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|Year : 2014 | Volume
| Issue : 2 | Page : 171-174
Medical simulation: A virtual world at your doorstep
Vice-Chancellor, DY Patil University, Navi Mumbai, Maharashtra, India
|Date of Submission||17-Apr-2013|
|Date of Decision||02-May-2013|
|Date of Acceptance||02-Nov-2013|
|Date of Web Publication||13-May-2014|
Dr. S N Oak
Vice-Chancellor, DY Patil University, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Medical simulation has come a long way in Western health care; however, in developing world, health education sectors have not adequately addressed its significance and role in preparing and updating heath care personnel. Validification, standardization, paucity of trainers, deficiency of a structured syllabus, and cost of equipments need to be overcome in the next decade. Despite these problems, worldwide acceptance of the concept of medical simulation is growing. It is undoubtedly the wave of future. Multidisciplinary, interprofessional, and multimodal simulation training is possible. Virtual worlds are increasing the vistas of training, making the actual health care dispensing more skilled and safe.
Keywords: Clinical skills training, medical simulation, simulators
|How to cite this article:|
Oak S N. Medical simulation: A virtual world at your doorstep. J Postgrad Med 2014;60:171-4
Simulation means "an imitation of some real thing, state of affairs or a process" for the purpose of solving a problem and making a judgment.  Warfare technology and aviation industry have made rapid strides in simulation and are the true proponents of this virtual world.  In developing world, we find applications of simulation in health care far and few. There is a need to establish dedicated simulation centers to support a cluster of medical schools, where undergraduates as well as postgraduates can learn diagnostics as well as invasive therapeutics without compromising the safety of a real patient.
| :: Emerging Need|| |
With evolution of the 21 st century, the lacunae in health care industry are obvious. There is shortage of health care personnel at all levels-doctors, nurses, technicians, and trained paramedics. Teaching programs at various levels are handicapped due to severe shortage of trainers.  Unfilled faculty positions are a serious threat leaving the educational institutes short staffed and under a constant peril of being derecognized by the regulatory council. Governments will continue to claim paucity of funds to cure the malady. Consequently, the ward-based training where "each one, teach one, and do one" principle was the gold standard of health care has suffered. Students providing care to the real patients under direct supervision of experienced, skilled senior faculty in a university as per the council certified accredited program, though the best way to learn, may not remain sustainable in the years to come. Moreover with the growth of insurance in health care sector, patients may no more be viewed as "Teaching Material" in hospitals  and then learning the skills of invasive procedures like, venous access, chest tube insertion, and tracheotomy may become increasingly difficult. Hence, the need of a dedicated medical simulation center where various aspects of health care-trauma, A and E, BLS/ALS techniques, anesthesia and cardiopulmonary interactions, cardiac catheterization techniques, minimal invasive surgical techniques, endoscopy techniques, gynecological interventions, and ultrasound imaging of human body-are becoming more than obvious.
| :: Evolution and Advancement|| |
Medical simulation evolved during the 1900s from a simple apprenticeship to learn the correct scientific principles and eventually necessitated quantifiable measures of competence in the domains of knowledge, skills, and professional conduct. Innovations in flight simulation, resuscitation technology, and advancement of quality medical grade plastics were essential milestones in its progress.  Computers facilitated the mathematical computations and the virtual reality made skills acquisition possible.
Surrogacy is the fundamental basic of medical simulation. In medical simulation, an acceptable substitute is used in place of a real patient. Educational surrogate can never be identical and exactly replicable to a real human patient, but the approximation of the reality is aimed at producing the desired educational impact. The ultimate effectiveness of simulation training is judged by how well the students have acquired the desired skills.  Current medical simulation can be classified into five categories according to a scheme proposed by pioneer David Gaba.  These five designates are verbal, standardized patients (SPs), part task trainers, computer patient, and electronic patient.
Verbal simulation is simply role playing. SPs are trained actors used to participate in assessment of history taking, physical examination skills, communications skills, and approach of the care giver. In developing world, SPs may be a financially untenable option; moreover, barriers of language, ethical, and customs issues will also make the application of this modality difficult. Part task trainers are simple anatomical models of body parts either in their normal or in pathological state representing a disease. The adoption of minimal invasive surgery gave a major boost to the development of part task trainers and this was also followed by ophthalmology, orthopedics, vascular interventional procedures, and endoscopy (bronchoscopy, upper and lower gastrointestinal endoscopy). Computer patients are interactive and are software based or an internet-based component of virtual world. Electronic patient now takes care of anesthesia modalities, drug domains, and even makes team-oriented simulation training possible. Various scenarios can be created by the instructor and the responses by the trainee can be assessed and quantified. Human patient simulation (HPS) should now become a part of undergraduate as well as postgraduate medical education. HPS replaces animal exercises and demonstrates human physiology at different scenarios. 
