Simulation of the clinical experience

Published on 01/06/2015 by admin

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Last modified 01/06/2015

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25 Simulation of the clinical experience

Simulated patients, manikins, models and computer simulations all complement experience with ‘real’ patients and have a place in a training programme.

The importance of learning in the clinical context was emphasised in the previous chapter. A key element in clinical teaching is the patient. There is now good evidence that exposure to the ‘real patient’ can be augmented usefully with a simulated experience. Simulated patients and patient manikins or models are widely used and have been found to be of value in undergraduate education and postgraduate training to complement the student’s experience with real patients. Some teachers have been sceptical about the use of simulation in medicine but its value is now proved. Simulation should be seen as a prelude to doing the real thing on a real patient, never as an end in itself.

In this chapter we look at different types of simulation, the educational strategies that need to be adopted and the concept of the clinical skills centre.

Reasons for simulation

Teachers should be familiar with the role that simulation can play in a training programme. There are many reasons why simulation is seen as an essential rather than an optional element:

• ‘Real patients’ may not always be available for clinical teaching. With changes in healthcare delivery patients’ stay in hospital is now shorter and during their stay they are occupied with investigation and treatment procedures. Patients may be less willing to have repeated exposure to students.

• With simulation every student can receive a guaranteed and standard clinical experience. Unlike with real patients a simulated experience can be made available to students at the most appropriate time to fit in with their learning programme.

• Repetitive practice is recognised as a key element in the acquisition of clinical skills. Learners can practise with the simulator until they have achieved the necessary mastery of the skill.

• Students are now introduced to clinical experiences earlier in many curricula and preparation on simulated patients and simulators can prepare them for their work with real patients.

• Trainees can be exposed to uncommon situations or rare clinical events that they may not encounter in their routine clinical experience.

• The management of crisis events can be practised and rehearsed so that students and trainees are better prepared should such events occur in real life. Airline pilots are trained in this way and simulators enable the pilots to deal with extreme situations such as engine failures.

• Students can learn a procedure in a risk-free environment. Learners can make mistakes and appreciate their consequences without causing harm to patients. Indeed in some areas it is now a requirement that a doctor demonstrates mastery of a procedure on a simulator before being approved to perform it on a patient. Uncoupling injury from learning sends a message to the public that patients are not ‘a commodity’ for training.

• Doctors need to be able to work as a member of a team. Simulation can address not only the acquisition of individual technical skills but also be used to train the learner to work in a coordinated and effective manner as a member of a team.

• The assessment of a learner’s mastery of a clinical skill is important. Simulated patients and simulators can be used for this purpose in examinations, including high stakes examinations, to assess the learner’s mastery of a skill as described in Section 5.

• Simulation can be used to provide students with a motivating and engaging learning experience. This can be designed to challenge the students, encourage their reflection and provide feedback about their performance. The experience can be customised to meet the needs of the individual learner.

Approaches to simulation

There are three approaches to simulating the real patient:

1. Simulated patients. These are individuals trained to play the role of a patient.

2. Simulators or manikins. These are devices or models that represent the functioning of the body or part of the body and with which the student can interact.

3. Virtual patients. The patient is represented in a computer simulation.

A hybrid approach has been developed by Kneebone and others that skilfully combines different patient simulations. A simulated patient, for example, can be used with a pelvic model attached. The student catheterises the ‘patient’, while at the same time communicating about the procedure with the simulated patient.

Choice of simulation

A number of factors should be taken into consideration when choosing the simulation approach to be adopted:

• The expected learning outcomes. Simulated patients are the obvious choice if communication skills are the expected learning outcome. Computer-based programmes designed for the purpose also have a role to play in communication skills training. If skills in auscultation are the required learning outcome, a manikin such as the Harvey cardiac simulator is appropriate. Virtual patients can contribute to decision-making, problem-solving and patient-management skills.

• The level of fidelity required. Simulators vary in how similar they are to the real situation they are designed to simulate. A high fidelity simulator may be unnecessarily complex and expensive, and a simple piece of plastic simulating a wound on the skin may be adequate to teach suturing skills. A higher fidelity simulator may be required in a high stakes examination but may not always be necessary in a training situation. However, students tend to be more engaged with a high fidelity simulation that more closely resembles a patient.

• The availability of simulators. This may be a limiting factor. If students do not have immediate access to a clinical skills centre with a full range of simulators, it may be possible to arrange access to a nearby centre. If a bank of simulated patients is not available, a simulated patient can be trained to meet the needs of a programme but this can be time consuming. Virtual patients that can be shared online across institutions and modified to suit a local context are now available.

Simulated patients

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