Simulation and new learning technologies

27 Pages·2004·0.73 MB·English

(cid:9)
Medical Teacher, Vol. 23, No. 1, 2oo1
Simulation and new learning technologies
S. Barry Issenberg,' Michael S. Gordon,' David Lee Gordon,' Robert E. Safford2
&IanR.Hart3
'Center for Research in Médical Education, University of Miami School of Medicine, Florida,
USA; 2Mayo Clinic, Jacksonville, Florida, USA; 3University of Ottawa, Ontario, Canada
SUMMARY Changes inmedicalpracticethatlimitpatientavail- Chinese proverb: "To prophesy is not easy. Particularly in
ability and instructors' time have resulted in poor physical regard to thé future."
diagnosis skills by learners at all levels. Advanced simulation
technology, includingthe use of sophisticatedmultimedia computer
systems, helps to address this problem. Formanyyears 'Harvey', Currentproblemsin medical skills training:a common
scénario
thé Cardiology Patient Simulator, and théUMedic Multimédia
Computersystem have proven to be effective tools to teach and Peter Smith, a senior medical student, exited thé OSCE
assess bedside cardiovascular skills when they are integrated into station with his preceptor and felt he had made thé correct
thé required curriculum of medical school and postgraduate diagnosis and initial treatment plan regarding his 72year-old
training. In thé future, virtual reality technology, based initially patient with exertional angina pectoris: unstable angina
on data front thé Visible Human Data set, will provide thé secondary to coronary artery disease to be confirmed by an
majority of simulation-based training. Models that provide a exercise stress test. To his surprise and disappointment, he
high level of visualfidelity and use sophisticated haptic devices was notified that his patient's exertional angina was thé
that simulate thé`touch'andfeel'ofa procédure or examination result of critical aortic stenosis, a diagnosis he missed by not
are now being used in selected medicalcenters. The présence of appreciating thé long systolic murmur at thé patient's upper
these tools is not enough. Evidence-based outcomes must show right sternal edge. Worse, thé patient would be at risk for
these systems to be effective instruments for teaching and assess- sudden cardiac death if he were to undergo exercise stress
ment, and medical educators must be willing to effect change in testing. Despite his disappointment, Peter was relieved to
medical educatignto ensure thé appropriateuse of these systems learn that he would still pass and graduate from medical
in thé next millennium. school.
Over thé next few days, Peter reflected on thé OSCE
encourlter and wondered how he, a graduating medical
Introduction
student, had missed an important bedside finding. He was
In thé past century, there bas been an exponential growth in upset with himself for not eliciting thé finding, but then
our knowledge of thé human body, its structures, its func- reflected on thé adequacy of his medical-school training in
dons, what can go wrong with it and why. The major auscultatory skills.
advances in diagnostic tests and imaging have been truly
remarkable and, along with our ability to prevent or cure Skills training during preclinical years
illness and prolong active life, have had a major impact on
thé quality of thé human condition. Over thé past few After each of his first two years of medical school, Mr Smith
décades, medical educators have been quick to embrace underwent an assessment of his ability to perform a complete
physical examination. However, during each of these
new technologies and pedagogical approaches such as infor-
matics, problem-based learning and just-in-tinte learning in sessions, he really went `thoough thé motions' of thé exam
an effort to help students deal with thé problem of thé and was not tested on his ability to elicit a specific finding.
growing information overload. He learned about thé physical findings of aortic valve stenosis
from a textbook rather chan from personal expérience.
Medical knowledge, however, bas advanced more rapidly
than medical éducation. Even as we unravel thé génome During his first 2 years of medical school, his mentors
seemed unconcerned about his inability to perform a
and begin thé era of proteomics, we use outdated and often
ineffective methods to teach skills and mold attitudes. detailed, organ-specific physical examination since he and
Fortunately, positive changes are on thé horizon for medical his classmates were never graded on their clinical skills
(Kassebaum & Eaglen, 1999).
