Introduction
Medical simulation, like so many topics in clinical medicine, is characterized differently by different people. Definitions are typically quite similar, always meeting the specific requirements of the individual describing it. The definition that I feel best illustrates medical simulation is: a device or series of devices that emulate a real patient care situation or environment for the purposes of training, evaluation, and/or research. Medical simulation has likely been used for centuries; however, the first modern simulators of note were developed to train clinicians (and then the lay public) to perform cardiopulmonary resuscitation; a therapy first introduced over 50 years ago [1]. Since then, simulators have advanced to include a variety of modalities. As the technology has advanced, so has the scope and sophistication of its use. In the following pages, I will provide the reader with a synopsis of simulation as it now exists in the world; its history, the theory supporting its use, the forces that have been influencing its advancement, types of simulators, the data supporting its use, and the barriers that have stood in the way of its successful adoption.
History of Simulation in Medical Education
The most commonly used model for clinical education in the United States, at its core, can be defined in a single statement: see one, do one, then teach one. Its origin is unknown however it is a product of the apprenticeship model in which mentors teach learners in the actual clinical setting; overseeing the performance of procedures on patients. For obvious reasons this is not the safest method of education for patients, and there are other limitations that are not as evident. At the least, this method may result in a lack of practice standardization and at the worst may lead to the propagation of improper techniques if the mentor, him or herself, has been taught incorrectly. Learning for the first time in the high-pressure clinical environment may result in loss of an opportunity to rectify poor technique before harm is done; resulting in loss of confidence and hesitation when learning future clinical skills.
Malcolm Knowles was the first to describe the differences between the adult and the child learner [2]. Unlike children who bring limited experience to the lesson, the adult learner brings with them a wide variety of experiences that will be integrated into the learning process. Adults also have different motivations to learn. Among others, Knowles describes the adult learner as goal and relevancy-oriented; if they don’t see the need for the knowledge, they are less likely to learn it. Although the "see one, do one, teach one" model takes advantage of adult learning theory by making the training relevant and the learner goaloriented, its limitations, an intensified emphasis on patient safety, and the mere fact that patients do not want trainees "practicing" on them has contributed to a major restructuring of clinical education in the United States. Other drivers of this change include the difficulty in adding additional years to graduate medical education programs as medical knowledge continues to grow and restrictions placed on trainee work hours.
In the late 1980’s and early 1990’s modern medical simulation transcended resuscitation as the medical community began to acknowledge the value of simulation in other high reliability industries. David Gaba, an anesthesiologist at Stanford University and a pioneer in medical simulation appreciated similarities between pilots in flight and anesthesiologists during surgery. In 1990, he adapted the principles of “cockpit resource management” developed in response to recognition that poor communication and poorly executed non-technical skills frequently contributed to aviation mishaps. He named this program Anesthesia Crisis Resource Management [3]. Anesthesiologists started to teach these principles more broadly and other disciplines rapidly began to adapt them to their specialties.
The next major advancement arose as a result of the evolution of the technology. In 2003, new human patient simulators were released that changed the face of simulation forever. Prior to this, medical simulators were extraordinarily expensive. Few institutions could afford them, resulting in limited familiarity with the technology, and as a result, an impediment to further innovation. These new, more affordable simulators brought about a dramatic increase in their availability and use. This resulted in both increased use and a corresponding increase in exploration and innovation. Team training continued to advance, however, increased utilization also led to a broadening of applications. New simulation modalities were introduced, and there was also a proliferation of research in simulation. Simulation became established in a variety of healthcare professions including nursing, EMS, and other allied health fields.
Modalities of Simulation
Modern medical simulation includes several categories of simulators. Again, their classification varies depending on who is classifying them. A reasonable classification scheme consists of full body simulators, partial task simulators, virtual reality simulators, screen-based simulators, homemade simulators, standardized patients, and hybrid simulation. Despite being a full body simulator, the original Resusci- Anne was merely a task trainer; only enabling users to perform a single task; cardiopulmonary resuscitation. In fact, prior to the development of high fidelity simulators, early pioneers of simulation used to put together part-task simulators to emulate a full body simulator enabling a variety of skills to be performed on a single, albeit strange-looking mannequin.
