R E S E A R C H R E P O R T

‘‘Practicing’’ Medicine without Risk: Students’

and Educators’ Responses to High-fidelity
Patient Simulation
James A. Gordon, MD, MPA, William M. Wilkerson, MD, David Williamson Shaffer, PhD, and
Elizabeth G. Armstrong, PhD

ABSTRACT

Purpose. To understand the responses of medical stu- were: Overall Assessment (i.e., ‘‘generally good experi-
dents and educators to high-fidelity patient simulation, a ence’’); Process Descriptors (i.e., ‘‘very realistic’’); Teach-
new technology allowing ‘‘practice without risk.’’ ing Utility (i.e., ‘‘broad educational tool’’); Pedagogic Ef-
Method. Pilot groups of students (n = 27) and educators ficacy (i.e., ‘‘promotes critical thinking’’); and Goals for
(n = 33) were exposed to a simulator session, then sur- Future Use (i.e., ‘‘more practice sessions’’). Thirty percent
veyed with multiple-choice and open-ended questions. of students and 38% of educators were impressed by the
Open-ended comments were transcribed and coded. They realism of the simulator, and they (37% and 25%, re-
were analyzed for recurring themes and tested for inter- spectively) identified the ability to ‘‘practice’’ medicine as
rater agreement. An independent focus group subse- the primary advantage of simulation. The focus group
quently performed higher-level thematic analysis. rated cost as the major current disadvantage (66%).
Results. Overall, 85% of the students rated the session Conclusions. Students’ and educators’ responses to
excellent and 85% of the educators rated it excellent or high-fidelity patient simulation were very positive. The
very good. Over 80% of both groups thought that simu- ability to practice without risk must be weighed against
lator-based training should be required for all medical stu- the cost of this new technology.
dents. Analytic categories derived from written comments Acad. Med. 2001;76:469–472.

Dr. Gordon is director, MEC Program in Medical It is 3 AM at your teaching hospital in it, she wonders, before she becomes the in-
Simulation, instructor in medicine, and Morgan–
Zinsser Fellow in Medical Education, Harvard Med- July, about ten years from now. A new tern?
ical School, Department of Emergency Medicine and third-year medical student is excited by her The next call night is not so busy, and
Institute for Health Policy, Massachusetts General first day on call with the Medicine team. the student recalls being told about the
Hospital and Partners HealthCare System, Center for
Medical Simulation and Harvard–Macy Institute, They just finished caring for a patient with ‘‘practice room.’’ She punches in the se-
Boston. Dr. Wilkerson is clinical assistant professor, congestive heart failure in the intensive care curity code and enters to see a full-scale
Department of Emergency Medicine, Medical Edu- unit (ICU). The student had watched the mannequin on a gurney connected to an
cation Scholars Program, Medical Readiness Trainer
Team, University of Michigan Health System, Ann senior resident and intern resuscitate the IV and ICU monitor—a desktop com-
Arbor, Michigan. Dr. Shaffer is lecturer on educa- patient, then exhaustedly return to sleep. puter and a projector system sit in the cor-
tion, Technology in Education Program, Harvard The student, still wide-awake, is amazed ner. She turns on the computer, and selects
Graduate School of Education, Cambridge, and (for-
merly) director of education, Center for Integration but confused by the myriad recent events ‘‘congestive heart failure.’’ A projected ho-
of Medicine and Innovative Technology, Boston. Dr. —the exam, the endotracheal intubation, lographic image suddenly blankets the
Armstrong is director of medical education and as- the invasive hemodynamic monitoring, the room, transforming the space into a virtual
sociate professor of pediatrics (Medical Education),
Harvard Medical School, and director, Harvard– medical therapy. She cannot quite put it all ICU, complete with dynamic sounds,
Macy Institute, Boston, Massachusetts. together, even after reading through her voices, and images.1 The mannequin starts
Correspondence and requests for reprints should be ‘‘on-call’’ manual. Rounds the next morn- moaning, its chest heaving, and exhaust-
addressed to Dr. Gordon, Division of Emergency ing are rushed and the student is called edly complaining of shortness of breath.
Medicine, Harvard Medical School, Department of away to a lecture. Even after reading a bit The student feels a fast thready pulse and
Emergency Medicine, Massachusetts General Hos-
pital, 55 Fruit Street, CLN 115, Boston, MA more and discussing it with her intern, she glances up at the monitor. Startled, she lis-
02114-2696; e-mail: 具 jgordon3@[Link]典. never does quite get it—would she ever get tens to the heart and lungs and hears au-

