Introduction
Undergraduate and postgraduate education of physicians and other medical personnel is conducted almost exclusively in clinical settings. This has several disadvantages including: 1) patients may be exposed to added risk from the actions of inexperienced personnel; 2) uncommon diseases or critical events are not encountered by all trainees; 3) practice in difficult or new procedures in anesthesia and emergency medicine are constrained because of the inherent risks to patients; and 4) the cooperation of the patient is required. To address these and other issues, realistic patient simulators have recently been developed and put in place for a variety of applications in the U.S. and in Europe.1 The Ministry of Health and Welfare of Japan is considering if and how simulators can support education and training of physicians in anesthesia and other specialties and allied medical professionals and students. To assist in this effort, we have surveyed opinions about the present status of simulator training from those who are now using simulators for clinical education throughout the world.
Materials and Methods
A survey was developed to ascertain how realistic patient simulators are being applied in clinical education. The following issues were examined: 1) objectives for use of the simulator, 2) characteristics of the simulator and facility, 3) present status of simulator use, 4) how the simulator is used for training medical students, postgraduate medical trainees and paramedical staff, and 5) personal opinions on the use of simulators in medical education. A Japanese version was prepared and later translated into English. Minor differences in wording were required to account for differences in educational systems. The survey was sent to 29 institutions: 7 in Japan, 17 in the U.S., 2 in Canada, 2 in Europe and 1 elsewhere. Surveys were mailed in December of 1996; the last was returned in June of 1997.
Results
All 7 Japanese institutions and 10 of 22 foreign institutions returned the completed questionnaire. Six of the 7 Japanese simulators are affiliated with a Department of Anesthesiology of a university hospital; one belongs to a Department of Emergency Medicine of a university hospital. Two of the foreign institutions are in Canada, the others in the U.S. Of these 10, six are affiliated with one or more Departments of Anesthesiology of university hospitals and one with a Trauma Center of a hospital. Of the three others, two are affiliated with nurse anesthetist training programs and one with a training program for respiratory therapists and surgical technicians.
Table 1 lists subjects for simulator education. The types of trainees for whom simulator education was targeted were assessed through a question in the form of “who did you intend to be the subjects for simulator education?” There was not much difference between Japanese and North American institutions in this question, except that Japanese institutions appear to be more likely to consider medical students, nurses, and medical engineers as subjects for training.
Table 2 gives the primary reasons for introducing a simulator. Again, we could not find much difference between Japanese and North American institutions, but the latter showed a tendency to consider training for medical students less important compared to those in Japan.
Table 1. Subjects for simulator education (Priority Score: 0-2)
| Japan | North America | |
| 1. Medical students (training in physiology) | 1.40±5 | 1.0±0.8 |
| 2. Medical students (clinical training) | 0 | 1.7±0.5 |
| 3. Anesthesia residents | 2.0 | 1.9±0.4 |
| 4. Residents (other than anesthesia) | 2.0 | 1.4±0.5 |
| 5. Post-training anesthesiologists | 1.3±0.5 | 1.7±0.5 |
| 6. Physicians (other than anesthesiologists) | 1.4±0.5 | 1.3±0.8 |
| 7. Nurses (continuing education) | 1.6±0.5 | 1.0±0.8 |
| 8. Medical engineers | 1.7±0.5 | 0.7±0.8 |
Table 2. Primary reasons for introducing a simulator (Priority Score: 0-3)
| Japan | North America | |
| BST of medical students for pulmonary and circulatory physiology | 1.3+0.5 | 1.3+1.1 |
| As a replacement for BST of medical students for anesthesiology without need for patient cooperation, risk, etc. | 2.7+0.5 | 1.7+0.8 |
| Introductory and/or competency teaching of residents for anesthesiology | 2.7+0.5 | 2.7+0.5 |
| To let residents experience rare and critical diseases/incidents | 2.9+0.4 | 2.6+0.8 |
| CME of general practitioners to maintain basic skills in emergency medicine | 1.9+0.7 | 1.7+1.1 |
| Clinical training in crisis management for physician specialists in anesthesiology | 2.3+0.8 | 2.7+0.5 |
BST: Bed-side teaching CME: Continuous medical education
Characteristics of the installed simulator were also studied. Three of the Japanese institutions and 5 in North America installed CAE (now Eagle Simulation, Inc.) simulators and others installed simulators from Medical Education Technologies, Inc.(METI) Table 3 shows opinions on the differences in characteristics between Japanese and North American institutions and differences between the two simulators. Items such as ease in changing physiological parameters and abundant scenarios were satisfied by both simulators. METI users cited controllability of the simulator without a dedicated operator as an important issue in their decision. (This feature was not originally available in the CAE simulator). Financial considerations seemed to be least important for both simulators.