Full body simulators
Full body simulators come in a variety of levels of fidelity. The most sophisticated of them have features that enable participants to interact with them in a manner closely emulating the care of a real patient. Typically, the learning takes place after the simulation; participants are debriefed by trained observers who use the scenario as an engagement tool to enhance learning. These simulators, [e.g. SimMan© [Laerdal Medical, Stavengar, Norway] and iStan© (CAE, Sarasota, FL, USA)] have varying levels of programmable physiology that can either be assessed by participants (e.g. pulse, respiration, and blood pressure) or displayed on physiologic monitors (e.g. cardiac rhythms, invasive hemodynamic monitoring, and oxygen saturation, among others) (fig. 1). These mannequins also enable participants to perform a variety of procedures. These may include: venous access, airway management, medication administration, childbirth, defibrillation and cardioversion, among others. Some simulators enable the instructor to alter the level of difficulty with which a procedure may be performed. They can be moulaged to make them appear to have a variety of conditions or injuries. The simulators are typically placed in a setting that mimics the real patient care environment promoting the suspension of disbelief that the participants are working in a simulated environment. Although customarily intended to provide comprehensive patient care scenarios, individual tasks or procedures may also be performed on these simulators. There is an assortment of newer simulators with such detailed human anatomy that anatomy may be taught using them. Some of these simulators have vascular systems that create simulated blood flow and others also allow the performance of an actual surgical procedure on them.
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Partial task simulators
Partial task simulators typically enable participants to perform a single procedure or a limited number of them. Some enable the instructor to control the level of difficulty of the task. Examples of these include venous access simulators, airway simulators, birthing simulators, and ultrasound guided proce- dural trainers. In surgery, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has developed and validated simulators in which, using actual laparoscopic instruments, the trainee may perform a variety of essential laparoscopic skills (e.g. intra- and extracorporeal knot tying) [4] (fig. 2). These simulators are used for both instruction and competency assessment.
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Virtual reality simulators
Virtual reality (VR) simulators have leveraged the technology of video gaming to produce simulators in which the user interface mimics the actual user interface; however the clinical interface is a digital reproduction. Besides simulation of actual procedures, many of these simulators enable the trainee to perform a variety of individual tasks necessary to competently perform a full procedure. Some of these simulators employ haptics; a computer-generated process by which the user has the same sense of touch (e.g. resistance, tension) that would be felt in the real environment (fig. 3). Many of these simulators have metrics that enable instructors to assess the user’s level of competence (fig. 4). Examples of available simulators include: laparoscopic surgery (multiple disciplines), endoscopic procedures, endovascular procedures, and robotic surgery. Some of the new VR simulators import patient imaging enabling the user to practice a procedure prior to actually performing it on an actual patient.
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Screen-based simulators
There are a variety of screen-based simulators currently in use. The first widely distributed screen-based simulator was developed for the American Heart Association to enhance the availability and utility of their emergency cardiovascular care curricula. In addition to instructional elements, these programs enable trainees to manage simulated cases displayed on the screen. Because the interface doesn’t permit the user to actually perform the selected action or procedure, these simulators are focused primarily on the cognitive domain. Other screen-based simulators have been developed that allow teams to practice communication and collaboration skills emulating a variety of simulated events. Some screen-based simulators have developed very sophisticated, multilayered scenarios used for education, independent practice, and assessment. Although the technology has been available for many years, its evolution has not developed the momentum that other simulation modalities have.
Homemade simulators
As simulation technology has advanced, so too has the level of innovation of simulation educators. In our simulation center we have been able to convert a variety of materials and/or animal products into devices used to increase the fidelity of a simulated scenario or to perform a procedure. This is done either because a simulator has yet to be developed or the cost of the manufactured simulator is prohibitively expensive. One of the first examples of this was the use of oranges to practice injections. We use a papaya to introduce train novices in uterine dilation and curettage (fig. 5). With this model the trainee must dilate the shortened stem of a papaya until they have gained access to its core where there are seeds loosely attached to the fruit by a thin membrane. The trainee must curette the seeds and membrane without curetting the fruit. The feel of this is very similar to that of the actual procedure. Animal parts obtained from slaughter houses can be mounted on scaffolds to emulate human anatomy on which simulated procedures can be performed. An example of this is the use of a pig’s esophagus and stomach suspended in a plastic mold of a human torso enabling the performance of a laparoscopic fundoplication.
