The role of simulation training in medicine.

Greenspan 1 in a recent BMJ report stated that simulation training can help in the establishment of consistent standards by defining how things should be done. She was writing in relation to its role in improving patients’ outcomes as outlined in the recommendations of the Francis report 2 . Simulation clarifies the specific role of all the care workers at resuscitations and other procedures. All experts in the field of simulation training emphasise that it allows everybody in the team to have an input and outdated hierarchy is set to one side. It is part of the transition from classroom tuition to safe clinical performance. Simulation has gained a wider acceptance in mainstream medicine. It has overcome the initial reservations that it would add little to the traditional approach of history taking, clinical examination and management. Atul Gwande 3 points out that medicine has long faced a conflict between the imperative to give patients the best possible care and the needs to provide novices with experience. Simulation helps to fill this gap. One of the important benefits of simulation is that it creates ‘’situation awareness’. Everybody has their assigned task during the performance of a procedure. The leader of the team oversees that all segments of the operation are proceeding smoothly. It is about having insight into what is going on so that you know precisely what to do. It is time critical and places an emphasis on both clock and space. Situation awareness is particularly important in medical emergencies where the information flow is high and poor interpretation can result in the wrong decision being made. Simulation is a set of conditions that allows staff in a classroom or laboratory environment to prepare for real life emergencies. A good simulation centre requires physical space, computerised simulators, trained instructors, and comprehensive course material. Simulation is the artificial replication of the real clinical situation. It allows trainees to think through complex emergency scenarios in a safe non-threatening background. It has been used in the aviation and maritime industries for many decades. The concept has been the avoidance of system failures and looking at the human factors that contribute towards error. Simulation helps to accelerate the learning curve and bring trainees up to the required standard more rapidly. It helps the trainee to fulfil Miller’s ladder of professional expertiseknows/ knows how/ shows how/ does. These 4 steps correspond to knowledge, competence, performance, action. The task can be repeated as often as is necessary and gaps in skills and knowledge addressed. It is very suited to emergencies when a large number of procedures have to be undertaken quickly. Simulation training is divided into low, medium and high fidelity. Low fidelity simulation is the use of written case studies or role playing. Medium fidelity simulation is the use of a mannequin head to practise bag and mask ventilation and intubation. High fidelity simulation is the use of computerised mannequins to mimic real life clinical situations that require the correct intervention on the part of the trainee. The latter provides a ‘total immersion’ experience. Simulation can be used, for example, to assess the trainee’s efficacy at cardiac compression. High fidelity simulation training is already well established in anaesthetics and surgery and is increasingly being utilised in other areas. Simulation helps to develop leadership and decision making as well as technical mastery. The debriefing after the exercise is important. It can be conducted using a format based on the Pendleton framework. Asking the trainee ‘what went well with that?’ assesses conscious competence. Further discussion led by the trainer brings out areas of competence that the trainee was unaware ofunconscious competence. Asking the trainee what he was less pleased about brings out conscious incompetence. Fourthly when the trainer brings up where he feels the trainee needs to improve he identifies the unconscious incompetence. When time is short the interaction can be reduced in order to concentrate on the areas that need immediate attention. Simulation training does have its limitations. It can’t anticipate patients’ unpredictable responses to resuscitation measures, medications or a surgical procedure. It requires personnel and specific time set aside. There must be good instructor –trainee arrangements. The differences between communication during simulation and real life critical care situations needs to be recognised and addressed. The dialogue between the members of the team must be targeted and effective throughout the resuscitation or procedure. If simulation sessions are not well conducted they can have the counter effect of making the participants feel uncomfortable and threatened. The process has the potential to be harmful rather than helpful. Simulation training programmes are now in place in a number of Irish centres. The College of Anaesthetists launched the CAST programme (college of anaesthetists simulation training) in 2010. Crina Burlacu4 points out that training in anaesthesia followed the apprenticeship model which relied heavily on clinical exposure. Despite years of clinical training, junior may have only limited experience of life-threatening situations. This problem is exacerbated by the reduction in working hours. Simulation provides an opportunity to conduct crisis management scenarios. Skills facilities have also been established across the Dublin teaching hospitals and in Cork and Galway. There are plans to set up assessment mechanism including inspection, evaluation and accreditation. This evaluation process will provide consistency across all the centres. Simulation training in medicine is gaining in importance and popularity. It facilitates honest constructive feedback and improvement without attributing blame. The challenge into the future will be to make it available and relevant for all healthcare workers dealing with acute or complex medical situations. The other factor is determining the magnitude of the role that it should play in undergraduate and postgraduate training programmes.