educators. Rapid advances in technology will lead to a révolu-
tion in thé teaching of both basic clinical skills and thé
manual skills necessary to perform invasive procédures and Skipstrainingduring clinical years
surgical interventions. Simulation technologies are available
During his thirdyear clinical clerkships, Mr Smith spent
today chat have a positive impact on thé acquisition and
more time in conférence rooms, discussing patient care or
retention of clinical skills. Virtual reality in particular is
playing an increasing role in thé skills training of healthcare
Correspondence: S. Barry Issenberg, M.D., Assistant Professor of Clinical
professionals. It is likely that medical éducation in 2020 will
Medicine Director, Educational Research&Technology, Center for Research
differ greatly front medical éducation in 2000, though one in Medical Education, Univenity of Miami School of Medicine. Tel: (305)
must keep in mind thé old, and probably apocryphal, 243-6491;fax:[phone];emaiL barryi(âgniamLedu
16 ISSN 0142-159X (print)/ISSN 1466-187X(online)/01/010016-08©2001Taylor & Francis Ltd
DOL 10.1080/01421590020007324
Simulation and new learning technologies
related journal articles with the ward team, than he did at developed a multimedia computer-based, self-assessment
patients' bedsides honing his skills (Shankel & Mazzaferri, program focusing on "physical examination and physical
1986). When the ward team did visit a patient with an diagnosis skills" (Norcini, 1993).
important physical finding, there was limited time to practice
his exam skills (Collins et al.,1978).This resulted from: Physical body simulators
• occasional reluctance or embarrassment of patients to Simulators now available and routinely used in medical
expose themselves to the large number of individuals on education vary in their complexity and ability to represent
the ward team; real-patient situations. Some models permit examination
• impatience of team residents eager to conclude rounds and manipulation by the student, but do not respond or
quickly in order to attend afternoon clinic; provide feedback.Othersare more sophisticated and interact
• impatience of attendings eager to conclude rounds quickly with die students.The simplest simulators resemble a person
in order to attend a privatepatient clinic or meeting, in size and weight only, much like a mannequin in a depart-
perform a procedure or experiment, etc.; ment store.Tbese types of simulators are used extensively
• difficulty locating patients undergoing diagnostic tests; in trauma cases to replicate automobile accident victims.
• rapid patient discharges due to efficient managed-care Learners use these simulators to practice cervical-coller
caseworkers. placement, removal of patients from automobiles, and other
Peter was aware of the availability of CD-ROMs and tapes ways to stabilize accident victims.These simulators typically
of heart murmurs in the library. However, these were have permanent and non-modifiable `injuries' such as head
optional resources with content that was never required or lacerations and contusions, a dilated pupil, or compound
tested. He knew of students at other schools that had these leg fractures. Any sense of realism is due to the scenario
rather than the simulator itself. The simulator does not
types of resources as part of their core curriculum and
wondered whether they were better skilled than he. Peter respond to any action and its sole requirement is to represent
a 'body', i.e. to be the approximate size and weight of a
realized that in a few months he would be seeing patients on
his own who may also have important auscultatory findings. typical person.
He further worried, if his auscultatory skills suffered, what
Anatomic-pathologic simulators
about his ability to perform a competent neurologic or
ophthalmologic examination? Why did those in charge of Another type of simulator is the simple anatomical model
his medical education not make sure he possessed the skills used to train students how to perform a single component
necessary to be a physician before allowing him to graduate? of the physical examination. Exemples include models for
Unfortunately for Peter, deficiencies in die performance of breast examination, eye examination, car examination, female
clinical skills are not limited to medical students; they are pelvic examination and male rectal examination. The
also prescrit among residents in internal medicine (Mangione advantage of such simulators is chat they enable teaching on
& Nieman, 1997; St Clair et al.,1992), emergency medicine a practical level without any imposition on real patients,
(Jones et al.,1997), and pediatrics (Gaskin et al.,2000). especially with sensitive topics such as pelvic examination.
When using simulators of lower fidelity it is important to
appreciate their limitations and use them in situations that
Simulation technology in the core curriculum: a
potentiel solution maximize their strengths (Macintosh and Chard, 1997).
