The Ever Changing Role of Education in Healthcare

Graduate level medical training is rooted in the traditional “apprenticeship model” for training physicians.  Commonly referred to as the “see one, do one, teach one method,” it has been ultimately ineffective when dealing with high-risk, low frequency critical care events such as cardiac arrest or respiratory arrest.  Health Care education utilizing computerized patient simulation technique is emerging as a valuable addition to graduate medical education.  It preserves the ability to apprentice physicians during a lifelike scenario while providing a controlled, safe, and reproducible environment.  Most importantly, it is shown that critical care skills acquired during scenario-based training (SBT) with computerized patient simulators (CPSs) can be transferred to bedside patient care.

While graduate medical education programs are increasingly offering critical skills training using CPSs, the use of SBT techniques is not yet a standard component of residency training.  The reason for this is likely multifactorial:

1) Many believe that standard training is sufficient to pass on the necessary skills for critical situations

2) It is a “new” technique and there is resistance to change.

3) It is an expensive technique with a large initial financial commitment.

The first two barriers listed above are being breached like water seeping through a dam.   Emerging literature is showing that physicians’ skills in resuscitation are poor overall and deteriorate rapidly with time.  SBT with CPS, however, is being proven an effective way to educate providers in critical thinking and procedural skill.

A recent study showed that SBT with CPS is superior to traditional apprenticeship education in internal medicine residents for initial airway management during respiratory arrest (CHEST 2007;132:1927-31).  The combined impact of a realistic replicated work environment and a believable clinical scenario resulted in trainee “buy in” and a highly effective learning experience.  SBT with CPS resulted in better retention of skill, both cognitive and procedural, and ultimately better bedside patient care.

Traditional written exams and board certification tests cognitive knowledge, while SBT with CPS evaluates critical thinking in conjunction with psychomotor skill.  Crucial to this technique, is its incorporation of debriefing; an excellent opportunity for self assessment and improvement.  Internal medicine residents, when polled, felt that traditional advanced cardiac life support (ACLS) training was ineffective; however, they felt uniformly that SBT with CPS was a positive experience, improving individual skill and team function (Crit Care Med 2004; 32:2422-2427) . 

Simulation training centers are currently available at very few sites as it requires advanced technology, substantial geographic space, and a highly trained staff.  These centers are shown to be highly effective but often require large financial investments for start-up and maintenance.  Perhaps a mobile, high-fidelity center with portable computerized patient simulators is a means to overcome this final barrier to superior patient care. 

It seems inevitable, however, that when we overcome these three barriers, the pace at which patient care will improve will be like the water being released from behind a newly opened dam.

Jason Gluck, DO