You are asked to evaluate an anesthesia resident’s clinical performance. Comments from the Clinical Competency Committee say he “can’t see the forest for the trees” and “lacks appropriate judgment in the operating room”. Technically, he is meeting his milestones and has little trouble with intubation, fiberoptic bronchoscopy, and line placement. He has an excellent bedside manner and usually has good rapport with surgical and nursing staff. In-training exam scores are above average amongst his peers.
Which simulation modality would be the BEST to elucidate his deficiencies?
- A) Standardized Patient Encounter
- B) Serious Gaming
- C) Part-task Trainer
- D) High Fidelity Simulation
D) High Fidelity Simulation
There are a variety of modalities available for simulation-based learning. Choosing the appropriate modality is important in order to provide the best education possible for the learner in the most efficacious way. There are many modalities which are cost-effective, simple, and direct. Others are more complex and resource intensive, however they provide many more opportunities for broad scale learning, assessment, and remediation.
Standardized Patient Encounters are live “actors” who are specifically trained to portray patients, family members, or other hospital staff such as physicians or nurses. Standardized Patient Encounters are best used to elucidate issues with communication or interpersonal skills. They can be also used for physical exam practice, but they are limited in their ability to truly simulate various pathologies or procedures. They can also be used as supplements to high-fidelity or low-fidelity simulations to increase the realism of the scenario. They are moderately resource intensive as they do require a fair amount of training and qualifications.
Serious Gaming is a fairly new and innovative simulation modality that uses games for purposes outside of entertainment to train and teach specific tasks or concepts. There are a variety of serious gaming types: adaptation, adventure, board game, management simulation, platform, puzzle, quiz, and virtual simulation. The gaming aspect helps to promote learning and to keep learners motivated and engaged. Adult learning theory principles are optimized through self-pacing and capacity for repetition, learner-control and real-time feedback, and accessibility to education when it is convenient and clinically useful. Automated scoring and action-specific feedback allow knowledge gains while decreasing demand on educators. Game development itself is fairly resource intensive and high cost; however, once the game is developed it can serve as a low-cost resource alternative for high-fidelity simulations.
Part-Task Trainers are low fidelity trainers, often models or mannequins that are used to replicate a specific physical task. They provide just the basic fundamentals for the procedure or skill being learned. Some examples include anatomic models for central line or IV placement, epidural or spinals, or airways for intubation or bag mask ventilation. They are not perfect representations of the task but for the learner they can cement the basic skills needed before they can fine tune their skills in real patient encounters. For the educator, they can help identify if any basic understanding or motor skill of the task is lacking. They are generally low cost and require little resources to provide.
High-fidelity Simulation involves creating an immersive simulation that best recreates a clinical scenario and often involves a computerized mannequin capable of responding to various drugs and interventions within a realistic physical clinical environment, complete with actors playing the role of patients and hospital staff. These scenarios place both the learner and educator in a complex learning environment that can help identify specific educational goals and provide direct feedback and reflection. Often, these simulations are also taped for playback and debriefing. These environments can help identify nuanced areas of deficiencies such as judgement, communication, and team training in high risk clinical scenarios. As such, high-fidelity simulation is the highest resource expenditure, requiring well-trained educators, technicians, space, and equipment. Scenarios are also lengthy, and time constraints may be an issue as well. However, high-fidelity simulation remains the gold standard in team training for rare and critical events.
- Levine AI, Demaria S, Schwartz AJ, Sim AJ. (2013) Part II Simulation Modalities. In The Comprehensive Textbook on Healthcare Simulation (pp.173-256). New York, NY. Springer Science and Media.
- Wang R, DeMaria S Jr, Goldberg A, Katz D. A systematic review of serious games in training health care professionals. Simul Healthc 2016;11(1):41-51
Alan Sim, MD
Assistant Program Director, Residency Training Program
Dept. of Anesthesiology, Perioperative, & Pain Medicine
Icahn School of Medicine at Mount Sinai Hospital
New York, NY
Dr. Alan Sim is the Assistant Program Director for Clinical Affairs for the Anesthesiology Residency Training Program at the Icahn School of Medicine at Mount Sinai Hospital. He completed a fellowship in Simulation Education in 2012 and has been involved in simulation education for anesthesia training for over 10 years. He is an editor on The Comprehensive Textbook on Healthcare Simulation. His research interests include serious gaming, virtual reality simulation, and enhanced recovery techniques for surgery utilizing non-narcotic anesthesia.