The above fictitious case highlights many of the problems Procedural skills simulators
occurring in academic medical centers today as a result of
Other simulators are used to learn, practice and assess
reduced physician teaching time and reduced availability
procedural and practicalskills.Thesesimulators are currently
of patients as educational resources. The increased use of
used to train learners in the following techniques:
simulation technology to supplement skills training with
repetitious, standardized training would appear to be a logical • intravenous access via cannula insertion and surgical cut
solution to the problem. Despite thewidespread availability down;
of simulation technology, however, its use has not yet become catheterization of the male and female bladder;
part of the cote curriculum at most medical schools. This airway management, including intubation (some of these
may soon change, regardless of the opinions of individual devices, including the Cricothyrotomy Simulator
faculty and medical educators. Several key organizations [Armstrong Medical Industries, Inc., Uncolnshire, IL]
have recognized the role of simulation technology in medical allow the learner to practice catheter oxygenation/jet
education and have recently implemented guidelines or ventilation via the cricothyroid membrane in cases of
programs to foster its development. The members of the laryngeal, pharyngeal, lingual tonsilar and epiglottic
Medical School Objectives Project, sponsored by the pathology; this is important because die clinicalopportuni-
Association of American Medical Colleges, stated in their ties for employing this kind of technique are otherwise
Medical Informatics Objectives chat "the successful medical rare);
school graduate should be able to . . . effectively utilize • soft tissue injection and aspiration of knee, shoulder,elbow
various computer-based instructional (and self-assessment) and wrist joints;
• ureteroscopy for practice of kidney stone removal.
tools, including electronic tutorials and patient simula-
tions" (Medical School Objectives Writing Group, 1998).
Surgical simulators
TheAmerican Board ofIntemalMedicine shares this view
as reflected initsdecision to form the Physical Examination Surgical training is one area that seems ideally suited for the
Self-Evaluation Process Committee. This committee bas use of simulators. Proficiency in surgery requires knowledge
17
S. Barry Issenberget al.
of underlying anatomy, dexterity and frequent practice. hasresulted in thé recent suggestion by dieAmerican College
Despite this apparent fit, there have not been many valid of Cardiology Task Force on Education (Gregoratos and
studies examining thé use of simulators for surgical training. Miller, 1999) Chat 'Harvey' should be integrated into thé
Simulators are currently available to train learners in thé day-to-day teaching of clinical cardiology.
following surgical techniques:
• simple wound closure, evaluating suture tension and
accuracy of placement; Computer-aided instruction: CD-ROM-based
software
• bowel anastomosis (closure), using sutures and staples;
• laparotomy; Computer-aided instruction (CAI) appears to be an ideal
• episiotomy and theed-degree tear of thé perineum (with method for teaching a cote of material repetitively. CAI
ability to practice suture repair at multiple levels); programs allow for an interactive educational process,
• toe surgery, including including ring block with local requiring active involvement by thé student or house off cet
anesthesia and wedge resection of thé nail bed and total in thé learning process. In addition, thé students are able to
ablation of thé nail; run thé programs individually, at cimes convenient to them
• dermatologic surgery, including cutting, suturing, and without thé need for direct faculty supervision. Currendy,
removal of sebaceous cysts, lipomas,perianalhematomas, there are hundreds of CAI CD-ROM programs available
and skin tags. for learners at all levels in many areas of interest. These
include programs that teach radiology and ECG interpréta-
tion, advanced cardiac life support, procedure skills and
Harvey, thé cardiology patient simulator
physical diagnosis techniques.
Harvey is a teaching device that provides a comprehensive
cardiology curriculum by realistically simulatiog 27 common
and rare cardiac conditions. The physical findings UMedic, Multimedia Computer System (MCS)
programmed in Harvey for each disease include blood pres- The UMedic MCS has been developed over thé last 15
sure, bilateral jugular venous pulses, bilateral carotid and years with multimedia features chat include computer and
peripheralarterialpulses, precordial impulses in six différent video graphics and réal-cime digitized video and audio.
areas and ausçultatoryy events. The latter are heard in thé Fifteen patient-centered case based programs comprise a
four classic auscultatory areas, are synchronized with thé comprehensive generalist curriculum in cardiology. Its
pulses and vary with respiration when appropriate. structure and content have been described elsewhere (Waugh
Harveyhasbeen subjected to rigorous testing to establish et al., 1995; Issenberg, McGaghie et al.,1999).
