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Simulation in Healthcare

Growin’ up*

Scerbo, Mark W. PhD

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doi: 10.1097/SIH.0000000000000190
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Simulation in Healthcare premiered in 2006 providing a forum for educators, researchers, clinicians, and developers to publish their scholarly work in an emerging arena, representing the intersection of simulation and healthcare. Under the leadership of Dr. David Gaba, the founding editor-in-chief (EIC), the journal has enjoyed tremendous success. It is the most revered peer-reviewed journal of its kind and one of the most successful accomplishments of our society. During Dr. Gaba's tenure, the journal was accepted for indexing by PubMed in 2008. Author interest in publishing surged, requiring an increase from 4 to 6 issues per year in 2010. The journal received its first Thomson Reuters Journal Impact Factor rating of 2.036 in 2011. At present, Simulation in Healthcare is the official journal for 21 national, international, and professional associations or societies. The journal is now in its 11th year and published its first special theme issue in April. This is a remarkable record of achievement by any measure and one in which all members of our society can take pride. We owe Dr. Gaba a debt of gratitude and wish him much success in his future endeavors.

I am humbled and honored to succeed Dr. Gaba as the second EIC of this prestigious journal. I come into this role with a different background than my predecessor. I am a human factors psychologist by profession. Human factors psychology is a synthesis of psychology and engineering. It is a discipline concerned with how to improve individual or team performance by creating a better fit between humans and their technology, with an emphasis on training, assessment, safety, and better design of tasks and equipment. Initially, I studied aviation and military simulation systems but shifted my focus toward healthcare around 2003. I knew that simulation provided a safe means to study human fallibility and improve human resilience in other high-risk domains and believed that healthcare was no exception. Since then, I have been fortunate to conduct research and collaborate with clinicians and healthcare providers from many different specialties including: anesthesiology, dermatology, emergency medicine, family medicine, interventional radiology, nursing, obstetrics and gynecology, oncology, pediatrics, sonography, surgery, as well as physician's assistants and standardized patients. Most important, in my new role as EIC, I am supported by an outstanding and distinguished team of associate editors, editorial board members, and peer reviewers whose expertise spans a diverse spectrum of clinical and technical specialties. I am also grateful to have the sage council of Dr. Gaba who will remain on the editorial board as founding EIC.

In addition to healthcare simulation, I am also involved in the training and education of simulation professionals. My university recognizes the pervasive and multidisciplinary nature of modeling and simulation and established an interdisciplinary steering committee with representatives from every college. I currently serve as chair of this steering committee, which is tasked with managing and guiding the pedagogical concerns of modeling and simulation across the university, including 8 modeling and simulation certificate programs in business; computer science; education; health sciences; international studies; math; modeling, simulation, and visualization; and human factors.


Who Are We and Who Do We Want to be?

The journal is “growing up.” We have entered our teen years. As children become adolescents, they begin to do more exploring, take more risks, and try to gain a better understanding of themselves. The psychologist, Erik Erikson, argued that adolescents often go through an identity crisis.1 They begin to ask questions about who they are, where they belong, how they fit in, and what they want to be. Those who are successful at resolving the issues surrounding their identity have greater confidence in themselves and are better prepared to enter adulthood. Perhaps, this is a good time to take measure of “who we are” and “who we want to be.”

Who Are We?

Well, we can be defined largely by what we publish. To do some introspection, I reviewed the last 3 full years of the journal (2013–2015), a representative snapshot of who we are now. I categorized the content by type of article, country of origin, primary themes, clinical specialty addressed, expertise level targeted, and the primary type of simulation addressed.

During this interval, we published 169 articles. Empirical investigations account for 46% of articles published, the largest percentage. The next largest category is technical reports accounting for 17% of the content. Commentary, reviews, special articles, editorials, letters to the editor, and case scenarios, each account for 5% to 8% of the content.

Most (61%) of the content originates in the United States or includes US authors, but we are indeed an international journal. Authors from Canada (11%), Australia (6%), Denmark (4%), and the United Kingdom (4%) constitute the next largest contributors, but we had authors from 21 other nations.

Classifying the topics of the articles is a little more challenging; however, a reasonable set of themes is shown in Table 1. This is not a rigorous classification scheme, and the themes are not necessarily mutually exclusive, but it does convey a general picture. Articles on assessment, education/training, and technology account for approximately 63% of our content. This number increases to 84% if articles on validation, teams, human factors issues, simulation theory, and patient safety are added to the count. By contrast, articles on medical knowledge, patient outcomes, and patient care account for only a small fraction of our content, approximately 6%.

