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The Human Face of Simulation: Patient-Focused Simulation Training

Kneebone, Roger PhD, FRCS; Nestel, Debra PhD; Wetzel, Cordula Dipl Psych; Black, Steven MRCS, Ed; Jacklin, Ros MA, MRCS; Aggarwal, Raj MA, MRCS; Yadollahi, Faranak MSc; Wolfe, John MS, FRCS; Vincent, Charles MPhil, PhD; Darzi, Ara MD, FRCS

doi: 10.1097/01.ACM.0000238323.73623.c2

Simulation is firmly established within health care training but often focuses on training for technical tasks and can overlook crucial skills such as professionalism and physician–patient communication. The authors locate this paper within current developments in health care and relate it to the literature on simulation. They make the case for placing real human “patients” (played by actors) within simulation environments, thereby ensuring that the training experience remains rooted in actual practice. By practicing repeatedly within a safe environment, technical skills, communication with patients and team members, decision making, and clinical judgment may all be practiced and mastered while preserving patient safety.

In elaborating this concept of patient-focused simulation (PFS), the authors draw on work already published by their group and several recent studies that are in review. These explore PFS in low, medium, and high complexity settings. Important or rare situations can be recreated and practiced, as well as key procedures required across a range of experience levels and clinical specialties. Finally, the case is made for curriculum redesign to ensure that simulator-based technical skills training and assessment take place within an authentic context that reflects the wider elements of clinical practice.

Dr. Kneebone is senior lecturer in surgical education, Department of Biosurgery and Surgical Technology, Imperial College London.

Dr. Nestel is senior lecturer in communication, Department of Biosurgery and Surgical Technology, Imperial College London.

Ms. Wetzel is research associate, Department of Biosurgery and Surgical Technology, Imperial College London.

Dr. Black is registrar, St Mary’s Hospital Regional Vascular Unit, London; and Department of Biosurgery and Surgical Technology, Imperial College London.

Dr. Jacklin is clinical research fellow, Department of Biosurgery and Surgical Technology, Imperial College London.

Dr. Aggarwal is clinical research fellow, Department of Biosurgery and Surgical Technology, Imperial College London.

Ms. Yadohalli is research associate, Department of Biosurgery and Surgical Technology, Imperial College London.

Dr. Wolfe is Consultant surgeon. St Mary’s Hospital Regional Vascular Unit, London.

Dr. Vincent is Professor of Patient Safety Department of Biosurgery and Surgical Technology, Imperial College London.

Dr. Darzi is Professor of Surgery and Head of Department of Biosurgery and Surgical Technology, Imperial College London.

Please see the end of this article for information about the authors.

Correspondence should be addressed to Dr. Roger Kneebone, Senior Lecturer in Surgical Education, Department of Biosurgery & Surgical Technology, Division of Surgery, Oncology, Reproduction and Anaesthetics Faculty of Medicine Imperial College London, Chancellor’s Teaching Centre, second Floor QEQM Wing, St Mary’s Hospital, Praed Street, London W2 1NY; telephone: 020 7886 7930; fax: 020 7886 1810; e-mail: (

In recent years, simulation has shifted to center stage within health care education and is now firmly established as a crucial component of training. Simulations range from simple benchtop models (for practicing basic skills such as venipuncture and urinary catheterization) to virtual reality computer systems and highly sophisticated recreations of clinical environments (such as the operating room or intensive care unit). Pressures from a rapidly changing health care landscape are hastening the shift to simulation-based training in many countries. Shortening of training programs, reduction of working hours, and ethical imperatives to protect patients from harm are having a profound effect upon traditional approaches to training. Moreover, opportunities for training within a clinical setting are unpredictable, and the learning needs of the trainee must always be subordinate to the clinical needs of the patient. Hospitals provide expert care to patients who are often extremely ill or who undergo surgical procedures within highly specialized units. Rising student numbers, in conjunction with continual pressures on bed occupancy, mean that time-honored educational patterns are no longer feasible.

These pressures have shifted the focus of health care education. It is no longer possible for trainees to gain all necessary skills simply at the bedside, in the operating theater, and through observation during a prolonged apprenticeship. Simulation offers obvious benefits.1 By practicing repeatedly within a safe environment, learners at all stages can gain necessary skills without placing real patients in jeopardy. In this setting, the needs of the learner can be given priority. Such learners may include medical students, postgraduate doctors, nurses, and other health care practitioners.