ACADEMIC MEDICINE, VOL. 76, NO. 5 / MAY 2001 469

dible crackles to the apex. As the patient begun to consider the enormous impli- ences. Section 1 was multiple-choice,
becomes unresponsive, a nurse’s voice re- cations for using high-fidelity patient asking participants to: (a) rate their
peats in the background, ‘‘We need to in- simulation in general medical educa- overall experience in the simulator (ex-
tubate!’’ Instantly, a video tutorial begins tion.3 As a first step in exploring the cellent, very good, good, fair, or poor),
to appear, complete with live footage of a potential of this new technology, we and (b) indicate whether simulator ex-
tube passing through the vocal cords. ‘‘Are conducted a qualitative analysis of stu- ercises should be a component of med-
you ready?’’ prompts the nurse, ‘‘The dents’ and educators’ reactions to pa- ical school training (mandatory, volun-
blood pressure is falling . . .’’ And the les- tient simulation to help better under- tary, unsure, or not at all). Section 2
son continues. stand the essential human responses to asked for general written comments. Ed-
The next morning on rounds, the team
this educational technique. ucators were specifically prompted to
is impressed with the student’s understand-
ing of congestive heart failure, especially
her discussion of wedge pressures (she had METHOD
Table 1
practiced floating a pulmonary artery cath-
eter the night before.) ‘‘Pretty soon,’’ says All third- and fourth-year medical stu-
the intern, ‘‘you’ll be ready for my job!’’ dents completing an emergency medi- Responses of 27 Medical Students to
their Experience with a High-fidelity
cine clerkship at the University of
Patient Simulator, 1999
Medical students are usually excluded Michigan Medical School in the spring
from the primary management of of 1999 (n = 21) participated, along Qualitative Comment Students
acutely ill patients, yet such experiences with clerks responding to an e-mail in- Groupings* % (No.)
can be vital to the integration of basic vitation (n = 6). Medical educators at- Overall assessment 48 (13)
and clinical sciences and to the devel- tending the Harvard–Macy Institute Generally good experience 41 (11)
opment of basic medical skills. Not un- Program for Physician Educators at Har- Generally useful experience 11 (3)
til internship do many young doctors vard Medical School in May 1999 com-
experience first-hand the anxiety of be- prised the educator population (n = 33). Process descriptors 59 (16)
Realistic experience 30 (8)
ing responsible for very sick patients, We used two comparable simulators Impact of pressured envi-
but by this point the risk of medical er- [Medical Education Technologies Inc. ronment 19 (5)
ror may be unnecessarily high. (student portion) and MedSim Limited General process comments 19 (5)
Over the last decade, however, com- (educator portion)]. Limitations of scenario 11 (3)
puter technology has merged with med- The medical students were individu- Personalizations or other
statements 4(1)
ical science to create high-fidelity pa- ally invited into the simulation room,
tient simulators. Originally designed to where an instructor mentored the stu- Teaching utility 30 (8)
train anesthesiologists for crisis manage- dents through two scenarios: (1) a Good teaching or learning
ment in the operating room,2 the sim- trauma patient with hypovolemic shock tool 30 (8)
ulators have evolved to sophisticated and a tension pneumothorax, and (2) a
Pedagogic efficacy 63 (17)
full-scale mannequins. They possess me- cardiac patient with marginally stable
Promote critical thinking 7 (2)
chanical lungs with physiologic air ventricular tachycardia. The students Opportunity for active learn-
exchange and auscultatory breath were instructed to evaluate and treat ing 22 (6)
sounds, palpable pulses with a blood the mannequin in real time ‘‘as if it Confidence building 7 (2)
pressure read-out and heart tones, and were a real patient,’’ and to use the in- Practice 37 (10)
Fills void in curriculum 4 (1)
extremity movements with a voice structor for assistance or teaching as
transmitter and reactive eyes. The sim- needed. Goals for future use 48 (13)
ulator can be intubated. All these fea- The educators were instructed to care More exposure desired 19 (5)
tures are coordinated by a computerized for a simulated case of anaphylaxis in Practice for internship 7 (2)
model of physiologic simulation, so that teams of six to eight, with assistance Bridge between preclinical
drugs and other therapy can be insti- from a facilitator posing as a nurse. All and clinical 15 (4)
Format suggestions 7 (2)
tuted on the ‘‘patient,’’ resulting in real- participants (students and educators) Testing vehicle 11 (3)
time changes in vital signs and clinical were debriefed in a case discussion af- Make it mandatory 7 (2)
condition that can be seen, heard, felt, terwards. *Kappa statistic for second-rater agreement on ma-
and truly experienced by the student. The participants completed a two- jor qualitative groupings = 0.67.
Only recently have medical educators part questionnaire about their experi-

