Share this article on:

Early Bedside Care During Preclinical Medical Education: Can Technology-Enhanced Patient Simulation Advance the Flexnerian Ideal?

Gordon, James A. MD, MPA; Hayden, Emily M. MD; Ahmed, Rami A. DO; Pawlowski, John B. MD, PhD; Khoury, Kimberly N. MD; Oriol, Nancy E. MD

doi: 10.1097/ACM.0b013e3181c88d74
Flexner Centenary: Article

Flexner wanted medical students to study at the patient bedside—a remarkable innovation in his time—so that they could apply science to clinical care under the watchful eye of senior physicians. Ever since his report, medical schools have reserved the latter years of their curricula for such an “advanced” apprenticeship, providing clinical clerkship experiences only after an initial period of instruction in basic medical sciences. Although Flexner codified the segregation of preclinical and clinical instruction, he was committed to ensuring that both domains were integrated into a modern medical education. The aspiration to fully integrate preclinical and clinical instruction continues to drive medical education reform even to this day. In this article, the authors revisit the original justification for sequential preclinical–clinical instruction and argue that modern, technology-enhanced patient simulation platforms are uniquely powerful for fostering simultaneous integration of preclinical–clinical content in a way that Flexner would have applauded.

To date, medical educators tend to focus on using technology-enhanced medical simulation in clinical and postgraduate medical education; few have devoted significant attention to using immersive clinical simulation among preclinical students. The authors present an argument for the use of dynamic robot-mannequins in teaching basic medical science, and describe their experience with simulator-based preclinical instruction at Harvard Medical School. They discuss common misconceptions and barriers to the approach, describe their curricular responses to the technique, and articulate a unifying theory of cognitive and emotional learning that broadens the view of what is possible, feasible, and desirable with simulator-based medical education.

Dr. Gordon is director, Gilbert Program in Medical Simulation, associate professor of medicine (emergency medicine), Harvard Medical School, and director, Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Hayden is assistant fellowship director, Gilbert Program in Medical Simulation, instructor in surgery (emergency medicine), Harvard Medical School, and assistant director, Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Ahmed is simulation medical director, Summa Health System, Akron, Ohio; at the time of manuscript submission, Dr. Ahmed was a fellow, Gilbert Program in Medical Simulation, instructor in surgery (emergency medicine), Harvard Medical School, and faculty fellow, Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Pawlowski is senior faculty, Gilbert Program in Medical Simulation, assistant professor of anesthesia, Harvard Medical School, and director, Thoracic Anesthesia Division, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Dr. Khoury is a fellow, Gilbert Program in Medical Simulation, and clinical instructor in population medicine, Harvard Medical School, Harvard Vanguard Medical Associates, Boston, Massachusetts.

Dr. Oriol is dean of students, associate professor of anesthesia, Harvard Medical School, and director of faculty development, Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Correspondence should be addressed to Dr. Gordon and Dr. Hayden, Gilbert Program in Medical Simulation, Harvard Medical School, and Division of Medical Simulation, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114; telephone: (617) 726-7622; fax: (617) 724-0917; e-mail:

Flexner wanted medical students to study at the patient bedside—a remarkable innovation in his time—so that they could apply science to clinical care under the watchful eye of senior physicians. Ever since his report,1 medical schools have reserved the latter years of their curricula for such an “advanced” apprenticeship, providing clinical clerkship experiences only after an initial period of instruction in the basic medical sciences. Although Flexner codified the segregation of preclinical and clinical instruction, he was committed to ensuring that both domains were integrated into a modern medical education. The aspiration to fully integrate preclinical and clinical instruction continues to drive medical education reform even to this day. In this article, we revisit the original justification for sequential preclinical–clinical instruction, and we argue that modern, technology-enhanced patient simulation platforms are uniquely powerful for fostering simultaneous integration of preclinical–clinical content in a way that Flexner would have applauded.

To date, we have observed that medical educators tend to focus on the use of technology-enhanced medical simulation in clinical and postgraduate medical education; they devote relatively little attention to the use of immersive clinical simulation among preclinical students. We present an argument for the use of dynamic robot-mannequins for teaching basic medical science in the preclinical curriculum. We discuss common misconceptions and barriers to the approach, describe our curricular responses to the technique, and articulate a unifying theory of cognitive and emotional learning that broadens the view of what is possible, feasible, and desirable with simulator-based medical education.

Back to Top | Article Outline

Flexner and Patient Safety: Then and Now

The Flexner Report offered a medical education paradigm that remains essentially unchanged today. Accredited medical schools would offer two years of standardized scientific instruction, followed by two years of immersive clinical experience, a process designed to enhance and maintain educational rigor across institutions. Although training methods and medical knowledge have evolved over time, the medical school experience has remained relatively static. One reason for such seeming immutability lies in the remarkable achievements of 20th-century medicine: Why change an approach that has been so successful, over so many years?

