Education by simulation: The evolution of Resusci Anne

When Resusci Anne throws a party, she has enough friends these days to pack a room. There's Noelle, the pregnant mannequin who gives birth; Harvey with his 27 cardiac conditions; and a host of other mannequins, torsos and body parts that can be probed, sutured and evaluated.

And the latest high-tech guests to the party are a parade of virtual reality setups, also known as box trainers. These devices boast haptic technology, which gives physicians a sensation similar to touching real tissue, muscles and organs.

In the past four to five years, schools everywhere seem to be adopting the technology. Educators say it is a great way to teach medical students and residents clinical procedures and teamwork, communication and leadership skills. And its use is not limited to trainees. Practicing physicians are finding it a powerful way to keep pace with new procedures as well as brush up on ones they know but haven't used in a while.

"We're going from a 'see one, do one' mentality to using adult learning theories," said W. Christopher Croley, MD, anesthesiology simulation director at Rush University Simulation Laboratory and a critical care physician in Chicago.

When put into practice, theories push the learner to higher levels of skill by having them actually demonstrate medical knowledge, he said.

The technology is so good that the residency review committee that oversees general surgery training will make it a general surgery residency requirement.

"Programs don't have to have high-tech simulators, but they will have to have something dealing with simulation," said L.D. Britt, MD, MPH, residency review committee chair for surgery and a professor at Eastern Virginia Medical School in Norfolk.

The technology received endorsements from two unusual sources. In 2004, the U.S. Food and Drug Administration made it a requirement that physicians who want to do stent procedures follow the manufacturers' training program, which includes extensive practice with a simulator. Medical liability insurers also seem to believe simulation training makes a difference. In Massachusetts, one insurer offers ob-gyns a discount if they pass a simulation workshop.

Amid this pell-mell growth, organizations are attempting to impose order. The American College of Surgeons has initiated an accreditation program for surgical skill centers used by residents and practicing physicians and has accredited 10 sites, with another nine under consideration. The Society for Simulation in Healthcare, which includes physicians, nurses and other health care professionals, is working on standards for all types of simulation sites.

Anesthesiologists led the way, starting back in the early 1960s with Resusci Anne. As evidence of patient safety improvements piles up and the technology grows more sophisticated, other medical specialties have taken notice.

For example, the American College of Chest Physicians plans to debut a 25,000-square-foot simulation center at its meeting in October. Afterward, the college will move the center with its nine learning stations to a permanent site at its Northbrook, Ill., headquarters and make it available to physician practices, residency program directors and other health professionals for continuing education.

Good practice for residents

Residents are the largest group of physicians tapping into this technology, and the amount of simulation devices available to them grows larger every day.

Devices range from less realistic, low-fidelity simulators such as the pelvic exam model with pressure sensors that give the student feedback on the hardness and position of their touch to high-fidelity mannequins, with a pulse and pupils that dilate, that can be intubated, ventilated and have a catheter put in.

Task trainers, devices built to teach specific procedures such as suturing a wound or tying a knot, allow for focused learning. Box trainers are used to develop more advanced skills, such as duplicating the touch of a laparoscopic procedure while the user looks on a video screen for the corresponding visual images.

While these devices are great for giving students more confidence and proficiency before performing their first rectal exam, the big appeal is the ability to practice high-stakes procedures without putting patients at risk.

Eugene Greenstein, MD, chief internal medical resident at Northwestern University's McGaw Medical Center in Chicago, has undergone simulation training for advanced cardiac life support, or ACLS. He now shepherds housestaff through the experience. In addition to learning ACLS, Northwestern's internal medicine residents use simulation to learn how to place a central venous catheter and remove excess fluid from around lungs.

"The same anxiety that comes over you when you come into a code is there," he said.

His residency program director, Diane B. Wayne, MD, associate professor of medicine at Northwestern University Feinberg School of Medicine, has developed a standardized ACLS curriculum with scenarios for six common arrhythmias. Residents take a test before and after each simulation session. If the resident forgets to place the central venous catheter or give a dose of epinephrine, there is real-time feedback. A follow-up test months later checks students' retention.

"I've seen people come in not knowing where to start," Dr. Greenstein said. "At the end, they take command of the room, assign tasks."

Dr. Wayne has been pleased by anecdotal feedback from nurses and anesthesiologists at both affiliated hospitals in Northwestern's program. "They call me and say, 'What have you done? Your residents are so much more organized at codes.' "

Her scientific research backs up what she hears anecdotally. Her study in Academic Medicine in October 2006 found that residents became more proficient at ACLS algorithms after simulation training and retained these skills when tested 14 months later. That was in contrast to previous studies that found a rapid decline in ACLS skills without refresher courses. Patient outcomes also have improved. Dr Wayne said a recent chart review that documented better patient outcomes after residents' ACLS simulation training will be published in the journal Chest this year.

Col. Bernard Roth, MD, on the pulmonary faculty at Madigan Army Medical Center in Tacoma, Wash., has witnessed simulation technology having similar benefits for his physicians in training. With work-hour limits making residents' time a premium, simulators help doctors hone their skills more quickly, he said. A study on flexible sigmoidoscopy skills, a common procedure for family and internal medicine physicians, found that residents who trained on a simulator became adept more quickly than their counterparts who trained the traditional way.

Simulation training is particularly important for lethal conditions that occur infrequently.

"You can learn on a simulator and have a plan and muscle memory for what to do when facing that situation," Dr. Roth said. Also, for physicians re-entering the work force, practice on simulators is a safe way to regain their skills, he said.

Not all learning on simulators is productive, though. If a student learns something wrong without being corrected, he or she will be the worse for the experience, Dr. Croley said. "We know people will go back to the experience they've had, right or wrong, in a real patient setting."

Feedback, repetitive practice and integration of simulation exercises into the curriculum are critical for effective learning with simulation technology, said S. Barry Issenberg, MD, assistant director of the Michael S. Gordon Center for Research in Medical Education at the University of Miami Leonard M. Miller School of Medicine. Dr. Issenberg has researched this topic extensively, reviewing more than 800 articles on simulation research before coming up with a best practices list for simulation education. No matter how fancy or simple the simulator, Dr. Issenberg said, if there is no one to guide the learner, whether a human instructor or a computer program, the net result can be negative.

Whether patients benefit from doctors training with simulators is another important question that Dr. Issenberg and others are exploring.

"Does simulation training make for fewer errors and better patient outcomes? That's the hardest to prove," Dr. Issenberg said. "The initial work shows a reduction in errors, but there are no signs of a reduction in deaths."

Practicing doctors learn, too

While simulation training is most prolific among students and residents, its use is gaining in continuing medical education.

The American College of Chest Physicians is one group actively investing in this technology for CME. Dr. Croley, who will be simulation center director at the ACCP's CHEST 2007 meeting, said developing this CME is not without hurdles.

"Many senior physicians who have not been exposed to simulation centers are reluctant to be educated in a simulation environment," he said.

They may be more familiar with the low-fidelity trainers, like Resusci Anne, and think their training might be on such devices. Also, they are used to the anonymity of written questionnaires for earning their CME credits. The idea of performing in front of others can be daunting. "There's a fear you're going to have knowledge deficits exposed in an open forum," Dr. Croley said.

But once physicians move past that initial barrier, Dr. Croley said, they are hooked: "We almost always have more requests than we can handle for this type of education."

Move over Resusci Anne. Harvey is moving in, and his posse of friends, TraumaMan, Gas Man and BabySIM, promise to keep things interesting.