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Simulation in Critical Care Medicine: The Next
Ten Years
P.G. Brindley
J.-L. Vincent (ed.), Annual Update in Intensive Care and Emergency Medicine 2011
DOI 10.1007/978-3-642-18081-1, ˇ Springer Science+Business Media LLC 2011
Introduction
Simulation is a risk-free strategy to improve training, competence, and efficiency
[1–9]. It also has the unique- but, as yet, not fully realized- potential to improve
clinical outcome [1–4]. It has, therefore, already been identified by many profes-
sional societies as a prime means by which to improve patient safety [1, 2]. Some
authors have also argued that, over the next decade, simulation will increasingly
become a social justice imperative in order that those disadvantaged by income
or illness do not also suffer disproportionately from inexperienced practitioners
[9]. Others are increasingly endorsing simulation as essential to spur a badly
needed “culture of safety” [2, 5]. For all of these reasons and more, simulation in
critical care medicine needs to be prioritized and promoted. It is not a luxury,
and we should not wait. However, as well as ‘doing it right now’ we need to ‘do it
right’. As well as arguing that we need ‘more’, we should understand exactly what
we need ‘more of ’.
For the last decade, the case for simulation has been made repeatedly, elo-
quently and persuasively [1–9]. What has been comparatively lacking is a clear
vision of just what critical care simulation programs should aspire to become
(Box 1). In other words, the first step for simulation was to persuade and engage:
The so-called ‘why’ of simulation. What will be increasingly needed in the next
decade is the ‘what’ of simulation. Without a clear destination, simulation will not
fully mature into a clear scientific discipline, nor will its potential be systemati-
cally leveraged towards better patient care.
Box 1. Ten developments for acute care simulation in the next ten years.
Facilitate the science of clinical performance
Facilitate the science of managing complexity
Incorporate ‘process engineering’ principles into curriculum development
Encourage competency-based, rather than time-based, criteria for training
Encourage a focus on the ‘system’ not just the individual
Encourage ‘deliberate’ education and training better matched to patient safety
Become the patient safety laboratory for the modern healthcare system
Become a vehicle for Crisis Resource Management
Become a key technique for team training
Foster a culture of safety
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The Danger of Complacency
Patient safety in developed countries is good...but it is certainly not good enough.
It has been widely publicized that medical errors are the eighth leading cause of
death, and as many as 100,000 people die annually from preventable medical
errors in the United States alone [10]. Many more patients are damaged, and
many exposed to errors, but lucky enough to suffer no obvious harm [11]. The
first point to make is that simulation is more than just a novel educational strat-
egy. Instead, over the next decade it should mature into a key tool for error miti-
gation.
Simulation programs will become increasingly commonplace in urban aca-
demic critical care programs. However, the goal of patient safety is to cover the
entire health delivery system, not just its most specialized and technologically-
dependant end. As such, the next phase of simulation’s growth has to be to
include simulation outside of traditional centers. This might be realized using
electronic simulation, portable simulation, or by providing satellite services.
Regardless, without a concerted effort, medical simulation may remain the pur-
view of established medical ivory towers. This could perpetuate a primary focus
on research publication over clinical change, intellectual property over sharing,
patient through-put over patient safety, and in-hospital care instead of care across
the continuum. This is not to denigrate the essential role of the academic center.
In fact, if simulation truly is to become a “revolution in health care” [1, 2], then,
as will be discussed below, we will need to grow the academic science of clinical
performance. We also need to make a science of reducing healthcare’s complexity.
Of course, securing dependable long-term funding will remain a priority.
However, proponents need to understand that if the first stage of simulation was
about engaging educators then the next decade also has to be about recruiting
researchers. Without robust research data, simulation may remain little more
than a ‘faith-based initiative’, with both zealous supporters and reactionary oppo-
nents – but little conclusive evidence to sway the agnostic majority. However,
even with data, changing medicine’s traditions will likely always be slow going.
For example, despite the demonstrated benefits of preoperative briefings, and
their recent endorsement by the World Health Organization, their use remains
relatively low [12, 13]. Physicians and other health-care providers need to be con-
vinced. They need to believe that incorporating new processes into their practice
will have a significant enough positive impact in order to make change a priority.
Healthcare workers have developed norms of practice that- whether ideal or
not- have served them faithfully. As a result, simply telling somebody that inno-
vations are in the ‘best interest of their patients’, and then expecting immediate
change is naı̈ve. Instead, proponents need to commit to a long-term strategy of
data, persistence, and pressure. Failure to do so will likely mean that simulation
continues to be seen as a luxury, to be addressed after ‘more pressing’ concerns.
Expressed another way, for simulation to achieve deliberate progress, it must
commit to a more deliberate approach. Therefore, it is worth outlining what it
will take to design a modern simulation curriculum, and a meaningful simulation
research agenda.
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Engineering a Better Simulation Experience
Unfortunately, in addition to lamentable patient safety figures, traditional medi-
cal curricula have been best described as ‘accidental’ [14]. Simulation must play
a key role in making education and training more ‘deliberate’. For example, cur-
rently, in pre-clinical years, we typically rely upon teachers to simply cover their
favorite topics, with minimal attention to relevance. This is also despite knowl-
edge that the didactic method is poorly translated to the clinical arena [15].
Meanwhile, during clinical training, education is still usually described in terms
of time rather than competence, or what has been called ‘input experience’ [16].
For example, trainees are told that they will “spend two months attached to the
ICU team”. Once a clinician completes formal training, the requirements for con-
tinuing education are typically minimal and self-directed. The transformation
over the next decade should be towards less focus on ‘input experience’ and more
on ‘outcomes-based education’ [16]. For example, an ‘outcomes based approach’
would specify that: “by the end of your rotation you will safely perform the fol-
lowing activities....”, or for the seasoned clinician “each five years you will demon-
strate the following...”. Simulation will have a key role to play in an outcomes-
based evaluation. It should also fill in ‘educational gaps’ that are inevitable in a
system that relies upon the random presentation of patients.
National educational organizations have recently summarized the skills
expected of the modern trainee and practitioner. These include the Canadian
CanMEDs model, the American Accreditation Council for Graduate Medical Edu-
cation, and the United Kingdom’s General Medical Council’s Good Medical Prac-
tice [17–19]. These frameworks expand medical competencies from knowledge
alone to- more difficult to define but no less important- competencies such as col-
laboration, communication, professionalism, and clinical judgment. It is hard to
know how these can be realized, quantified,or evaluated, without simulation. In
a similar vein, any simulation program would be wise to build future curricula
around these modern educational domains.
A logical simulation curriculum should also be more deliberately matched to
safety data [11]. After all, most of our clinical errors are predictable. Studies have
repeatedly shown that poor communication, poor teamwork, procedural mishaps,
drug errors, and postoperative complications (such as infections and thrombi)
represent a majority of adverse outcomes [20–23]. In other words, if education
really is about improving outcomes then we also know which problems warrant
our finite attention [11, 25]. Routine audits could establish major problem areas
(i.e., common shortfalls; steps that require particular precision; or processes that
require the coordination of many people). These results should then be widely
shared, rather than just the purview of a select few senior clinicians or adminis-
trators. A relevant curriculum can then be drafted (using all relevant experts and
a modified-Delphi approach) and alpha-tested in order to produce a polished
product. Next, wide-scale dissemination occurs using the optimized material (i.e.,
beta testing) [2, 11]. The process then begins again, ad infinitum. In this way,
educators are not merely passing facts from one generation to another, but are in
fact running the patient safety laboratory (or ‘crash-test site’) for modern health-
care [2, 11]. We are also applying principles of ‘process engineering’ to medical
training and clinical care delivery. In this way, simulation educators become
important agents of change, and as highly valued as good researchers or clini-
cians [11].
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Too often, educational courses are designed and run, and only after their comple-
tion do investigators try and make sense of the data that has been generated [16].
As a result, the future of simulation will necessitate research questions that are
predefined, but also more ambitious: “What features of medical simulation lead
most to effective learning?” Over the next decade, simulation research must
increasingly look at outcomes, and particularly those outcomes at the higher end
of Kirkpatrick’s hierarchy [26]. These are as follows: Level 1: participation in edu-
cational experiences; Level 2a: change of attitudes; Level 2b: change of knowledge
and/or skills; Level 3: change in behavioral practice; Level 4a: change in profes-
sional practice; Level 4b: benefit to patients. Previously, the focus was on levels 1
and 2 or what had been described as “happy scores” [16]. For example, we can
rate the first two levels of Kirkpatrick’s hierarchy by simple questionnaires, given
before and after a course. However, even the biggest simulation enthusiast should
admit that the lower levels of evidence are unlikely to change behavior. Question-
naires may have been useful in the early days to demonstrate to skeptics that
learners responded positively to simulation-based education. In the next decade,
they may still provide useful teaching evaluations. However, they are no longer
likely to garner publication.