its educational efiicacy.Themost comprehensive evaluation A recent multicenter study demonstrated chat UMedic
of any simulation technology was thé multicenter study of could be integrated into thé entire four-year medical school
Harvey sponsored by thé National Heart, Lung, and Blood curriculum (Petrusa et al., 1999). A total of 1586 students
Institute. (Ewy et al.,1987). It involved 208 senior medical at six medical schools completed 6131 programs and rated
students at five medical schools. Fourth-year medical thé educational value of thé system favorably compared
students who used thé Cardiology Patient Simulator (CPS) with otherlearningmaterials.The study resulted in a recom-
during their cardiology elective performed significandybetter mended four-year curriculum plan for thé UMedic system.
than thé non-CPS-trained group, who learned in thé Valid pré- and post-tests were then created to measure
traditional manner from real patients. This was true not outcomes in bedside skills (Issenberget al.,1998) and were
only on thé CPS skills post-test (p < 0.001), but also on thé used in an additional multicenter cohort study involving
live patient skills post-test (p < 0.03). In addition, there was senior medical students at five institutions that compared
no statistically significant différence in thé way patients thé UMedic system with traditional methods for teaching
perceived thé professional behavior of CPS-trained and bedside skills in cardiology (Issenberg, Petrusa et al.,1999).
non-CPS-trained students. The latter data address thé In thé intervention group, UMedic modules replaced instruc-
concern chat simulators may negatively impact physician tion in bedside skills that occurred during teaching rounds
behavior. In another study involving more than 200 second- and individual patient work-ups. There was a statistically
year medical students at thé University of Michigan, significant improvement in thé pré- to post-test scores of
incorporation of Harvey into a required physical skills course thé UMedic trained students compared with non-UMedic
significantly improved overall cardiac examination skills as students (p < 0.001). Similar results occurred in a similar
measured by pré- and post-tests of unknown findings on recent study involving second- and theed-year internal
thé simulator (p < 0.001) (Wooliscroft et al.,1987). medicine residents (Issenberg et al.,2000).
In addition to its use as an educational cool, Harvey has The most successful application of UMedic has been in
been used as a systematic and objective tool for testing its combined use with Harvey. In this way, thé learner has
bedside cardiovascular examination skills (Ewy et al., 1987; thé benefit of a large `patient pool' on which to practice
Jones et al., 1997; Wooliscroft et al., 1987; Gaskin et al., bedside skills along with a multimedia teaching program
2000). Testing with simulators such as Harvey is actually that provides `live' faculty presentations and feedback in an
more effective than testing with actual patients. With a interactive format. While this type of learning now Cakes
simulator, there is complete control over thé specific task place in defined areas such as clinical skills or learning
selected, e.g. a bedside cardiac exam, as well as thé resource centers, future systems will use more advanced
complexity of thé task. Exact validation of `patient' findings technology to enable universal access at any time and place
leads to a standardized and more-objective skills-testing to chose who wish to learn or need to be tested. Undoubt-
process.Theproven value of`Harvey' as an educational tool edly,there systems will incorporate thé use of virtual reality.
18
Simulation and new learning technologies
Virtualreality
physiology or performing a therapeutic procedure. In the
Virtual reality (VR) is a concept that is intumately familiar beginning, most learners are able to focus only on one or two
and intuitively obvious to children as a consequence of of these components at a time, contributing to both risk and
video-game technology but which is far less familiar to adults stress.
who teach and practice medicine. Its roots are in the branch Virtual reality simulation systems allow learners to
of computer science dedicated to artificial intelligence. At practice the procedure a portion at a time, without risk to a
its simplest, virtual reality bas been defined as, "an artificial patient. These systems, if validated, could potentially also
environment which is experienced through sensory stimuli be used to assess the learners skills for certification of
provided by a computer and in which one's actions partially competence (boards, hospital credentialing, etc.) and for
determine what happens in the environmenC (Merriam maintenance of skills or acquisition of new techniques once
Webster Collegiate Dictionary, 1996). in practice.
