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Simulation Education

Ideal education for 21st century doctors involves simulation center

In the 10,000 square feet of the Mayo Clinic Multidisciplinary Simulation Center, life hangs in the balance every day.

And the physicians, surgeons and medical students honing their skills at the center are grateful that it does — because the outcomes are always excellent and powerfully instructive in this newest form of experiential medical education. No lives are lost, and vital lessons are learned from computer simulations, robotic mannequins that can be programmed to respond as a patient might, and trained human actors cast as "standardized" patients who react in scripted ways. Just as aviation pilots master complexity through cockpit simulators, at Mayo Clinic's Multidisciplinary Simulation Center, health care professionals across disciplines improve performance and reduce errors through comprehensive medical care simulation training.

Case study: Anesthesia complication

Consider this real-life anesthesia story about a rare and usually fatal complication of regional anesthesia:

Mayo Clinic anesthesia residents undergo a number of simulation-based exercises on crises that may happen to patients who are undergoing regional anesthesia. The exercises are both teaching sessions and opportunities to "rehearse." During a real situation in the summer of 2007, a patient undergoing a regional anesthetic suffered a severe toxic reaction and their condition began to deteriorate rapidly. But because the Mayo Center Multidisciplinary Simulation Center prepared physicians to know what to expect and handle it, they knew how to quickly and safely reverse the situation.

Explains Mayo Clinic anesthesiologist Laurence Torsher, M.D., "Two of the people participating in the patient's care had undergone simulation-based training approximately eight weeks earlier in which they had experienced a simulated decompensation (heart failure) very similar to what they saw occurring in front of their eyes. The resuscitation was executed seamlessly and, in under 10 minutes, the patient was stable again without any permanent sequelae (an aftereffect of disease or injury)."

In a debriefing that occurred after the event, those two residents identified specific points from their simulation session that directly contributed to the successful and rapid resuscitation of the patient. "This experience clearly demonstrates the value of rehearsal in managing medical emergencies. Through living the experience in simulation, the team knew what to do and had the confidence to act swiftly, even though the correct treatment in this case was very unorthodox," says Mayo Clinic physician and simulation committee chair Roger Harms, M.D.

Distinguished with accreditation

In 2007 the American College of Surgeons (ACS) accredited the Mayo Clinic Multidisciplinary Simulation Center as one of 11 outstanding simulation centers in the United States.

ACS accreditation is testament to the Mayo center's embodiment of the highest standards of excellence. Opened in fall 2005, in its first 12 months the center hosted 4,053 learners in classes each typically a half-day long. "That high level of programming and usage is unprecedented in any simulation center to my knowledge," explains the center's medical director, William Dunn, M.D., who also is president-elect of the international Society for Simulation in Healthcare ( "We are deeply honored by this recognition because it signifies that we have achieved a benchmark of excellence in adult learning through experiential education in simulation." Adds David Farley, M.D., Mayo Clinic surgeon and vice chair for education in Mayo's Department of Surgery in Rochester, "Health care needs simulation centers of excellence such as ours to support educational vision. We are preparing teams to care for patients not only now — but in the future as well."

Caring for patients of the future

With today's pace of technological advances in health care, physicians are increasingly faced with the daunting tasks of mastering new bodies of knowledge, technologies and procedures. How will physicians and surgeons now in practice learn new best-practice techniques while maintaining daily workloads taking care of their patients? Dr. Dunn's answer is that they can attend a Mayo ACS-accredited simulation center for intensive course work, seminars and team training.

"That's exactly what we are doing now with our own physicians, surgeons and medical students, and we are having excellent results," Dr. Dunn notes. "We're committed to it because the rationale for simulation-center-based medical education is persuasive: administering medical care is a high-risk proposition, and the more experience, exposure and practice team members receive, the likelier we are to improve the care we give to real patients, at minimized risk." Says Dr. Farley, "Surgeons need centers of excellence such as ours to serve as resources that have the vision to prepare them for caring for patients of the future. For example, when new technology comes along for robotic eye surgery, there needs to be a way to prepare surgeons to take advantage of it and get it to patients as safely and quickly as possible. That's where we come in. We're planning for that day now — not waiting for 2015."

Inside Mayo's Simulation Center

The term simulation center can mean many things. Some medical centers call the closet where a mannequin is kept for demonstrating cardiopulmonary resuscitation the simulation center. The Mayo Clinic Multidisciplinary Simulation Center is a state-of-the art complex. Four of its larger rooms can be configured to be exact replicas of surgical suites that Mayo Clinic surgeons operate in: or emergency rooms; or rooms within intensive care units; or a cardiac catheterization laboratory. Like independent stages in a theater, all rooms are multipurpose. Additional smaller rooms (up to 10) provide realism for training within spaces configurable as inpatient hospital rooms, an outpatient clinic, or other areas. The equipment and its placement in the rooms are identical to those used in real patient care at Mayo Clinic.

Control booths, observation rooms, and/or high-tech cameras attached to every room allow medical educators to teach new techniques and simulate medical emergencies requiring hands-on, real-time problem solving. Physician instructors watch the scene unfold from behind the control booth glass. The simulated situation is often recorded, and then reviewed and critiqued by the entire health care team and instructors. Participants then can repeat the situation and practice proper responses.

Simulator as educational tool for experiential learning

While the Mayo Clinic simulation center's facilities are impressive, its most distinguishing feature is the educational expertise behind it. "Our simulator is set up to be an educational tool to achieve goals that foster deep learning, such as cognitive imprinting," Dr. Dunn explains.

He relates a common learning experience doctors undergo. "If you talk to the average doctor about his or her most potent learning experience," he says, "it would go something like this: 'I saw this difficult patient and I didn't know enough about the condition, even though I remembered studying it. So I reread the literature, and because I had the experience of taking care of a patient with the condition, what I read stuck like it never stuck before.' Our simulator offers the same capacities to utilize this same learning mechanism of active learning."

Health care simulation centers are a relatively recent phenomenon, evolving over the past decade. They originated in critical care and anesthesiology. Because of medicine's traditional rigid boundaries between disciplines, simulation centers have tended to remain confined to narrow areas of expertise.

Mayo is an exception. Because Mayo Clinic has been a multidisciplinary group practice for more than a century, movement across specialties is fluid, and encouraged. As a result, the concept of a simulation center at Mayo is rooted in its ability to serve all fields of practice.

"By using simulation centers in medical education, we are at the forefront of an avalanche of change," Dr. Dunn says.

The future of simulation in medicine

Within medical training in the United States, the medical licensing exam process requires health care professionals to pass test components based in simulated settings, using actors as "standardized patients." This occurs at only one point within the many years of training required for the average physician. In the future, simulation techniques may be utilized much more within all fields of specialty training, and well beyond the medical student years, including continuing medical education, and recertification for licensure from specialty boards.

To assure that the highest quality of health care professionals are in practice, Drs. Dunn and Farley agree that future medical licensing, training programs, and board-level specialist credentialing processes should involve outstanding performance on select simulation-based exams. Says Dr. Dunn, "We need to demand uniform excellence in training and assessment of health care professionals, in fair, standardized, respectful manners — raising the bar and modeling for others. And comprehensive, accredited advanced simulations centers such as ours will play a pivotal role in achieving this."

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