Question

Analyze the challenges and potential solutions in current medical training specifically related to simulated clinical experience. Discuss at least 3 simulators.

Answer 1

Word simulation is derived from the Latin word ‘simulare’ which means ‘to copy.

Simulation is a method/technique that is employed to artificially create a particular set of conditions to study or experience something without going through the real event. The use of simulators in medical training and education offers useful opportunities to reduce risks to patients and learners, improve learner’s competence and confidence, increase patient safety, and reduce health care costs in the long run.

Safety is an important consideration for learners, especially in professional training. Simulation can provide a safe environment to reflect on and learn from mistakes without a threat to professional identity. It becomes more important in the current changing scenario of an increased number of medico-legal cases that have impacted training practices by limiting skills training in real patients.

There is also control over the sequence of tasks offered to learners. According to the maxims of teaching-learning, learning should start with easier/ simpler and then proceed to complex or more challenging ones. However, in the real world, it is not always possible to control what tasks are available at the time of training. But simulation permits for the sequential presentation of learning opportunities.

It has also made it possible to ensure learning particularly when resources are depleted or real-life situation required for aimed learning situation is not available coupled with the rapid explosion of knowledge, and busy schedules of physicians leaving them with less time for teaching medical students.

Simulation can be adapted to accommodate the need of preclinical, paraclinical and clinical subjects of the medical curriculum.

Challenges in current medical training specifically related to simulated clinical experience:

While simulation-based education has become increasingly popular, there are many barriers to its greater acceptance and utility.

Incomplete mimicking of human systems: Human body systems very complex and diverse. Models and instruments can never match that level of human complexity completely. Some scenarios may be too complex and difficult to simulate conceptually while technological limitations may also make it difficult to produce real physical characteristics and clinical signs in the mannequin, such as changes in skin color and facial expression cannot be taught, as well as simulators are not able to respond as a whole accurately after interventions. As a result, the simulation experience may not replicate a similar real situation and results in ineffective/ poor learning experience.

Solution:

Progressive advances in technology allow greater diversity and choices of realistic simulation modalities, and improvements in innovative instructional designs will further facilitate complex training scenarios, as witnessed in the gaming industry.

Defective learning: Poorly designed simulation can promote negative learning. For eg: if physical signs are missing in the simulation model, students may neglect to see the impact of the intervention on physical signs, though that may not be directly part of the experience. If learning bandaging skills on a mannikin, the obstacles in placing the part in the desired position in a real patient complaining of pain, may demand change in procedure but that is not the case in learning the procedure on the manikin.

So it prepares a learner, who can work in ideal situations but is not competent enough to handle real-life situations due to the interplay of many physiological and environmental factors.

Simulation-based learning may also encourage shortcuts, such as omitting patient consent and safety procedures and may foster artificial rather than genuine communication skills.

Solution:

There is a need for improvements in technology and working of simulators that can respond, and communicate. Educators also plan to learn experiences in such a way that it provides enough opportunity for learning in simulated situations followed by experience in real-life situations in a variety of settings. It will ensure patient safety as well as comprehensive learning for the learner.

Cost factor: Simulation laboratories are quite costly. They use high-tech, high-cost training tools, both in terms of initial purchase prices as well as maintenance charges. A single high-fidelity simulator with its monitoring system and other necessary equipment may cost up to $200 000. Also, synthetic body fluids, replacement skins, bandages, syringes and other supplies are necessary to simulate the experience of treating real patients. Hence, they are not affordable to many teaching hospitals, or many teaching institutes then opt for cheaper versions of them. The simulation gives the impression of a method.

Solution:

Although high-fidelity simulators may be costly, some simulation training may be effectively undertaken with lower fidelity mannequins and hence reduced equipment costs and constraints.

In situ simulation training may also reduce the need to conduct the simulation in a fully equipped training center, thus avoiding the facility cost.

Standardized patients or trained actors or other students act as a patient and may facilitate patient interaction training with lower associated training and running costs.

Careful analysis of the ability to practice without risk must be weighed against the cost of this new technology.

Time factor: Incorporating time-slot for simulation in an already burdened medical curriculum is difficult. Another consideration is due to the cost factor there are not enough simulators and students need to wait for a long time while another student is practicing on a simulator, so it wastes a lot of time.

Solution:

Careful planning of simulated learning and other experiences simultaneously can avoid idle sitting by other students in waiting time.

Lack of qualified trainers: Simulation is a new concept, and many professors are not comfortable in using these simulators particularly computerized ones. Lack of an adequate number of dedicated and exclusive resource personals is another challenge.

Solution:

Teachers must be given thorough training about the use of simulators, their different parts and handling of the simulator.

