As a medical simulation educator, I get a lot of curious looks when I share my job title with people both inside and outside of medicine. Medical simulation is defined by the Society of Simulation in Healthcare as the imitation or representation of one act or system by another. It has four main purposes in health care: education, assessment, research, and health systems integration to facilitate patient safety. Modern medical simulation dates back to the 1960s when the first cardiopulmonary resuscitation (CPR) manikin, Resusci-Anne, was designed by Ausmund Laerdal. Since then, the technology has accelerated, and medical simulators have made their way into most medical schools and a growing number of residency programs. Yet, relegating medical simulation largely to academia deprives large sectors of the health care system of the power of simulation to educate and transform health care.
Despite advances in medical technology, in 2023, misdiagnosis was estimated to cause death or disability in 795,000 patients in the United States. Medical errors are complex and multifactorial. The last decade of patient safety has been defined by a Safety I paradigm, in which safety and risk committees often dissect a case, often through a reductionist approach, and often produce a new policy, procedure, or worse yet, online learning module to attempt to increase safety and quality. Yet, we’ve not seen a significant drop in medical errors. While some of this may be due to better reporting, the prevalence of these errors is terrifying for patients and medical professionals. Along with the clear harm to patients, being involved in a medical error as a medical professional may lead to secondary trauma, which is emotional pain from the anguish, sorrow, guilt, or other emotions related to being involved in the error. Even witnessing an error can lead to the phenomenon of vicarious trauma.
Safety I think often highlights what is going wrong in medicine. Applied to clinicians, we may invest in costly individual simulations to improve and later assess clinical and procedural skills. Safety II is an emerging area of focus in the field of patient safety and quality, and rather than looking at what goes wrong, it looks at what goes right. Applied to health care, we could spend more time looking at the teams that have the best outcomes. Through observation, we could learn how these teams overcome many of the same hurdles that trip up other teams.
Rather than keeping medical simulation in the lab and tied to medical school and residency, it’s time for medical simulation to be an integrated part of health care operations. When a new policy or procedure is considered, imagine running a simulation instead of simply discussing it at a meeting to see how it works in the clinical environment. When variations in quality and safety are found in various teams or units, rather than assigning an online module, imagine running a simulation on a unit and observing what happens. A key part of the simulation is the debrief, which occurs afterward. When simulations occur in the clinical environment, teams often uncover equipment and systems issues that can be addressed.
Medical training involves individual achievement. Medical students pass tests, residents complete rotations, and finally, pass board exams, all individually. In reality, medicine is a team sport. There are countless times that I know that I could have made a medical error without the shared wisdom of the team. Yet, unlike a sports team that has countless practices together before the big game, many health care teams are fluid. Increasing simulations in the clinical space, with the same equipment and all team members present, moves learning out of the individual realm and has the power to achieve team learning. Furthermore, when systems issues are found and acted on, this creates organizational-level learning.
As a medical simulation educator, I often get asked by administrators, “How much does simulation cost?” I can share spreadsheets with the cost of simulators and staff salaries, which is not an insignificant number. Yet, administrators should ask, “What is the cost of not doing simulation?”
It’s a harder question to answer, but I’m convinced it is massive. I’ve sat around so many tables reviewing a medical error, and the most common root cause is communication failure. Almost always, someone will share that they felt uncomfortable or had a key piece of information and didn’t feel safe speaking up. A key tenet of medical simulation is psychological safety. Just like we can teach clinical and procedural skills, we can also teach communication, teamwork, and leadership skills through simulation. In so many organizations, I’ve heard that the culture is broken, and there’s no clarity on how to transform it. Simulation is the vehicle. Simulations get teams interacting; in a simulation, people can try new ways of communicating. In the debrief, people can reflect and gain new insights. I’ve watched teams transform after a simulation, and this ripple perpetuates, as most teams are not fixed, and these members co-mingle into other teams in the organization. The true power of medical simulation is not that it teaches the team to respond to each possible medical scenario. Rather, it helps them develop a healthy communication strategy that can unlock the ability to be more adaptive and supportive to one another in the ever-changing health care environment.
Health care is hard right now. We are facing a projected physician shortage on top of a huge nursing shortage that continues to compound the many issues in health care. Medical simulation does not have to be in a lab or expensive. There are low-cost and minimal-time interventions that can fit any budget and even the busiest of settings. We’ve invested in the individual training of our workforce; it’s time to invest in the team to improve health care for both our patients and our health care professionals. Just like you wouldn’t imagine getting on a plane where your pilot hadn’t been through simulations, it’s time that we demand the same for us and our patients.
Andrea Austin is an emergency physician and medical simulation director.