Other high-risk professions did not wait for scientific proof before initiating
simulation [25], and, as a result, nor should critical care medicine [11]. However,
if simulation is really about a new approach to error reduction [2], then it must
be open to unbiased examination followed by full disclosure. This means there is
no choice but to push research, publication, and debate [16]. This also means that
simulation programs of the future will require more than just enthusiasm and
money. They also need to reach out to the widest possible talent-base. This will
presumably include psychologists, human-factors experts, and educational theo-
rists. It will also mean a continued ‘charm offensive’ with those that have, so far,
remained unconvinced.
Updating our Understanding of Simulation
As outlined above, simulation already has both fervent apologists and vocal crit-
ics. These battle-lines are not only destructive; they are also increasingly out-
dated. For example, it must be admitted that medical simulation has yet to be
shown to directly save lives. However, considerable evidence has now shown the
unique ability of simulation to create safer patient environments [1–8]. Although
research must continue, simulation has already shown that it can increase adher-
ence to clinical guidelines, decrease time to competence, enhance team perfor-
mance, and increase skill retention when compared to didactic instruction [1–8].
Therefore, another key future step will be to stop denigrating simulation for its
supposed lack of proven benefit. Given deplorable adverse outcome data [10],
despite decades of traditional research, even skeptics need to accept the need for
alternatives such as simulation.
On the other hand, simulation’s proponents must also acknowledge that it is
far from perfect, and far from a panacea. For example, simulation is not realistic
enough, sufficiently proven, or sufficiently resourced, to justify a wholesale rejec-
tion of bedside learning. It is, therefore, best understood as a supplement to, not
a replacement for, traditional training and maintenance of competence. Simula-
tion can shorten the learning curve, decrease knowledge decay, permit manual
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skills development before any patient exposure, improve performance under
stress, finesse teamwork, and even optimize communication [2–8]. However, it is
also only one technique to improve safety. Moreover, it is not enough to simply
spend time on a simulator [2], just as it is not enough simply to spend time on a
clinical rotation. The focus should be on aiding long-term retention, and chang-
ing not just knowledge but also skills and behaviors [2–4, 16, 25]. Educational
time, no matter in what form it takes, must be based upon sound principles of
adult learning.
Simulation and Adult Education Theory
Good adult education means clear expectations of educators, just as it requires
clear expectations of learners. Simulation is also better understood as a tech-
nique, and not just a technology [2, 11, 14, 25, 27]. As such, the mere purchase of
simulation equipment will never be enough to facilitate behavioral change or to
achieve patient safety. Previously, millions of dollars were wasted assuming other-
wise. Simulation must also no longer be promoted merely because it is ‘novel’ or
‘popular’. The future of simulation will be won or lost based upon its unique
focus on an immersive, reflective, and emotionally engaging experience that leads
to long-lasting behavioral change.
High fidelity simulation can be delivered with very low fidelity tools. However,
in most cases, using realistic settings, believable cases, and real equipment will
increase emotional engagement [1, 2]. As a result, in future, when a hospital pur-
chases equipment it should include enough products so that the team can prac-
tice with the very same equipment that they are expected to use. This is in con-
trast to the early days of simulation, where programs improvised with broken or
mothballed supplies. In addition, rather than excessive attention spent trying to
make simulation enjoyable, we should accept that appropriate levels of perfor-
mance anxiety can mimic the stress of clinical work, and thereby increase the
likelihood of situational awareness and behavioral change [1]. At the same time
as striving to make simulation ever more realistic, we should also stop being so
apologetic for its current state. In a revealing letter-to-the-editor, a medical simu-
lation proponent donated his house, scheduled for demolition, to the police force
and fire brigade. He agreed to them simulating a hostage-taking, followed by a
house fire, but on condition that he was included as a participant [28]. The
unapologetically critical debrief that he witnessed made it clear to him that non-
medical groups have accepted the validity-regardless of the reality- of simulation.
[28]. It was clear that doing so had greatly improved the level of immersion, and,
therefore, the usefulness of the exercise. In short, believing simulation was real
made it more likely to be useful.
Adult education should be followed by reflection, which typically takes the
form of a structured debrief by experts in feedback and formative evaluation [2,
14, 27]. Simulation experts have long incorporated this structure, but there is also
no reason why bedside education cannot be similarly modernized. As a result, the
question is not whether all teaching should take place in the simulation labora-
tory versus at the bedside. Instead, the challenge is how to harness the best learn-
ing opportunities from both. In other words, however novel or exciting the edu-
cational strategy, it is a means to an end (i.e., patient safety and skill develop-
ment), rather than an end in itself.
