ARTICLE Simulation-Based Medical Education: An Ethical Imperative ‘Amitai Ziv, MD, Paul Root Wolpe, PRD, Stephen D. Small, MD, and Shimon Glick, MD ABSTRACT Medical training must at some point use live patients to hone the skills of health professionals. Buc there isso fn obligation to provide optimal treatment and to ensure patients’ safety and well-being. Balancing these two heeds represents 0 fundamental ethical tension in medical education. Simulation-based learning can help initiate this tension by developing health professionals knowledge, skills, and atcicades while protecting patients fiom unnecessary risk. Simulation-based training bas teen institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number cof reasons, including cos, lack of rigorous proof of effect fand resistance 10 change. Recently, the international patient safety movement and the U.S. federal policy fgenda have created a receptive atmosphere for ecdical training must at some point use live "patients to hone the skills of health profes fionals. At the same time, there is an bligation to provide optimal treatment and ‘Dr Bis deputy dicen, The Chim Shabu Meal Cee, en recto, Prat Cover for Metical Siulaton (MSR), Tel-Hasame, Imac Dr, Wobe oat te Couer jor Boalics, Depanmets of Pach and remo! Unensy of Females and ch of Bots, Natoma Srey and Spare Amato Dr. Sal dest, he Univer F Chace, Dewlopng Contr for Patt Saf, Deporient of Ghetagy and Creal Care, de University of Chicago, Cego Feed Be Oks profesor amet, iomant falaboots Cae fo pane abel Fas, Moshe Pres Cater for Meal Ban Ben a erty of te Nees, lal, Cor for Mell Education, Ben Garon Unie of he Nees Ia CCamespndence and saves for reins shxdd be sent 10 Dx. Smal Strona of Chie Deveaing Canter fr Patent Safty Prete of ees and Cicl Ca, Unser of Chay Mist eee) South Marland Avenve, MC 4028, Chicago, H 60857 ame Nara '334-230%; fac (73) "7025447; ema {somal awe ches eh. Acapewic Mepicine, VOL ‘expanding the use of simulators in medical training, Strang the ethical imperative £0 “fist do ao hae” in the face of validated, large epidemiological studies dlsribing unacceptable prevearable injuries to patients es reall of medieal management. Four themes provide fa framework for an ethical analysis of simulation-based ‘medical education: best standards of care and training, sitor management and patient safety, patient autonomy, and social justice and resource allocation. ‘These themes sre examined from the perspectives of patients, Tears ‘educators, and society. The use of simulation wherever feasible conveys a ctitical educational and ethical ‘message to all: patients are to be protectid whenever posible and they ate not commodities to be used ot Conveniences of taining ‘Acad. Med. 2003;78:783-788. to insure patients’ safety and well-being. These conflicting needs create a fundamental ethical tension in medical education, one that is widely recognized although little discussed. Recent articles in the bioethical literature have condemned the unreflective use of patients—especially Sedated or dying patients—as taining coos for elinicians." ‘Simulation-hased medical education (SBME) (see Table | foran overview) can bea valuable tool in mitigating these ‘ethical tensions and practical dilemmas. Recent discussions Gf medical error and risk reduction strateyies** have highlighted simulation 9s an important tool in improving the safe delivery of medical care. Nevertheless, medicine thas lagged bebind other high-technology, high-risk profes sions in the use of simulation, such as aviation, in which so- histiated technical and behavioral sls ae necessary” ‘The reasons include financial outlays in an era of increasing cost containment, limits to accurately modeling complex fhuman pathophysiology, demands for rigorous scientific evidence of effectiveness, and resistance to change from 18, No. 8 | Avoust 2003 83 i q 1SIMULATION BASED MEDICAL EDUCATION, CONTINUED a strong professional culture. However, a more receptive atmosphere for expanding the use of simulators in medical training may now exist. An. international patient safety movement based on epidemiological studies delineating the numbers and costs of preventable patient injuries due to ‘medical management has reinvigorated the principle of “fist do no harm" in policy debates ‘Simulation has been used unsystematicaly since the eal days of medicine. Inthe 16" cencury, mannequins (referred tos ‘phantoms") were developed to teach obstetrical skills and reduce high maternal and infant mortality rates."® Today, it is common for students todo theie frst injections on ait ‘orange, practice suturing on pieces of cloth, rehearse medical interviews while role playing, oF practice physical examina. tion on simulated (standaedized) patient-actors."™! Application of modern. medical technologies requires complex team interactions that mandate improved training techniques. Advanced SBME ean provide realistic repre Sentations of complex clinical environments and allow ‘educators co alter patient reactions and responses in ways unattainable with actual patients. The recent Institate of Medicine report on medical errors recommends such an Interactive use of simulation.*"* Recent studies have supported the efficacy of screen-based and realistic site Jators in enhancing technical, behavioral, and social skills in medicine." Modern medical simulation falls into five tain categories'® (Table 1). Further research is needed to establish the effectiveness of each of these categories of SBME, as well as their limitations. Equally important isan examination of the ethical features of SBME and its potential contributions and challenges to medical pedagogy In the rest of this aticl, we discuss the four themes that provide a framework for an ethical analysis of SBME: best, standards of care and training, error management aad patient sufety, patient autonomy, and social justice and resource allocation Bust STANDARDS Best Standards for Patient Care Patients have the right to receive the best care that ean be reasonably provided. It is understood that physicians-in- training will teat patients. However, from an ethical perspective, harm to patients as a byproduct of training ot lack of experience is justified only after maximizing approaches that do not put patients at risk, ‘The clinical encounter in a teaching environment may focus too much on training, 2¢ times to the detriment of the patient. Although instructors monitor trainees and patients during procedural and cognitive tasks, strategies to place patient well-being foremost occasionally fail. Novices ex: 184 AcapEMIC MEDICINE, VoL Table 1 ‘Simulation Tools and Approaches Used in Simulation-Based | Medical Education EES Tool or Approach __Dessiption Lowtech simulators Models or mannequins used To practice simple physical maneuvers or procedures. Simulatedstandardzed Actors trained to rale-pay patients, for patents training and assessment of history taking, phyla, and communication skis Programs to train and assess cla ‘nowiedge and decision making atoprative ciel incient ‘management, problem-based ling, plyscal agnosis in erecogy, acute card lte support High-fidly visual, audio, touch cues, and actual tol that are intagrated wth Computers Virtual reaity devices and simulators that replicate a cinical sting, eg, utasound, ‘ronehaszopy, carcoiogy, laparoscopic surgery, arthroscopy, somoidoscony, dentistry CComputerdriven, tul-ength mannequs Sinuited anatomy and physiology that allows banding of complex ae high "sk ela stuatlons in eke setings, incuding eam traning and intgraton of mutipa simulation eves Seree-based computer simulstors ‘Complex task raners Reali patint simulators perience significant performance anxiety, generally cannot focus on multiple tasks, and follow simple rules inflexibly.”? SBME allows trainees to more often have their first encounters with real patients when they are at higher levels of technical and clinical proficiency. Practitioners cat use SBME to improve proficiency when learning new procedures or when honing existing skill. The use of simulation wherever feasible also can convey a. ctitical educational and ethical message to all stakeholders in hhealth care: patients are to be protected whenever posible and they are not commodities to he used as conveniences of caining Best Standards for Education The responsibility of educators, decision makers, and society to provide clinicians with the best training and ‘most constructive learning experience can also be viewed as 78, No. 8 / Avoust 2003SILATION-BASED MEDICAL EDUCATION, CONTINUED 4 moral commitment to trainees. Yet, i tation, production pressure, and cost cutting have. placed Unprecedented constraints on training, making systematic training in real settings unattainable. SBME may allow onsistent trainee exposure to a varity of clinical pre Sentations and procedural contexts, including atypical pat fems, rare diseases, critical incidents, near misses, and Uses The process and structure of medical education then becomes a series of progressive choices by educators rather than a response to ad hoe efinical availabilities. SBME can be complex and subtle, enabling taining for encounters such a5 unanticipated patient demise. Curicula have been developed ane tested in which medical stodents and residents engage “speaking” computerized mannequiss who unexpectedly die, of in which simulated operating fom resuscitation