Table 4 gives the present status of simulator use. All of the Japanese institutions use simulators for clinical training of medical students, whereas North American institutions mainly use it for anesthesia resident training. Japanese institutions use simulators 60% of the time for clinical training of medical students, 20% each for resident training of anesthesiologists and of other specialists. In the North American institutions, simulator use differs greatly between institutions, but, roughly speaking, it is used 46% of the time for anesthesia resident training, 20% for medical students and 9% for residents other than anesthesiology. Simulators were used 1.7+0.8 times/week in Japan and 2.8+1.7 times/week in North America. The average length of a session was 2.3+/-0.5 hours in Japan and 4.1+/-2.9 hours in North America.
Table 3. Characteristics of installed simulators (Priority Score: 0-3)
| CAE | METI | |
| 1. Physiological parameters can be changed easily | 2.8+0.5 | 2.9+0.3 |
| 2. Many scenarios are built in | 2.3+0.8 | 2.4+1.0 |
| 3. Scenarios can be created easily | 2.0+1.2 | 2.2+0.8 |
| 4. Can be controlled without a dedicated operator | 1.4+1.2 | 2.4+0.7 |
| 5. The price or other financial considerations | 0.8+0.7 | 1.4+0.7 |
CAE: CAE Patient Simulator (now Eagle) METI: Human Patient Simulator
Table 4. Present status of simulator use (Priority Score: 0-3)
| Japan | North America | |
| 1. Medical students (training in physiology) | 0.6+0.5 (0) | 0.9+1.1 (1.9+3.0) |
| 2. Medical students (clinical training) | 2.0 (60.4+20.9) | 1.6+0.8 (20.4+18.9) |
| 3. Nursing/paramedical students | 0.7+0.5 (0) | 0.4+0.8 (2.8+7.3) |
| 4. Residents (other than anesthesiology) | 1.7+0.5 (16.1+14.5) | 1.6+0.8 (9.4+10.9) |
| 5. Physicians (post-training non-anesthesiologist) | 1.1+0.4 (1.4+3.8) | 0.9+1.1 (3.3+4.3) |
| 6. Anesthesia residents | 1.9+0.4 (18.3+7.7) | 1.9+0.4 (46.2+19.3) |
| 7. Post-training anesthesiologists | 1.1+0.4 (1.4+3.8) | 1.4+0.8 (6.6+7.1) |
| 8. Nurses | 1.1+0.4 (0.7+1.9) | 0.9+0.9(3.4+7.7) |
| 9. Medical engineers | 0.9+0.7 (0.7+1.9) | 0.7+1.0 (5.5+10.0) |
The use of a simulator for teaching of medical students was another topic in the study and included:
1) Curriculum for training in physiology
Two of the Japanese institutions reported that the medical student curriculum consisted of training in physiological monitoring training (mainly ECG) and clinical pharmacology. Three North American institutions reported curricula in respiratory physiology training, cardiovascular physiology training and clinical pharmacology of the autonomic nervous system .
2) Curriculum for clinical training (see Table 5 )
Because of the difference in education systems, simulator clinical training was provided for 5-6th year students in 4 institutions and one in each of 4-6th, 5th, and 6th year students in Japan. In North America, 3-4th year students were the subjects in 3 institutions and one in each of the 4th, 2-3rd, and 2nd year students.