Invasive procedures: 'See one, do one, teach one' Computer-based anatomic models
Teaching learners how to perform invasive medical For the last decade, computer based volume renderings of
procedures and assessing their performance is a challenging the whole body and specific organs have been generated.
task.Traditionally, learners have observed more experienced Initial efforts used the Visible Human Project (VHP) data
physicians performing a procedure. After a brief apprentice- set, a databank of high-resolution digital anatomy of both
ship, supplemented by reading textbooks and occasional men and women, available from the National Ubrary of
practice on cadavers, the learner is then allowed to begin Medicine (Visible Human Project, 1999).First implemented
doing portions of the procedure on patients under the in 1994, the VHP bas given researchers access to data in
tutelage of the mentor. This process is inefficient and multiple modalities, including X-ray-based computed
inevitably leads to considerable anxiety on the part of die tomography (CT) and magnetic resonance imaging (MRI).
learner, die mentor and at times even the patient. These anatomic models are remarkably lifelike, and
Thoracentesis, for example, is a common and relatively demonstrate realistic surface textures.
straightforward procedure in which a needle is passed
through the chest cavity to allow drainage of pleural fluid
Virtual endoscopy
surrounding the long for diagnostic and/or therapeutic
purposes. Typically, a second-year medicine resident will Simply viewing the surface of an anatomic model, although
demonstrate the procedure for a first-year resident with the visually pleasing in an artistic sense, accomplishes little.
implied promise that the next time a patient on their service Physicians wish to look inside the body, a concept first
requires the procedure, the first-year resident will perform dramatized in the 1966 movie Fantastic Voyage (Fantastic
itwith the second-year resident 'talking him or her through Voyage, 1966). In that movie a physician suspected foul play
it'. Inevitably, after performing the procedure once or twice when a diplomat became ill. He introduced a miniaturized
himself, the inexperienced teach the even more submarine into die diplomat'sbody to make a diagnosis. In
inexperienced, leading to the medical adage, 'sec one, do the 21st centuryvirtualendoscopy systems allow the learner
one, teach one'. to see examples of normal patients and those with disease
Invasive procedures are difficult to learn because they so that the student is able to anticipate how tissues will
require an understanding of complex these-dimensional appear at the actual physical endoscopy. If the patient model
anatomy and tactile skills for the manipulation of a probe is constructed using graphical data from an actual patient's
(needle, scope, catheter, surgical instrument, bioptome, etc.), imaging data (CT/MRI, etc.), die virtual endoscopy bas the
commonly referred to as acquiring the 'feel' for the perform- potential to replace the invasive procedure for diagnosis.
ance of the procedure (Robb, 2000). 'Mis inherent And if die procedure to be performed is therapeutic, one
complexity inevitably leads to a high complication rate and couldrehearse the therapeutic procedure on a VR Smulator
steep learning curve. prior to performing the identical procedure on the patient.
As students complete their formal training and enter This would be of particular value when unusual or
practice, medical centers will require that they be 'creden- particularly challenging cases are encountered.
tialed' to perform a variety of procedures. Usually this In many instances only the spatial or surface
requires documentation that the physician has performed a characteristics of pathology are required (e.g. ulcer, coronary
minimum number of procedures, die lirait having been set obstruction, etc.), but virtual techniques currently cannot
in some cases by national professional bodies and in others replace physical biopsy when pathological examination of
by the local medical center credentials committee, and a tissue is required (Blezek & Robb, 1997).Thismay change
written statement from the training director of the institu- in the near future. Characterization of tissues by MRI,
tion from which die practitioner bascome certifying his/her ultrasound and other techniques is progressing rapidly
competence to perform the procedure. For the most part (Satava & Robb, 1997). Benign tissues may be differenti-
such statements are qualitative; only in rare instances are atedfrom malignant ones in the future based on their surface
they based on objective measures of assessment. characteristics as assessed by MRI.
