Volume 35 Issue 4, winter 2008, pp. 595-598

Simulation offers an attractive solution to the profound changes affecting traditional approaches to learning clinical procedural skills. Technical developments in physical models and virtual-reality computing make it possible to practice an increasing range of procedures “in vitro.” However, too narrow a focus on technical skill can overlook crucial elements of clinical care such as communication and professionalism. Patient-focused simulation (the combination of a simulated patient with an inanimate simulator or item of medical equipment) allows clinical procedures to be practiced and assessed within realistic scenarios that recreate clinical challenges by placing a real person at the center of the encounter. This paper draws on work with human clinical procedures, exploring the parallels with veterinary practice and highlighting possible developments in client-focused simulation. The paper concludes by arguing for closer collaboration and dialogue between the medical and veterinary professions, for the benefit of both.

In human clinical practice, profound changes in the landscape of care are revolutionizing the way health care professionals learn procedural skills. Traditional approaches based on an extended apprenticeship are no longer feasible. In the case of surgery, for example, patients used to stay in hospital for many days before and after routine operations. Now, operations are carried out in specialist units and patients are discharged within hours of their procedure. This dramatically reduces the potential contact time with medical students and other learners.

Radical reductions in working hours mean that students may qualify as doctors without having performed or even witnessed many of the procedures that would have been second nature a generation earlier. Moreover, major changes in public expectations and an altered ethical climate mean that it is no longer acceptable for students and inexperienced doctors to perform procedures on real patients without adequate training. There is clear evidence that recent graduates lack confidence about their ability to perform clinical procedures safely and well.1 And it seems likely that the pressures of workload and public expectations will only increase.

The veterinary profession is facing similar training issues. The number of students has risen in recent years, and providing sufficient opportunities to develop the required skills, particularly practical ones, has become increasingly challenging. Veterinary schools are placing more emphasis on providing tertiary referral services and, by implication, students’ access to first-opinion material is becoming more limited. Compared with doctors, veterinarians face the additional challenge of treating a diverse range of species, and are often required to function as both surgeon and physician. Although there is now a move toward post-graduate specialization, many veterinarians still work in mixed practice and veterinary graduates are required to demonstrate a basic level of proficiency for the common domestic species (e.g., as defined in the United Kingdom by the Royal College of Veterinary Surgeons’ Day One Skills).2 Questions are also being asked about the use of animals as an educational resource, and there are moves to look for alternatives where possible.3

This changing world demands that we radically rethink how students should learn the clinical skills that will underpin their practice throughout their careers. It is no longer justifiable to believe that students, doctors, and veterinarians will simply “absorb” the skills they need. A clear structure for learning is needed, together with new approaches and innovations to supplement existing training methods.

What can educational theory tell us about learning procedural skills? Elsewhere, Kneebone has set out four theoretical approaches.4 In summary, these are as follows.

The acquisition of technical expertise requires sustained deliberate practice, underpinned by the determination to improve. Evidence from domains both within and outside of medicine show that truly expert performance requires a minimum of 10 years of intense and focused preparation, supported by feedback from skilled teachers.5,6 Simply repeating a procedure is not enough—the learner's active engagement is essential. To use a clinical example, assisting at procedures and operations is an important part of learning, but on its own is not sufficient.

The role of the tutor is crucial, but often underrecognized. Vygotsky's concept of the zone of proximal development (ZPD) is useful here.7,8 The ZPD is where a learner can do things with expert tuition and support that they could not do on their own. To be effective, such support must be sensitive to an individual learner's stage of development and should “fade” when no longer needed. Contemporary aids to clinical learning (such as simulations and e-learning programs) can be seen as resources within the ZPD.9

The context of practice is also crucial to effective learning. Clinicians function within communities of practice and learning, where experienced and inexperienced professionals work together to provide patient care.10–12 According to this view of apprenticeship, novices learn as much from being a part of a community in which the expert is also a part as they do from direct tuition. Such communities of practice play an essential role in the construction of professional identity.

The affective component of learning is very powerful, but frequently overlooked. Its effects can be positive (e.g., inspirational teaching) or negative (e.g., deliberate humiliation). A positive emotional climate can greatly benefit learning, but this needs to be deliberately created rather than left to chance.