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Standardized patients
Standardized patients are actors who play the role of patients, family members or providers in order to enhance the fidelity of a simulated scenario. Although special training is not absolutely necessary, in many cases these actors have specialized training and can participate in the debriefing process. Standardized patients were first used medical schools as part of the Objective Structured Clinical Examination (OSCE), described by Harden in 1979 [5]. These ex- aminations are designed to test the clinical skills of medical students including communication, history taking, physical examination, and interpretation of test results. Standardized patients may also be used in simulation scenarios that may or may not include mechanical simulators. They are also useful when scenarios are focusing on interactions rather than clinical care. For instance, when a psychiatrist needs to interact with a manic patient, or a physician must have a difficult conversation with a patient.
Hybrid simulation
Hybrid simulation is the use of a variety of different models to recreate a scenario or procedure. Classically, it involves the use of a standardized patient with which the trainee interacts to make the diagnosis and a task trainer to perform the required procedure.
Drivers of simulation
Technology and interest in simulation has unquestionably advanced since the introduction of Resusci-Anne in 1960. Although a full body simulator, the original Resusci-Anne only enabled performance of mouth-to-mouth resuscitation and chest compressions. Much of the early growth was organic; resulting from incremental advancements as a result of an individual’s or specific user-group’s interests. The last ten years, however, have seen a dramatic increase in the slope of simulation’s growth curve. This growth has been influenced by a number of factors, not the least of which has been the introduction of more affordable simulators. This resulted in more potential innovators, and ultimately in a plethora of new simulators and methods to employ them. There were, how- ever, a number of forces that have had a great impact on the growth of simulation. These include societal factors and institutional factors, as well as the recognition that healthcare education was in need of reevaluation and change.
Societal Pressures
At the same time simulation was being introduced to a greater number of users, there was a groundswell of interest in the US to enhance patient safety. Although there were a variety of reasons for this, one report in particular, became the crucible for the impetus to address the issue. In 1999, the Institute of Medicine released a landmark report, "To Err is Human: Building a Safer Health System" [6]. Although the report was comprehensive in its scope, it is often distilled down to a single statistic: There are an estimated 44,000-98,000 deaths each year due to avoidable medical errors in US hospitals!! Healthcare in the US began to undergo change as a result of attempts to address this problem. Examples of interventions include computerized order entry with decision support to assist with ordering of medications and tests, the development of electronic health records, the use of checklists, among many others. Medical education did not escape this process; many feeling that simulation could be helpful in addressing numerous sources of medical error.
Patients, educators, and common sense have led to the use of simulation to enhance the safety of a variety of procedures. In the past, it was not unusual that the first time a clinician practiced a procedure was on an actual patient. This has a consequence for both the patient and the learner. Patients in the US have become less willing to be “guinea pigs” for the training of novice clinicians. In one study of patient attitudes toward trainees performing procedures on them, only 49% of the patients were completely comfortable being a trainee’s first patient on whom they performed suturing. This dropped to 29% for intu- bation, and 15% for a lumbar puncture [7]. Novices generally do not gain advantage either; especially if there is a bad outcome. Simulating with directed practice in a safe environment enables the novice to attain some degree of competence, and confidence; out of the pressure-filled atmosphere that is inherent to the clinical setting. Mistakes may be made and corrected, without having to explain the mistake to the patient or to a distraught family member. Mastery can be attained over time employing both simulation and the real patient care environment.
Institutional Pressures
There are growing pressures on medical institutions to hold down costs and continue to improve the care that patients deserve and are now demanding. This must be accomplished in an environment that demands greater efficiency at less cost including fewer staff. It was once allowable for medical trainees to work almost unlimited hours in the course of a week; not uncommonly spending up to 36 continuous hours taking care of patients. There are now rules that mandate that residents may only work up to 80 hours per week with added restrictions on how many continuous hours they may work (this includes time specifically dedicated to educational pursuits) [8]. With less time available for education, many training programs are searching for new approaches to maximize learning under these restrictive conditions. The traditional lecture, during which a single presenter can deliver the content to an almost unlimited number of attendees, is probably the most efficient but least effective method of teaching adults. Lectures are beginning to be supplanted by active, small group learning of which simulation is just one example. Many training programs have integrated simulation into their curriculum and some have transformed their didactic curriculum into simulation-based curricula.