While some of Flexner's original goals remain as relevant today as they did 100 years ago, the introduction of new training approaches and new technology requires a reevaluation of the optimal training paradigm. Fundamentally, Flexner's preclinical–clinical sequence was established, and has endured, to preserve patient safety; a student ignorant of human anatomy, physiology, and pharmacology cannot practice safe medicine. However, one of the most effective ways to truly understand medical science is through caring for real patients. Flexner understood this duality. After his report, all medical students would have both scientific grounding and bedside instruction, provided in a graduated sequence at an accredited institution of higher education. That sequence, science before practice, not only made practical pedagogical sense but also reiterated the primacy of patient safety in an era when “medical practice clearly lagged behind medical knowledge.”2

In the 21st century, the patient safety imperative is even stronger.3 And the intensive patient care experience, largely inaccessible to the preclinical student previously, can now be realistically accessed through simulation technology.4,5 Dynamic mannequin-robots can now talk, blink, breathe, and move themselves into the very first days of medical school, allowing simultaneous rather than sequential exposure to advanced clinical care.6 This technology can be especially powerful when combined with standardized actor-patients and other problem-based clinical exercises.7 Of course, Flexner had hoped that the third and fourth years of medical school would provide a clinical platform for integration and contextualization of basic science concepts. But the modern clinical clerk cannot, and should not, assume personal and emotional responsibility for complex patient care. Yet only by being immersed in the process as a primary caregiver does full understanding emerge. With simulation, student autonomy in caring for dynamic illness is no longer constrained by the risk of learning on real patients. That autonomy can now be simulated in a realistic yet artificial environment, allowing the curricular position and sequence of such an experience to depend solely on its value in advancing pedagogical objectives.

We have extensive experience with simulation-based instruction, having logged thousands of hours working with preclinical students in our immersive simulation labs. We have established an empirical basis6,8–10 for commenting on the advantages and disadvantages of offering immersive clinical experiences to students beginning in the earliest days of medical school. Our understanding of medical simulation also rests on decades of prior work integrating clinical material into the preclinical curricula worldwide, particularly the use of problem-based learning (PBL), standardized actor-patients, and objective standardized clinical examinations (OSCEs).11–14 We have found the mannequin-simulator to be unique in representing a standardized patient who is always available to “get sick,” exhibiting progressive changes in physiologic condition to the point of severe illness, on demand.

Back to Top | Article Outline

Early Bedside Simulation: Theory and Practice

The Gilbert Program in Medical Simulation at Harvard Medical School (HMS) was founded in 2001 to “bring to life” good teaching cases for medical students at all levels, using high-fidelity patient simulation to foster the Flexnerian ideal of experiential learning in an environment that does not threaten patient safety.15,16 Since the completion of an educational reform process in 2006, the HMS curriculum has formally included dynamic mannequin simulation from the very beginning of medical school. In fact, simulation is now a required part of the new Introduction to the Profession course that students take upon matriculation.10 Each year this initial experience (two days for each student in the simulator lab) is among the most highly rated components of the course.

Of note, the kind of simulation activity we offer in our lab has very little to do with CPR, codes, or procedures; rather, it animates classic patient–doctor encounters that typically occur during an acute episode of a common illness whose pathology cannot be recreated with standardized actor patients (e.g., tachycardia, wheezing, hypotension). In small groups of three to five, students walk into the laboratory and gather around a robot-simulator on a stretcher, who invariably says (in a voice transmitted through the head by an instructor watching from behind a curtain), “Hello, Doctor. I don't feel very well. Can you help me?” The combination of a real voice in the setting of an acute illness serves two purposes: (1) to animate a dynamic interview between a patient and his or her physician in the setting of pathophysiology that clearly defines the illness, and (2) to generate a unique and reliable level of emotional activation and engagement among the students. These two items are often critical companions in enabling efficient and indelible learning in medicine. How many physicians did not truly understand the basic medicine of diabetes, or congestive heart failure, or shock—until they actually took care of patients presenting with these illnesses? Ironically, this level of understanding often comes only after graduation from medical school, typically during internship or early residency.

In codifying a preclinical–clinical medical school training sequence, Flexner, writing at the same time that John Dewey17 was articulating the theory of experiential learning, clearly understood that medical students need clinical experience to amplify and complete their basic science education. Accordingly, over the course of the 20th century, medical educators created clinical correlations and case-based tutorials in the preclinical years, and they provided standardized patients and “subinternships” in the clinical years. Yet, none of these modalities can provide the educational power of perceived autonomy and responsibility for an acutely ill patient. And the opportunity to safely experience such autonomy and responsibility has simply been unavailable to undergraduate medical students until the advent of realistic simulation technology.

