Use of Simulation – The Pros (& Cons)

Prof K.R. SethuramanDean – Faculty of Medicine &

Deputy VC – Academic/International AffairsAIMST University

Viewpoints From

• Students’ perspective

• Educators’ ,,

• Pedagogy support

• Research ,,

• Patient safety & rights

How Learning Used to be…

• No Computer• No Internet• No TV• No Video• No Mobile Phone

• Less Diversions!

Net Geners Learn Differently

• By 21 years of age,– 10,000 hours playing

video games– 20,000 hours on e-

mail – chat – blog – 20,000 hours watching

TV– 10,000 hours on cell

phones, and– under 5,000 hours

reading

• They need:– fast paced, highly

stimulating presentations

– increased interactivity with content & each other

– information that relates to the learner’s world

– multiple options for obtaining knowledge.

Susan El-Shamy. Training for the new and emerging generations. Quoted in http://scope.lidc.sfu.ca/mod/forum/discuss.php?d=521

Parenting Net Generation!

Educating the Next-Generation

• Medical education has responded by increasing the amount of :– multimodal content (visual, auditory, kinesthetic

“hands on” practice)– active learning (read, write, discuss)– experiential/contextual learning (job shadowing,

simulation labs)– problem based learning, team projects.

Simulation for Residents with Kinesthetic Learning Style

• An individual’s preferred way of learning: – Auditory (listening – lecture),– visual text (reading print -

textbook),– visual picture (seeing images,

diagrams), – tactile kinesthetic (learning by

doing, hands-on), – verbal internal kinesthetic

(learning by putting into own words)

• A study of learning styles of 20 anaesthesia residents: – strongly (90.0%) or

moderately (10.0%) tactile kinesthetic

• Medical simulation will be a valuable Hands-On teaching modality, – especially for students with

a strong tactual kinesthetic learning preference.

Linda M. et al. Value of Medical Simulation for Residents with Tactual/Kinesthetic Learning Styles [State University of New York] in ANESTH ANALG 2005;101;S1-S90

The CanMEDS initiative – Royal College of Physicians and Surgeons of Canada

Specialist roles for the future specialist:

1. medical expert/decision maker,

2. communicator,

3. collaborator,

4. health care advocate,

5. manager,

6. scholar

7. professional

CanMEDS initiative focuses on those ignored in resident training: – communicator, – collaborator, – manager and – Professional

Simulation has been advocated to train residents in these roles

Ref - Brown & Finucane. “7 roles…” in ANESTH ANALG 2005;101;S1-S90

The CanMEDS initiative – RCPSC

• Residents’ experience with real critical events is unsatisfactory. – The frequency of these is

unpredictable – Staff take over managing

critical events when they occur

– Poor pre-planning and inadequate debriefing.

– Traditional teaching by clinical work, rounds, anesthesia conferences, etc do not deliver substantive learning

• Resident rated simulation based learning high – learning was powerful and

experiential – Simulator learning

allowed for deep integration of book knowledge with practical skills,

– especially in the areas of communication, collaboration, teamwork and leadership.

Bottom line: “Simulation use must be strongly endorsed at an institutional and university level.” – RCPSC

End-Of-Life Communication – Usefulness Report of Simulation

• high-fidelity simulation with professional actors;

• observation of other trainees engaged in simulation;

• debriefing with the learning team;

• Supporting learning activities and material

• Most helpful items -– Direct participation &

interaction with “realistic” actors

– Observation of other trainees – hearing other trainees

discuss difficult conversations

– Debriefing and discussion with the learning team

– Feedback provided by the proxy patients and –parents

What Components of an End-Of-Life Communication Simulation Program are Most Helpful To Trainees? [Boston and Harvard Medical School] Elaine C. Meyer, et al in ANESTH ANALG 2005;101;S1-S90

End-Of-Life Communication – Feedback on ‘what was learnt’

• Communication skills – value of speaking

honestly, – allowing for silence,

and – individualizing their

language and approach

– based on the family’s needs and preferences

• Relational skills – listening, – showing concern, and – bringing their own

humanity to bear during difficult conversations

– are highly valued and long-remembered by families

How hazardous is health care?