Technology and simulation walk hand in hand. Early experience with resuscitation mannequins laid the foundations for simulator-based training.2 Recent developments in mannequin design offer high levels of realism within anesthetic simulation, while virtual reality computer programs address a wide range of surgical and interventional procedures.3–7

Much innovation in the field of simulation is prompted by technological developments, including computer gaming and other drivers both within and outside of health care.8 Indeed, such developments are crucial if the field is to remain dynamic and evolving. However, simulation manufacturers’ agendas may not always be aligned with the requirements of learners and their teachers.9,10 Moreover, there is a danger of creating ever more complex simulators for their own sake, and of losing sight of the wider picture. In particular, learners must integrate a complex set of skills and behaviors in order to become expert clinicians. These include technical skill, communication with patients and team members, decision making, clinical judgment, professionalism, and a host of others.

In this paper we argue for a broader focus, aligning technology, simulator development, and educational design to ensure that simulation-based experiences achieve the outcomes outlined above. In particular, we describe the inclusion of real people (simulated patients, or SPs) within simulations. As far as we are aware, our group at the Faculty of Medicine of Imperial College London is the only group systematically to explore and develop the combination of SPs with inanimate simulators.

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Traditional Simulation Training

Part task trainers form the backbone of simulator-based training. Such trainers represent isolated procedures or parts of the body, allowing the individual components of a practical procedure to be practiced (e.g., venipuncture, bowel anastomosis, endoscope manipulation).10,11 Many are highly convincing and provide excellent opportunities for repeated practice.12–21 Yet we have much to discover about the transferability of isolated technical skills and the optimum conditions for applying them in a clinical setting.1,17,22 In order to make sense, such skills must be applied within their clinical context.

It may be entirely reasonable to break each task down into component steps, each one of which learners must master before attempting to reassemble them. On the other hand, it might be that technical skills are best learned in an authentic context, mirroring more traditional conditions of learning at the bedside or in the operating theater. Cognitive and constructivist learning theories emphasize the critical role of context for learning,23,24 unlike early behaviorist theories, which were oriented toward task acquisition.25,26 Given that technical tasks in clinical practice are rarely performed in social isolation, we argue that highly contextualized learning environments are likely to be more effective for promoting learning. It seems probable, however, that there will be different learning styles, approaches to learning, and intellectual development levels. A “one size fits all” philosophy is likely to fail some learners.27

High-fidelity simulators (as opposed to task trainers) are now well established in anesthesia and emergency medicine training. This field has been led by anesthetists, who have done outstanding work in crisis management and in raising the importance of training for effective teamwork for safe practice.28–36 Such simulations can accurately recreate the conditions of an operating room, using authentic equipment (e.g., monitors, operating lights, anesthetic equipment) to generate a high degree of realism. Important or rare situations, as well as crises, can be presented and practiced.

However, surgical practice is a team effort which involves different disciplines.37–41 Although some simulations are interprofessional, they seldom address the wider picture by ensuring that surgical, anesthetic, and nursing needs are all met during the same training episode. Moreover, by focusing on technical tasks, surgeons in particular can lose sight of the overall perspective that underpins safe practice. They can become fixated on what happens in the operating field, losing track of the need for continuity (preoperatively, intraoperatively, and postoperatively).

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Patient-Focused Simulation Training

A crucial element here is the inevitable artificiality of using simulators (however sophisticated) to take the place of human beings. A promising alternative is the combination of real human beings with high-fidelity simulated environments, or patient-focused simulation (PFS). Relating to a “patient” while performing a procedural task evokes a range of professional behaviors in trainees that aid the suspension of disbelief and encourage “buy-in” to the simulated experience.

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Clinical skills and procedures

Invasive procedures on conscious patients illustrate this point. From the patient’s point of view, a successful intervention requires much more than technical expertise, although such expertise is clearly fundamental to a successful outcome. Effective communication, clinical judgment, professionalism, and an ability to recognize and respond to the unique features of each individual are some obvious requirements.42 Yet part-task trainers, however realistic they may be, can only address technical aspects of performance, and other elements of behavior may be ignored.

Our group has developed the concept of scenario-based assessment for clinical procedures.43–48 By combining a professional actor (SP) with a simulator (physical model or virtual reality [VR] computer), participants are forced to engage with a real human being while performing a procedure. In our experience, this creates a completely different qualitative experience from working with an inanimate simulator. The necessity to relate to a human being appears to activate a wide range of skills and behaviors, forcing the technical task into a clinical context. Over the last five years we have applied the concept of PFS to an increasing range of procedures, exploring its applicability at different levels of complexity.

