It’s All Simulation: Breaking Paradigms and Building Bridges Towards Enhancing Simulation-Based Education and Assessment

 By Petra Duncan

 “Many great ideas are often ignored or missed only to be rediscovered at a future date with better understanding and acceptance” Kathleen Rosen (2008)”

“When you are building a cabinet at home, do you hire the guy with the screwdriver or the guy with the toolbox?”  Our opening plenary speaker, Geoffrey Tobias Miller, inspired and excited the audience when he gave his dynamic speech on Sunday June 3, 2012.  “Tools for simulation include standardized patients, mannequins, task trainers and limbs – what else does your tool box contain?”  Simulation really is about patient care, not mannequin care. The goal is learning to do things well with patients using all of the tools available.  It is agreed that we are getting better at using simulation tools in combination with each other. 

In her introduction, our ASPE President, Gayle Gliva-McConvey spoke of her personal experience with Dr. Miller particularly regarding a phrase of his that has inspired her –simply said “It’s all Simulation”. Geoffrey Tobias Miller is currently the Director of Simulation Technologies & Research at the Eastern Virginia Medical School.  Prior to this he was the Associate Director of Research and Curriculum Development at the Michael S. Gordon Center for Research in Medical Education, University of Miami Miller School of Medicine.  He has spent 22 years in the nursing and patient care business.  He now works in the areas of patient simulation, simulation-based instructional development, interactive multimedia computer learning systems, emergency medical skills training, terrorism response, disaster medical response and management, homelands security and emergency preparedness.

It is easy to understand why he is frequently asked to speak at state, national and international conferences.   To continue his list of accomplishments, Geoffrey is active in the areas of applied outcomes research in education with an emphasis on the creation and improvement of methods of clinical competence assessment using advanced educational technology and simulation.  Presently, Geoffrey develops implements, disseminates and evaluates innovative curricula and assessment systems that are used by healthcare providers, medical schools and US Army medical teams throughout the United States.

At this point I feel compelled to tell you that I included Geoffrey’s middle name (Tobias) just for Gayle, since she professed such admiration of it!  Geoffrey did comment that it was the first time in a long while that he had heard his middle name used so much.

The first part of the presentation was dedicated to discussing the various components, skills and advantages of developing simulations, always coming back to our “tool box” image regarding the many types of tools there are and how to make them work for us.  We can build and arrange our tool box to create better health professionals in any field.  Interdisciplinary partnerships and education play a huge part in today’s simulation world and we need to continue building pathways to work with others in the different fields.  There are many dictionary terms out there suggesting the meaning of simulation. Dr. Miller referred to Simulation as the representation of characteristics of behaviors of one “patient/illness/procedure”, through the use of person or device.  It is simply a tool (method) to accomplish and support a learning process and create a better product. The Wikipedia explanation (June 2012) of the main purposes of medical simulation outlines 4 types:  “human” simulation, “non-human” simulation, mannequin and simulators such as CasPer the CPR Dog (the only truly “non-human” simulator, said Dr. Miller). Whilst the opportunity for deliberate and repetitive practice is most important, the feedback, learning and assessment are the essential pieces.  In other words, we provide the tools for the real education afterwards. 

 Slowly but surely, Universities are integrating Standardized Patients with other simulation methods into the overall curriculums.  Learners can practice and be assessed by using increasing levels of difficulty, e.g. beginning with a task trainer model and then moving to a more technical model with a greater range of applications.  Controlled simulation environments are safe and learner centered.  Multiple learning strategies can be employed.  Simulation can represent a range of clinical variation and fosters individualized learning in performance based education.  Students can practice as many times as they wish, using different tools or methods.  A wide array of outcomes can be clearly defined and measured.  The questions were asked of us– what is the outcome you want your students to achieve?  What are the best tools?  How can we improve on simulation validity?  Enough contexts need to be created to accomplish the desired education and assessment outcomes.  Geoffrey Miller used the term cognitive dissonance (lack of agreement/consistency or harmony) to express his thoughts around the “unspoken divide” between the SP world and other simulation.  How do we get people to work together?  How do we break the divide?  It is extremely difficult to bring everyone together and it is not uncommon to hear of more than one simulation center on a Campus, all doing different things to create the same ends. 

