Simulation and its Role in Medical Education Cancer in a Tertiary Care Hospital


Article By

G.V. Prabhu



Medical simulation allows the acquisition of clinical skills through deliberate practice rather than an apprentice style of learning. Simulation tools serve as an alternative to real patients. A trainee can make mistakes and learn from them without the fear of harming the patient. There are different types and classification of simulators and their cost vary according to the degree of their resemblance to the reality, or ‘fidelity’. Simulation based learning is expensive. However, it is cost effective if utilized properly. Medical simulation has been found to enhance clinical competence at the undergraduate and postgraduate levels. It has also been found to have many advantages that can improve patient safety and reduce health care costs through the improvement of the medical provider’s competencies. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method in undergraduate and postgraduate education.


Introduction :

Medical education has undergone significant changes all over the world. One of the reasons for the changes is concern for the patient’s safety. “To Err Is Human”, a landmark report released by the Institute of Medicine (IOM) in 1999 estimated that medical errors cause injury to approximately 3% of hospital patients and results in a minimum of 44,000 and perhaps as many as 98,000 deaths per year  in  the  United  States.[1]  Medical  errors  also contribute to the cost of medical care throughout the world. The annual cost attributable to all adverse drug events and preventable adverse drug events for a 700 bed American teaching hospital was estimated by one study to be $5.6 million and $2.8 million respectively.2 Though it is expected that such medical errors occur in India, there are no studies on their extent in Indian hospitals.

Call for a change in the instructional methods have resulted in innovative medical curricula. As evidenced by the endorsement by many of the international bodies and medical schools, it is universally accepted that clinical skills constitute an essential learning outcome. The acquisition of appropriate clinical skills is key to health education; however, students sometimes complete their educational programs armed with theoretical knowledge but lack many of the clinical skills vital for their work. A major challenge for medical undergraduates is the application of theoretical knowledge to the management of patients. While simulation based learning is not yet well established in this region. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method for undergraduate and postgraduate education.


Materials and Methods :

This is a narrative review of literature on a medical simulator and the use of simulation in medical education. A literature search using MEDLINE/PubMed database for English language publications and reference lists from relevant articles published. The main search terms were medical simulation, medical simulator, medical education, and clinical skills.



Traditionally, the acquisition and ongoing improvement of high level psychomotor skills required by future physician take place in an apprentice style model of ‘See One, Do One, Teach One.’ This apprentice style of learning is no longer considered acceptable because of the increasing concern for the quality of patient care and safety and change in health care systems. There are many reports that indicate concerns for the level of skill that medical graduates possess.[3] Concerns about patient safety and fewer available patients for learning, and many other factors have led to the introduction of simulation and the development of simulation centers and clinical skills laboratories in medical education.



Simulation has been defined as a situation in which a particular set of conditions is created artificially in order to study or experience something that is possible in real life; Aviation and aerospace industries have been using simulation as a teaching tool for many years. There are many examples of curricular reform that include clinical skills training, the use of simulators, and the creation of clinical skills centers. Recently, the inclusion of clinical skills training into the curricula of medical students has seen significant growth. On the other hand, simulation based medical education can be defined as any educational activity that utilizes simulative aides to replicate clinical scenarios. Simulation tools serve as an alternative to the real patient. Trainers can make mistakes and learn from them without the fear of distressing the patient. Experiential learning or learning from experience during simulation based training sometimes involves the use of clinical scenarios as the bases of learning. The practice of a scenario can be videotaped for immediate feedback to participants during the debriefing sessions.

Debriefing after a scenario is an important component of full scale simulation. Video recording of the scenario is also used to initiate discussion and to make sure that all learning objectives were covered. However, training through simulation should be viewed as an adjuvant and not a replacement for learning with real patients. Simulation is not intended to replace the need for learning in the clinical environment, so it is important to integrate simulation training with the clinical practice during curriculum development.