Back to Top | Article Outline

Emotion as a Catalyst for Efficient and Indelible Adult Learning

How many physicians can recall a case that forever changed their practice? Writing in the New Yorker magazine, Dr. Jerome Groopman15 speaks to the power of personal experience when he recounts the case of an elderly woman whom he treated as an intern and who subsequently died from complications of a pneumothorax: “As a medical student I had read about pneumothorax, but I had never encountered an actual case. After that incident, the diagnosis occurred to me whenever someone entered the emergency room. I could not look at a chest x-ray without lingering over the area between each lung and the chest wall.” As Dr. Groopman suggests, reading a case description, attending a lecture, participating in a discussion group, or sitting at a computer will rarely, if ever, generate such a potent memory. While all of these methods can be effective at achieving core pedagogical objectives, they simply do not generate the kind of memories that typically shape and solidify individual expertise in medicine. Such expertise often emerges based largely on lessons learned from personal patient encounters in which the practitioner was individually responsible and emotionally invested. The theory of medical simulation we articulate here is rooted in the power of a simulated environment to reliably generate a sense of personal responsibility and emotional engagement in the dynamic care of an ill patient; we feel that this artificial yet realistic platform offers a multimodal sensory experience that can be matched only by an actual encounter with a sick patient, but carries none of the inherent risk of clinical care.

Although our current generation of robot-mannequins is fairly rudimentary by 21st-century standards (these robots cannot replicate skin pallor or temperature, are devoid of facial expression or nuances of body posture, and have limited other physical exam findings), they are remarkable in fostering emotional engagement among health providers during simulated exercises.9,18 Time and again, the same data have surprised us: Most individuals who participate in simulated exercises can reliably suspend disbelief and will find themselves fully engaged in the care of a “plastic dummy.”6,8–10,18,19 This often surprises even the participants themselves. They are nervous and invigorated, confused and surprised, frustrated and determined. In a dedicated qualitative analysis of the simulation experience, medical students consistently confirmed the realistic impact of the encounter,18 offering commentary like “[you] feel like you are interacting with a live patient,” “makes you think on your feet,” “makes you sweat,” and “[provides] lessons that will stick with me.”

Some very simple factors seem responsible for such a human reaction to an inanimate object. For example, the power of the human voice is essential; in our labs, we do not do simulations in which the simulator does not talk and engage the students in a dynamic way. This means that each and every simulation requires an experienced clinician to “throw” his or her voice into the mannequin to replicate an authentic patient encounter. The simple words, “Doctor, I don't feel well. Can you please help me?” are so very powerful to the human ear that we make them a part of every single simulation we do. Putting such a voice into a humanoid figure—even a rudimentary one—whose eyes are blinking, whose chest is rising, whose pulses are palpable, and whose vital signs appear on a beeping monitor, evokes a remarkably robust level of empathy and sense of responsibility for the dynamically ill patient that is simply not possible in other controlled educational venues.

We believe that the core emotional experience of doctoring is one of the most powerful forces in anchoring, integrating, and reinforcing medical learning. A process like simulation that can safety recreate such an emotional response promises remarkable pedagogical benefits, a premise supported by the work of cognitive scientists who study the role of emotion and affect in the learning process.20,21 Consider, for example, a new intern fresh out of medical school who is working on-call in the hospital for the very first time. He is caring for an elderly man with excruciating flank pain from a large kidney stone, and decides to administer a bolus dose of morphine for comfort. Shortly after receiving the morphine, the patient becomes overly sedated and appears quite ill. Surprised and alarmed, the young practitioner calls a code. Amid great anxiety and a flurry of activity, the backup team arrives to revive the patient with a simple reversal dose of naloxone.

Now consider what happened in this young practitioner's mind, almost instantaneously, at the point-of-care. For the rest of his life, he will remember the simple step of narcotic reversal—a memory powerfully anchored by the strong emotions of the moment. These emotions are inherently much more intense than any he would have experienced in his medical school pharmacology lectures. We intuitively sense that learning that occurs in a highly activated state is often more memorable; learning achieved in less activated states may be harder for students to recall and apply when they confront a complex new challenge. The theory of “grounded cognition”22 articulates this notion that “knowledge of the world is ‘embodied,’ or grounded, by a network of broadly distributed, diverse, multimodal states which are encoded during the experience of a given stimulus.... What you know about an object is therefore based, in part, on its affective impact in the past.”20

Preclinical science curricula, as traditionally conceived, typically do not provide “affective impact”; that is, they are not typically grounded in a particularly powerful experience or emotional state. Perhaps that is why in one early medical school simulation experiment,23 clinical students were unable to apply routine basic science knowledge to a case of narcotic overdose. None of the students thought to administer the pharmacologic antagonist, naloxone, even though narcotic reversal is a basic concept that is universally taught, tested, and reinforced across the medical school curriculum. Instead, they intubated the patient—saving his life, but with an invasive procedure which might have been avoided. We hypothesize that embedding and discussing dynamic simulation experiences like this within, for example, a core pharmacology class, might instill an affective anchor to help students to more easily understand, remember, and apply basic knowledge as they transition to clinical practice. Our prior pilot work, suggesting that immersive simulation can accelerate the acquisition of basic science expertise among preclinical students,8 supports this view.

