Simulated Scenarios: Real-Life Benefits

Medical education has undergone fundamental changes over the past few years, and I expect it will continue to do so long into the future. We’ve shifted from a didactic, lecture-based system of training to a competency-based one that focuses on creating capable doctors instead of living medical textbooks. We’re moving from volume-based healthcare to a value-based model in which it’s as important for doctors to know how to interact with their patients as it is to know how to treat them. And, of course, technology is insistently pressing into our classrooms and continuing professional development. So how can we best take advantage of these changes? Simulation can have a significant impact on medical education – but what exactly is it, and how can it benefit pathologists?

What is simulation?

Simulation is an umbrella term for a broad spectrum of activities. Essentially, any time you recreate the clinical experience – whether for education or to optimize clinical processes – you’re working with simulation. The key is that the entire patient journey can be simulated, from admission to discharge, which means you can use it at any stage of the process to improve your understanding or ability.

The spectrum of simulation also encompasses a wide range of techniques, from something as low-tech as standardized patients all the way up to full mannequin simulators and virtual reality. It’s the latter modalities that most people think of when they hear the word “simulation” – things that recreate a patient (vital signs, pathophysiology, reactions to treatment) – but, as vital as that aspect is, there are others just as important to replicate. For instance, environmental fidelity (faithfully recreating the clinical setting) or psychological fidelity (creating a scenario that “feels real”).

It’s important to be inclusive in our definitions of simulation; if not, we risk treating it as a standalone educational activity instead of an integrated part of the medical curriculum that touches every aspect of teaching – and that’s how it should be.

Where does it fit?

The main focus of education used to be on medical knowledge – but we now realize that doctors need to be proficient in many different competencies. Here in Canada, we call them intrinsic roles: communicator, collaborator, leader, health advocate, scholar and professional, all of which are centered on the medical expert. We’ve also moved from the “apprenticeship model” to more team-based care; we interact with far more colleagues than we did a century ago. Doctors don’t pass on their training one-to-one anymore; instead, you develop a new doctor under multiple supervisors.

I also think that doctors spend less time in the clinical setting than they used to because of work-hour restrictions and a better understanding of wellness issues. Years ago, trainees would work extremely long hours to experience as many different cases and procedures as possible – but, since then, there has been an exponential increase in our medical knowledge, so there’s no way to see and do everything you may need in the future, no matter how much time you spend in the clinic.

So how does simulation fit into that picture? Consider a learning curve with a mastery asymptote. Simulation can accelerate a person through the steep part of that curve. If they can learn the basic skills or core competencies in a simulated environment, then when they enter the clinic, they are refining those skills as opposed to learning them for the first time on a living subject. And for some essential competencies, the right patient simply doesn’t walk into the clinic often enough; if you rely only on what comes through the door during medical training, you’ll miss out on a great deal of learning. Simulation fills those gaps, and will continue to be valuable long after medical school – after all, refreshing your knowledge of core competencies is an important part of continuing professional development.

The challenge is that today’s medical educators didn’t train with simulation, and most of them have little exposure to it even now. Educators typically train others in the paradigms they are most used to, which may be why simulation has been slow to gain a strong foothold in medical education. But it is growing. We’ll know we’ve been successful advocates when educators begin delivering the bulk of their curricula through simulation. It’s a resource-intensive method, of course, and less cost-effective than delivering a lecture to 500 people – but does the lecture deliver effective learning? Simulation, on the other hand, is a powerful and effective form of learning – and that’s where its differentiating teaching value lies.

What difference does it make?

There are different levels of evidence for the impact of simulation in education:

• T0research measures learner satisfaction. Do they like being in the simulation environment? Do they think it is a valuable experience? The downside is that it’s not valuable research because the answers are obvious. Who wouldn’t like being in a simulator with a 1:5 teacher:student ratio instead of sitting in a boring lecture?
• T1research assesses whether learners’ knowledge, skills or attitudes have actually changed, and involves retesting students to see whether or not their performance has improved after learning in a simulated environment.
• T2 research assesses whether or how newly acquired knowledge, skills and attitudes affect the learner’s practice when caring for patients. If a student improves their ability to perform a physical exam by practicing on – for example – a standardized patient, you’ll be able to see that improvement when they begin working with actual patients.
• T3 research asks a big question: are learners changing patient outcomes? Emerging research suggests that doctors trained in a simulated environment are better at placing central lines – and, because of that, the infection rate after placement decreases. Others might see reduced morbidity and mortality in a cardiac resuscitation. This is all new research, but I expect to see more of it in the near future, because improved patient care is the true objective of simulation-based training.

Increasing impact

I think doctors are unaccustomed to active assessment. After our certification examinations, we go on to practice for several decades, and most of our continuing professional development is passive: lectures, conferences, reading… Of course, it’s human nature not to enjoy exposing oneself to criticism – and that’s why we have to change the model so it’s about coaching, not criticizing. Simulation helps by letting instructors coach in replicas of real-world situations, so that learners can see the direct impact on their actions and on patient outcomes. I hope that seeing such effects will encourage people to engage with simulation even more.

Once they’ve tried it, people tend to think: “Hey, that wasn’t so bad!” They recognize the power of the simulation; they appreciate the coaching; they learn. In this instance, the challenge is to lead the horses to the water in the first place, not to make them drink. We’ve tried things like incentivizing simulation training and tying it to accreditation, but we still haven’t seen widespread uptake. In my opinion, if we really want to see simulation take off, we need to remove barriers. We must lower the cost and make it easier to access simulation centers. And if that doesn’t work, we might need a small top-down push. I think we have to say to ourselves, “If we truly believe simulation is such a powerful form of learning, then at what point do we consider mandating it for training and professional development?” Some core competencies – for instance, resuscitation techniques – are impossible to test in any other way.

Meeting needs

We still need to improve our equipment – that’s currently the least realistic aspect of simulation! One day we may get Star Trek-style holodecks for medical education – but if we want them to be functional, we have to make sure they’re actually meeting clinical needs. Even the best simulator will go unused if there’s no need for it – either because it teaches something that no one uses, or because it teaches something so common that there’s no need to invest in an expensive, high-tech simulator to demonstrate it. For example, a frozen section simulator for trainee pathologists would be pretty pointless – they’re going to do so many throughout the course of their career that there’s no need for a simulator to teach that skill. We need to figure out where the educational needs lie and then develop simulation technologies that address them.

Pathologists may wonder, “Where does simulation fit into our education? We don’t do resuscitations; we don’t do complex surgeries; what gaps does simulation fill for us?” In pathology, the benefit of simulation – as in any other specialty – is that it offers us the chance to improve the patient experience. However, it’s not about equipment fidelity; it’s about environmental and psychological fidelity. There are, of course, some procedural skills – specimen preparation and so on – that may be best attempted in a simulated fashion at first (rather than in a high-stakes patient diagnosis), but that’s not where I see the highest return on investment for pathology. I think pathologists can use simulation to learn how to better communicate with patients, and how to collaborate with other medical specialists. We can all benefit from better communication skills, especially for patient interactions.

Simulation isn’t the answer to every question in medical education, but I think we’re on the cusp of a revolution. If we can get both teachers and trainees comfortable with using simulation techniques, and make sure that those techniques target clinical and educational needs, then we’ll be heading in the right direction – and we’ll also be well-prepared for the holodecks of the future!