Experience with medical student simulation education.

T he anesthesiology department at the University of Pittsburgh School of Medicine has offered human mannequin simulator courses to medical students since 1994 (1). The first simulation course was part of the required anesthesiology clerkship and used a patient simulator with a mathematical model of physiology. Classes focused on inducing general endotracheal anesthesia, managing a patient with a right main-stem intubation, anaphylaxis, and postoperative myocardial ischemia. Scenarios were executed from scripts run by a simulation technician who manipulated the simulator’s vital signs. The course was taught with groups of four students and a single simulator; therefore, instructors used the simulator as a demonstration device as they guided participants through the exercises. Face-mask ventilation was difficult with this simulator because it was not possible to establish an adequate seal. However, because its physiology model required ventilation, many simulation sessions frequently degenerated into unintended ventricular fibrillation codes. Because the scenarios were not programmed, the classes relied on the faculty to be familiar with and facile at executing the scenario scripts. These factors contributed to inconsistent application of the simulator as a teaching tool and probably discouraged new faculty involvement. Prophetically, the new millennium brought a new simulator, SimMan (Laerdal Corporation, Stavanger, Norway). SimMan has supple, lifelike facial features that facilitate face-mask seals. The Laerdal simulator does not use a mathematical model of physiology; vital signs change either in response to interventions or can be directly entered into the simulator’s computer controls. The simulator’s stable physiology and simple controls made it possible to expand the content of simulation courses. In July of 2001, the “Introduction to Anesthesiology” simulation course for firstyear anesthesiology residents began. The course curriculum is similar to the thirdyear medical student course, stressing intravenous induction of general endotracheal anesthesia and task-specific objectives like room setup and anesthesia machine check. In July of 2002, a simulation course was added to the clinical anesthesiology elective for senior medical students. The course helped expand the clinical scope of the elective by emulating scenarios involving neuroanesthesiology, obstetrical anesthesiology, placing and managing double-lumen endotracheal tubes, and preoperative management of patients in congestive heart failure. Table 1 shows the medical student and first-year anesthesiology resident simulation classes taught in the academic year beginning July 2002. Clearly, the volume of courses and the number of participants and facilitators was expanding. To meet this challenge while improving quality and consistency, the simulation course curricula would have to become more self-contained and easily managed. Our Winter Institute for Simulation Education and Research (WISER) made that transformation possible. The WISER Center offers a sophisticated infrastructure of physical facilities, simulators for full or partial-task training, the ability to easily measure participant performance objectives, and Web support to enable simulation education. Intuitively, simulation education will benefit from participants beginning the simulation with a thorough understanding of the cognitive goals of the course. Participants are best to be prepared to induce general anesthesia on a simulated patient after they understand the objectives of general anesthesia, drugs used to produce the objectives, and the algorithm for inducing it. The WISER Web site (www.wiser.pitt.edu) displays the course curriculum, including video discussions and demonstrations of cognitive and psychomotor skills. Course surveys are also collected. Responses are stored and analyzed through a secure database, providing instantaneous course feedback. Logistic information such as faculty and participant course assignments and locations are posted. The school of medicine and the University of Pittsburgh Medical Center can also access the Web site to facilitate and simplify course documentation and reporting. WISER Center personnel also assist in programming SimMan. Running simulations from programs is central to medical student simulation education. Participants work, explore, and experiment during the simulation exercise. By internalizing those experiences, simulation participants presumably develop a deeper, more personalized understanding of the course goals and objectives. A simulation program must respond consistently so that participants’ actions demonstrate the course objectives. For example, if a student chooses propofol to induce unconsciousness in a hypovolemic patient, our course objective dictates that the simulator respond with hypotension and tachycardia. The simulator teaches students about the pharmacodynamics of the drug without relying on the facilitator to remember to change the vital signs. Although consistent response to participant actions makes simulation education possible, the physiology displayed during the simulation makes that education applicable in the real, clinical world. If we ask participants to rehearse clinical skills in a simulated environment, then the onus falls on those who create simuFrom the Medical Student Simulation Education and the Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA.