Medical education in the digital age: personal reflection on a simulation fellowship

As a graduate from medical school in the long, hot summer of 2006, I had never encountered anything as advanced as a human–patient simulator, or manikin. Resusci-Annie had been the peak of this technology during my training and interactions with actors or actresses playing roles had always taken place in classrooms, lending themselves very little in the way of fidelity.

In the last year, I have undertaken a simulation fellowship at Guy’s & St Thomas’ NHS Foundation trust, learning how to use technology to enhance learning, both in my primary role through simulation and debriefing, but also in other projects related to the development of e-learning resources.

The rise of technology-enhanced learning in the last 10 years has been dramatic. We now have courses using human–patient simulators to teach topics as complex as extra-corporeal membrane oxygenation, recognition of the acutely deteriorating pregnant woman and transfer of patients with multiple co-morbidities from community to hospital and back again.

Simulation training is embedded into the training of foundation doctors and newly qualified nursing staff at our trust, and it is increasingly common that delegates on our courses are not naïve to the modality. Concurrent to the rise in simulation training has been the availability of training posts working in simulation centres, learning the skills required to create educational experiences through the use of simulation and facilitated debrief.

These posts, often referred to a Simulation Fellowships, are in their nascent phase, with little standardisation of roles and responsibilities and a varied approach to personal development. There is very little published information about the role beyond the individual job specifications, and an overview of the role and opportunities afforded by it published in BMJ careers in 2010. ¹ A survey of simulation fellowships from the United States which identified 17 different fellowships concluded that the programmes varied in length, sponsorship and prerequisites. ²

A nationwide survey in progress currently has identified 40 fellows who similarly report a wide variety of experiences. The digital age and the elevation of technology-enhanced learning has created a wealth of opportunities for interested parties; however, we may be in danger of not maximising those opportunities through failure to support the individuals in these programmes. Further information from the nationwide survey will help to clarify the minimum standards for the role, both from the point of view of the employer and the trainee.

The last few years of simulation have also seen a significant trend from uni-professional to inter-professional training. Whilst studies have shown significant benefits to this approach, it poses extra challenges to the technology. Evidence shows that nurses and doctors respond to different cues in establishing the realism of the scenarios we present them with.

Doctors are more likely to respond to a scenario which is clinically credible. They look for validity in the simulated experience and it is noted that what constitutes validity are the ‘practice, phenomena and action … not the body as an unchanging action’. ³

Developments in technology allow us to be increasingly ambitious in recreating complex clinical scenarios. We can create more valid experiences of practices and procedures as well as more clinically credible representations of phenomena.

However, this assessment of realism may not be common to all delegates on our courses, particularly when they are multi-disciplinary. A recent article showed that, whilst nursing student performance was not significantly different in simulation using either hi-fidelity human–patient simulators or standardised patients, the realism of the standardised patient was preferred by participants.

Nursing staff, who generally have a different approach to patients, may respond more to the degree of realism in the appearance of the ‘patient’, the creation of that patient as a realistic person and their role in a relationship with that person. With this in mind, we have to be careful that our ability to mimic the clinical components of a scenario doesn’t move beyond our ability to simulate the human component for the success of our inter-professional programmes.

So where are things going? We have an increasing ability to deliver training through simulation to a wider group of delegates. Technology is enabling us to be more ambitious in what we can simulate. Evidence is accumulating that training in this way is effective, both in terms of cost but also in terms of learning for our delegates.

My experience has reinforced many of these findings. I have designed and delivered a training programme utilising lectures, workshops and hi-fidelity simulation to improve the recognition, assessment and management of Sepsis, particularly targeted at ward-based staff. Gathering information from digitally reported clinical incidents within our trust has been a powerful tool to inform the development of this course, and the use of e-noting may offer a tool through which we can assess the impact of this training.

Avoiding blame-culture, simulation could become part of the response to clinical incidents, utilising the electronic records to recreate the actual events. This may have the benefit of engaging both the validity of the clinical aspects of the scenario, but also the undeniable human element of a real case, improving credibility across the disciplines.

Utilising simulation in this way, clearly placing it as a positive response to an event, exploring the real systems and interactions that contributed to the experienced outcome, could be a powerful way to inculcate resilience into an organisation. Treating each event as an opportunity to learn and adjust, rather than to admonish and constrain would be a powerful statement of intent and may now be achievable with a high degree of realism.

My other significant project this year has been a series of exercises designed to simulate potential presentations of suspected Ebola Virus Disease to our trust. Again the use of technology, including human–patient manikins and portable cameras has been a vital step in the development of a resilient system to deal with this potential challenge.

These projects highlight two of the great strengths of simulation, targeting common problems to improve awareness, and creating the opportunity to experience rare or unusual events so that staff may prepare for them. Using digital technology can enhance how we deliver simulation-based training. However, we must be aware that the process of evolution doesn’t always correlate with an improvement for all of our learners. We must not lose sight of what benefits our learners when considering the affordances of the latest technological developments.