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Letter From The Editor
In this issue we are pleased to bring you the exciting news that Dubai Healthcare City will launch a world-class tertiary care teaching hospital. This story has been developing for several months, as faculty from HMI, health care leaders in Dubai, a team of architects from a top firm, and clinical and administrative experts from throughout the Harvard medical community have worked together to design every component of the University Hospital.
Around Harvard
Photo courtesy of Harvard Medical School
Patient Simulators Move Downstream
Realistic mannequins give medical students a framework and context for learning basic science during their preclinical years
Over the past decade mannequins that breathe, talk, blink, and respond like real patients have allowed a growing number of doctors and nurses worldwide to hone their skills risk-free. But while these simulators are now commonplace among programs that train residents and clinicians, they’ve been a bit slower to penetrate medical school curricula, where they also can greatly facilitate learning. “Simulation has become almost ubiquitous, but so far it is mostly being used in superficial ways,” observes simulation pioneer Jeffrey Cooper, PhD, HMS Professor of Anaesthesia and Executive Director for the Harvard-affiliated Center for Medical Simulation. “It is only now beginning to transform the way medical education is delivered.”
This transformation can be glimpsed in a few schools across the country. Places like the Gilbert Program in Medical Simulation at Harvard Medical School (HMS), the Michael S. Gordon Center for Research in Medical Education at the University of Miami, and the Center for Immersive and Simulation-based Learning (CISL) at Stanford University, are using patient simulators to teach students to “practice” medicine long before they have the skills to do treat a patient. To some, the approach seems radical. Yet, as course directors and students at the vanguard have discovered, simulation has myriad benefits beyond helping to develop technical prowess. This HMI World Forum takes a look at what they’ve encountered at Harvard Medical School.
No CPR dummy
Simulation can take many forms. Scenarios range from low-fidelity role-playing exercises (such as reenacting an event) and task training (endotracheal intubation), to high-fidelity, full-motion simulations in which students conduct a realistic surgical procedure.
At HMS the Gilbert Program in Medical Simulation has been helping course directors integrate simulation into various curricula and giving students “on-demand” access to simulators since 2001.
Rather than focus on tasks, the founders decided early on to use high-fidelity simulation to enhance cognitive learning—a novel approach that some outsiders initially find confusing. “For most people, mannequin simulators conjure up visions of CPR and intubation training,” explains James Gordon, MD, MPA, the program’s director and HMS Assistant Professor of Medicine in the Department of Emergency Medicine at Massachusetts General Hospital (Gordon is pictured above on the right). “The kind of work we are doing is fundamentally different from that.”
The Gilbert Program focuses on teaching undergraduate medical students core doctoring skills, including the initial patient interview and history-taking, basic physical exam, differential diagnosis and therapy, and communication about the case with patient, family members, and other staff.
The program has become increasingly popular, and since its founding has accommodated nearly 8,000 student visits across HMS, the Harvard School of Dental Medicine, and the Harvard-MIT Health Sciences and Technology program. Acceptance into the earliest phases of the curriculum, says Gordon, was catalyzed by the success of a small weeklong pilot program he delivered, along with HMS Associate Professor and Dean of Students Nancy Oriol, MD, to high school and college students during the summer of 2005.
Laying a foundation
Funded by the University Provost, the Harvard Summer PreMedical Institute, as it was called, invited 10 high school and 11 college students to spend 6-8 hours a day for over a week at the HMS Gilbert Program simulation labs, learning all about what goes into becoming a doctor. The HMS faculty treated them like medical students and interns and expected them to manage increasingly complex case material. A mannequin called Stan (short for “standard man”) was central to the curriculum. Stan had a difficult week, suffering from asthma, pneumonia, various types of heart attacks, septic shock, and trauma. The students learned to interview, diagnose, and treat him.
Some skeptics argue that this mode of teaching takes novice students beyond their experience and expertise. Gordon acknowledges that this is true, but points out that the Institute’s (and Gilbert Program’s) objective is not to increase technical proficiency or dexterity, but rather to provide a “context for integrating and recalling the advanced basic science that students learn during their preclinical education.” For example, he notes, a simulation involving tracheal intubation might be introduced to “bring to life” a lesson in pharyngeal anatomy, airway physiology, and respiratory failure, in addition to giving students a sense of what it’s like to work with a talking, emoting patient.
Throughout the summer institute, students recorded their impressions and experiences in journals. The results, says Oriol, were “stunning. The journals showed that early exposure to the simulator taught the students to think like a clinician. They learned the humanity of medicine.”
To one student the program“affirm[ed] the idea of medicine as an approach—a way to perceive things—rather than as a predetermined solution that can be memorized and regurgitated when necessary.”
Another got a whiff of what medical education is supposed to be about, writing, “Unlike every other pre-med class I had taken, I wasn’t just memorizing facts but I was applying everything I had ever known to try to help treat Stan.”
Other students discovered a new appreciation for courses that seemed purely academic. As one put it, “It is just what I needed to give me that extra drive to learn about physics. I was starting to think that physics was boring and useless. Now that I know how a defibrillator works I think physics is almost the best thing since sliced bread.”