Table 5. Curriculum and evaluation of simulator education for medical students (n=number of institutions)
1. Curriculum in Japanese institutions.
1) Adverse events during general anesthesia: Observation of clinical course and treatment (malignant hyperthermia, hypotension, massive bleeding, anaphylactic shock, pneumothorax, asthma, attack, etc.) (all)
2) Normal induction of general anesthesia: Observation of clinical course (4)
3) Monitoring: Observation and knowledge in clinical settings (3)
4) Airway management: Hands-on training and treatment of airway obstruction (4)
5) Crisis management: Resource allocation, decision making, etc.(1)
2. Curriculum in North American institutions
1) Normal induction of general anesthesia: Observation and practice (2 institutions using simulator training as informal examination at the end of anesthesia clerkship) (4)
2) Care of critically ill patients: Skills and knowledge (3)
3) Monitoring: Observation and knowledge in clinical settings (2)
4) Airway management: Hands-on training and treatment of airway obstruction (2)
5) Advanced cardiac life support training (1)
3. Specific methods of evaluating educational effect
1) Student feedback: Comparison with staff and/or faculty feedback (6)
2) Skill evaluation: On-sight or video evaluation (2)
3) Questionnaire (1)
4) No answer (5)
4. Problems experienced with simulator training
1) Lack of manpower : Instructors and scheduling (6)
2) Major hardware/software problems: Mannequin, scenarios (3)
3) Scenarios are too specialized for medical students (1)
4) Weak in neurological evaluation: Consciousness level, light reflex, etc. (1)
The contents of education in Japan are general anesthesia, monitoring and clinical training in advanced cardiac life support ( ACLS ); in North America the topics are clinical training in anesthesia and evaluation of readiness for clerkship, airway management and ACLS training.
Simulators were used for these purposes 1.2+/-0.6 times/week in Japan and 1.3+/-1.0 times/week in North America; the average length of a session was 2.3+/-0.7 hours in Japan and 2.3+/-1.0 hours in North America. The average participants for a session was 4.3+/-1.3 in Japan and 5.7+/-2.6 in North America. The number of teaching staff needed for a session was almost the same; 1.3+/-0.4 in Japan and 1.2+/-0.4 in North America. The specific ways of evaluating the educational effect and problems experienced are also shown in Table 5.
Table 6 summarizes the specific ways of evaluating the educational effect and problems experienced in the use of a simulator for postgraduate training of physicians. Training in Japan includes clinical training in general anesthesia and also for experience in and treatment of complications often encountered during anesthesia, e.g., hypotension secondary to massive hemorrhage, hypoxia, arrhythmia, and rare anesthetic complications, e.g., malignant hyperthermia, anaphylactic shock, anesthesia machine failure. Only one responding institution reported training in crisis management. Three of eight North American institutions reported training in crisis management as proposed by Gaba et al.2
Table 6. Curriculum and evaluation of simulator training for physicians (n=number of institutions)
1. Curriculum in Japanese institutions
1) General anesthesia: Knowledge and practice skills (3)
2) Adverse events: Knowledge, diagnosis and treatment (malignant hyperthermia, massive bleeding, coronary spasm, bronchospasm,
anaphylactic shock, etc.) (7)
3) Crisis management (1)
2. Curriculum in North American institutions
1) General anesthesia: Knowledge and practice skills (2)
2) Adverse events: Knowledge, diagnosis and treatment (5)
3) Crisis management (3)
4) Didactic session on new drugs (1)
5) Management of multiple trauma (1)
6) Emergency airway management (1)
3. Specific method of evaluating training effect
1) Student feedback: Comparison with staff and/or faculty feedback (5)
2) Skill evaluation: Video evaluation (3)
3) Questionnaire:Immediately and 6 months after the training (2)
4) Grading system for evaluation is being developed (1)
5) No answer (1)
4. Problems experienced with simulator training
1) Lack of manpower: Instructors and scheduling (9)
2) Major hardware/software problems: Mannequin, scenarios (2)
3) Lack of reality (2)
Simulators were used for this purpose 1.7+/-2.2 times/week in Japan and 4.9+/-7.4 times/week in North America. The average length of a session was 2.1+0.6 hours in Japan and 4.0+/-3.0 hours in North America. The average participants for a session was 2.1+/-1.0 in Japan and 4.9+/-2.7 in North America. The number of teaching staff needed for a session was 1.4+/-0.5 in Japan and 1.9+/-1.2 in North America. North American institutions used simulators more frequently and for longer hours for this purpose compared to those in Japan. Three Japanese institutions and 4 North American institutions used video taping for evaluation. All of the Japanese and 5 North American institutions considered video effective.
Use of a simulator for postgraduate training of paramedical staff and other purposes was also studied. Three North American institutions with a nurse anesthesia teaching program responded to this survey. They reported that simulators are used for education in physiology and pharmacology for nurse anesthetists and for skill reinforcement such as for airway management, invasive monitoring, respiratory care and ACLS. Two of these institutions use simulators for research, e.g., for evaluation of a new monitoring device.