When novice students first arrive at our simulation labs, they are understandably tentative in beginning to interview a robot-mannequin. As the case progresses, they more fluidly converse with the simulated patient and begin excitedly to work through the clinical problem. The subsequent case discussions are driven by genuine intellectual curiosity, a form of intrinsic motivation that represents a powerful commodity in adult learning.24 Adults learn best when they want to (intrinsic motivation), not because they are told to (extrinsic motivation). In preclinical medical education, PBL has emerged to encourage active exploration and understanding of integrated concepts rather than passive memorization of isolated facts.25 In many ways, immersive simulation is the natural extension of PBL; however, in addition to group discussion of a paper case, simulation allows students to “meet” the patient in a dynamic environment. For example, among our first-year physiology students, we have observed that a simple 15-minute simulation exercise in cardiogenic shock can fundamentally enhance their understanding of the Frank–Starling mechanism, a core of basic cardiovascular physiology. Seeing and touching a talking, moving, breathing simulator infuses an intellectual PBL exercise with the spark of emotion, transforming the experience into a memorable episode that allows students to anchor, contextualize, and remember scientific material with a depth and efficiency not otherwise accessible.

Back to Top | Article Outline

Full Immersion as a Mechanism to Accelerate Expertise Among Novices

The approach described above—immersive clinical simulation as a catalyst for medical learning—may initially appear more applicable to clinical clerks and residents than to preclinical students. After all, this is the kind of learning intended by the clinical clerkship and postgraduate training sequence. However, we have found great value in providing complex clinical encounters for preclinical students in the simulator lab from the very beginning of the first year. We introduce simulation early for two reasons: (1) We want students to learn how to translate knowledge into thoughtful action before they enter the live clinical arena, and (2) we think that contextualizing basic science knowledge within a complex clinical framework not only enhances basic science understanding but also accelerates the development of medical expertise. Investigators have suggested that simultaneously integrating basic and clinical science principles into the educational process may produce clinicians who are more diagnostically accurate, especially when confronted with challenging cases.26–29 The concept of knowledge “encapsulation”30 describes how clinicians synthesize biomedical concepts to explain the cause of an illness, helping to ground their diagnostic and clinical reasoning. When teaching medicine using encapsulation principles, clinical concepts must be taught alongside underlying biomedical causes. This approach seems to facilitate greater recall of basic pathophysiologic processes and to improve diagnostic processing speed during clinical encounters.27

Notably, one of the key elements of our approach to simulator-based medical education is that the students are not “mentored” during the exercise at all. That means that novice students will enter the lab to care for a patient complaining of chest pain, for example. If the students have no previous medical experience at all (i.e., they are newly matriculated MD students or dedicated PhD students), we provide, before the exercise, a 30-minute orientation that includes a summary of how to take a patient's history, perform a physical exam, generate a differential diagnosis, obtain confirmatory tests, and identify a treatment plan. Then, we instruct them to depend on their common sense and life experience in guiding their approach to care. We tell the students to pretend that they have graduated from medical school and now are in a hospital emergency department as a group of interns caring for a patient. Students can ask for attending consultation, but, for purposes of the simulation exercise, the consultant is usually focused on helping the students to present a concise summary of the patient's presentation and differential diagnosis—not on guiding them through the case. At the end of the case, an experienced clinical faculty member debriefs with the students, discussing the episode by anchoring their clinical care in basic science principles.

Importantly, we tell our students that this accelerated approach is quite contrary to traditional notions of graduated learning, whereby educators sequence individual building blocks of information to introduce advancing layers of complexity (i.e., chemistry before biochemistry, biochemistry before physiology and pharmacology, and all of these before clinical care and management). This “building block” approach is logical, time-tested, and effective—and it is the principal educational approach that guides our students' preclinical education, except when they enter the simulator lab. In the simulator lab, educators rely on a complementary approach, where they present to the students, explicitly and without performance expectations, advanced clinical material that is purposefully beyond their level of training. If students are not briefed on this pedagogical approach before going into the session, they will be frustrated by their inexperience rather than stimulated by the advanced nature of the exercise. Similarly, teaching faculty must avoid the temptation to focus on routine clinical care algorithms. The goal of the session is not to teach clinical medicine but, rather, to provide a memorable framework in which students may better understand and contextualize core scientific principles. Once the (rather surprised) novice students assume personal responsibility for care—even in such a contrived and seemingly premature circumstance—they rely on one another and on common sense to create a personally powerful experience. This experience of personal responsibility for optimal patient care, in turn, fosters early intrinsic motivation to study and understand basic biomedical or humanistic concepts, ranging from the pathophysiology of end-stage cardiomyopathy to the complexity of end-of-life care. In essence, the simulator exercise allows students, from their earliest days of medical school, to deconstruct an authentic experience into basic principles, providing a synergistic complement to the traditional learning plan.