It has become clearer that the clinical environment is not necessarily the best venue for learning; especially for novices. In addition to the unpredictable nature of the experience, there are pressures that make this environment less conducive to learning. This includes the pressure of practicing on real patients, sometimes in critical situations. With an emphasis on clinical efficiency, the extra time needed to train trainees negatively affects the efficiency demanded of clinicians. For example, if a procedure typically takes an experienced clinician 60 minutes to complete, and the addition of a trainee adds an extra 20 minutes to the procedure, over the course of eight hours, two additional procedures can be performed as a result of the elimination of the trainee. In the era of healthcare finance reform, hospital administrators are very interested in these issues.
With an ever-expanding volume of information and skills that a physician is expected to know and be competent in, there has been an increasing emphasis on determining the best and the most efficient approach to training them. In the past, when it had been determined that trainees had "too much to learn" in the time allotted, the response of certifying bodies was to increase the duration of training programs. In the early part of the 20th century, graduate medical education was typically one or two years. In 2013, it is common for some specialty trainees to spend 8-10 years becoming competent in their field and allowed to sit for the certifying examination. This has been made even more challenging by the addition of restrictions on work hours. Under these circumstances, it is no longer suitable to depend on luck and chance to expose trainees to the numbers and types of patient presentations or procedures necessary to develop competence. Simulation has become a valu- able tool used to ensure exposure to less common patient presentations and procedures; increasing the likelihood that trainees will gain the appropriate experience required.
Traditionally, teaching outside of the clinical realm was relegated to darkened lecture halls or classrooms. With a shrinking number of training hours, many program directors are recognizing the need to maximize the return on investment of time; an ever-shrinking commodity. On-line education, small group teaching, and problem-based learning have all been efforts to improve educational quality and effectiveness. Simulation is now being explored as a means to maximize the quality of education. Besides team and procedural training, medical simulation has begun to replace lectures as a method for teaching content. An emergency medicine residency at Harvard has supplanted lectures with simulation- based scenarios as a means of engaging learners [9]. They believe that by introducing a topic using simulation and allowing participants to succeed or fail in the management of the simulated scenario, adult learners are more likely to be motivated to learn. The topic is deemed "relevant" to these goal-oriented adult learners.
As an example, the topic of management of toxicological emergencies might be introduced to participants using a simulated scenario in which a patient is brought to the hospital by in an intoxicated state due to an unknown ingestion. The participants will need to provide immediate care, develop a differential diagnosis, and perform or order the appropriate tests that will lead them to the appropriate diagnosis. Once the diagnosis is made, they will need to initiate appropriate therapy. During the post-scenario debriefing, the instructor will lead a discussion of the case, pointing out (or having participants point out) both positive and negative actions taken. The instructor, taking advantage of this engaged audience, may now broaden the discussion to the diagnosis and management of other toxic exposures.
Educational Theory Supporting the Use of Medical Simulation
In the end, the purpose of any educational method is to effectively, efficiently, and durably impart knowledge or skills to learners. Traditionally, medical education has consisted of three core components: classroom and laboratory instruction, independent study, and apprenticing in the clinical setting. Each contributes to the goal by cultivating a sound foundation of basic knowledge supported by practicing what has been learned to attain competence and confidence. As stated earlier, adult learners are goal-oriented, more receptive to learning when the subject matter has relevance to them. Physician trainees appear to learn most effectively when they are engaged in the care of actual patents. The learning of technical skills provides the learner with real- time feedback, motivating them to continue to practice in order to perfect the skill. Content education, however, is most often presented in a unidirectional lecture-style. If executed effectively, the relevance created through simulation, like caring for actual patients, can be employed as a powerful engagement/ motivational tool.
Learners arrive at a learning encounter with two levels of competence: actual competence and perceived competence. Most often, the level of perceived competence is greater than the actual competence. In some cases the learner may actually have more competence than they give themselves credit for; however in my experience, this occurs in the minority of cases. By the conclusion of a simulated scenario in which learners will perform to the level of their actual competence, there is a recalibration of their perceived competence; resulting in the creation of relevancy and a more goal-oriented learner. I have termed this the closing of the "competence gap" (fig. 6). If the learning encounter is a lecture, the learner maintains the perception that they know the material better that they actually do; detracting from the relevance of the content presented. Audience response systems capitalize on this same premise; making learners commit to an answer and motivating those who answer the question incorrectly to pay better attention. Because errors occur in the presence of co-learners, it is essential to develop a psychologically safe simulation environment in which mistakes may be made without the fear of condemnation or embarrassment.