Classification of Themes Published (2013–2015)

Turning to clinical specialty, most of our content addresses anesthesiology (16%). Emergency medicine, general medicine, and surgery, each account for 11% of the articles, followed by nursing (10%), pediatrics (9%), and obstetrics and gynecology (8%). Other specialties with more than 1 article during this period include cardiology, EMTs/paramedics, internal medicine, and radiology. Approximately 76% of the articles address practicing clinicians and residents. The remainder focuses on students or expertise at multiple levels. Only 1 article employed patients as their primary participants.

Approximately 50% of the articles address mannequin or physical model simulators. The next largest percentage (17%) addresses standardized patients or actors. Research on virtual reality (VR), hybrid systems, or multiple formats accounts for 26% of the articles. However, we have occasionally published articles on animal models, cadavers, and center or hospital operations.

In sum, we publish a lot of research on how to use simulation for training and assessment, ways to improve the simulation experience for learners, and methods for developing and evaluating new simulation systems. In some respects, our identity seems to have a strong human factors foundation with a healthcare focus. We address a fairly broad range of clinical specialties but tend to publish perhaps most in areas where the simulation systems are more plentiful and have histories that reach further back. Finally, most of what we publish originates in the United States, but nearly 40% of our content comes from outside the United States or includes international authors.

Who Do We Want to be?

As we look ahead, we want to continue doing what we do well. One of the strengths of the journal is its diversity: diversity of topics published, specialties addressed (clinical, instructional, and technical), varieties of simulation, and membership among the associate editors and editorial board. We want to continue to attract submissions from across the broad spectrum of healthcare simulation. New developments and rigorous research in one application or specialty area informs the entire community. We want to maintain diversity among the ideas and opinions we publish. We also want to continue to encourage diversity within the editorial and reviewing processes of the journal.

Another strength of the journal is our roster of international partners. Although we are the official journal for many national associations, we do not receive many articles from members of these associations. Our international partners are a tremendous resource for the healthcare simulation community and the journal, and we need work harder to encourage their participation.

Introspection can be critical, so we must also think about areas where we could do better. One important area concerns the impact of simulation on patients. In their 2011 review, McGaghie et al2 described 3 phases of translational science research. The first phase (T1) focuses on science that moves basic laboratory findings into the clinical research paradigm (eg, do theories of education and training predict outcomes in simulation research?). In the second phase (T2), results from clinical research are evaluated for their effects on patients. What is the impact of results obtained in simulation studies on patient outcomes and do they inform clinical practice? The last phase (T3) addresses science aimed at greater public health concerns. What can be done to improve prevention or better manage the health needs of the population? As noted previously, much of the content we publish is at the T1 level. Although much research is still needed at the T1 level, it is time to begin looking beyond our simulation centers and take on the challenge of translational studies at the T2 and T3 levels.

We should not shy away from material that originates outside of healthcare that has meaning for our community. Lessons learned in other domains with a history of simulation can be invaluable to a community that is still young. For example, the military and other high-risk domains often describe simulations as live, virtual, and constructive.3 According to this classification scheme, live simulations are those in which real people operate real equipment. In virtual simulations, real people interact with simulated systems (ie, physical or virtual models). Constructive simulations are qualitatively different. They represent software specifically developed to simulate people (agents) interacting within simulated systems. Many in our healthcare simulation community are familiar with live and virtual forms of simulations that incorporate mannequins, part-task trainers, VR systems, and standardized patients. To date, there has been less interest in constructive simulations; however, there is great potential for these types of systems. They can be used to model the delivery of healthcare services, inform providers and administrators about the potential impact of policies, and incorporated into live and virtual simulation scenarios to enhance the environmental and operational context.

Furthermore, we need to embrace the power that simulation offers beyond training providers. In many other high-risk domains, simulation is the conduit through which technological advances are evaluated. In aviation, new hardware and software are often evaluated in flight simulators and test aircraft before seeking US Federal Aviation Administration approval. This approach is beginning to gain acceptance in healthcare as simulation centers work with medical device manufacturers to provide context-based user evaluations of equipment before seeking US Food and Drug Administration approval.

Change is inevitable. To the extent that change can be better managed with simulation, it can provide smoother and safer transitions that serve the healthcare community and the patients. For example, Ventre and coworkers4 conducted in situ simulations to evaluate the operational readiness of a children's hospital obstetric unit before it opened. Over the course of several days, they uncovered multiple deficiencies in equipment, staffing, and communication and were able to have them addressed before accepting patients.

