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Simulators in training and teaching

Created: 12/8/2008
Updated: 25/9/2008


The most common use of the simulator is for teaching and training. There are a number of reasons for their popularity in being used for training in anaesthesia:

1. They simulate a high degree of reality.
2. No risk for a real patient.
3. Predictable, programmable, standardisable, reproducible scenarios presented.
4. Repeated assessments at present times possible.
5. Allows for practice on clinically rare scenarios.
6. Videotaping allows for review.
7.Simulation can be stopped or restarted for teaching.

Studies in error evolution and critical incidents in anaesthesia have shown that human error is a major contributor. The opportunity to encounter certain rare life-threatening anaesthetic emergencies, such as malignant hyperthermia, in actual clinical practice is limited. Drawing from the experiences of the aviation industry, Gaba et al. noted that in order to be effective, these skills must be actively taught rather than acquired through reading about it or by “osmosis”. Finally, based on Ericsson et al.’s work, it has been shown that the crucial factor in developing expertise is the amount of deliberate practice. As a result, one of the seminal uses of the high fidelity simulator in anaesthesia is in training and rehearsing for crisis management.

The success of the use of the simulator for crisis management has resulted in a broadening of the simulator use in anaesthesia. Many centres are using the simulator for medical student and resident teaching. In the context of teaching medical students, the full scale simulator has been used to demonstrate basic airway skills, principles of cardiopulmonary physiology and to provide an experiential introduction to the practice of anaesthesia, as well as aspects of critical care. For anaesthesia residents, the simulator has been used to familiarise new residents to the operating environment, learn the basic principles of giving a general anaesthetic and to learn to deal with common and rare intraoperative problems. It has also been used to run ACRM-type scenarios where higher levels of training, such as communication, team and resource management, are taught.

In addition, high fidelity simulators have been used to study human error and to teach the non-technical skills in anaesthesia, as developed by Fletcher et al., such as task management, team working, situation awareness and decision making. The issue of patient safety also underpins these uses of the simulator. The simulator has also been used for continuing medical education. Issenberg et al. have recently reviewed the elements of high fidelity simulation that contribute to successful learning, including the ability for repetitive practice and feedback.

Despite the enthusiasm and high ratings with which the participants give to such training programmes and the intuitive usefulness of training with a full-scale simulator, the efficacy of such training compared with traditional methods of teaching is difficult to prove.

The simulated setting will never fully recreate real life and the unpredictability in which real patients may respond to various interventions. In addition, in a simulated setting, hypervigilance on the part of the participant because of the anticipation of an “impending crisis” or, alternatively, a “cavalier attitude” because of the knowledge that this is not a real patient, may hamper how well the simulated setting mirrors the way the participant would respond to real life. Because of these limitations, it is difficult to make conclusions on how well performance in the simulator setting will predict performance in real life. Whether training on a full-scale simulator makes a significant difference in patient outcome is even more difficult to ascertain. Because of its substantial cost, full-scale simulators also have to answer to the question of its cost effectiveness as compared with traditional methods of teaching in anaesthesia.

There are only a few studies which look at the efficacy of simulator-based training. Chopra et al. found that simulator-based training of participants in the handling of a malignant hyperthermia crisis resulted in better adherence to established guidelines than in a group who had not received similar training. By contrast, Morgan et al. compared the efficacy of simulator-assisted versus video-assisted teaching in medical students in their performance in the management of three scenarios. They found no difference in the scores of the students in their group. Nyssen et al. compared the treatment scores and “time to diagnose” of anaesthesia residents and anaesthetists trained on a full-scale simulator versus a computer screen-based simulator. They found no difference based on the type of simulator used. However, they did admit that crisis management involves more than just the ability to diagnose and carry out the technical tasks – it also involved behavioural aspects such as communication and team management, which were not tested in their study. Yee et al. studied the effect of training residents in anaesthesia crisis management using a high-fidelity patient simulator and found an improvement in their non-technical skills after a single exposure.

Thus, despite its apparent advantages as a teaching tool, the verdict is still out as to whether the simulator is cost effective or whether it improves performance to the extent that it leads to better patient outcome.

AUK would like to thank Dr Anne Wong M.D., M.Ed., F.R.C.P.(C), for her contribution to this section based on her work; Wong AK. Full scale computer simulators in anesthesia training and evaluation. Can J Anesth 2004; 51 (5): 455-464


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