Introduction

Simulation training has its roots in the aviation industry, with the first flight simulators built in the 1930s. The military, NASA, and commercial airlines further pioneered simulation techniques to improve pilot training and safety. The field of medicine implemented forms of simulation for training as early as the 1950s, but it wasn’t until the turn of the century that medical simulation took off. Anesthesia was an early adopter of simulation; a first simulator appeared in the 1960s, which could reproduce some physiology, respond to drugs, and teach basic airway management. Since then, medical simulation has expanded across all disciplines of medicine.[1] In particular, internal medicine residencies are increasingly making use of simulation to teach their house-staff, mediate deficiencies, and maintain proficiency in key areas of practice.[2]

The medical simulation utilizes multiple diverse modalities to teach learners in internal medicine.[1] For example, scenarios with standardized patients are often used to assess interpersonal skills and communication; while task trainers, cadavers and animal models are employed to replicate procedures without putting patients at risk;[3] and medical emergencies are simulated with interactive software, virtual reality, and high fidelity mannequins which have led to improved patient survival in some cases.[1][4][5] Debriefing, which occurs at the end of the simulation, is a key aspect of learning, soliciting learner self-reflection, and uncovering the ways they think about and approach medical problems.[2][6]

Simulation is poised to expand in the future. Much like aircraft pilots are routinely tested for proficiency and ability to handle emergency situations during their careers, medical boards are starting to use simulation to assess clinical competency. For instance, the American Board of Internal Medicine (ABIM) offers the option of a simulated cardiac catheterization skills assessment to interventional cardiologists to maintain their certification in this procedure. Similarly, the American Board of Anesthesiology board exam incorporates an Objective Structured Clinical Examination (OSCE) to assess communication, professionalism, and technical skills. These offerings will likely expand to internal medicine and other specialties. Another growing and evolving area of simulation is virtual reality, which will have an increasing application to all fields of medicine; sight, sound, and new functions such as haptics provide an immersive world for learners to develop clinical skills.[1][5] Interprofessional simulation is useful to understand and improve team dynamics and communication and is particularly important to the role of the internal medicine physician who is tasked with coordinating patient care.[7] And beyond training and education, simulation has real-world implications, including improved patient safety and healthcare quality.[3][4][8]

Issues of Concern

There are limitations to medical simulation. These include clinical validity, financial constraints, personnel availability, simulation space, and bias against the benefit of simulation. The simulation does not always lead to improvements in skill acquisition or patient outcomes. Simulation may lack clinical validity, and/or acquisition of skills is inadequate due to the inexperience of the learner, the duration of the simulation, or the need for repetition.[4] Furthermore, it is challenging to attribute improved patient care outcomes solely with simulation when other confounding factors are present (e.g., clinical experience, time, and fatigue). Medical supplies and clinical trainers can be scarce and cost-prohibitive. Simulation centers have personnel requirements, including simulation technicians that can set up, operate and breakdown scenarios, a standardized patient program, and medical staff who can instruct learners, though they often have competing clinical requirements. Many training programs do not have access to medical simulation or space to conduct these activities.[9] Some also view simulation as superfluous and believe the best learning occurs at the bedside. Fortunately, there are some workarounds to these problems. For instance, old and expired medical equipment from other healthcare settings can be used and reused in simulation, DIY low-cost simulators can be constructed, and residents employed as teachers. There are emerging adaptive trainers that obviate the need for expert instructors and resources, and simulation space can be shared among multiple residency programs and healthcare organizations.[2][10] As simulation gets adopted into training programs with demonstrated benefit to education and patient care, it will become more accepted as a learning modality by the healthcare community.

Curriculum Development

Internal medicine programs are incorporating simulation into their curriculum because it serves the dual functions of training and competency assessment. Residents learn with simulation, and it has been demonstrated to improve patient outcomes. Simulation can also be used to assess core competencies and requisite skills inherent to the Accreditation Council for Graduate Medical Education (ACGME) and ABIM.