Back to Top | Article Outline

Programmatic Overview

General approach and logistics

The teaching laboratories of the Gilbert Program in Medical Simulation are located on the site of the historic Surgical Research Laboratory, situated in the heart of the medical school campus. These original laboratories, founded by Dr. Harvey Cushing at the time of Flexner's report, have served generations of faculty and students31 and still look essentially the same as they did when Dr. Joseph Murray conducted his original research on kidney transplantation in the 1950s and 60s. The five original operative suites have been transformed into five modern simulation labs, each equipped with a mannequin-simulator on a stretcher, a whiteboard, a seminar table, and a Web-connected plasma display. Given the labs' proximity to preclinical student lectures, tutorials, and other laboratory venues, the Gilbert Program focuses on preclinical student education. (Clerkship students also have the benefit of simulation facilities stationed across the Harvard-affiliated community of hospitals, which provide an important venue for continued integration of realistic exercises across the continuum of clinical and postgraduate education.)

Simulation curricula include required, selective, and elective components. The simulation lab rarely “creates” new curricula; instead, lab faculty work with course directors to “animate” existing curricula, identifying areas for which adjunctive simulation exercises would provide added value. As mentioned above, in a typical session, groups of three to five students will work together in teams to take care of the simulated patient. The case, which proceeds just like any basic clinical encounter, will begin with a faculty member or clinical specialist throwing his or her voice through the speaker in the mannequin's mouth, and asking for help from the students. From there, the students will interact with the simulated patient, taking a history, performing a limited physical examination, and ordering diagnostic tests and treatments. The students are expected to use their collective knowledge of the biosciences and medicine to create a differential diagnosis. Because exam findings are limited, a dynamic history and vital sign display are essential. A faculty member facilitates the session and then debriefs with the students, discussing the case immediately after the end of the clinical encounter.

The simulator cases range from common presentations of common illnesses, such as community acquired pneumonia, acute cholecystitis, or pediatric fever, to more complex cases such as septic shock or acute myocardial infarction. The faculty members who serve as facilitators allow the students to care for the patients independently, and these facilitators rarely, if ever, intervene to guide medical care, even to augment the students' inherently limited clinical knowledge. The main task of faculty during the case is to keep students from becoming sidetracked or misinformed by imperfections in the simulated environment (e.g., by distorted heart or lung sounds caused by the internal movement of simulator machinery) and to orient them to the clinical setting. Faculty prompting occurs when the supervisor either assumes the role of a primary care physician or specialist “calling in” to ask for a report, or acts as a nurse, pharmacist, respiratory therapist, or other clinical colleague seeking guidance. At the conclusion of each clinical case, the faculty facilitator will discuss the care provided in a manner similar to any routine case conference, but with a focus on understanding the medicine through critical application of basic science principles. This debriefing is the essential task of the faculty and the most critical component of the entire simulation episode. The debriefing faculty member will answer student questions about the case, provide teaching and feedback on the encounter, and discuss targeted areas of scientific and humanistic importance.

Back to Top | Article Outline

Faculty development

A majority of the teaching in the Gilbert Program is performed by a handful of core faculty members, including fellows in medical simulation and selected teaching residents. Experienced simulation instructors can conduct an entire session by themselves without additional support personnel in the room. The ability to independently orchestrate a simulation session requires that the instructor be the voice of the patient, act as the consultant, manipulate the software program for the mannequin, and debrief with the students on the topic of interest. Pairing content experts (MD or PhD instructors) with simulation faculty has been uniquely effective in fostering high-level discussion; however, content experts without simulation training can struggle in the lab without dedicated faculty development and support.

Given the reliance on a core faculty of simulation experts, a principal challenge to our work has been the recruitment, training, and support of program instructors. Dedicated salary support through extramural, fellowship, departmental, or institutional funds is essential. In the absence of such funds, programs must depend on faculty and fellows for whom medical education is a career pathway encouraged and subsidized by their supervisors.

Two key principles have guided our faculty development work in preclinical simulation: (1) Instructors should not intervene to prevent the students from making mistakes, and (2) instructors should not routinely allow the simulated patient to die (unless simulated death is planned as part of a curricular module that specifically focuses on death and dying). This establishes a paradox which can be difficult for new faculty to reconcile. Students must be allowed to experience their own mistakes, and yet we have observed that an unintended “death” in the simulator lab can be unexpectedly traumatic for novice students. Even if a faculty member expertly leads a postmortem debriefing, a simulated death during a routine case invariably diverts all class energy into the death—usually at the expense of the session's original learning objectives. In avoiding this scenario, the faculty must be skillful at supporting the students without promoting a false sense of security. False security (“No matter what I do the patient won't die”), if conveyed, may reinforce erroneous behavior, arguably the most dangerous consequence of the poorly run simulation exercise. For those patient scenarios in which either the action or inaction of the students constitutes a serious error, the simulated patient will become exceedingly ill, if not moribund—and the faculty will often prompt the students to “transfer” the patient to a higher level of care (i.e., an intensive care unit or the operating room). This allows the faculty to preserve the lessons of the case, including the potential fatal outcome, and yet protects those students particularly sensitive to the simulator “dying in front of them.” Using this approach raises fundamental questions about the nature and import of realistic fidelity in medical simulation; this is a key area of research that will help better define both the risks and benefits of learning in a simulated environment.32