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000

10,000,000

Number of encounters for each fatality

To

tal l

ives

lost

per

yea

r

REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthHealth CareCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

ScheduledAirlines

European Railroads

Nuclear Power

Note: both dimensions are logarithmic scales

Swiss Cheese Model of Accident Causation

Modified from Reason, 1991 © 1991, James Reason

LATENT FAILURES

Triggers

DEFENSES

Accident

Regulatory Narrowness

Incomplete Procedures

Mixed Messages

Workload Pressures

Responsibility Shifting

Inadequate Training

Attention Distractions

Deferred Maintenance

Clumsy Technology

Goal Conflictsand Double Binds

The World

SBME is Now Becoming a Vital Need

• Bristol Case of high mortality in Paed Card– The training of doctors in advanced

procedures– How to approach the so called learning curve

of doctors for standard procedures– How clinical competence and technical

expertise are assessed and evaluated – How doctors explain risks to patients

• GMC inquiry raised several such issues

Editorial - All changed, changed utterly. BMJ 1998;316:1917-1918

An Ethical Mandate for All

• Patients are to be protected from all avoidable harm

• They are not commodities to be used as conveniences of training

Amitai Ziv, et al. Simulation-Based Medical Education: An Ethical Imperative. Acad. Med. 2003;78:783–788.

Barriers to Student Access to Patients

• Bedside teaching is in steady decline– Only about 50% were accessible – 35% (70% of above) agreed to give history– 34% agreed to be examined– Assessed by repeated cross-sectional audit– too few to provide current student population

with extensive clinical experience

• We must use Simulated Patient encounters

Leslie G Olson et al. Barriers to student access to patients in a group of teaching hospitals. MJA 2005; 183 (9): 461-463

SBME (Simulation-Based Medical Education) is an Ethical Imperative

• Medical training must use live patients to hone the skills of health professionals.

• But we have an obligation to ensure patients’ safety and well-being by providing optimal treatment.

• Balancing these two creates ethical tension in medical education.

• SBME can mitigate this tension by taking care of– best standards of care and

training, – error management and

patient safety, – patient autonomy, &– social justice

Simulation of Vaginal Birth for Third Year

Harvard Medical Students • it is not unusual for

students to complete their labor rotation without conducting a normal vaginal delivery.

• The goal of this pilot program was to provide a realistic simulation of a normal & abnormal vaginal deliveries to students of 3rd year.

• Post-course evaluations were uniformly positive.

• Sample comments include: – “Wonderful way to learn”; – “I forgot it was Friday

evening”; and – “Great combo of didactics

and teaching”

Roxane Gardner et al. in ANESTH ANALG 2005;101;S1-S90

Simulations may be effective if used wisely

• Evidence of the effectiveness of carefully implemented simulations:

• A review of 109 studies looked at whether medical simulations actually facilitate learning.

• The best available evidence shows a benefit for simulations when four conditions are met:

1. educational feedback is provided,

2. learners are given the opportunity for repetitive practice

3. exercises based on the simulation are integrated with the curriculum, &

4. tasks range in difficulty.

Editorial – Med Teacher 2005;27: 10-28

Cynic is one who -

• Knows the Cost of Everything…but the Value of Nothing– Oscar Wilde

The Future of Simulation

The IOM report made strong recommendations with regard to medical simulation:

“Establish interdisciplinary team training programs, such as simulation...”

Use procedures to mitigate injury through simulation training.

Create a learning environment. “Use simulations whenever possible.”

(IOM Report: To Err Is Human: Building a Safer Health System, Institute of Medicine. National Academy of Sciences. 1999)

Simulation & Transformation of Medical Education

• Three pillars of a major transformation occurring in medical training today: – Patient centered care with an

emphasis on quality and safety;

– new training models, including standardized clinical encounters and simulations; and

– competency-and milestone-based education, training, and credentialing.

• We must accept the primacy of patient welfare and embrace our commitment to professional competence

• In future, medical education, residency training, CME/CPD and clinical privileges in practice will bear little resemblance to the past

Gary J. Becker, Simulation and the Coming Transformation of Medical Education and Training. Radiology 2007; 245:7–9

Future Vision of Simulation in Healthcare

• Systematic training and assessment – a major priority.

• Simulation training will be applied to individuals, teams, work units, and organisations.

• Simulation will be an important "bottom up" tool for – creating a culture of

safety and – for fostering changes in

work procedures and systems.

• Facilitate competency focussed clinical training and practice.

• Costs of simulation based training will vary depending on its complexity.

• Benefits of simulation may be hard to measure.

• Key drivers of simulation include public, insurers, professional societies, accrediting organisations, & regulatory agencies.

D M Gaba. The future vision of simulation in health care. Qual Saf Health Care 2004;13:i2-i10

Vote for Simulation !Vote for Simulation !