t necessary to wait for the evidence to catch up: “No industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it.”
“We know that experience makes a difference,” Kharasch said. “It certainly makes a difference at the bedside.”