Training faculty to allow students to make mistakes without reinforcing erroneous behavior takes dedicated time and effort, but it is relatively straightforward. New faculty are usually ready to provide simulation instruction in their area of clinical expertise after only a few observation and training sessions with experienced program faculty. Our simulation fellows undergo a much more structured faculty development curriculum over the course of a full year. This includes a Certificate of Teaching and Learning with a Concentration in Healthcare Simulation, newly offered by the MGH Institute of Health Professions, which is an interdisciplinary graduate school founded by Massachusetts General Hospital ( Coursework includes the Harvard Macy Institute Program for Educators in the Health Professions (, the Institute for Medical Simulation Comprehensive Workshop (, and a mentored simulation-based teaching practicum facilitated by a doctoral-level educationalist.

Back to Top | Article Outline

Curricular integration

Introduction to the profession.

In the summer of 2005, we conducted a weeklong medical simulation program with high school and college students, designed to explore the feasibility of full clinical immersion for teaching complex biomedical concepts to novice students.10 The success of this program inspired one of the medical school curricular reform committees to consider a similar program for the incoming medical and dental students. As of 2006, all matriculating medical and dental students spend two days of their first two weeks of school in the simulation laboratory, working in small teams to manage complex cases and to reflect on the interdependency of medicine, science, humanism, teamwork, communication, and critical thinking in health care.

Back to Top | Article Outline

Preclinical simulation.

Several of our first- and second-year preclinical course directors collaborate with the simulation laboratory to provide mandatory or optional sessions to complement didactic and other laboratory work in the courses. Cases can focus on relevant clinical anatomy to complement the students' cadaver dissections, using a tension pneumothorax, for example, to animate key tissue planes. In the first-year physiology course, students compare and contrast simulated cases of inferior and anterior myocardial infarction to better understand preload, afterload, and other cardiac physiology concepts. In the second year's pathophysiology course, simulator cases on community acquired pneumonia and acute respiratory distress syndrome complement coursework in pulmonary pathology. We have also used the simulation laboratory to teach pharmacology concepts previously demonstrated in animal laboratories, such as the dramatic effect of epinephrine on heart rate and blood pressure.

Back to Top | Article Outline


In recent years, the largest proportion of the teaching in the Gilbert Program has occurred during voluntary simulation sessions, attended by independent study groups. The groups typically schedule one-hour weekly or biweekly meetings. A simulation faculty mentor is assigned to each group and orchestrates every session. The faculty mentors design, run, facilitate, and debrief one or two clinical cases during each session. Students may request cases (e.g., a case of respiratory distress if the concept of ventilation–perfusion mismatch is not clear to them after a lecture), cases may complement current classroom topics (e.g., an anaphylaxis case during their immunology block), or faculty mentors may select a case from a random assortment of cases in the Gilbert Program's case bank. In the 2008–2009 academic year, as many as 30 student groups (approximating a significant proportion of all preclinical students) requested weekly sessions. The cases used during these voluntary sessions are chosen by the simulation mentor in consultation with his or her student groups.

Back to Top | Article Outline

Clerkship simulation.

On finishing their preclinical sequence, today's clerkship students spend less time with the kind and volume of sick patients who would have previously provided a wealth of basic science correlates. This is partly due to more preventive and effective modern medical practices, which result in less endstage pathology for students to observe, and partly due to the modern culture of safety, which now (rightly) precludes a level of student independence that many 20th-century trainees may have experienced. One of the long-standing curricular offerings of the Gilbert Program is a yearlong course of simulation sessions for students assigned to the Cambridge Integrated Clerkship.33 In this course, selected cases animate common clinical presentations that faculty directors feel the students should understand by the end of the third year. This provides a longitudinal venue for integration of basic science and clinical concepts as students prepare for residency. Other Harvard-affiliated clerkships and clinical electives now offer a variety of simulator-based programming, including a weeklong immersive experience for third-year surgical students at the Massachusetts General Hospital. Before graduation, all medical students participate in a simulator-based geriatrics OSCE as part of the fourth-year comprehensive clinical examination.

Back to Top | Article Outline

Postgraduate simulation.