470 ACADEMIC MEDICINE, VOL. 76, NO. 5 / MAY 2001

identify curricular goals best suited for written comments (section 2), a quali- tion exercises should be mandatory
simulation. tative analysis model was used.4,5 Qual- (82%).
The multiple-choice responses (sec- itative research attempts to understand
tion 1) were tabulated by frequency. For phenomena by gathering a rich set of
Section 2, Unrestricted Written
data for a limited number of instances
Comments
to create a ‘‘thick description’’ that al-
Table 2
lows the researcher to interpret events
The qualitative analysis of the medical
from the subjects’ perspective.6 Written
students’ written reactions is reported in
comments from the questionnaires were
Responses of 32 Medical Educators to Table 1. One student, expressing a level
transcribed and coded into thematic
their Experience with a High-fidelity of overall enthusiasm shared by half his
categories by a physician–investigator
Patient Simulator, 1999 colleagues, noted, ‘‘I think everyone
trained in qualitative analysis. The na-
could benefit from this.’’ Thirty percent
Qualitative Comment Educators ture of these categories was determined
of the students commented on the re-
Groupings* % (No.)† by the content of the written responses.
alism of the scenario, with almost 20%
The literature on qualitative research
Overall assessment 38 (12) noting the sense of urgency. One said,
Generally good experience 38 (12)
often refers to ‘‘emic’’ concepts, concep-
‘‘The simulator puts the student in the
tual categories derived from textual
‘hot seat’ and forces the student to
Process descriptors 56 (18) analysis (‘‘phonemic,’’ meaningful units
think through emergent problems in a
Realistic experience 38 (12) of sound). Higher-order analytic cate-
Not a realistic experience 6 (2) systematic way.’’
gories were developed based on these
General process comments Nearly two thirds of the students
fundamental emic concepts. The major
or limitations 19 (6) cited specific reasons for their enthusi-
analytic categories (and examples of
Personalizations or other asm. Most often they cited opportuni-
statements 6 (2)
subcategories) were: Overall Assess-
ties for active learning and practice
ment (‘‘generally good experience’’),
through simulation: ‘‘It was good to pro-
Teaching utility 50 (16) Process Descriptors (‘‘realistic experi-
vide for medical students critical situa-
High potential as broad ed- ence’’), Teaching Utility (‘‘broad edu-
ucational tool 9 (3) tions where we have to think what to
cational tool’’), Pedagogic Efficacy
Good testing or evaluation do—as medical students we have seen
(‘‘promotes critical thinking’’), and
tool 3 (1) residents do it, but never really have
Goals for Future Use (‘‘more practice
Should be part of our insti- been forced to think for ourselves,’’ and
tution or curriculum 9 (3)
sessions’’). (See Tables 1 and 2.)
‘‘[it] enables students to gain confidence
Addresses breadth of is- Using this coding scheme, another
in abilities before setting foot on the
sues (problem solving, investigator (doctoral-level educator,
floor.’’ Several students asked for more
teamwork) 13 (4) non-physician) independently re-
Good for emergency or sessions: ‘‘The simulator seems to be an
grouped the comments, providing a test
acute care training 9 (3) excellent transition between observa-
for inter-rater agreement and generating
Best for students or practi- tion as a student and caring for our own
a kappa statistic. Finally, the principal
tioners? 9 (3) patients,’’ and ‘‘Every medical student
investigator conducted a focus-group in-
should have the opportunity to learn
Pedagogic efficacy 6 (2) terview with an independent group of
using this simulator several times each
Promotes enhanced mem- 39 educators to further explore domi-
year during all four years of medical
ory–retention 6 (2) nant themes.
school.’’
Goals for future use 84 (27) The educators’ responses are shown
Part of overall teaching and RESULTS in Table 2. They were also enthusiastic:
evaluation 19 (6) ‘‘This is a facility that should be made
Basic science teaching 16 (5) Section 1, Overall Rating and Use available not only to medical students
Clinical science teaching 44 (14) but also to other professionals.’’ Thirty-
Realistic practice sessions 25 (8)
The students rated the session excellent eight percent were impressed by the re-
Critical thinking exercises 9 (3)
Teamwork exercises 6 (2)
(85% of responses), and indicated that alism, while only 6% were bothered by
simulation should be a mandatory com- the simulator–mannequin: ‘‘While it is
*Kappa statistic for second-rater agreement on ma-
jor qualitative groupings = 0.75. ponent of their medical curriculum clearly fake, the simulator is very good
†One of the 33 educators provided no written com-
(89%). The educators rated the session —makes realistic breath sounds, pulses,
ment or reaction. excellent or very good (combined heart sounds, and the monitors are re-
85%), and also indicated that simula- alistic.’’ Others noted, ‘‘[The simulator]