Virtual reality products project images, vibration, sound, smell, and even wind to deliver different clinical experiences. Three-dimensional photorealism has made possible a simulated vision with a separate view for each eye and evolution of haptic interface devices have enabled the students to get the "feel" of what they are doing or to what organ they are touching within the human body. Medical simulation today can give the learner an idea of proprioception, tactility, and even of the force that he is applying during a procedure.  The greatest advantage of virtual reality is the ability to try and fail without harming the actual patient. "It is only through failure that the true pathway to success lies." 
| :: Advantages of Simulation Training|| |
Medical simulation can never be considered as a substitute to actual ward-based clinical real patient interaction training. Conventional training is the best, as far as learning communication, bed side manners, physical examination, and history taking is concerned. Medical simulation laboratory primes a student forward rounds and patient assessment. Every student must spend designated hours and undergo a structured syllabus course under the supervision of an instructor before he/she steps in a clinical ward. Invasive procedures must be first practiced on mannequins to acquire an acceptable degree of skills and proficiency before embarking upon a human patient. The simulation thus greatly enhances patient safety and autonomy of the patient is respected. [Figure 1], [Figure 2] [Figure 3] and [Figure 4] represent typical simulation labs.
Simulation laboratory enables the students to learn and acquire the new skills in relatively shorter time. Students can repeat a set of actions and exercises as many times as they want. Moreover, the self-training module can help them to perfect their skills at hours and pace convenient to them and at times even in the absence of an instructor. In the absence of such a laboratory, specific educational experiences may take several weeks or months to accumulate in a clinic. Once simulation has produced mastery of fundamental skills, it can expose the students to different levels of difficulties, abnormalities and other problems. The system can inject variations which compel the students to think and modify their treatment plans. Learning is evidence-based and the simulator laboratory, thus provides a learner centric and yet teacher-enabled environment. The repeat attempts of the performance by the learner are mapped and the student can see for himself the progressive improvement that he is making. This is a morale booster. Debriefing is a very vital component of the course and this promotes the culture of trust and openness in learning. Adverse events reporting increases as there is no fear of a blame game. Silence is sinister and denial of a mistake in medicine is a sin and simulation helps to break these unhealthy practices.
Another significant advantage of medical simulation is its applicability across the health professions. One can tailor the course contents and the syllabus for nurses, technicians, and paramedics. They then can be trained to work as a team. Telemedicine can be incorporated to facilitate distant learning and preceptor concept in health care dispensing.
A real-time feedback enables the learner to understand where he went wrong and simulator can also give valid useful suggestions. Quantification of the performance and time taken to achieve the desired result can be monitored and this works like a corrective tutorial improving the student's thought process and clinical skills. Virtual systems can also evaluate learner's response to a hazardous condition that would not be allowed in learning environment with real human patient, for example, explosion of a hazardous gas.
| :: Limitations and Critical Review of Medical Simulation|| |
At the beginning of the 21 st century, there was considerable interest in reforming the health care teaching and delivery and it was felt that the medical simulation would change the competency, skills, and behaviors of medical personnel. This initial excitement turned into a "tempest in a teapot."  Cost of the simulator equipment is high and that makes its widespread applicability difficult. Hospital administrators and health care planners give a lukewarm response to simulation when it comes to budgetary allocations. Training continues to play a second fiddle to the inexorable demands for clinical service. Simulator training helps to improve invasive skills, but behavioral modifications are inconspicuous. Professional societies, specialty boards, accrediting bodies, and regulatory councils have failed to act and have considered this exercise and facility as superfluous and extravagant. Mandatory programs of simulation training have been opposed by existing practitioners and also surprisingly by hospitals. There have also been court malpractice cases in Western world, where simulation training center has been blamed for inadequate exposure and a pseudo-confidence booster to a medical practitioner who subsequently commits a clinical error.
Every scientific advance goes through phases of suspicion, ridicule, blind acceptance, iatrogenic complications, and then a plateaued prudent inclusion at a level, where it deserves to be in. Medical simulation is a supplement, not a substitute to the age-old training methods. It prepares a student to make the bed side assessment and experience more meaningful and effective.
| :: Future of Medical Simulation|| |
In developing world, simulation deserves to have a strong future in health care. It will help to fill up the worrisome gap between declining number of medical teachers and growing need of students. Computer-based technologies are evolving with astounding rapidity and finding their presence felt even at remote places in developing world. The needs of medical training will get converted in demands and this will drive the market to evolve supply of simulation technology in medical schools and hospitals.  Regulatory councils will include the simulation laboratory work as a mandatory component of undergraduate as well as postgraduate years and all these efforts will make health care dispensing safer, effective, and efficient.
| :: Summary|| |
Medical simulation has come a long way and yet there are major barriers in its widespread applicability in health education. Validity issues, cost of equipment, availability of trainers, and acceptance of a structured syllabus-based course-programs are some of the critically important aspects of simulation in developing world. Virtual world is at our door steps! It is up to us to allow it to enter to make our real world safer and meaningful.
| :: References|| |
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|4.||Satava RM. Accomplishments and challenges of surgical simulaton. Surg Endosc 2001;15:232-41. |
|5.||Zvara DA, Olympio MA, MacGregor DA. Teaching cardiovascular physiology using patient simulation. Acad Med 2001;76:534. |
|6.||Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004;13 Suppl 1:i2-10. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]