Because patients present for care according to time and chance, each trainee will have a variable clinical experience. Simulation provides a powerful mechanism to mitigate that variability, particularly in the postgraduate years. While the duration of medical school training remained static over the 20th century, postgraduate programs have steadily increased in length, partly to accommodate constant growth in medical knowledge; theoretically, ever-increasing years of residency and/or fellowship training allow trainees to learn more and more, and to manage the full range of patients before independent practice. However, into the 21st century, particularly with the advent of resident work hours restrictions, the postgraduate sequence cannot expand ad infinitum. Educators, directors, and administrators must begin to explore nontraditional models of education that foster more efficient transfer of information from the very earliest days of medical training.

Back to Top | Article Outline

Barriers and Challenges

Some faculty with whom we discuss simulation are concerned that a “plastic machine” will replace rich student interactions with live patients, and that such reliance on technology undervalues the complexity of clinical practice. Simulation can never replicate the clinical encounter, nor should it. Indeed, as noted earlier, the very nature and import of “high fidelity” in the field of medical simulation remains a subject of great debate.32

In our lab, we have identified simple ways to improve fidelity in the face of limited technology. For example, all staff who provide the voice of the patient must have some clinical practice background. This ensures that personal nuances of the interview are realistic (“Doctor, could you please call my wife?”) and allows the staff to immediately correct any faulty impressions created in the simulated environment. For example, if the chest wall speaker that produces heart sounds is not working properly, a student may begin to think seriously about the pathophysiologic implications of distant heart sounds. This may be a robust thought process, but it will sidetrack the scenario. Staff can either verbalize the proper findings or arrange to play the sounds from a separate speaker. It will be important for future simulation work to study the unintended consequences of scenario manipulation. Sometimes heart sounds will in fact be hard to discern on a real patient, and the student needs to learn how to handle uncertainty when there is no corrective oversight to explain the findings.

For these reasons, dedicated faculty outreach and education (principally through live demonstrations) are critical in clarifying the programmatic purposes and capabilities of simulation, as well as the expectations of faculty and learners in the face of the chosen learning objectives. The faculty must see, hear, and feel the potential of the technology for themselves. If the goal is to teach advanced clinical exam skills, the faculty will often be sorely disappointed. The current generation of full-body simulators, expensive and sophisticated as they may be, have relatively limited physical exam capability. However, even the current rudimentary technology can provide the emotional and cognitive fidelity required to promote sophisticated critical thinking and practice—the core of our program.

Any simulation environment requires significant resources to maintain, and stakeholders must perceive that the benefits justify the cost. In our own program, we need five fully staffed simulator rooms running simultaneously to service an entire class cohort of up to 200 students. Although we can cycle 50 students per hour through the lab, scheduling and staffing logistics remain a significant challenge. Without question, successful integration requires the support of course directors who are fully vested in allocating scarce class time for collaborative simulation effort.

Back to Top | Article Outline

In Sum

Flexner strongly believed that the preclinical laboratory should be an important component of medical education. Although his report codified a preclinical–clinical curricular sequence, he likely could not have imagined the possibilities in medical education available as a result of medical simulation. The simulation laboratory now allows clinical experience to be safely incorporated into the curriculum from the first days of medical school, providing early scaffolding to facilitate enhanced understanding and application of medical knowledge.

On the basis of our experience, we think that immersive clinical simulation in the preclinical years not only provides a standardized and efficient venue for presenting core clinical correlates, but that it may also accelerate the development of translational scientific expertise. Simulation uses emotion as a catalyst for recall and integration of knowledge without any risk to patients or providers. This mechanism—personal clinical experience to solidify scientific learning—is the very core of the Flexnerian ideal.

According to Flexner, “There is no cement like interest, no stimulus like the hint of a coming practical application.”1 We believe that if simulation laboratories were available in Flexner's time, they would have figured prominently in his report.

Back to Top | Article Outline


The authors would like to acknowledge the generosity and vision of G.S. Beckwith Gilbert and Katharine S. Gilbert of the Gilbert Family Foundation, who have steadfastly supported and encouraged this work. They would also like to thank Suresh Venkatan, MBBS, and Wayne Stathopoulos, NREMT-P, along with former Gilbert Program fellows and colleagues at the Institute for Medical Simulation in the Center for Medical Simulation in Cambridge, Massachusetts, who through the years have been invaluable in helping to advance the work presented here.

Funding/Support: Funding for this work was provided by the Gilbert Family Foundation.

Other disclosures: None.

Ethical approval: Not applicable.

Previous presentations: Elements of this work were presented to a Joint Session of the Association of American Medical Colleges (AAMC) Council of Deans and the Group on Information Resources, AAMC Annual Meeting, November 6, 2005, Washington, DC.