Table 7 describes personal opinions by the person responsible for the simulator education. All institutions considered simulator education potentially effective.
Table 7. Personal opinions on the use of the simulator in medical education (n=number of institutions)
1. Japanese institutions
1) Medical students showed enthusiasm and willingness to participate, and learned a lot. The contents of scenarios such as brand name of drugs do not suit in the Japanese medical practice. Manpower, scenarios, location of installation are the problems.
2) Ethically effective. Manpower, time and cost are the problems.
3) Effective teaching tool for medical students. Manpower is the problem. Need of a national/international conference on exchange of information and scenario development.
4) Should be used more. Should be used for acquiring knowledge and management skills in critically ill patients.
5) Change of concept on medical education. Should be used more. Manpower, time and cost are the problems.
6) Change of concept on medical education. Cost, incomplete scenarios, hardware/software, noise are the problems.
7) Educational effect is great. Lack of instructors and need of proper space are the problems. Need of a national/ international conference on exchange of information between teaching institutions.
2. North American institutions
1) Unbelievable potential.
2) Very worthwhile when added to standard teaching methods. Require repeated exposure to improve skills.
3) Will continue to increase.
4) No answer.
5) Very useful.
6) This will be the way of the future for education of physicians in the management of acutely ill patients.
7) Outstanding
8) *Excellent tool, however it is not a substitute for clinical instruction. Simulated cardiovascular waveforms are not yet physiologically comparable to actual waveforms.
9) *The future of health education. Upgrading necessary.
10) *Essential. However, need full time employee dedicated to use.
* institutions for nurse anesthetist training program.
Discussion
Our initial objective in this study was to assist the Ministry of Health and Welfare of Japan in deciding if and how to support the use of simulation in medical education. Yet, as far as we know, this is the first survey of how these realistic simulators are being used in medical education throughout the world. It reflects the situation reported in the first half of 1997. The growth of simulation is such that the data may already be obsolete. We identified only 29 simulators at the time of this survey. There are now estimated to be approximately 70 throughout the world in over 15 countries. Yet, even these first simulators, which in future years, especially with the development of ever more sophisticated virtual reality programs, may be seen as relatively primitive, are being used with a certain level of satisfaction. However, problems such as lack of manpower for teaching and proper means of evaluating teaching effects were cited as being problematic.
There appear to be differences in the use of realistic simulators between North America and Japan. Japanese institutions tend to use them more for teaching medical students than do North American institutions while both use simulation for training of anesthesiology residents. This difference was reflected in the average time distribution and duration of simulator use per week: Japanese institutions used it 60% of the time for medical students and North American institutions used it 60% of the time for anesthesia resident training. Also, North American institutions used simulators more frequently and for longer hours compared to those in Japan. The present survey does not provide information on which to ascertain the reasons for these differences.
The response rate was only 59% (17/29), which is lower than we had hoped for. Information from the non-respondents could have altered the findings on differences relative to medical student training for instance. The survey should be repeated soon since the number of simulators worldwide has approximately doubled in the last year. Other questions should be addressed. For instance, what are the sources of funding for purchase and operation of the simulator?; What have been the specific difficulties in staffing?; What are the specific characteristics of the simulators that need improvement to be more functional for their application?; and Has there been synergism between specialties in working with the simulator?
Until now, no standardized uses of this type of simulator have been reported, although a program does exist for training instructors in anesthesia crisis management. We suggest that further efforts be made to standardize or at least publish curricula so that the centers offering simulator training can better share training materials and experience. As most institutions lack manpower, we should seek effective ways of international cooperation in supporting this costly technology.
References
1. Gaba DM: Simulators in anesthesiology. In Mosby, ed. Advances in Anesthesia. Mosby – Year Book, Inc., 1997, pp.55-94, vol. 14.
2. Howard SK, Gaba DM, Fish KJ, et al: Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63:763-770,1992.
3. Gaba DM, Fish, KJ, Howard SK: Crisis Management in Anesthesiology. Churchill Livingstone, 1994.
Note: An instructor’s course is offered by a consortium of simulation centers including the Center for Medical Simulation (Boston, MA), The VA/Stanford Simulation Center (Palo Alto, CA) and the University of Toronto based Canadian Simulation Centre for Human Performance and Crisis Management.