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Brief simulation exposures are unlikely to model the myriad behaviors required
of a ‘good doctor’ [13, 25, 27]. These include the sense of ‘patient ownership’, the
need to follow a patient through the entire arc of their illness, and even the need
to soldier on even when fatigued. Occasional simulation exposures also fail to
duplicate the myriad ways in which the same disease can present whether because
of subtle differences in anatomy, physiology, genetics, age, or culture. As such, it
is also not outdated to promote the apprentice model, the traditional gradual
assumption of responsibility, or to demand expertise through volume. As a result,
the next decade will be about achieving the best mix of both simulation and bed-
side experience. This will only be possible when we better understand the impact
of finite instructional time, limited educational dollars, increasing clinical loads,
the huge reduction in trainee work hours, decreased tolerance for trial and error
with real patients, and even the attitudes of modern learners. In short, we need
a more sophisticated understanding of the putative benefits and limitations of
simulation as well as the traditional apprentice model [14].
As outlined above, current curricula typically focus on factual knowledge [2].
However, human performance errors, not knowledge errors, are the most com-
mon reason for errors in acute care [1–15]. It is, therefore, imperative that any
simulation curricula in the next decade address human factors, such as leader-
ship, teamwork, situational awareness and communication. These skills, known
collectively as ‘crisis resource management’ (CRM) [2–5, 11–12, 16], can be
taught through structured clinical exposure or via well-crafted simulation. The
current trade off is that simulation is safer, but clinical practice is more realistic.
Regardless, of all human errors, suboptimal communication is the number one
cause of patient error [18–23]. This means that ‘verbal dexterity’ may be more
important for the modern practitioner than a capacious brain or nimble hands.
This is because strong verbal communication skills are key whether for establish-
ing a shared mental model; coordinating tasks; centralizing the flow of informa-
tion; refocusing attention; or even for stabilizing emotions [18–23]. When it
comes to verbal communication, practical strategies can be readily borrowed
from aviation. These include how to be appropriately assertive, how to manage
interruptions, and how to confirm that instructions are not only heard but also
understood and completed [13, 22–24]. CRM has been widely implemented in
almost all high-risk professions. However, acute care medicine has been a com-
parative laggard. Perhaps this was because CRM did not readily lend itself to tra-
ditional didactic education. Simulation is ideally suited to fill this ‘educational
gap’.
Simulation and Error Mitigation
Many now accept the shocking patient safety numbers [13]. However, the next
stage is to make it better understood that most errors are not because of inade-
quate knowledge (i.e., medical ignorance). Instead they are typically problems in
transforming that knowledge into meaningful clinical action under the real-world
conditions of patient care (i.e., medical implementation) [15]. Other high-risk
professions, most notably aviation, faced similar challenges, but reconfigured how
they train and maintain competence [15]. This was associated with a log-reduc-
tion in fatalities. In other words, practical strategies and modifiable curricula
already exist, and we should ‘beg, borrow and steal’ wherever possible. The next
808 P.G. Brindley
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decade has to be about reaching out to expertise wherever it can be found. This
will represent a substantial departure for an insular, self-regulating, profession
such as medicine.
Addressing error also means training practitioners to avoid, capture, and miti-
gate errors, rather than assuming they result from mere arrogance, stupidity, or
sloth [1–3, 11–16]. Applying engineering principles also explains the putative
benefits from strategies such as checklists, standard operating procedures, redun-
dancies, and fail-safes. Simulation will increasingly be used to practice and per-
fect these strategies [16]. In fact, this is one way in which to win over skeptics.
The traditional fear is that protocols and checklists will create mindless autom-
atons: Slaves to a checklist and highly trained individuals no longer capable of
using common sense, pattern recognition or judgment [12, 13]. However, as could
be increasingly shown through simulation, a well-crafted checklist should encour-
age rather than discourage independent thought [1, 2]. A good checklist gets the
‘easy’, ‘routine’ or ‘mundane’ dealt with (“did the patient get antibiotics?”). This
frees up the brain for more complex issues (“how can I best resuscitate this
patient”). Simulation should also be used to show that checklists need to be prac-
ticed, and that often they need to be shortened in order to focus on what really
matters, namely safety. For example, in the setting of a single pilot flight, the avia-
tion safety list was shaved to only six items, of which the first is the most telling:
“Remember to fly the airplane” [13]. While this may seem facetious, the point is
that pilots may be so eager to fix the problem, or overly curious as to what went
wrong, that cognitive overload makes them forget what really matters. The point
is that simulation, now and in the future, must always be about making work eas-
ier for average clinicians and life safer for average patients. The next decade for
simulation will also be about attempting to optimize the culture through which
we deliver care [25, 27].