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Besides the benefit of motivating learners through objective self-evaluation, medical simulation takes advantage of the benefits of active learning. In 1999, Russell and Feldman-Barrett formulated a model of affect that consolidated several descriptive models that had been independently derived by a variety of researchers (fig. 7) [10]. This two- dimensional model consists of the core affective feelings involved in mood and emotion distributed in quadrants defined by two axes. The x axis is the continuum from unpleasant to pleasant, and the y axis is deactivated to activated. Alertness, excited, elated, and happy populates the right upper quadrant. In the left upper quadrant are tense, nervous, stressed, and upset. The right lower quadrant consists of calm, relaxed, serene, and contented. The left lower quadrant contains fatigued, lethargic, depressed, and sad. It is thought that learning is maximized when the learner’s emotions are positioned at the top of the model; in the area defined by tenseness and alertness. When the learner is sitting in the classroom or lecture hall, their emotions are typically located in the pleasant though deactivated quadrant. The tactical use of simulation can consistently place the learners in the activated zone between tense and alert. Again, placing the learner in the more unpleasant zone towards stressed or upset will likely detract from the benefit of being in the simulated environment.
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Data Supporting the Use of Medical Simulation
Simulation as a learning tool appears to have face validity as it places the learner (and patients) into a safe environment. It allows for deliberate practice and the ability to practice until a defined level of technical proficiency is reached. There are, however, additional costs, besides money that must be considered when employing simulation. Among these are physical space, a level of technological proficiency, and an increased commitment of faculty time. Because of these costs, simulation has been compelled to prove its value more than any other new educational innovation introduced into medical education. Value is also difficult to quantify. In medical education it can mean cost, acceptance of the model, efficiency of learning, effectiveness of learning, durability of learning, and the effect of the model on clinical outcomes. As simulation has grown, so has the effort to answer these questions. Most early research was qualitative, focusing on simulation’s acceptance as a learning tool. Efficiency and effectiveness of cognitive and skill acquisition was the next focus of research. Durability of learning through simulation and determining the appropriate interval for retraining has been another focus. Finally, and most difficult to study, is the translation of simulation’s effects on clinical outcomes. In the following paragraphs, I will offer examples from the literature that have supported the use of medical simulation.
Effect on Cognition
In a pilot study by Gordon et al. in 2006, the effect of medical simulation on acquisition of cardiovascular physiology knowledge in medical students was evaluated [11]. In this study, first-year medical students were randomized to a standard tutorial format (control) or standard tutorial format plus participation in a simulated case (intervention). They were assessed immediately after the simulator session and at one year using a six item test. They found that after immediate testing there was a statistically significant difference in the mean scores of the two groups [mean score 4,0 (control), 4,7 (inter- vention), p=.005]. After one year, the difference was maintained [mean score 4,1 (control), 4,7 (intervention), p=.045]. Based on multivariate analysis the addition of simulation was a significant determinant of performance.
Effect on Skills Retention
In 2010, Bonrath et al. assessed the effect of simulation on the acquisition and retention of laparoscopic skills in novices [12]. Thirty-six medical students underwent training in nine skills of increasing complexity. There was a pre-course and immediate post-course assessment of both accuracy and speed of completion. Participants were divided into two groups of eighteen. One group underwent reassessment at six weeks and the other at eleven weeks. They found that all participants showed excellent skills ac- quisition immediately following the training session. The group assessed at six weeks retained eight of nine skills at immediate post-course levels. The group assessed at eleven weeks retained only four of the nine skills. The authors concluded that by eleven weeks the participants had ample deterioration of skills to warrant more practice. More work on the durability of skills and knowledge acquired through simulation is clearly needed and is a focus of further study.
Effect of Simulation-based Learning of Technical Skills on Cognitive Learning in the OR
Palter et al. assessed the effect of prior acquisition of technical skills using simulation on the acquisition of cognitive knowledge in the operating room [13]. They randomized eighteen novice surgical residents to either the intervention group or the control group. All participants were taught how to perform a fascial closure and were allowed to perform one on a simulator. The intervention group was then allowed to practice on the simulator until they reached technical proficiency. Both groups then performed a fascial closure on a real patient in the operating room. During the procedure both groups were read a script of pertinent clinical data. Each participant was assessed on the technical quality of the closure as well as their ability to retain the scripted information. Both technical performance and cognitive performance were statistically better in the intervention group. This points out the potential benefit of “front-loading” skills acquisition in the simulated environment as a means to enhance cognitive skills acquisition in the OR. More study is needed.