Simulators are classified into different categories.[4,5] An example of the classification of simulators is shown in Table 1. Simulators can be classified according to their resemblance to reality into low fidelity, medium fidelity and high fidelity simulators.[4] Low fidelity simulators are often static and lack the realism or situational context. They are usually used to teach novices the basics of technical skills. Example of a low fidelity simulator is the intravenous insertion arm (Figure 1) Resusci-Anne (Figure 2).

TC- Jul 2016 - 030 - Intravenous insertion arm TC- Jul 2016 - 031 - Resusci-Anne

Moderate fidelity simulators give more resemblance  of reality with such features as pulse , heart sounds and breathing sounds but without the ability to talk and they lack chest or eye movement. They can be used for both the introduction and deeper understanding of specific, increasingly complex competencies . An example of a moderate fidelity simulator is the “Harvey”cardiology simulator (Figure 3) .

TC- Jul 2016 - 033 - “Harvey” cardiology simulator TC- Jul 2016 - 033 - “Harvey” cardiology simulator

High fidelity simulators combine part or whole body mannequins to carry the intervention with computers that drive the mannequins to produce physical signs and feed physiological signs to monitors. They are usually designed to resemble the reality. They can talk, breathe, blink, and respond either automatically or manually to physical and pharmacological interventions. A good example of a high fidelity simulator is the METI Human Patient Simulator (HPS) which is model driven (Figure 4) and the “Noelle” obstetric simulator which is instructor driven. In general, the  higher  the  fidelity,  the  more  expensive  it  is.


TC- Jul 2016 - 034 - METI Human patient simulator (HPS)

Virtual reality can also be incorporated into the simulators (mostly part task simulators) to enhance learning. Virtual reality is best described as a concept of advanced human computer interaction. Virtual reality varies greatly according to its level of sophistication in its level of realism and of the user’s interaction with the virtual environment.[6] This technology is frequently used in endoscopic and laparoscopic dexterity training. High fidelity and virtual reality simulations can bridge the gap between theory and practice by immersing the learner in a realistic, dynamic, complex setting.

Nonetheless, simulation can only imitate but not replicate reality. The recreation of “reality” or “fidelity” is important for the success of simulation and for the participant. Since some simulators can be used to encourage independent or self-directed learning, they should be integrated into the overall curriculum.

Effective learning requires repetitive practice and feedback during the learning experience. Issenberg et. al. [6] performed an excellent systematic review and identified ten features of high fidelity medical simulation that can lead to effective learning. Those ten features are listed in Table 2.

TC- Jul 2016 - 035 - Table 2 - ten features of high fidelity medical simulation


Simulation can be used to resemble existing curricular material. The simulated scenarios are realistic enough to engage the students emotionally, thus providing a unique learning experience, where the high fidelity simulator “patient” actually talks, breathes, blinks, and moves like a real patient. Simulation can be adapted to accommodate the need of various medical specialties such as anesthesia, emergency medicine and trauma, intensive care medicine, obstetrics, pediatrics, and radiology as well as for the use of other professionals such as nurses, paramedics, and respiratory therapists.[7]

Simulation laboratories are quite costly. The ability to practice without risk must be weighed against the cost of this new technology. Simulation has many advantages, for it results in highly trained medical graduates who are less likely to make life threatening or costly medical errors.[5,8] Some of the advantages of simulation are listed in Table 3.

TC- Jul 2016 - 036 - Table 3 - advantages of simulation

Employing medical simulation techniques can help move medical training from the old “See One, Do One, Teach One” method into a “See One, Practice Many, Do One” model of success.9 Simulation based teaching has proved to reduce risks to both patients and learners.[10,11] It has also proved to be effective in both undergraduate and post graduate education as well as faculty development.[12,13]



In conclusion, the promise of simulation based medical training offers useful opportunities to reduce risks to patients and learners, improve learners’ competence and confidence, increase patient safety, and reduce health care costs in the long run. However, robust research is needed to see if simulation training does actually improve patient outcomes.

TC- Jul 2016 - 037 - Writers Art pg 52



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