Temple Times Online Edition
    SEPTEMBER 23, 2004
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Getting ready for the real thing

Medical and health science programs are increasingly using simulation to prepare students for patient encounters

Third-year medical student Melissa Ritterman examines standardized patient Lisa Norton in preparation for the clinical skills assessment now required by the federal government.

Throughout the Health Sciences Center, simulation is an increasingly hot new teaching tool. Practically, it allows professors to actually plan and schedule lifelike medical events. And students are able to “practice” without fear of real-life complications or consequences.

Simulation can take the form of a computerized mannequin, an actor trained to portray a patient, or something much like a flight simulator that is used to learn complex surgical skills.

Primarily spurred by increasing concern about medical error and liability, the trend means students can enter the working world better prepared. Traditionally, medical and health science students have “learned by doing,” or interacting with real patients in the hospital. Simulation gives them the opportunity to hone basic communications and doctoring or nursing skills before working with real people.

History of simulation in medicine
Mannequins have been a part of clinical training for most allied health and medical education institutions, including Temple, for many years. Early versions were called “partial task trainers” — models of arms or feet, or three-dimensional models of various musculoskeletal and organ systems in a human body.

Later models, including “Mrs. Chase,” “Harvey” and “Air-Man,” progressively more sophisticated, were capable of simulating normal and abnormal heart sounds, breathing and other vital signs.

The latest versions incorporate virtual-reality computer technology that allows teachers to present the students with complex, interactive and lifelike experiences. Professors can program the severity and length of an “event” such as an allergic reaction, a heart attack or a drop in blood pressure.

According to one recent Columbia University review on simulation centers, 69 U.S. and eight international schools now use mannequin simulators. Many allow faculty to observe students remotely, either in an adjoining room or via the Internet.

Another growing simulation tool is the “standardized patient,” an actor trained to portray a patient with a specific set of symptoms. Medical schools have been using standardized patients to conduct training and assess clinical skills for at least 30 years, while nursing and other health professions schools started using standardized patients within the past year or so.

College of Health Professions
At 5-foot-8 and 150 pounds, SimMan, or “Simon” as he is called in the nursing department, may seem like any one of the thousands of students returning to Temple this fall. In fact, his vital signs are the same. But there is one big difference: Simon is a mannequin.

Actually, Simon is a computer-driven patient simulation mannequin, who, along with his “sim-buddies,” is changing the way students, residents and professionals learn and practice their skills.

“Simon will give our students the chance to make mistakes and perfect the skills they’ll need on the job,” said associate professor of nursing Kim Alexander Noble. At the College of Health Professions, Simon resides in a fully equipped hospital room, outfitted with heart monitoring and intravenous equipment.

SimMan has a preprogrammed library of heart, lung, bowel and vocal sounds, a movable head and jaw, and open airways and lungs that allow students to practice techniques like intubation and gain experience with other airway complications. SimMan, whose physiological age can be adjusted from 6 years old to adult, is also capable of playing out potentially thousands of different scenarios including chest pain, asthma and pneumonia. Additional software and components can be purchased to create and run different lessons on trauma, wounds and bleeding.

This year, nursing researchers at the College of Health Professions will also begin to explore the value of standardized patients in nursing education. While this method of learning, called “clinical skills assessment,” is a proven success within medical education, it is still fairly new to the field of nursing.

With the support of a grant from the Pennsylvania Higher Education Nursing Association, nursing students will interact with actors trained to portray actual patients with specific symptoms. In addition to providing nursing students with a controlled setting and extensive feedback, this learning method also eliminates the medical and legal issues involved in working with actual patients.

“Real patients can present with a set of symptoms that do not match student’s skill level, be too ill to interact fully with students or cause severe student anxiety that distorts evaluations,” said primary investigator Jane M. Kurz, associate professor of nursing.

Kurz said a study of this kind can go a long way in making a case for “more objective measures of competency” and may ultimately convince academic administrators that the use of standardized patients is a worthwhile practice.

Kathleen Mahoney and Lori Martin-Plank, also faculty in Temple’s nursing department, are collaborating with Kurz for this study.

School of Medicine
The School of Medicine is putting the finishing touches on a Sim-Center in the ground floor of the old Dental School building at the Health Sciences Center. The Sim-Center will offer training on SimMan and SimBaby, clinical skills assessment with standardized patients and surgical simulators for medical students, residents and practicing physicians.

In the late 1980s, anesthesiologists were the first physicians to use simulation training.

“As anesthesiologists, we face many rare but dangerous potential medical catastrophes in the operating room,” said Andrew Herlich, professor of anesthesiology and otolaryngology at the School of Medicine and anesthesiologist at Temple University Children’s Medical Center. One such catastrophe is malignant hyperthermia, a potentially fatal but uncommon condition triggered by anesthesia.

“Although these events are rare, we needed a way to prepare anesthesiologists for the worst because when they actually occur there is no time to spare,” Herlich explained.

For practicing physicians, simulation training helps improve existing skills and reduces chances of medical error. It’s also a great way to learn about new techniques and scientific findings.

Reducing error is also an important benefit for resident and medical student training. Simulation allows residents to build on the skills they learned as medical students and allow medical students to practice general skills, such as starting an intravenous line, placing a catheter and conducting breast and pelvic exams.

Ultimately, when used systemwide, ongoing simulation training and practice will help in reducing malpractice premiums, experts say.

The Medical School also prepares students through simulated patient encounters using standardized patients. While medical students have practiced their clinical skills with standardized patients for several decades now, the federal government recently made passing a test of the skills a licensure requirement.

For medical students, the clinical skills assessment test, a daylong event for which they begin practicing in their third year, is like a typical day in the clinic or hospital. In simulated exam rooms, students see about 10 to 12 standardized patients for about 15 minutes each, record their medical histories and suggest diagnoses and follow-up.

“This is preparation for working with real patients, but not a replacement,” said Michael Curtis, director of the standardized patient program at the Medical School. “It helps students get over their jitters and understand basic techniques. They gain valuable experience in end-of-life issues, ethical dilemmas and giving patients bad news.”

From the test, students learn their strengths and weaknesses, and faculty, through video and the Internet, can get a good indication of where the students and the class stand in terms of clinical skills.

“Although we are evaluating students’ so-called bedside manner, we try to make the test as objective as possible,” Curtis said. “We want them to know how to communicate clearly, without using too much medical jargon, and to be able to conduct a physical exam effectively and appropriately. Do they make good eye contact? Do they drape the patient appropriately with sheets? As they palpate the body or listen to the heart, do they explain what they are doing and why they are doing it?”

Ultimately, Curtis explained, it’s about establishing good rapport with the patient. Studies have shown that patients will often make healthcare decisions based on how much they like a doctor.

The advantages to using simulation in health sciences education are boundless. It promises to reduce error and liability, improve the skills of medical professionals and reduce high malpractice premiums. With advances in technology, simulation will provide even more benefit in the years to come.

It will always, however, be a part of and not a replacement for real-time, person-to-person contact. Students and teachers alike know that it is the spontaneous interaction with a man, woman or child that has the most lasting impact.

- Tory Harris and Eryn Jelesiewicz