Effect of Simulation on patient outcomes
An example of translational research using simulation is this elegant study by Barsuk et al. on the effect of a simulation-based education program on the rate of catheter-related bloodstream infections (CRBSI) [14]. The intervention was completion of a four hour simulation-based mastery program in ultrasound-guided central venous catheter insertion. They used two controls. The first was a patient acuity-matched ICU in which clinicians did not receive the intervention. The other control was the rate of CRSBI in the intervention ICU prior to institution of the training program. Ninety-six residents were in the intervention group. The rate of CRBSIs in the intervention group was 0,5 infections per 1000 catheter days as opposed to 3,2 infections per 1000 catheter days in the historical control group. In the matched control group the results were even more impressive, 0,5 infections per 1000 catheter days versus 5,03 infections per 1000 catheter days; a ten-fold decrease in infection rate. This represented 140 hospital admission days saved as a result of the intervention. The researchers went on to assess the monetary savings to the institution as a result of the intervention. They calculated an $800,000 annual savings; representing a 7:1 return on investment.
Obstacles to the use of simulation
The adoption of medical simulation represents a major transformation in medical education. Instead of the standard unidirectional lecture format that medical educators have become all too accustomed to; lectures can now be "brought to life" through simulation resulting in a higher degree of engagement of learners. Since 2000, there has been a dramatic increase in the use of medical simulation in the US and throughout the world. This growth has occurred in spite of significant obstacles. Although other obstacles exist, I believe that the three most important ones to be navigated are money, technology, and fear of change. Unlike the implementation of a problem-based learning curriculum that requires minimal capital investment, the adoption of simulation requires an investment in equipment and infrastructure to successfully support its use. Another impediment is the need to operate and maintain sophisticated technology. Fear of change is another barrier that healthcare educators must overcome in order to endeavor on this tremendously rewarding journey.
Financial
I have too often heard from well-meaning simulation novices that the most expensive component of their project was the purchase of the simulator. Many simulation projects fail because the developers take a narrow view of the cost of simulation. Although simulators can be relatively expensive, the true cost of simulation is in developing and sustaining an infrastructure to support its ongoing use. One must consider many issues including: simulator maintenance (and replacement), facility costs, supporting equipment, disposables, and instructors/staff. One must also consider who is going to administer the entire project. There are a variety of strategies for financing simulation. The most common strategies are institutional support, fee-for-service, philanthropy, and grant funding. Most often it is a combination of these that provides the financial support for the project.
The most sustainable strategy is for the simulation program to become a line item in the budget of the institution. In order to develop the administration’s support for this, one will need to demonstrate the value of simulation as well as develop a plan to use the funding effectively and efficiently. When defining value, one must consider simulation’s educational value. Other less tangible contributions include simulation research, institutional reputation, hospital efficiency and effectiveness, patient safety, staff and patient satisfaction, amongst others. Fee- for-service is another commonly employed strategy. In this strategy users are charged for the use of the simulator. Determining fees can be difficult and will depend on many factors including center overhead, program costs, market influences, within or outside of institutional user status, complexity of the program, etc. Developing relationships with other institutions, industry, and public safety agencies are among the groups that a center will have to market itself to. A common misconception is that fee-for-service will cover the operating costs of the center, however in my many years of experience in simulation, I have never known this be true. The most unpredictable strategy for funding is through philanthropy and/or grants. Unless one receives a philanthropic gift whose investment dividends are large enough to support the ongoing costs of the center, this strategy is difficult to rely on. It is also difficult to rely on grant funding to support your day-to-day mission. In this era of cost containment, there is less and less grant funding available and even less that will support funding the cost of operations. In the end, a combination of these strategies is typically employed.