Thoughtful planning is critical to executing a successful simulation exercise. Examining learning theory, coordinating resources, and revision is necessary for a successful simulation. Planning meetings and “dry-runs” of the simulation are useful to set the objectives and expected outcomes, determine what equipment, materials, and learning space are required, and to work out initial kinks. Instructors should further consider how many learners will be present, the duration of the simulation and if repeated sessions would be beneficial. In general, smaller group size is preferable because it allows for repeated practice and an optimal balance between learner observation and active participation. “Chunking” parts of the skill, limiting teaching to only essential information needed, and increasing the difficulty only after achieving proficiency avoid cognitive overload. Outcomes from the simulation should be considered in the context of the learner, with novice learners advancing slowly while experienced individuals can be expected to make rapid progress in skill acquisition. Learners should be allowed to struggle and even fail. This promotes self-sufficiency, improved problem-solving, and troubleshooting skills. The duration of medical simulations is best limited to a set amount of time, approximately 75 to 90 minutes. Depending on the complexity of the skill, repeat practice may be beneficial; in some cases, only one practice session may achieve proficiency.[1][11] 

New curricular innovations can be trialed in simulation. One large academic program successfully employed senior medical residents to facilitate simulation training for their first years. Surveyed interns rated the program highly, and senior residents thought the program was educationally valuable for the first-year residents, improved their teaching skills, and translated to improved teaching on the wards. Programs like these are effective educational models and benefit both the resident teacher and learner. This may be a good model for internal medicine residency programs with many learners but few teaching faculty.[2][10]

Clinical Clerkships

As internal medicine residents rotate through their clinical clerkships, simulation can be used to prepare them for the experience, assess if objectives of the rotation are met, and remediate if they are not. As an example, at the Mayo Clinic Internal Medicine Program in Florida, residents start their critical care rotation with a day of “boot camp” in the simulation center. During this time, they receive instruction in sterile technique for gowning and gloving, placement of central lines under ultrasound guidance, and practice ventilation and intubation. Further simulated practice occurs during the emergency medicine rotation, which includes learning the management of medical emergencies such as hyperkalemia, pneumothorax, and gastrointestinal bleed and procedural skills such as ultrasound (e.g., FAST exam), abscess drainage and placing chest tubes. Dedicated practice like this enhances patient safety.[5] The simulation center is also used to assess competency periodically during the three years of residency, and simulations are specifically designed to remediate residents when necessary. Residents are encouraged to self-direct their learning and return to the simulation center for further practice.

Assessment of Procedural Skills

Procedural skills can undergo evaluation in a few ways. Instructors can use written exams to check for understanding among learners; however, this does not capture procedural nuances such as technique and dexterity. Simulation using procedural checklists ensures that learners have both an understanding of the procedure and can perform it in the correct sequence with the appropriate technique.[12][13][14] Complications of the procedure and patient outcomes can also be used as a surrogate of competency and skill, although this is more difficult to obtain and associate with simulation training.[8][15]

Medical Decision Making and Leadership Development

Debriefing can be used to understand how learners make medical decisions by evaluating the medical knowledge, interpersonal, and communication skills that comprise them. Instructors should ask learners open-ended questions that help them self-reflect about their performance. A method of debriefing termed “debriefing with good judgment” is best suited for this, being direct but non-confrontational. In this model, the instructor determines the mental model, or frame, of the learner; this allows the instructor to understand why the learner took specific actions during the scenario. While still valuing the frame of the learner, even if it was misguided, the instructor reconciles it with their own frame for the scenario and makes a clear teaching point.[6] The majority of simulation should be spent in debriefing as it is where most learning occurs. Debriefing also promotes a culture of trust and openness in medicine.[5] And learners enjoy this part of simulation; Mathai et al. (2014) found that surveyed first-year residents rated debriefing as a program highlight of their pilot simulation program.[2]

Simulation can be useful for leadership training. There are many situations in medicine that require leadership, particularly medical emergencies such as cardiopulmonary resuscitation. Third-year internal medicine residents were divided into simulation and lecture groups to study the effect of simulation on leadership performance during several scenarios of cardiopulmonary arrest. The simulation group attended two two-hour simulation sessions, while the lecture-based group attended two two-hour lectures. Crisis resource management (CRM) skills such as calling for help, assigning tasks, and asking for input from the group were assessed six months after the intervention and again one month before the residents graduated. The group that underwent simulation training demonstrated significantly better performance in several areas of CRM, including requesting the roles of the arriving code team personnel, assigning patient care tasks, and asking the team for suggestions. Furthermore, these same residents who had participated in simulation showed better communication skills such as requesting and receiving information from the team.[16]

Interpersonal and communication skills are required to become board certified in any specialty though internists certainly need strong skills to interact well with clinical staff and patients. Simulation can be used to improve communication. For example, otolaryngology residents improved their communication skills in just three half-days of simulated sessions over the span of three years. In this study, the residents participated in simulations with standardized patients. The cases featured difficult ethical situations that the residents had to navigate and demonstrate their communication skills. A debriefing followed the scenarios with a faculty member on how to improve communication. The overall rating of communication by medical observers significantly improved each year of the study. Even residents who obtained low scores in their first year were able to achieve the average level of performance of their colleagues in subsequent years.[17]