When learning to perform an invasive procedure, the learner
must simultaneously correlate the clinical assessment of an
Touch, feel and haptics
ill-and possibly sedated-patient, manipulation of a probe
or surgical instrument, and the these-dimensional interpreta- Haptics, the study of touch, allows the incorporation of
tion of a two-dimensional imaging study, all the while assessing tactile stimuli into VR systems allowing the learner to obtain
19
S. Barry Issenberget al.
the`feel' of an invasive procedure (Blezek & Robb, 1999). It
the scope tube, while electrical actuators provide translational
is generally agreed that this is the most difficult part of and/or rotational force feedback based on the state of the
teaching an invasive procedure and that improvements in endoscopy simulation.
this area of instruction have the potential to steepen the
Initial results of studies to assess the effectiveness of this
learning curve and improve patient safety. Haptic-force system in simulating bronchoscopy have shown that the
feedback devices, the simplest of which is the joystick, are device can differentiate experts (defined as individuals who
commercially available (Massie, 1996). performed over 500 bronchoscopies) from those with
To illustrate die use of such devices, consider die difficulty
intermediate experience (defined as individuals who
of teaching a learner toperformdeep nerve block techniques. performed more than 25bronchoscopies but fewer than 25)
The deliveryof local anesthetics to the spinal nerves or die or beginners (defined as individuals with no experience in
deep plexuses, such as die celiac, for relief of pain is the performing a bronchoscopy) (Mehta et al., 2000). Experts
epitome of the learner having to get die `feel'.The teacher performed the procedure in a significandy shorter period of
demonstrates and explains that as the needle passes through time and with fewer mistakes (e.g. `collisions' of scope against
skin onefeels a `pop' as the resistance of the skin is overcome. mucosa wall) than the intermediate and beginner groups.
Passage of the needle through the paraspinal muscles In an era where the numbers of skilled teachers are
engenders less resistance. One bas to be careful not to strike declining and pressures to increase patient volumes are
either die kidney which would feel `firm' or the vertebrae increasing, fewer mentors are available. VR simulation
which would be `hard'. As the needle approaches the systems have die potential to greatly improve the training of
descending thoracic aorta the `pulsations' can be felt on learners at all levels in various fields of medicine. The saure
the tip of the needle which is tien directed away toward die technology that simulates a bronchoscopy can bc used to
celiac plexus. simulate an ophthalmologic, neurologic or cardiovascular
If one mounts a force transducer on a needle and passes physical examination. The potentiaI advantage of these
it through the unembalmed tissues of a cadaver on the saure systems compared with die current method for testing and
path discussed above, one can direcdy measure the force certification, including written and oral examinations, is
required to overcome the resistance of each structure. that they allow die examinee to demonstrate clinical skillsin
Delivering those sequential forces to the learner using die a controlled clinical environment while still exhibiting cogni-
force-feedback device, a virtual needle, allowsdie learner to tive and language skills (Gaba et al., 1998).
experience how passage of the needle into a patient feels
(Martin et al., 1999). Others have calculated die relative
Discussion
densifies of tissues using the Houndsfield units from CT
scans andtienhave assigned relative forces to various tissues Despite the availability of devices with advanced simulation
to achieve the saure end (Satava & Jones, 1999). technology designed specifically for the instruction and
assessment of medical students and physicians, too many
medical schools fail to employ such devices to teach and
Current state-of-the-artvirtual simulators evaluate learners' skills (Kassebaum & Eaglen, 1999). The
presence of these tools is not enough. Evidence-based
Initial VR simulation systems were crude, but improved
outcomes must guide medical educators who are willing to
rapidly as the speed and capacity of computers increased.
effectchange.
Thesenewer systems,while much more realistic in simulating
In an article in the End-of-the-Millennium Special Issue
die experience, were prohibitive at most medical centers
ofScientific American, entitled 'The Unexpected Science to
because of their high cost. Recently, a more affordable VR
simulator was developed to provide multiple uses in a single Come', Sir John Maddox wrote, "The most important
discoveries of the next 50 years are likely to be ones of
unit. 'Me Pre0p Endoscopic Simulator (HT Medical
which we cannot now even conceive" (Maddox, 1999).