ACADEMIC MEDICINE, VOL. 76, NO. 5 / MAY 2001 471

actually simulates the high-stakes envi- They felt that the experience promoted ibility of realistic medical simulation re-
ronment’’ of acute care, and ‘‘invokes critical thinking and active learning, main to be tested, our analysis suggests
true adrenaline response’’ so that infor- and that it allowed them to build con- that high-fidelity patient simulation
mation ‘‘will stay with the learner fidence and practice skills in a suppor- may be a powerful new tool to bridge
longer than reading and repeating.’’ tive environment. They wanted more basic and clinical science, foster critical
Half of educators commented on the exposure, and felt the simulator allowed thinking, and enhance retention, all
teaching utility of the simulator, partic- them to integrate basic and clinical sci- while encouraging teamwork and prac-
ularly that it ‘‘included problem solving ences and to practice for residency. tice—for the real patient.
and team building’’ and ‘‘helped to de- The medical educators also found the
mystify crisis management.’’ The authors gratefully acknowledge the Center
experience stimulating and realistic,
for Medical Simulation, Boston, MA; the Medical
The educators also commented on and they saw opportunities for integrat- Readiness Trainer Team, University of Michigan;
the breadth of potential applications. ing basic clinical teaching with ad- and Alice Frohna, PhD, Rodney Hayward, MD,
Some thought the simulator would be vanced problem solving, especially and James Woolliscroft, MD, University of Mich-
helpful for basic science instruction, pri- given the opportunity to reflect on the igan Health System, for their contributions to this
project.
marily in pharmacology and physiology. case after the simulator session.9 The
Almost half predicted usefulness for educators identified opportunities for
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