Based on the above theories, an ideal learning environment would allow learners to repeatedly practice on simulators, with expert support and feedback when needed. Such practice would be closely aligned with the learner's clinical environment and would take place within a supportive, learner-centered educational milieu. Yet, all too often, courses are one-off encounters that have been designed according to the needs of the institution providing them rather than the learners who attend.

So, how are clinicians to learn how to carry out procedures? Simulation offers an attractive alternative to practicing on real patients, and a wide range of physical and computer-based simulators exists.13 Simulation is also being increasingly adopted in veterinary training.14

By working on models, the argument goes, learners can gain necessary skills without jeopardizing the safety of the patient (human or animal). But what are these necessary skills, and can simulation indeed provide them? And how does simulation fit alongside the educational theories outlined above?

Much emphasis has been placed on the acquisition of technical skill. Simulation, whether via bench-top models or sophisticated virtual-reality (VR) computer programs, offers the opportunity to practice repeatedly. Used systematically, such practice can lead to expertise, especially if sustained. However, this raises important issues around the extent of practice required. Since there is a great deal of variation within any group of learners, it is impossible to be prescriptive about the number of hours required to achieve a given level of competence. A more compelling argument is for competency-based training, where learners continue to practice until they reach a desired level of skill. However, simulator use is frequently episodic, governed by practical issues of access and availability, rather than a structured curriculum that ensures a steady consolidation of skills through repeated opportunities for practice. Although much remains to be learned about how best to use simulation for learning practical skills, it seems that simply providing a simulator will not necessarily ensure effective learning, any more than providing clinical exposure will guarantee a given outcome.

A more serious criticism of simulation is that too much emphasis on technical skill offers an oversimplified picture that misses important elements of clinical practice. This is not to underplay the importance of technical skill, nor to undervalue the usefulness of initial practice, especially for novices. However, the wider context of care is missing when learners practice on bench-top models that represent isolated body parts, and procedures learned in a skills center may bear little relation to the learner's community of practice.10 In addition, becoming expert on a simulator can give a misleading sense of confidence, hiding the messy, uncertain, and unpredictable nature of clinical reality.

Experience in the workplace is a vital element of clinical training. In an increasingly busy workplace and with increasing student numbers, there is a risk that students will not be able to benefit fully from this valuable learning opportunity unless they have been adequately prepared. Clinical skills centers offer a crucial role here, but opportunities will be lost unless such centers can mirror clinical practice. An oversimplified, “sanitized” form of skills training may interfere with professional learning rather than reinforcing it.

Technical skills are just one part of a wider picture. Clinical procedures require the integration of technical expertise with communication, team working, and other skills, all requiring high levels of professionalism. A major problem with simulators (as opposed to simulation) is that they cannot recreate the subtleties of human interaction, however technologically sophisticated they may be. Yet it is the human element that constitutes the unpredictability and challenge of clinical practice. In the veterinary field, the clinician has the added complexity of dealing with both the patient and the client.

In human practice, these issues are addressed, to some extent, by the “high-fidelity” simulations developed by anesthetists for team-based crisis management. These complex scenarios, equipped with sophisticated mannequins, allow rare or safety-critical events to be practiced by teams of professionals working together. However, such simulations focus on dramatic events that require urgent intervention, and can divert attention from important but more mundane practices that ensure the safety of routine care.15 Performing a straightforward procedure in the clinic or operating theatre, for example, demands vigilance and situational awareness to ensure that small dysfunctions are noticed and corrected early, without escalating into serious problems. It seems likely that similar issues will affect veterinary training.

The challenge is to use simulation in a way that reflects actual practice, without producing either an unrealistic fragmentation into component tasks or undue emphasis on major crises. Ideally, simulation should recreate the characteristics of routine clinical practice, ensuring a balance between technical skills and human relationships that reflects the uncertainties of real life in the workplace. With that in mind, how can this functional realism be achieved?

One possibility is to combine humans with inanimate simulators. Patient-focused simulation (PFS) is the combination of a simulated patient (SP) with a physical model or VR simulator. SPs are professional actors who have been trained to play the role of a patient and give focused feedback. Such hybrid simulations offer a more authentic experience, tapping into many elements of actual clinical practice by requiring each learner to communicate with a human being while performing a procedure. In our experience, this creates a rich, yet safe, environment for learning and assessment that overcomes many of the limitations of orthodox simulation.16

A research group at Imperial College London has explored PFS at different levels of complexity and challenge, and across a range of different human procedures. These have included commonly performed procedures such as urinary catheterization and venipuncture;17 endoscopy;18 and surgical operations under local anesthesia such as carotid endarterectomy.19 The researchers have also explored the potential for creating different levels of challenge within scenarios, such as interactions with patients who are distressed, angry, disabled, or unable to speak the clinician's language.20 In one scenario, for example, a hostile and abusive patient with an infected toe requires an intramuscular injection of antibiotics. The patient's anger (convincingly portrayed by an actor) can easily result in the learner over-focusing on the technical task and losing sight of the wider clinical picture, such as failing to ask about possible allergy to antibiotics.