Systems, Gaithersberg, MD) is a realistic training simula-
Foreseeing what new technologies will be in use in the year
tion system that integrates force feedback, multimedia, and
2020, far less predicting their impact on the day-to-day
3D graphics on a personal computer (Tasto et al., 2000).
practice of medicine and its teaching, is an exercise fraught
The Pre0p simulator comprises a computer, a display
with danger.Thecompilation of essays by the Pulitzer Prize-
monitor and an AccuTouch Endoscopic Interface Device
winning Richard Rhodes, entided `Visions of Technology',
that consists of a proxy endoscope that looks like a real
is replete with examples of predictions that, in retrospect,
endoscope and is electrically connected to the second part
missed the mark significandy. Some predictions, however,
of the interface device, a robotic mannequin into which die
are remarkably prescient. One essay points out that, over
endoscope can be inserted. Various sensors track the state
the past 100 years, die technological status of die world as
of the system and send this information back to die host
a whole advanced at a roughly exponential rate, doubling
computer.Thesimulation uses this information to compute
every 20years (Rhodes, 1999).
appropriate visual and tactile responses to the motions
Four general predictions may be offeredon the impact of
imparted by the user. These responses are transmitted to
simulation and virtual reality technology on the practice of
the user through visual, audio and haptic modalities, creating
medicine and medical education in 2020:
die illusion for the user that he/she is insertiog the endo-
scope into a real patient. The robotic mannequin has been (1) Anything to do with the human body in sickness and in
designed to accept proxy bronchoscopes, sigmoidoscopes, health that is `digitizable'-and thus `storable',
colonoscopes, gastroscopes and ureteroscopes through the `manipulable', `clonable' and `transmissible'-will be,
appropriate anatomic models.Tracking of scope motions is and the computers involved will become faster, smaller
achieved with sensors that monitor insertion and rotation of and cheaper.
20
Simulation and new learning technologies
(2) The présence of such stored `medical avatars', whether thé future of medical education, one thing is sure-medical
originally created for diagnostic purposes or teaching educators are not `early adopters'. It took 30 years for
purposes, will allow for virtual-reality learning expéri problem-based learning (PBL) to truly become mainstream
ences customized for thé individual trainee for a specific in thé field. The need to inculcate a culture of lifelong
case. learning is more talked about than practiced, and some
(3) Simulation technology is unlikely to have a major impact medical educators still think that OSCE is an organization
on thé training of history taking, and, unless we take of oil-producing nations. So we will take thé easy way out in
appropriate steps to prevent it, any effect on thé promo compiling our prédictions regarding thé impact of technology
tion of appropriate attitudes is more likely to be néga- on thé future face of medical education. Although we use
tive than positive. thé word `will' in making thé following predictions, we are,
(4) The major impact of such technologies will be on skills in truth,realIy suggesting whatshouldhappen.
training through their ability to provide on-demand
access to `deliberate practice'. The undergraduate curriculum will be unrecognizable
in thé traditionaI sense since thé stages will be marked
Skillsmaybe defined as "actions (and reactions) which an less by organ/system or discipline-based blocks or rota-
individual performs in a competent way in order to achieve tions, and more by thé attainment of measurable
a goal" (Ericsson, 1996). One may have no skill, some skill outcomes, thé rate of which will vary from student to
or complete skill.Therefore,whenteaching or testing a skill, student. The merging of educational strategies such as
thé level of acceptable mastery musc be defined depending PBL and self-directed learning with thé just-indîne
on thé training level. Ericsson has demonstrated that, in availability of information through IT and thé use of
competitive performance domains such as athletics, music cumulative learning portfolios of practical and clinical
and chess, thé différences between individuals, from novice experiences as a major assessment cool will allow, within
to champion, "are among thé largest reproducible différ- limits, students to progress through thé curriculum at
ences in performance observed for normal adults". He also their own pace.
suggests that similar large différences would beexpected in (2) Increasingly, in thé early years, thé acquisition of
other domains of expertise (including medicine), in which knowledge and understanding will be through self-
there is a long period of education followed by an apprentice- directed (but outcomes driven) learning. Information
ship. to facilitate that learning will be delivered over thé
The most important identifiable factor separating thé Internet, using fast broadband `pipes' to transmit text,
elite performer of skills from others is thé amount of `deliber- audio, video, chat groups and, where appropriate for
ate practice'.This includes practice undertaken overa long understanding, simulations and virtual reality. All of
period of time in order to attain excellence, as well as thé this willbeenhancedby live group discussion and tutor
amount of ongoing effort required to maintain it. Deliberate input.