Technological changes on the horizon are coming faster and will have profound effects on patient care and healthcare. Consider VR. The delivery of games, entertainment, and information via VR systems is now becoming commercially viable. A wide variety of choices are available from moderately expensive systems specifically designed for developers and enthusiasts to systems for less than US $100 that can be coupled to a smart phone. The potential for offering providers and patients VR content and simulations is unprecedented, and they will soon expect it.

Ultrasonography is another example. Portable and even handheld systems allow clinicians to evaluate their patients rapidly and more thoroughly. Ultrasonography is becoming pervasive and is now being incorporated into undergraduate medical curricula.5 Although it is debatable whether portable ultrasonography systems will replace the stethoscope as a diagnostic tool,6 it is clear that the technology is creating a great need for simulation-based training systems. Several commercial simulation systems are currently available, and it is likely that the genuine ultrasonography systems will continue to develop in parallel with simulation systems.

Perhaps most important, the robots are rising. They are not limited to vacuums in our homes. Google's driverless cars have been tested on the roads since 2012. Artificial intelligence in software based on algorithms and neural networks allows you to talk to your phone and directs your attention to items that should appeal to you when surfing the Internet. Cybathon 2016, the first Olympic competition for people with physical impairments and their robotic-assisted prosthetics, will be held in Zurich this October. Many in the healthcare community may be familiar with robot-assisted surgery (eg, the da Vinci Surgical System by Intuitive Medical, Inc); however, these systems are actually telerobotic systems that require a human to operate them. By contrast, researchers have reported on an autonomous robotic system for soft tissue surgery driven by a plenoptic 3-D, near-infrared fluorescent imaging system and a suturing algorithm derived from surgeons.7 Their initial results showed better performance of the robotic system over expert surgeons using a robot-assisted system. An autonomous surgical system is qualitatively different from a telerobotic system because most of the authority over its actions has been delegated to the system. In other high-risk domains such as aviation, the advantages of automated systems are often accompanied by well-documented opportunities for human error.8 Simulation has played an important role in revealing potential unintended consequences of highly autonomous systems and will be critical for evaluating automated systems in healthcare.

Finally, let's not lose sight of the fact that what we do matters. In the April 2016 issue of this journal, we published a set of 6 articles and 2 editorials on a special theme: the management of highly communicable diseases. The articles address a range of uses of simulation to educate workers on the spread of disease, how to prepare for an outbreak, lessons learned from exercising protocols and their implications for safety, as well as several case scenarios for readers interested in conducting exercises in their own institutions. One could argue that this collection of articles represents the journal at its finest. The work transcends any specialty area or any specific simulation method. It provides state-of-the-art information that has meaning for healthcare providers, workers, and patients across the globe. It can be considered T3-level research that informs the greater public. Although we cannot predict where and when another outbreak will occur, we have provided a starting place for people to turn for information when the next outbreak does occur.


In his inaugural editorial, Gaba said, “A new journal is a work in progress.”9 We may be a little older, but that has not changed. There is still work to be done. Thus, I invite all of you to participate in the next phase of our history. Act like teenagers. Explore new applications for simulation. Question the status quo. Make new friends and reach out to other healthcare and simulation communities. Simulate the future to guide the present. Be fearless in your ideas for using simulation to improve healthcare. Send us your best work. Give us your feedback. Volunteer to review articles. Most importantly, help continually reaffirm our identity: Simulation in Healthcare, the finest journal of its kind.


1. Erikson E. Identity, youth and crisis. New York: Norton; 1968.
2. McGaghie WC, Draycott TJ, Dunn WF, Lopez CM, Stefanidis D. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011;6:S42–S47.
3. Testa J, Adlinger M, Wilson K, Carauna C. Achieving standardized live-virtual constructive test and training interactions via TENA. Interservice/Industry Training, Simulation, and Education Conference (I/ITSEC) 2006:1–10.
4. Ventre KM, Barry JS, Davis D, et al. Using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit. Simul Healthc 2014;9:102–111.
5. Miller GT, Scerbo MW, Zybak S, et al. Learner improvement from a simulation-enhanced ultrasonography curriculum for first-year medical students. J Ultrasound Med in press.
6. Wittenberg M. Will ultrasound scanners replace the stethoscope? BMJ 2014;348:g3463.
7. Shademan A, Decker RS, Opfermann JD, Leonard S, Krieger A, Kim PCW. Supervised autonomous robotic soft tissue surgery. Sci Transl Med 2016;8:337ra64.
8. Parasuraman R, Riley V. Humans and automation: use, misuse, disuse, abuse. Hum Fac 1997;39:230–253.
9. Gaba DM. The future's here. We are it. Simul Healthc 2006;1:1–2.
© 2016 Society for Simulation in Healthcare