After the journals were presented to the HMS curriculum committee responsible for creating "Introduction to the Profession," a mandatory course for all first-year medical students, Gordon and Oriol (Dr. Oriol is pictured below with students) were enlisted to help integrate simulation into the course's curriculum.
Simulation remains a key component of that introductory course, and has been integrated into all four years of the HMS curriculum. First-year students have visited Stan during courses on anatomy, physiology, pharmacology, and cardiovascular pathophysiology. Second-year students bring paper cases to life in a section of the neurobiology course called Human Nervous System and Behavior, as well as during Patient-Doctor II, Human Systems, Introduction to Clinical Medicine, and independent elective time. Third- and fourth-year students visit the lab during a handful of other courses as part of core clerkships in medicine, surgery, and integrated care, as well as during elective time in critical-care anesthesia and emergency medicine. Course directors determine the structure of the sessions, but usually they encompass three-to-five students managing a few clinical cases over an hour or two.
Build it and they will come
One challenge simulation advocates face is convincing educators to add yet another element to an already crowded curriculum. But at Harvard, course directors get to decide on their own how, when, and whether they want to use the tool. “We set ourselves up as a resource that caters to the needs of course directors and students, and we develop whatever infrastructure works for them,” explains Gordon.
Photo by Liza Green, courtesy of Harvard
Medical School Photo Services
This means that the use of simulators is always in a state of flux. But one constant and thriving endeavor has been the “on-call medical education service,” begun in 2001 to give students an opportunity to practice on the simulator during their own time. Groups of students schedule a half-hour or hour with one of the five simulators and work with a clinician-mentor on a case related to their current coursework. Over the past seven years the number of visits has been increasing at a steady clip. Today the center accommodates over 2,500 student visits per year across all four years of the medical school curriculum.
Cooper believes this student-centered approach represents one of the keys to the Gilbert Program’s success. “Students are very smart about what works for them,” he says. “They figure out how they learn. If you build an open environment and give them a tool like this and it works, they will use it.”
Contextual, flexible, emotional
The advantages of using a simulator to teach basic science are immeasurable. More than just a “cool” activity, simulation provides an enhanced environment for experiential learning and reflective thought. High-fidelity patient simulators allow for human interaction, emotional learning, and the ability to make errors without putting actual patients at risk—all powerful tools for helping students absorb and remember what they are learning. “With the simulator, you can take students beyond their expertise,” explains Oriol. “We can safely allow students to try things out, make mistakes, and correct them.”
Meanwhile, the emotional reaction to having made and corrected an error can be powerfully instructive. Brian Bergmark, a first-year medical student at HMS, attests to this. “When the simulation begins, I feel a rush of excitement, anxiety, and curiosity, and find myself operating as if there were a real patient in front of me gasping for breath and calling for help,” he says. “On some level, of course, I feel the deep comfort of knowing that I will cause no harm during that one-hour session, but the drive to diagnose and treat accurately is no less urgent.”
Gordon and Oriol surmise that simulation may allow some medical students to understand and retain complex information more efficiently than would be the case with traditional teaching methods. Second-year student Mark Gromski serves as a good example. “After giving an incorrect medication and seeing a maladaptive change in vitals or staring blankly at an EKG while the patient's condition slowly deteriorates, the urgency of the situation feels real,” he says. “This heightened gravity... prepares me for the quickly approaching pressures and environment of a real medical setting... Also, I remember things better and longer when I am actively engaged and when there is more on the line.”
Simulation may also accelerate learning, notes Gordon. In a week students can experience the number and breadth of cases on a simulator it might take years to encounter in a clinical setting.
What’s more, simulation allows for flexible learning in a dynamic environment. “We can replicate any patient at any time for any purpose for any student or faculty member,” says Gordon. “We can allow novices to practice until they acquire a certain level of expertise, and we can standardize students’ exposure to certain disease processes.” Today, such standardization is the focus of growing attention as simulation moves into assessment and credentialing.
Capturing a new generation
Click here to read reactions from HMS students on working with a simulatorAlthough undergraduate-level simulation work is in its infancy, many educators believe they are laying the foundation for the future of medical education. “I believe we are about to be presented with a generation that has been manipulating reality through simulation from the time they were old enough to reach their computer,” says Oriol. Like medical simulation, “many of today’s computer games involve analyzing situations, acting on them, and seeing the results. This is very different from the experience of students we’ve had in the past.”
Oriol adds that whereas previous pre-medical students were used to learning and working independently, many of today’s students are accustomed to being part of a Web-based community and are no strangers to groupthink. “When they come to medical school we should capture that, because it’s a very fertile field for helping people learn and explore,” she says.
Cooper agrees in the power of this technology to radically alter the way students learn and teachers teach. “We have not yet seen the ways in which simulation will fundamentally transform medical education,” he says. “We are still using it as a tool that helps people do a few things, versus using it as a transformational lever.”
--Written by Natalie Engler for Harvard Medical International