fails. The “deaths” of such simulated patients can evoke close-toreal feelings of oss and esponsibility The SBME protocols may even involve ctors posing as the “families” of the simulated patient. Clinician trainees can be trained and evaluated on their approach to informing families of adverse events oF the death of a loved one Seudent autonomy in medical education leads to better. trained students with a more humanistic outlook toward patients As swith learners in general, trainees and providers in health care learn at diferent speeds and have tlfferent edacational needs. SBME allows trainees to prctice clinical sills at their own pace, repeating, pro- Cectures as needed to gain comfortable levels of confidence and proficiency. Best Standards for Skills Evaluation Simulation-hased skills assessment has played a major role in the transformation of the determination of providers Competency. The traditional focus on the assessment of Coanitive skills has slighted the skills of commenication, tnanagement, cooperation, and interviewing, Deficiencies ih these skills are causal factors in adverse outcomes.” Simulation-based assessment has increasingly become a standard method for evaluation.™™°" Objective struc: tured clinical exeminations (OSCEs) have become a part of licensure examination, in both Canada (by the Medical Council of Canada)" and the United States (by the Educational Commission for Foreign Medical Graduates). * Carently, simulation assessment is restricted to “low-tech” methods, using standardized patients to evaluate history taking physical examination, and communication skills. AS the deity of medical simulators improves, however, performance assessment sties of hands-on management thle may advance beyond current methods constrained by the use of live patients. Consequently, more professional Acamsaie Mepicme, Vou. boards may eventually include more sophisticated simula tion based performance assessment in theit routine ceri cation and recertification procedures.” ERROR MANAGEMENT AND PATIENT SAFETY ‘Although medical tiainees should be closely supervised, ‘specially during the early parts of their clinical training, it is inevitable that trainees will oceastonally cause prevent- able patient injuries. Although such sisks are_usually Considered an unavoidable concomitant of training, the hhatm caused is ethically tolerable only when sninimized co the degree possible by medical pedagosy Tn the clinical setting, errors must be prevented oF terminated immediately by supervisors to protect the patient, In contrast, in a simulated environment, errors Pan be allowed to progress to teach the trainee the im- plications of the error and allow reactions to rectify de- Miations. Video feedback strengthens the impact of these learning opportunities and may provide strong incentives © modify behavior. Learning from errors is a key component Of improving expertise and serves to organize future Ibehavior Errors and failures of expertise occur throughout health professionals’ careers? SBME is therefore as valuable for ontinaing medical education and tecertification as itis for novice preparation, The model for the use of simulation in systematic, career-long approach already exists in aviation. House staffs often hanglle medical mistakes by denial discounting personal responsibilty, or distancing them- Selves from the consequences.”” Mistakes made during sitmulated exercises do not eause harm to living patients and tan be more easily exposed and discussed. Mishaps in the course of leaming can thus be reviewed openly without Concer of liability, blame, or guilt—even decisions and etions chat result in the death of the simulated patient, SBME can help break the culture of silence and denial in medicine regarding untoward outcomes and mistakes and theit implications about the learner's competence, SBME an foster and nourish a culture of safety, possibly ian proving the quality of event reporting, an important 2° tional policy directive.” Simulation approaches provide additional means for exploring vulnerabilities in health care delivery and for tring that information to improve the competence of providers, the system of care, and interaction between the two. Examples of systems-level applications of simulation include uniform training for interdsciplinary in-hospital Tesusctation teams and the increasingly relevant assess then of technology, information systems, and procedures. ° 78, No. 8 | Avoust 2003 1885, i | |SIMULATION-RASED MEDICAL EDUCATION, CONTINUED PATIENT AUTONOMY A fundamental principle of modern bioethics is. that patients have the right to direct their own cate.