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Outside the Lab Training and education, Profession, Technology and innovation

Simulations for Safety

Simulation-based learning constitutes one of the key elements in skills acquisition for medical professionals. Although this methodology has not yet been consolidated at all levels – due mainly to limitations in human capital and material resources – the need to provide training in a safe setting and improve patient safety is increasingly in the spotlight. The US Institute of Medicine’s 2000 landmark report (1), “To Err is Human,” highlighted the number of deaths caused by medical errors and brought safety issues to the forefront of public concerns.

Patient safety is not limited to invasive procedures typically thought of in the context of malpractice, such as improper cardiopulmonary resuscitation, avoidable complications during surgical procedures, or poorly administered serum therapies. Patient safety also includes every single point in the process of care, because each one carries an inherent risk. More specifically, the WHO describes patient safety as “a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur (2).”

Moreover, multiple studies have demonstrated that “simulation-based training is superior to the standard model of learning and is recommended in the latest guidelines,” and that “training in a simulated environment is effective at the beginning of the learning curve, and the skills acquired on a simulator can be transferred to a clinical setting (3).”

Likewise, the traditional Halstedian model of training based on “see one, do one, teach one” has been replaced by “see one, simulate many, do one competently, and teach everyone.” This supports the undeniable importance of being able to practice, make mistakes, and learn in a safe setting with proper guidance from a qualified teacher. One might even argue that it is unethical and dangerous for professionals in training to perform invasive procedures on patients without having previously practiced them and acquired the necessary skills to perform them competently. Given this state of affairs, the need to evaluate and standardize those skills among trainees is clear.

Our intention is to provide every student with the opportunity to learn in a standardized way with an approach based on clinical cases.

Years ago, my colleagues and I began developing clinical simulation modules focused on deliberate practice. In essence, these are workshops with highly structured objectives for skills acquisition. Our intention is to provide every student with the opportunity to learn in a standardized way with an approach based on clinical cases. We always provide a clinical context along with a digitized case study using whole-slide images to ensure that our modules are well-suited to current requirements around the world. These modules are easily integrated into medical school pathology courses and can even be incorporated into Objective Structured Clinical Examinations, thereby also increasing pathology’s visibility as a medical specialty.

After developing simulation teaching modules for different areas of knowledge in pathology – including fine needle aspiration (FNA), dissection, and microscopic diagnosis – I decided to create a mobile application that was not-for-profit and free to download, with the goal of democratizing clinical simulation for pathologists. The result is SimInPath, which is currently available for both Android and iOS devices.

Application design focused on assessing medical students, including residents, through a series of modules: gross dissection, FNA, ultrasound-guided FNA, palpation of lesions suitable for FNA, punch biopsy, and microscopic diagnosis. We used technology currently available on the market (currently limited to an FNA simulator I previously developed). The simulator (4) was modified for the palpation, ultrasound-guided FNA, and punch biopsy modules, whereas handmade simulated lesions made of silicone were specially designed for macroscopic dissection. To avoid any potential conflict of interest as the inventor of simulator, I decided to donate any royalties generated from the sale of the simulator to the Spanish Society of Pathology (the Spanish branch of the IAP) to be used for workshops and training courses for medical students and residents.

As pathologists, we need to position ourselves at the forefront of education to improve both the quality of training and our (historically misrepresented) image as medical professionals. Certain skills, and our more “interventional” duties, have gone unnoticed despite the clear impact our decisions have on patients’ health and wellbeing. Digitization and simulation – not just as technologies, but as teaching methodologies – will help us to achieve these goals.

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  1. LT Kohn et al., To Err is Human: Building a Safer Health System. National Academies Press (US): 2000.
  2. World Health Organization, “Towards eliminating avoidable harm in health care.” Available at:
  3. TMH Naur et al., “Training and certification in endobronchial ultrasound-guided transbronchial needle aspiration,” J Thorac Dis, 9, 2118 (2017). PMID: 28840013.
  4. E Alcaraz-Mateos et al., “A novel simulator model and standardized assessment tools for fine needle aspiration cytology training,” Diagn Cytopathol, 47, 297 (2019). PMID: 30474299.
About the Author
Eduardo Alcaraz Mateos

Pathologist and Cytopathologist in the Department of Pathology at Morales Meseguer University Hospital, Murcia, Spain.

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