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 [1] 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. Another important finding came from the Harvard Medical Practice Study 1, in which the authors reviewed over 30,000 randomly selected hospital records at New York State in 1984 as part of an interdisciplinary study of medical injury and malpractice litigation. They found that injuries from adverse events occurred in 3.7% of hospital admissions, 27.6% of which were due to negligence and in which 13.6% led to death. [2] 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 as $5.6 million and $2.8 million repectively. [3] Though it is expected that such medical errors occur in Saudi Arabia, there are no studies on their extent in Saudi hospitals.
Calls for a change in the instructional methods and medical teaching course have resulted in innovative medical curricula. The new curricula stress the importance of proficiency in several clinical skills by medical graduates rather than mere acquisition of knowledge. As evidenced by their endorsement by many of the international bodies and medical schools, [4] 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. Some medical schools in the Middle East have changed their curricula and adopted such educational strategies as problem-based learning. Also many medical schools have started to utilize clinical skills laboratories for training. However, 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 of MEDLINE/PubMed database for English-language publications and reference lists from relevant articles published between 1990 and August 2009 was conducted. The main search terms were medical simulation, medical simulator, medical education, and clinical skills. All articles thought to be relevant to the title and/or abstracts were retrieved. These articles were reviewed if they were considered relevant to the search.
Clinical Competence
Medical training programs should ensure that students have the necessary learning opportunities and assessed by the appropriate methods. Clinical skills competencies including communication skills, history-taking, professional attitudes, awareness of ethical basis of healthcare, physical examination, procedural skills, clinical laboratory skills, diagnostic skills, therapeutic skills, resuscitation skills, critical thinking, clinical reasoning, problem solving, team-work, organization skills, management skills, and information technology skills should be part of the core undergraduate curriculum. [5] 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. The pressure of managed care has shaped the forms and frequency of hospitalization and led to a higher percentage of acutely ill patients and shorter inpatient stays. This has resulted in fewer opportunities for the medical learner to access a wide variety of diseases and physical findings. Relying on exposure to real hospital patients during training years may result in an ad-hoc method of learning clinical skills, as this depends on the availability of cases, and consequently to less than optimal development and performance of clinical skills. There are many reports that indicate concerns for the level of skills medical graduates even in western countries possess.
The acquisition of expertise in clinical medicine requires the learner's engagement in deliberate practice of desired learning outcomes. According to Issenberg et al (2002) [8] "Deliberate practice involves (a) repetitive performance of intended cognitive or psychomotor skills in focused domain, coupled with (b) rigorous skills assessment, that provides learners (c) specific, informative feedback, that results in increasingly (d) better skills performance, in a controlled setting." 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.
Aviation and aerospace industries have been using simulation as a teaching tool for many years. Simulators are now widely used in education and training in a variety of high risk professions and disciplines, including the military, commercial airlines, nuclear power plants, business and medicine. [11] Recently, the inclusion of clinical skills training into the curricula of medical students has seen significant growth. There are many examples of curricular reform that include clinical skills training, the use of simulators, and the creation of clinical skills centres. [12] 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; or a generic term that refers to the artificial representation of a real world process to achieve educational goals via experimental learning. [13] A simulator is defined as a device that enables the operator to reproduce or represent under test conditions phenomena likely to occur in actual performance. 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. [14] Experiential learning, which is a part of the definition of simulation, is an active process during which the learner constructs knowledge by linking new information and new experience with previous knowledge and understanding. Experiential learning or learning from experience during simulation based training sometimes involves the use of clinical scenarios as the bases of learning. [15],[16] The practice of scenarios can be done individually, but it is mostly carried out by a team from the same or different specialties or professions in a simulated environment made to resemble the intended environment as closely as possible in order to immerse students in an experience closest to real life. 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. Debriefing can focus both around the cognitive process involved in the recognition of the problem and the implementation of the management guidelines and the technical level at which the ability of the learner to apply rules and appropriate responses in a stressful situation is evaluated.
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During the full scale scenario-based training, the learner can acquire such important skills as interpersonal communication, teamwork, leadership, decision-making, the ability to prioritize tasks under pressure, and stress management. 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.
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