*! Standards of informed consent require full disclosure of all pertinent information, and give patients virtually unrestricted rights to refuse a treatment, to participate in research, or to be treated by a traince or novice." Ti practice, however, these ethical precepts are often. violated, Patients are frequently asked in a perfunctory fashion ia learner can engage them or are not asked at all Sometimes, patients may not even realize they are being treated by a trainee.” Academic care is time pressured, complex, and hierarchical. Patients may be tired, in pain, or sedated, Procedures for obtaining consent for major anesthesia and surgery have been weakened by the rapid pace and fragmentation of care today. The right to refuse 1 procedure performed by a trainee is often qualified and may be a fiction in some settings. Research in informed consent procedures indicates that patients frequently do not grasp the nuances and consequences of theit consent, even under optimal conditions.4¥° Unconscious, heavily sedated, and recently dead patients ate vulnerable subjects for medical training.*® Articles have periodically exposed such practices as the use of anesthe- tized women for preoperative pelvic examinations by trainees."” A. recent survey of physicians-in-training con- firmed the practice of performing nontherapeutic, invasive training procedures dusing cardiac resuscitation and pre- sented a review ofthe literature on the controversy of using the recently dead for such purposes.°*® SBME can significantly reduce the need for training on such patients, helping to fulfill an ethical imperative.”” SBME can also enhance the quality of informed consent by having learners practice informed consent procedures on simulated patients in ethically challenging scenarios, resulting in a more ethically sensitive approach when actual patients are involved later. SOCIAL JUSTICE AND RESOURCE ALLOCATION ‘The basic bioethical principle of distributive justice requires that citizens equally share risks of medical innovation, research, and practitioner training. Yet, academic health systems (AHSs) are located in urban areas (only wo of more than 115 AHSs are not within a metropolitan statistical area [MSA]), and they provide disproportionate amounts of care to the poor. For example, although AHS hospitals account for only 16% of the beds within MSAs, they recently were noted to account for 45% of the hospital-based charity care. As AHSs also. provide the vast majority of medical training, its clear that the already 786 AcADEMIc MEDICINE, Vou disadvantaged are parties to an unwritten contract to beat 1 disproportionate amount of the risk of novice training. It is therefore an issue of distributive justice that SBME be explicitly ditected toward reducing the proportion of indigent patients used as objects of medical training. SBME also reduces the need to use five animals for training. Simulators can provide models of human physiol- ‘ogy and metabolic responses as well as (and sometimes better than) animals cypically used for training purposes Only recently, the Subcommittee on Advanced Trauma Life Support (ATLS) and the Committee on Trauma of the American College of Surgeons has approved an alternative ‘model for use during the ATLS Surgical Skills Practicum: fan anatomical human body mantkin.*' AN ETHICAL IMPERATIVE Medical schools are redesigning their curricula and rethink ing the nature of medical education. This transformation includes a greater emphasis on bioethics, patient-focused care, and the incorporation of the fruits of the medical— technological revolution. Although overreliance,on techno- logical medicine may sometimes be a threat to humanistic care, the proper use of simulation technology has the po- tential to enhance humanistic training in medicine. To optimize the use of SBME and overcome resistance by health professionals, SBME trainers should be skillfal in creatinga receptive atmosphere, providing constructive fed: back, and using video feedback and debriefing. Skillial use ‘of SBME can use the intensity of the simulated experience to nourish culture change and support recognition of fallibi- ity and areas of weakness.22 ‘The costeffectiveness of potentially expensive SBME should also be examined in terms of improvement of clinical competence and its impact on patient safety and error reduction in an era of limited resources.*® Encounters with teal patients will always remain essential in exposing health providers to the full complexity of practice. SBME fs thus a complementary educational modality rather than an at- tempt to replace real-patient training encounters. ‘We suggest that the proper and careful development of SBME is an ethical imperative. 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