Continuing Education

Simulation is well suited to provide continuing medical education (CME). It is more engaging and effective for learners because it is in-person and uses multiple media to teach a concept or skill (e.g., usually a didactic lecture followed by simulated practice). And since it more closely approximates clinical practice than traditional CME, clinical outcomes are more likely to be affected.[18] As mentioned in the introduction, specialty boards are starting to incorporate simulation for maintenance of certification, similar to the aviation industry. Currently, internists maintain their board certification with a traditional written board exam every ten years or with a knowledge check-in every two years, in addition to logging twenty Maintenance Of Certification (MOC) credits for each testing attempt. This approach is limited to assessing medical knowledge in a multiple-choice format, which does not necessarily lead to good patient care or outcomes.[19] Simulation provides a more comprehensive, reproducible, and realistic assessment of clinician performance, taking into account not only medical knowledge but also decision making and communication. There are limitations to the scalability of this, including access, time, and cost, but as virtual reality and Web-based technologies advance, this will likely become more feasible.[18] If used in this capacity, the simulation could ensure that internists are maintaining a required level of competency in their practice more than traditional board testing.

Clinical Significance

Simulation is not a replacement for clinical learning but rather a supplement.[5] Residency duty hour and workload restrictions, shortened hospital lengths of stay, and the demands of the electronic health record have contributed to less clinical time and opportunities for patient learning.[3][4] Patients also reasonably expect not to be the subject of practice. Simulation serves the purpose of filling in these educational gaps and preventing harm to patients. Currently, trainees practice clinical skills under the supervision of an expert. In the future, adaptive trainers will be able to provide learners with education and skills geared to their specific needs. And as previously mentioned, simulations can be designed to assess competencies set forth by the ACGME. When used in this way, simulation ensures that medical training is complete and standardized while maintaining patient safety.[3]

Pearls and Other Issues

• Simulation was borne out of the field of aviation and has expanded across all medical specialties and professional fields in healthcare. There are new and innovative ways of teaching medicine via simulation. Internal medicine training programs are using simulation in their educational curriculum.
• There are limitations to medical simulation. However, creative solutions can bridge problems with cost, resource requirements, and personnel. The simulation will take time to be universally accepted by the medical community.
• Internal medicine residency programs use the simulation for training and to assess clinical competency, specifically the ACGME milestones.
• Simulation improves procedural skills, medical decision making, leadership, and communication, which may lead to downstream benefits in patient care and outcomes.
• Simulation has further potential to transform CME and the board certification process. Simulation realistically captures the interplay of medical knowledge, decision making, and communication that affect patient outcomes.
• It is essential to realize that simulation is not a replacement for clinical learning. Simulation is geared to address educational gaps in training and prevent patient harm.

Enhancing Healthcare Team Outcomes

Simulation fulfills the sentiment expressed by Dr. William Mayo nearly a century ago: “there is no excuse today… to learn on the patient.” It improves procedural skills among trainees and may lead to fewer patient complications and better clinical outcomes.[9][12][13][14][15] For example, Barsuk et al. (2009) reported a reduction in catheter-related bloodstream infections following the implementation of a simulation training program of central line placement for internal and emergency medicine residents.[9] Moving forward, internal medicine residencies should consider a standardized way to teach procedures safely. A large meta-analysis found the best way to tie simulation to clinical practice was the use of medical procedural services.[8][20]

Healthcare is complex and requires a team approach; however, most health professional training occurs separately from one another. Interprofessional simulations are important because they foster teamwork, which is necessary for modern medicine.[5][7] Simulations improve communication and healthcare team functioning and may lead to improved healthcare quality and outcomes.[4] They are also insightful observational tools. Using simulated medical scenarios to study the interactions of internal medicine residents and nurses across domains of diagnostic reasoning, patient management, patient monitoring, and team communication, Blondon et al. (2017) identified aspects of interprofessional collaboration that led to good patient care. However, mutual lapses in the team and patient communication were apparent, which led to oversight of clinical changes and overall poor management. Even high individual ratings of medical knowledge among residents and nurses did not necessarily translate into effective team management and patient care.[19] This kind of feedback could be very useful in improving interprofessional communication and may lead to better patient care.