Technology
Although simulator user interfaces are becoming less complex, there is still a learning curve to become competent in their use and remain competent for continued use. It is hard enough to convince people to convert their traditional model of instruction into a simulation-based program. Add- ing the need to program the simulator and prepare, operate, and break down the equipment is an almost insurmountable obstacle that stands in the way of successful use of a simulation center. When people consider the development of a simulation program their first assumption is that they will need a physician or nurse to "run the center". Although physician and/or nursing leadership is critical, these people are typically the most expensive and busiest people in the institution; likely having too many other responsibilities to attend to the day-to-day operations of a simulation center. Using technicians to perform the majority of the tasks necessary to run the center is a solution employed by most successful simulation centers. Physicians and nurses are important contributors to curriculum development and instruction. In well-functioning simulation centers, once the work of developing the curriculum is complete, faculty merely show up minutes before the program and leave immediately after; showing great deference to this already overburdened resource. The number of technicians that is required is dependent on a number of factors including, center size and extent of center usage.
Resistance to change
Once the financial and technological challenges are overcome, reluctance to change is the next obstacle. Physicians have been educating using lectures and bedside teaching for years. Because this feels so comfortable for them there can be significant resistance to change. Another reason educators are hesitant to use simulation is that unidirectional lectures feels safer to them than does teaching in an interactive small group. Lectures insulate the teacher from the unpredictability that interactive teaching may introduce. In fact, if one doesn’t pay strict attention, post-simulation debriefing can easily turn into a lecture.
Although resistance to change is difficult to eliminate, there are strategies that simulation centers can use to minimize its effect. The first is to recognize that the use of simulation represents a significant change for your colleagues. It is wise to develop a program for new faculty that introduces them to the technology and the basics of teaching and learning using simulation. For faculty who will be providing team training, a specific debriefing course should be offered. As our simulation center has grown, we have added a curriculum developer whose chief responsibility is to assist faculty in the development of new curricula or bringing existing presentations "to life" using simulation. Although many believe that the technology is the most important component of simulation, the success of a simulation program is most dependent on the quality of the curriculum and teaching. Strategic investment in this is essential.
Other uses of simulation
Although medical simulation has earned its repu- tation as an important teaching and learning tool, there are a wide variety of simulation applications that can help maximize one’s return on investment. These include using simulation as an assessment tool, for research, for process improvement, and in product development. As simulation has become more prevalent, it has been used more often as an assessment tool. There are a variety of institutions and certifying bodies that require graded performance on simulators as a means of assessing competency. Successful completion of the Fundamentals of Laparoscopic Surgery (FLS) Assessment, of which a component is proving proficiency (efficiency and precision) in basic laparoscopic skills on simulators, is required by the American Board of Surgery as a prerequisite to sitting for their certifying examination. Most educators believe that validation of simulation as an assessment tool (as has been done with FLS) is imperative before simulation is employed in these high stakes assessments. Medical simulation is also being used as a research tool. Much research focusing on the validation of simulation as an educational and assessment tool has been and will continue to be done; however simulation has now become a tool for the study clinical care. A study by Arriaga et al published in the New England Journal of Medicine in January 2013, used a simulated operating room to assess the utility of checklists in the management of operative crises [15]. This study could not have been carried out in the actual operative environment due to the unpredictable nature of these low frequency, high acuity events. The assessment of new or modified processes in the simulation setting has streamlined the introduction of many clinical processes. Another nontraditional use of simulation is the testing of new or newly modified medical devices in the simulated setting. Industry engineers and user interface specialists are given an opportunity to observe their products in action used by real clinicians, facilitating the delivery of more mature products for testing in the real clinical environment.
Future of simulation
The use of medical simulation has advanced at a rapid pace since the early 2000s. The boundaries of its use has also rapidly expanded; encompassing not only education, but assessment, research, process improvement, and medical device evaluation. There are modes of use that have yet to be realized. Limitations of the technology will need to be addressed. The simulator’s insufficient representation of an ac- tual patient is a significant limitation. An example of an important advancement will be the development of skin and mucous membranes that realistically and reversibly change appearance paralleling physiologic perturbations. In actual patient care, clinicians, often respond to changes in a patient appearance. Today, simulators can only reveal physiologic changes using patient monitors and vital signs. There has also been a steady increase in the development of more affordable devices that can be used to emulate real anatomical structures. As the technology advances, the cost of simulation will likely decrease; increasing its availability. With this, I believe that we will also see advances in the theory and application of simulation and more ingenuity of our faculties. No matter what technological advances occur, it is important to remember that the value of medical simulation rests not on the technology, but on the quality of curricula and the expertise of the teachers presenting it.