Now that Geoffrey had the attention of the audience and the atmosphere was one of fun, excitement and enthusiastic interest, he took us on a time travel journey through the world of simulation.  We looked at the evolution of simulation sequentially; war games, nursing schools, Resusci Anne (1960), culminating in Doctor Howard S. Barrows and the first simulation program. When you look even further, origins of medical simulation date as far back as 300 – 600 AD.  Geoffrey showed us pictures of early sculptures revealing the internal and external human head and explained that there was standardized instruction taking place in acupuncture schools in China, possibly dating back as far as 1067AD.  In 1758 Madame Du Coudray, a midwife, built a birthing machine and took it around the country to promote practice and training in better birthing.  She created a national training program.  Then in 1850, Dr. Giovanni Galli built a more technical model which included the use of fluids.  The Germans also started building birthing models and took part in this resurge of simulation.  The Ophthalmophantome (C. 1900) was what you could call a “hybrid simulator” a more advanced model where eyes had been added.  This device was used by Ophthalmology students to hone surgical skills.  In 1907 Dr. Gabriel Schlatter built a pelvis model with a “puppet” used to teach techniques and birthing procedures.

Much of the 20th century is what you could term the “dark ages” of simulation, before the huge movement in 1960.  Health professionals realized that they had to learn how to communicate and care for their patients more effectively.  So, as Geoffrey Miller points out in his presentation, there was a lot more happening before what we consider the birth of simulation.  Geoffrey went on to discuss more development through the years with Dr. Paula L. Stillman and Dr. Ron M. Harden and their research and work on the OSCE.  Lots of good work followed in the years between 1990 and 2000.  1992 was a good year for the world of simulation – it kept appearing in all kinds of articles, papers, programs and events.  The early years of the 2000’s saw the formulation of many simulation groups and organizations springing into action such as SSH and SESAM. 

The hybrid mannequin will never have the technology to perform like the standardized patient.  You need to bring both methods together to get the best device.  At this point Geoffrey introduced the work of Professor Roger L. Kneebone, from the Imperial College London, who made a significant impact in the area of hybrid simulation from about 2002 onwards. Today’s definition of the hybrid simulation is the combination of professional SPs with inanimate models to create realistic clinical encounters.

Once the floor was opened up to questions and comments, it was obvious that the discussions around the room could have gone on for hours.   Geoffrey Miller had to contend with both challenging and interesting questions from the crowd.  There was discussion as to what are the right techniques and how do we get faculty groups working together more effectively?  One ASPE member commented that the lecture got her thinking about how to deconstruct and reconstruct beliefs; what are people doing in other labs?  She wanted to speak with other simulation labs and expressed a desire for collaboration, so as not to confuse the students.  There is a need to pull it together and build bridges to make some of it happen.  Human tendency is to say “this is mine”.  One of our members questioned why there appears to be a high emphasis of standardized patient work with undergraduate students yet not so much on the postgraduate side?  It seemed to be a common thought that we need to get the “powers that be” to see and understand a need to collaborate and incorporate simulation.  People who are seeing it for the first time are “wowed” by the technology.  We need to keep reminding people over and over again about using simulation to also learn how to develop relationship; Help people to find the right way for the greater clinical better.  The real integration is happening here…

The audience was also impressed by Geoffrey’s “all in one slide” approach for the presentation.  I would be remiss if I did not mention that many were curious and wanted to know more about the Prezi system of presentation utilized as opposed to the traditional power point method.  So much so, that when the questions began at the end of the session, the first remark from an audience participant was “thank you for the Prezi”.  This led into a short discussion of using this type of presentation tool.  It’s a great way to put your main thoughts into one slide and then study and dig away at each word and phrase, bringing each piece visually to the forefront as you address the idea’s, experiments, history and current knowledge. 

Geoffrey Miller left the room to huge applause.  What does the future hold for simulation?  How do we avoid repeating the past paradigm?  When we look at all the tools, technology, and knowledge – really it is all simulation. This writer felt enthusiastic about the coming days and the positive future for simulation.