In veterinary medicine, as an extension of the communication skills modules that allow students to practice dealing with clients in routine consultations and difficult situations,21 there is also scope to combine the actor (simulated client) with a physical model or VR simulator. One example has used a VR simulator in a role-play exercise to let students practice diagnosing bovine fertility cases, while also having to deal with the “farmer.”22

From this work it seems clear that PFS (or a veterinary equivalent) offers a different qualitative experience—one that taps into clinical practice to create a powerful learning opportunity. This approach combines the benefits of simulation (i.e., safety, a supportive learner-centered environment, and focused feedback from expert clinicians and “patients”) with the challenges of real life (i.e., interacting with real people and linking simulation to actual practice). Crucially, video recording of procedures allows learners to see themselves as others see them.

It can be difficult enough for a novice clinician to interact effectively with just one patient in a clinical encounter. However, many real-life consultations involve several people at a time. Patients may present with relatives, while doctors have to work with others in their clinical team. In pediatrics, for example, a doctor will often have to talk to one or both of the patient's parents while carrying out a procedure such as taking blood or siting an intravenous infusion. This demands a high level of interpersonal skill. PFS has much to offer here, both in re-creating such encounters and providing clinicians with feedback about their performance.

There are obvious parallels with veterinary practice. In small animal practice, the veterinarian has to establish a relationship with the animal and its owner, often under emotional circumstances. For others, performing a procedure on a cow or horse under the scrutiny of a farmer or horse owner can be highly stressful, especially when the clinician is inexperienced or lacks confidence. The new graduate must also learn to communicate appropriately with clients, understanding and using their “language.” Additionally, because a farm is run as a business the financial implications of any recommendations must be considered while ensuring that the welfare of the animal is safeguarded.

Advances in simulation technology offer solutions to some of these problems. Physical mannequins are becoming increasingly sophisticated and are often computer enhanced, providing a wide range of cases and feedback on performance, and reacting to the trainee's actions. VR simulators can track learners’ movements as they manipulate instruments on a screen. Recent developments in haptic technology allow a learner to practice internal examinations, building up a touch picture while being “led” along a pre-recorded expert path, gaining an insight into the expert's technique and allowing for repeated unsupervised access to the training environment. However, unless such added functionality is also situated in clinical “reality,” the full potential of such technology may not be realized. PFS offers major benefits in this area.

On a cautionary note, those who create new teaching tools and methods have a responsibility to demonstrate their validity.23 New simulations, whether involving technological advancements or innovative new uses, should take place within a rigorous framework of evaluation.

It seems likely that simulation will play a growing role in medical and veterinary education. Advances in simulator technology, together with innovative approaches such as PFS, make simulation increasingly attractive as a parallel to clinical experience.

It is crucially important that simulations be designed and validated to meet the needs of our learners, and not solely driven by and responding to advances in technology. PFS, like any innovation, must be examined critically and evaluated with rigor and detachment. The affordances of technology need to be matched with the needs of learners and set within a theoretical framework that allows us to make defensible decisions about how to design educational programs and allocate resources. Again, these programs themselves must be evaluated with the same rigor as the simulations that are used within them.

Core skills—technical expertise, high levels of sensitivity and interpersonal skills, and the ability to interact with people while carrying out a demanding task—underpin both the medical and veterinary professions. As such, both professions are faced with a similar challenge: how to master those core skills in a landscape of decreasing opportunities for workplace training. This challenge must be addressed if we are to ensure the health professionals of the future are equipped with the skills they need.

Simulation is an exciting field with enormous potential. Thoughtfully designed and imaginatively applied, simulation can revolutionize medical and veterinary education. There is a need for closer collaboration and dialogue between our two professions, forging a creative synergy that can enrich both and make the best use of scarce resources. This is the time to start working together to achieve those common aims.

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