An instructor to learner ratio of 1:3– 1:4 is ideal and should be maintained.

Insufficient supporting evidence/ research: A major concern regarding simulation-based education is the lack of concrete evidence on its effectiveness in improving patient outcomes. There is only a limited amount of good quality evidence on the effect and validity of simulation-based training.

While there are, only a few studies that have provided a solid foundation for change in clinical practice. Although increasingly more data is supporting its effectiveness to improve knowledge, procedural skills, behavior, teamwork and communication but these studies do not typically report impact on clinical outcomes. This uncertainty has led to skepticism towards this learning method.

The major challenge to medical simulation is the fact that evidence to date is weak in methodology. Most of the published work is descriptive and limited in generalisability. The assumption that such learning is directly transferable to the clinical context is often untested

Solution:

There is a need to conduct research studies to assess and quantify the benefits and effectiveness of simulation training by evaluating the clinical competence of those undergone simulation training in real situations.

The development of a quality assessment guide/ tool to be used competence of learner in clinical settings as well as learning exercises on simulator may help in the accumulation of high-quality evidence for the effectiveness of healthcare simulation for education and training.

The attitude of learners and trainer: Participants will always approach a simulator differently to real life and trainers are also relaxed in observing the experience. Two common changes in attitude can occur are hypervigilance which causes excessive concern because one knows an event is about to occur and cavalier/casual behavior which occurs because it is clear no human life is at stake.

Technical / Programming difficulties: The simulation models have to be manipulated by facilitators and engineers in such a way as to replicate a physiological response that may be desired under specific circumstances. Manipulating these systems following desired simulation goals is often cumbersome.

Learner specific teaching not possible: It provides the same learning opportunity to all those using. Instructors who wish to present circumstances according to the abilities of different learners (advanced tasks for proficient students while basic tasks to beginners or slow learners), but this individualized approach is not possible in simulation-based teaching.

Haptic IV simulator

One of the most commonly performed basic nursing skills is intravenous (IV) catheter insertion. IV catheterization, cannulation, or insertion is a complex and invasive procedure. How to insert an IV catheter is the most challenging skill taught in nursing school. Traditional methods of instruction for IV insertion vary between different schools. Traditionally it consists of faculty didactic presentation followed by faculty demonstrating the procedure in clinical settings, on learning by observation to other nursing staff and then doing or see-one do-one format.

In simulation-based labs, a haptic IV simulator is used to provide this learning experience.

The approximate cost of one haptic IV simulator ranges between US$20,000–US$25,000. However there is no information regarding the cost of consumables or faculty time needed to teach this skill, a cost comparison between these instructional methods would be beneficial.

Identified the cost of the haptic IV simulator as being an issue in developing countries but also mentioned that the traditional method of teaching IV insertion requires a high faculty-to-student ratio which is also costly

Current use of haptic IV simulators and traditional training methods continue to have different outcomes. Some of the studies indicated a decrease in student anxiety levels and an increase in cognitive gains with practice but these results were not related to the method of IV instruction. Other studies indicated performance improvement by a decrease in insertion time and band constriction time with the use of the haptic IV simulator.

These IV simulators technology does not teach all aspects of IV insertion, including successful cannulation, they only teach the process. Students need faculty support and feedback during practice on the IV arm but during the learning process other options may be more feasible and cost-effective.

Resusci-Anne

Resusci-Anne, " a mannequin/ trainer for teaching cardiopulmonary resuscitation (CPR) to emergency medical technicians. Before the use of one of the first cardiopulmonary resuscitation training simulators called Resusci-Anne, patient care had been simulated using both cadaver and animal models.

Another well-accepted mode of simulation incorporates the use of standardized patients. Actual actors (or more commonly untrained volunteers) have been used extensively to simulate large-scale disaster responses. Although Resusci-Anne was developed as a full-body simulator, she was a part-task trainer used exclusively for the practice of CPR. These simulators enable learners to interact with, assess, and perform a variety of procedures on a simulated patient that through a variety of anatomical and physiological modifications controlled by the instructor behaves as would an actual patient. Depending on the level of fidelity, these simulators breathe, speak, and have pulses and heart and lung sounds, and they can display a wide variety of physiological parameters on their monitors.

Although the fidelity of Rescue Annie the clinician-patient interaction may be excellent, the introduction of accurate pathophysiological patient responses to changes in disease states or interventions is difficult to produce.  However, what has been gained in physiological fidelity is offset by the loss of the interactive fidelity that a standardized patient can provide. So one hybrid simulation, for instance, one may develop a scenario with both a human-patient simulator and a standardized patient is better than simulator alone.

Harvey cardiology monitor

It is also not as effective since monitoring is influenced by bvarious factors and it is quite expensive.