practice has been defined as thé opportunity to tackle "a (3) Realizing that, despite regional, national and
well-defined task with an appropriate difficultylevel for thé international différences in core curriculum content,
particular individual, informative feedback, and opportuni- there are overlapping commonalities, a growing amount
ties for repetition and corrections of errors" (Ericsson et al., of thé learning material required for core learning will
1993). be shared between medical schools and delivered over
In thé early part of thé last century, Sir William Osler thé Internet. In some cases, these would be single
wrote, "Thé art of medicine is to be learned only by expéri- learning items such as texts and interactive simulations.
ence, `tis not an inheritance; it cannot be revealed. Learn to In other cases, whole modules or even blocks will be
sec, learn to hear, learn to feel, learn to smell, and know that used communally.
by practice alone can you become expert" (Osier, 1919). (4) In thé later years, cumulative electronic learning
However, it is well known Chat, during both undergraduate portfolios will map each individual students progress
and postgraduate medical training, there is an inherent in meeting thé learning outcomes.Theywill ensure that
capriciousness in regard to opportunities to gain deliberate all students are exposed to patients illustrating thé key
practice in learning new skills or honing old ones. Even common problems faced by primary-care physicians
when opportunities to practice specific skills do occur, there and that thé students have seen thé `prototype' cases
is often no `informative feedback or opportunities for repeti- around which clinical problem solving is based.
tion or correction'. Thé problem in medical éducation is Appropriate use of these learning portfolios will also
that thé subjects necessary to `deliberately practice upon' ensure that thé underlying anatomical and pathophysi-
are human beings, with all their diversity and variability. ological concepts are reinforced as clinical cases are
Simulations and virtual reality hold out thé promise of encountered.Thiswill require more basic science input
unlirnited access to deliberate practice as part of skills into thé later years of thé curriculum.
training. As thé skills required for thé practice of invasive (5) Simulators and simulations will become more software
medicine become more numerous and more complex, such than hardware, i.e. more virtual reality than real.
access to practice and rehearsal will become more essential. (6) The réal power of VR simulations is their potential
widespread accessibility. Simulations, with all their inter-
activity, will be widely available over thé Internet. For
Technology and medical education: what does thé
many, thé limiting factor will be thé availability of thé
future hold?
hardware `front end'-thé controls that allow thé
The year 2020 seems such a long time away, yet 1980 seems operator to interact appropriately with thé simulation.
just a short timeago!Whenlearning from thé past to predict For some simulations a standardized front end will be
21
S. Barry Issenberget al.
thé norm, as gaming joysticks and ports have become. Notes on contributors
For thé more complex procedures special hardware will
be necessary. Such hardware will be relatively S. BARRY ISSENBERG, MD is Assistant Professor of Clinical Medicine
inexpensive and can and should be scattered around aCnedn tiesr tfhoér DRierseecatrocrh o ifn E Mdeudciactaiol nEadlu Rcaetsieoanrc(hC aRnMd ET)ecahinthoélo Ugynivaeirstihtyé
clinical facilities and accessible round thé clock so that of Miami (Florida) School of Medicine.
on-demand skills training, rehearsal or updating is avail- MICHAELS. GORDON, MD PhD is Associate Dean for Research in
able. In some cases, thé hardware may be inexpensive MedicalEducation,Professor of Clinical Medicine (Cardiology) and
enough to be purchased by individuals, allowing them Director of thé CRME ai thé University of Miami (Florida) School
to deliberately practice or rehearse anywhere they avant of Medicine.
even at home with thé kids. Regular upgrading of thé DAVID LIEGoRDoN,MD is Associate Professor ofClinicalNeurology
skills appropriate to their practice using simulatorswill and Director of Emergency Medical Skills Training at thé CRME.
be a normal part of continuing professional develop- IAN R HART, MB ChB MSc, is Professor Emeritus aithé University
ment (i.e. continuing medical education, or CME)- of Ottawa, Canada. He is an international consultant in thé field of
even for those practicing in thé community. medical education.
And finally, do not forget gaming and thé gamers, who, ROBERT E. SAFFORD, MD PhD is thé Barbara Woodward Lips
more than any other group, brought simulations into Professor of Medicine and Chair, Department of Internal Medicine,
aithéMayo Clinic, Jacksonville (Florida).
thé mainstream. If there is any challenge to their manual
and décision-making skills out there, they will avant to
try it and compete with others. And there will be
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