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Low-complexity procedures

Initial work by our group focused on relatively straightforward procedures such as urinary catheterization and simple wound closure under local anaesthesia.48 Our preliminary studies with undergraduate medical students have been supplemented by further research with over 300 postgraduate doctors, nurses, operating room technicians, and an increasing range of specialist care practitioners.43,46,48–51

More recently we have developed a panel of tasks that samples both technical and patient interaction skills (judgment, communication, professionalism) by presenting 12 clinical scenarios (e.g., venipuncture, urinary catheterization, suturing, intravenous infusion). These represent procedures that newly qualified doctors are expected by the UK General Medical Council and other bodies to perform competently.

In each case, a simulated tissue model or item of medical equipment is combined with an SP who plays a predetermined role, reflecting the breadth of clinical challenges expected of newly qualified doctors (Figure 1). Scenarios include patients who are angry, distressed, frightened, blind, deaf, or unable to speak English. In this Integrated Procedural Performance Instrument, each participant’s performance is mapped onto a matrix of complex behaviors to provide a global picture of that individual’s practice (paper under review). We are currently applying this performance instrument to medical students and to doctors within the first year of qualification and are broadening our range of scenarios to cover key procedures required by health care professionals across a spectrum of experience levels and clinical specialties. Detailed, independent evaluation is key to this development process.

Figure 1

Figure 1

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Mid-complexity procedures

Gastrointestinal endoscopy demands sophisticated manipulative skills combined with high levels of patient-centered awareness. We have combined VR endoscopy simulators with SPs to create authentic scenarios.46 The presence of a conscious patient, who sees the same screen as the operator, requires endoscopists to be able to manage potentially difficult consultations during a procedure.

The SP lies adjacent to the VR simulator with his or her knees drawn up beneath a sheet (Figure 2 and Figure 3). An audiolink to the VR simulator prompts the patient to respond authentically to the endoscopist’s maneuvers, for example, groaning if there is undue force or excessive insufflation of air. This scenario enables the endoscopist to rehearse the integration of complex sets of skills, including how to respond if an abnormality appears.

Figure 2

Figure 2

Figure 3

Figure 3

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High-complexity procedures

We have successfully introduced the combination of SPs and surgical simulators into complex operations.

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Laparoscopic cholecystectomy.

We have used a sophisticated VR minimal access surgery simulator within the simulated operating theater (SOT) environment. In these scenarios the surgeon begins by encountering the “patient” (SP) in a preadmission area, with a full set of clinical notes (i.e., outpatient notes, results of investigations, and drug chart). The patient presents an authentic clinical history, and the surgeon is required to establish a rapport and then gain consent for the operation.

The surgeon then enters the SOT and performs the procedure on the simulator, dealing with any operative problems that may arise. A commercially available simulator (LapMentor) offers numerous variations of a standard operation (laparoscopic cholecystectomy, with anatomical variants), all with force feedback.14 The realism of the simulator is augmented by the head and feet of a resuscitation model, the instrument ports are covered by a layer of artificial skin, and the model is covered by surgical drapes (Figure 4 and Figure 5). The video feed from the computer is connected to a standard laparoscopic stack and other operating team members (anesthetist, runner nurse, and surgeon’s assistant) are present. Furthermore, the scenario enables the surgeon to directly interact with the assistant, who is controlling the view from the laparoscopic camera.

Figure 4

Figure 4

Figure 5

Figure 5

At completion of the procedure, the surgeon must write the operation note, and then visit the “patient” in the recovery room. The patient–doctor interactions are recorded with discreet web-cams, to be analyzed post hoc. Our pilot studies (paper in progress) suggest that contact with the “patient” preoperatively and postoperatively may strengthen the surgical illusion by recreating the conditions of actual practice. Ideally, however, the patient would be present throughout the procedure.

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Carotid endarterectomy.

Increasingly, complex surgical procedures are carried out under local or regional anesthesia, so the patient remains aware throughout the surgery. Surgeons, interventional radiologists, and other clinicians must therefore be able to perform demanding technical tasks while managing the wider clinician-patient interaction, even if something untoward happens. When carotid endarterectomy (CEA) is performed under local anesthetic, for example, the surgeon must remain aware of the patient’s neurological status throughout this complex and demanding operation, in order to recognize incipient stroke and respond accordingly.

Our group has developed a CEA simulation, using SPs (trained using a patient-derived script) in conjunction with a physical CEA model within a high-fidelity SOT (paper under review). A full surgical team accurately recreates the conditions of actual practice (Figure 6). Each surgeon begins by interviewing the “patient” (SP) and gaining consent for operation. While the surgeon prepares for the procedure, the SP is positioned on the operating table, the CEA model is placed alongside his or her neck, and the area covered with surgical drapes. The surgeon, supported by a full team, carries out the procedure on the model. The SP remains in audio contact with a control room using an intercom and on a given signal can simulate an intraoperative stroke.

Figure 6

Figure 6

Participating surgeons’ performance is recorded during crisis and noncrisis scenarios and feedback is given postoperatively. Their perceived stress levels are mapped retrospectively after the simulated operation, using self-report measures, while physiological stress markers are measured throughout the operation. Surgeons receive expert feedback on their technical and nontechnical behaviors immediately after the session. A study of 60 simulated procedures (paper under review) has established the feasibility of the scenario and the high perceived levels of realism it provides.

Preliminary data from our studies suggest that evaluating a surgeon’s performance in the SOT may allow more accurate discrimination of a wide range of required skills, compared with benchtop models that address technical skills only.52 Data on both are currently being evaluated.

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The Benefits of Patient-Focused Simulation

From our experience, we believe that the presence of a real person within a simulated scenario adds enormously to the perceived authenticity of the experience. Involving a human “patient” creates an anchor to each clinician’s actual practice, which in turn taps into a complex web of conscious and unconscious professional responses. These include empathy, communication, clinical judgment, and decision making. Accessing such responses through mannequins and computer simulators alone is not feasible, given the current state of technology. Indeed, there seems a danger that practitioners may learn to “play the simulator.” Yet the ultimate focus of any health care training must be the patient.

We suggest a radical alternative to current curriculum design, using PFS to enrich and augment task-based training and to ensure that concerns for patient safety remain real. At key levels of training and clinical practice (novice, intermediate, advanced), realistic scenarios will allow clinicians to demonstrate the full range of their skills within a safe environment. The patient’s perspective will contribute to a rounded picture of each clinician’s practice, as will that of the procedure/operating team, allowing feedback on all aspects of trainees’ performance. By examining behavior under routine as well as crisis conditions, PFS will hold up a mirror to actual practice. This will allow trainees to map and document their progress, while regular validation of established specialists could confirm excellence or give early warning of problem areas and poor performance.

In contrast to clinical experience, PFS offers “on demand” facilities that can be tailored to the needs of individual learners and accessed at any time. Unlike the current separation between technical skills training (using benchtop models) and crisis management (using high-fidelity simulation), PFS offers a framework for recreating authentic clinical experience across a spectrum of procedures and challenge levels. Each level can provide formative and/or summative assessment, meeting the educational needs of learners and the regulatory needs of the profession and society. This may allow areas of weakness in a clinician’s practice to be identified and rectified before patient safety is compromised.

Potential applications include initial training on invasive procedures for novice clinicians (e.g., bedside procedures, central line insertion), high-level interventional and diagnostic procedures for specialists in training (e.g., coronary stenting, urological interventions), and case-directed simulations for team-based work, where a problematic case is recreated, rewound, and replayed (e.g., ventilatory failure requiring intensive care). Effective, patient-focused training in less complex procedures is required in primary care and other areas of clinical practice. Because procedures are an essential part of most branches of clinical practice, we believe that the principles of PFS can be applied within a wide range of specialties and can be tailored to address the specific requirements of each discipline.

Although such a change will have resource implications, the potential benefits are enormous. Indeed, rapidly increasing numbers of medical students and other health care learners coupled with reduced training trajectories and decreasing opportunities for learning on patients make radical changes inevitable.

We have assembled a body of work that explores the combination of humans as SPs within simulations of varying complexity. These range from simple bedside procedures to highly demanding operations, covering a gamut of clinical situations alongside technical tasks.

Current computer simulations, however technically sophisticated, cannot begin to reproduce authentic human behavior. They are unable to mirror the unpredictability of actual patient encounters. Yet it is managing this human element that characterizes the expert clinician. Tapping into such responses seems a sine qua non for recreating complex, real-world behaviors that require judgment, communication, and professionalism.

From our experience it appears that the presence of a human “patient” within a simulation can trigger authentic responses from trainees on a level that computers or models alone are unable to achieve. This may be the case even when a human encounter is separated in time and space from the simulated procedure, as in the laparoscopic cholecystectomy we discuss above.

We believe that the PFS approach has wide potential applications within many health care disciplines. We therefore make the case for an imaginative synergy between simulated patients and simulator technology. Neither on its own is sufficient, but each can enrich the other to provide a learning experience of great power. We believe that simulation in the 21st century must embed technical excellence within a matrix of authentic professional behavior.

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