Back to Top | Article Outline


1 Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Boston: Updyke; 1910. Available at: Accessed November 29, 2009.
2 Ludmerer KM. Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999.
3 Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
4 Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Qual Saf Health Care. 2004;13(suppl 1):i11–i18.
5 Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004;13(suppl 1):i2–i10.
6 Gordon JA, Oriol NE, Cooper JB. Bringing good teaching cases “to life”: A simulator-based medical education service. Acad Med. 2004;79:23–27.
7 Kneebone R, Nestel D, Wetzel C, et al. The human face of simulation: Patient-focused simulation training. Acad Med. 2006;81:919–924.
8 Gordon JA, Brown DF, Armstrong EG. Can a simulated critical care encounter accelerate basic science learning among preclinical medical students? A pilot study. Simul Healthc. 2006;1:13–17.
9 Gordon JA, Wilkerson WM, Shaffer DW, Armstrong EG. “Practicing” medicine without risk: Students' and educators' responses to high-fidelity patient simulation. Acad Med. 2001;76:469–472.
10 Gordon JA, Oriol NE. Perspective: Fostering biomedical literacy among America's youth: How medical simulation reshapes the strategy. Acad Med. 2008;83:521–523.
11 Harden RM, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence using objective structured examination. BMJ. 1975;1:447–451.
12 Barrows HS. An overview of the uses of standardized patients for teaching and evaluating clinical skills. AAMC. Acad Med. 1993;68:443–453.
13 Moore GT, Block SD, Style CB, Mitchell R. The influence of the New Pathway curriculum on Harvard medical students. Acad Med. 1994;69:983–989.
14 Peters AS, Greenberger-Rosovsky R, Crowder C, Block SD, Moore GT. Long-term outcomes of the New Pathway Program at Harvard Medical School: A randomized controlled trial. Acad Med. 2000;75:470–479.
15 Groopman J. A model patient: How simulators are changing the way doctors are trained. New Yorker. May 2, 2005:48–54. Available at: Accessed October 8, 2009.
16 Freidrich MJ. Practice makes perfect: Risk-free medical training with patient simulators. JAMA. 2002;288:2808, 2811–2812.
17 Dewey J. Chapter 12: Thinking in education. In: Democracy and Education. Available at:∂=12&division=div1. Accessed October 8, 2009.
18 Takayesu JK, Farrell SE, Evans AJ, Sullivan JE, Pawlowski JB, Gordon JA. How do clinical clerkship students experience simulator-based teaching? A qualitative analysis. Simul Healthc. 2006;1:215–219.
19 Gordon JA, Tancredi DN, Binder WD, Wilkerson WM, Shaffer DW. Assessment of a clinical performance evaluation tool for use in a simulator-based testing environment: A pilot study. Acad Med. 2003;78(10 suppl):S45–S47.
20 Bliss-Moreau E, Feldman Barrett L. What's reason got to do with it? Affect as the foundation of learning. Behav Brain Sci. 2009;32:201–202.
21 Barrett LF, Russell JA. The circumplex model of affect. In: Sander D, Scherer K, eds. The Oxford Companion to Emotion and the Affective Sciences. New York, NY: Oxford University Press; 2009.
22 Barsalou LW. Grounded cognition. Annu Rev Psychol. 2008;59:617–645.
23 Gallagher ML, Pawlowski J, Raemer DB. Is the simulator an effective tool for medical student learning in the clinical clerkship? clerkship? (abstract) J Clin Monit Comput. 1998;14:513–514. Video available at: Accessed December 1, 2009.
24 Ryan RM, Deci EL. Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemp Educ Psychol. 2000;25:54–67. Available at: Accessed September 28, 2009.
25 Norman GR, Schmidt HG. The psychological basis of problem-based learning: A review of the evidence. Acad Med. 1992;67:557–565.
26 Woods NN, Neville AJ, Levinson AJ, Howey EH, Oczkowski WJ, Norman GR. The value of basic science in clinical diagnosis. Acad Med. 2006;81(10 suppl):S124–S127.
27 Woods NN. Science is fundamental: The role of biomedical knowledge in clinical reasoning. Med Educ. 2007;41:1173–1177.
28 Woods NN, Brooks LR, Norman GR. It all makes sense: Biomedical knowledge, causal connections and memory in the novice diagnostician. Adv Health Sci Educ Theory Pract. 2007;12:405–415.
29 Woods NN, Brooks LR, Norman GR. The role of biomedical knowledge in diagnosis of difficult clinical cases. Adv Health Sci Educ Theory Pract. 2007;12:417–26.
30 Schmidt HG, Rikers RM. How expertise develops in medicine: Knowledge encapsulation and illness script formation. Med Educ. 2007;41:1133–1139.
31 Tilney NL, Tilney MG. Joint ventures. Harv Med Alumni Bull. Spring 2004:51–55. Available at: Accessed October 8, 2009.
32 Dieckmann P, Gaba D, Rall M. Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc. 2007;2:183–193.
33 Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School–Cambridge integrated clerkship: An innovative model of clinical education. Acad Med. 2007;82:397–404.
© 2010 Association of American Medical Colleges