Practice makes perfect

Cate Swannell
Med J Aust
Published online: 1 June 2015

Whether it is a standardised patient, a partial-task trainer, a mannequin (high-fidelity simulator), screen-based computer simulator or a virtual reality environment, medical simulation has come a long way.

Verbal role-playing has served its role in medical training for centuries, as have anatomical models, but it was not until the invention of the Link flight simulator in 1929 that the possibilities for medical education via simulation began to open up.

The first standardised or simulated patients — humans acting as patients with different conditions and providing feedback to the student or clinician — were used in 1963 at the University of Southern California (USC) in the United States, as a way of teaching neurology students. In 1993, the Medical Council of Canada was the first to use standardised patient examinations in their licensing procedures.1

In 1960, a partial-task simulator known as Resusci Annie, designed for teaching mouth-to-mouth resuscitation, was developed. Later, a spring was added inside her chest for practising cardiopulmonary resuscitation.

Partial-task simulators really took off in the 1990s, with the advent of laparoscopic surgical techniques and more advanced computer technology leading to simple box trainers like the laparoscopic training box and the sinus surgery simulator.

Software-based simulation also boomed in the 1980s and 1990s. Anaesthesia, cardiology and the management of medical emergencies benefited, and the development of interactive web-based programs led to the interactive simulated patient.

The first full-scale human patient anaesthesia simulator mannequin came out of USC at the same time as standardised patients in the early 1960s. Today, mannequins such as SimMan and SimBaby offer full-scale high-fidelity, sometimes with a half-million dollar price tag.

In the virtual world, environments such as Second Life, which was initiated in 2003, are being used by universities to enhance distance learning. In 2007 a Second Life simulation known as Ann Myers Medical Centre began to run medical simulations.

At the recent Royal Australasian College of Surgeons’ (RACS) Annual Scientific Congress in Perth, Professor Terry Gallagher, head of Technology Enhanced Learning and the Director of Research at the ASSERT for Health Centre at University College Cork in Ireland, presented the results from a 21-site prospective, randomised and blinded study by the Arthroscopy Association of North America on simulation-based training.

The results show that orthopaedic surgeon trainees randomised to proficiency-based progression simulation training performed 40%-60% better (with fewer errors) than two matched control groups.

“This is the largest and best controlled clinical study of simulation-based training ever conducted. The results have important implications for patient safety and what we mean by ‘training’”, Professor Gallagher told the conference.

“Simulation and technology enhanced learning are effective because they offer the opportunity for the trainee to engage in deliberate practice with metric-based performance feedback.

“It also means that we can ‘quality-assure’ the performance of graduating trainees with an ‘outcome’ rather than a ‘process’ based approach to training.2

Professor Guy Maddern, professor of surgery at the University of Adelaide, and the lead on the RACS research into surgical simulation, says one of the biggest attractions of simulation training is the removal of the pressure to be perfect.

“The opportunity to train and improve skills and gain experience in a non-patient environment is very attractive”, Professor Maddern tells the MJA.

“You can make mistakes and experiment without the possibility of harming a patient.”

The downside, he says, is that simulation training can be expensive, with little evidence that the most costly simulators produce better results.

“It can be incredibly expensive — up to half a million dollars, usually around $100,000–$200,000. They can be wonderful to play with but it is hard to measure if it is any better than the simple box trainer.

“In fact, during our RACS evaluation we found that for teaching basic skills, the box trainer is better than [something that requires] costly maintenance.”3

Professor Maddern maintains that the more complex the surgery, and the patient, the less suitable simulation training can be.

“Simulation for complex interactions is not great”, he says. “For example in the case of colonoscopy, simulation is quite good for learning how to manipulate the machine and removing polyps, and it’s certainly better to learn in a simulator than on a patient.

“But there’s no way it’s well developed for many patients with very difficult anatomy or complex situations.”

There is one area in which surgical simulation is more cost-effective, he says.

“There’s a myth that it takes a surgeon to train a surgeon.

“What’s needed is a skilled trainer. It makes more sense to have a surgeon provide oversight to a team of trainers, who are arguably better than surgeons [at teaching], and are certainly cheaper than surgeons.

“Context is critical. For a simple operation, simulation can teach suturing techniques, for example, and strategies; but it’s not sufficiently good for complex open surgeries.

“That’s why we have mentors — an apprenticeship model — for more advanced work.

“Simulation can enhance our ability to do things, but surgeons will never be redundant.”


2. RACS press release: Simulation training – a paradigm shift in how doctors are educated and trained; Wednesday 6 May, 2015


A podcast with Professor Debra Nestel, Professor of Simulation Education in Healthcare for Monash University School of Rural Health, is available at

  • Cate Swannell



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