Gary Player, a famous South African golfer once said. This saying is not limited to golf, or even sport, but applicable to many other fields in life as well. Probably also to medicine.

We all know from our own experiences, that a lesson taught in a typical classroom is not necessarily a lesson learned. Sitting in overheated classrooms, listening to a boring teacher reading his PowerPoint slides and later leaving the “presentation” wondering what was new.

But we know from our own experience, the most valuable lessons we learnt were probably not taught but experienced ourselves, e.g., assisting a senior doctor doing a certain maneuver in obstetrics or doing a procedure under close supervision.

What is the reason behind it?

Long time ago, two wise men said:

  • I hear and I forget, I see, and I remember, I do, and I understand” (Confucius, a Chinese philosopher and reformer 551 BC to 479 BC.)
  • a few years earlier, but in the same region, Lao Tzu said “Knowledge is a treasure, but practice is the key to it

Hundreds of years later, in the year when mankind landed on the moon a person called Edgar Dale published his “cone of learning”1

In 1984, Kolb et al. published the Kolb’s learning theory which basically is a four-stage process of how we acquire and embed new knowledge: concrete learning, reflective observation, abstract conceptualization, and active experimentation2. I guess we are all aware of this important research.

These and many other publications were used in other industries and lead to a more effective and modern way of learning.

In commercial aviation for example, many years ago and due to many accidents and near misses, simulation is today mandatory in assessing, training and accreditation worldwide.

The first (primitive) flight simulator was seen 6 years after the first flight, which took place in 1903.

Other industries followed and made simulation mandatory in their branches.

Medicine however is there since the dawn of time and simulation is still not mandatory for us healthcare providers.

Interestingly, learning in the last years was often even by us teachers described as “see one, do one, teach one” making this saying probably one of the most prominent sayings when it comes to learning (skills) in medicine.

Many argue that this is contradictory to a safe and patient-oriented approach and should no longer be accepted in our high-risk environments.

So why is simulation not more common in medicine? Is it that we are such a safe industry and training is not needed?

Unfortunately, this argument was smashed when the study “To Err is Human: Building a Safer Health System” was published in 2000 by the institute of medicine3. Also, the follow up studies by CDC showed that medical errors account for thousands of deaths per year.

In May 2016, the British Medical Journal4 published an article with the headline: Medical error—the third leading cause of death in the USA. The article estimated that as many as 250,000 deaths per year in the United States were caused by medical error.

Many other studies are underlining this issue and speak against the thesis that we are a safe industry and do not need training.

Is it that there is not enough literature to support the effectivity of healthcare simulation?

There are numerous studies showing that it has positive impact on patients 5 and it is reducing patient harm6. It is also improving quality of care independent of the condition7,8.

More research shows that simulation is not just effective in training undergraduate medical students 9 but also postgraduates 10. It is effective in training lifesaving 11, clinical skills 12,13 and communication skills 14.

Some evidence shows that simulation is “superior to traditional clinical education” and that it produces strong educational interventions that have impact immediately and is long lasting 15.

Finally, when done appropriately, simulation is well-liked by learners and teachers 16.

Lack of literature cannot be the reason honestly.

Is it that simulation in healthcare is so new that we have not really had the chance to implement it on a broader basis?

In the 18th century, obstetric simulators were very advanced already and could, e.g., leak amniotic fluid and blood and were already used to train complications of childbirth.

This happened many years before the first flight simulator was developed. But for whatever reason the trend in healthcare was never strong enough to have a breakthrough.

There are no obvious arguments why medical simulation is not more common or mandatory.

To avoid that all of us are now leaving depressed with the “to err is human” in mind, I would like to end with a saying from an unknown person that is more optimistic: To improve is human, to grow is human and to learn is human.

Written by Lukas Drabauer from Alpha Medical Concepts (AMC)

  1. Dale, E. (1969) Audiovisiual Methods in Teaching, (3rd Ed.) (New York, Holt, Reinhart & Winston).
  2. Kolb, David A. 1984. Experiential Learning: Experience as the Source of Learning and Development. Prentice-Hall, Inc., Englewood Cliffs, N.J.
  3. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
  4. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PMID: 27143499.
  5. Zendejas B, Brydges R,Wang AT, Cook DA Patient outcomes in simulation-based medical education: a systematic review. Journal of General Internal Medicine, 01 Aug 2013, 28(8):1078-1089 DOI: 1007/s11606-012-2264-5 PMID: 23595919 PMCID: PMC3710391
  6. Pian-Smith MC, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, Raemer D. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc. 2009 Summer;4(2):84-91. doi: 10.1097/SIH.0b013e31818cffd3. PMID: 19444045.
  7. O’Connor PJ, Sperl-Hillen JM, Johnson PE, Rush WA, Asche SE, Dutta P, Biltz GR. Simulated physician learning intervention to improve safety and quality of diabetes care: a randomized trial. Diabetes Care. 2009 Apr;32(4):585-90. doi: 10.2337/dc08-0944. Epub 2009 Jan 26. PMID: 19171723; PMCID: PMC2660457.
  8. Morrow R, Fletcher J, Mulvihill M, Park H. The asthma dialogues: a model of interactive education for skills. J Contin Educ Health Prof. 2007 Winter;27(1):49-58. doi: 10.1002/chp.94. PMID: 17385732.
  9. Weller JM. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ. 2004 Jan;38(1):32-8. doi: 10.1111/j.1365-2923.2004.01739.x. PMID: 14962024.
  10. Morgan PJ, Cleave-Hogg D. Simulation technology in training students, residents and faculty. Curr Opin Anaesthesiol. 2005 Apr;18(2):199-203. doi: 10.1097/ PMID: 16534339.
  11. Toback SL, Fiedor M, Kilpela B, Reis EC. Impact of a pediatric primary care office-based mock code program on physician and staff confidence to perform life-saving skills. Pediatr Emerg Care. 2006 Jun;22(6):415-22. doi: 10.1097/01.pec.0000221342.11626.12. PMID: 16801842.
  12. Ramsey PG, Curtis JR, Paauw DS, Carline JD, Wenrich MD. History-taking and preventive medicine skills among primary care physicians: an assessment using standardized patients. Am J Med. 1998 Feb;104(2):152-8. doi: 10.1016/s0002-9343(97)00310-0. PMID: 9528734.
  13. Costanza ME, Luckmann R, Quirk ME, Clemow L, White MJ, Stoddard AM. The effectiveness of using standardized patients to improve community physician skills in mammography counseling and clinical breast exam. Prev Med. 1999 Oct;29(4):241-8. doi: 10.1006/pmed.1999.0544. PMID: 10547049.
  14. Vaidya VU, Greenberg LW, Patel KM, Strauss LH, Pollack MM. Teaching physicians how to break bad news: a 1-day workshop using standardized parents. Arch Pediatr Adolesc Med. 1999 Apr;153(4):419-22. doi: 10.1001/archpedi.153.4.419. PMID: 10201727.
  15. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010 Jan;44(1):50-63. doi: 10.1111/j.1365-2923.2009.03547.x. PMID: 20078756.
  16. Ahmed S, Al-Mously N, Al-Senani F, Zafar M, Ahmed M. Medical teachers’ perception towards simulation-based medical education: A multicenter study in Saudi Arabia. Med Teach. 2016;38 Suppl 1:S37-44. doi: 10.3109/0142159X.2016.1142513. PMID: 26984032.




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