Simulation as an Agent of Culture Change
The term “disruptive innovation” [29, 30] refers to any change that alters a prod-
uct or service in ways that were not expected. This is because this innovation pro-
motes a different set of values and substantially upsets the status quo. Disruptive
innovations in healthcare include the fact that we are opening the way to a new
division of labor among health care providers. We are changing task allocation,
flattening hierarchies, changing communication norms, and democratizing deci-
sion-making [16]. We have an increased focus on safety, at the same time as we
have pressure to make the most efficient use of limited personal [11]. In short, we
are modifying how, where, and by whom care is delivered. This means potentially
jarring changes to personal identities, job descriptions, and team composition.
These new roles and responsibilities need to be practiced. The unpredictable
effects of change also need to be studied. Simulation is, of course, no panacea.
However, it might increasingly become a ‘rapid response system’ for culture
change, especially when compared to the protracted time line associated with tra-
ditional research.
If we accept that the history of medical simulation has pitted well-meaning
enthusiasts against justas well meaning traditionalists, then we should also
accept that something is required to break this impasse. This may well occur in
the next decade as regulatory agencies finally mandate simulation as a condition
Simulation in Critical Care Medicine: The Next Ten Years 809
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of employment or certification. Aviation clearly has many lessons for medical
training [11]. It also offers a probable timeline for the transition from encourag-
ing simulation to mandating it. The time from the first flight simulators to when
they became mandated for all commercial pilots was approximately 30 years.
Similarly in medicine, many clinical advances have followed a 30-year timeline
from proposal, through acceptance, to expectation, and finally to a condition of
accreditation. As a result, many proponents predict that simulation will be
expected by regulatory boards, and given the 30-year timeline, this would occur
within this decade. As a result, training programs have few options other than to
lead, follow, or begrudgingly comply. In other words, the question is not can we
afford to simulate, but rather can we afford not to – especially if we wish to
attract and retain the best. However, as previously stated, the goal is to have good
simulation not merely to simulate [25]. The challenge is, therefore, bigger than
just obtaining one-time funds to establish simulation facilities. The challenge is
actually whether we have the humility to learn from others, the insight to
expunge the worst of our entrenched traditions, and the pride to unapologetically
retain what is best.
We may be approaching simulation’s ‘tipping point’. However, the next decade
should still employ both the ‘carrot’ and the ‘stick’. For example, mandating sim-
ulation could rapidly increase its acceptance as routine and non-punitive in much
the same way as mandating life support courses did. However, lowering malprac-
tice for participants is probably equally beneficial. The concern is that health care
workers are unlikely to be supportive if simulation becomes another demand on
their time or wallet. This is where administrators and regulatory boards must
step up. Equally, established clinicians need to show leadership with more than
words. We must put aside our pride and participate, just as senior pilots partici-
pate in regular flight simulation. Only in this way will patient safety and self-
improvement be seen as a shared goal [11].
To some these issues may seem self-evident or common sense. However, there
are still many health-care organizations where tradition is valued over innova-
tion, where errors are not reported for fear of repercussion, where subordinates
are chastised for speaking-up, and where those in quality-control are viewed as
adversaries Within the next decade we need a healthcare model which is opti-
mized for safety and quality but balanced against the need for efficiency. The cur-
rent data strongly argue that we have a long way to go [11, 13]. Simulation is only
one strategy, but is one with enormous potential. If not, it will be not only a huge
lost opportunity, it will also be patients that pay the price.
Conclusion
Within the next decade, simulation should play an integral role in what has been
described as a “healthcare revolution” [1, 2]. To do so it must be central to how
personnel are educated, trained, and sustained. Simulation proponents should
promote a model where clinical personnel, teams, and even whole systems
undergo continual training, rehearsal, and refinement. This vision is inspired by
other high-reliability organizations, particularly aviation, but we must also appre-
ciate healthcare’s differences. Furthermore, optimizing patient safety is far more
complex than merely adding simulation on top of the current system. The future
of simulation will say a lot about our entire profession’s attitude towards how
810 P.G. Brindley
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seriously we take the safety of our patients. When it comes to optimizing simula-
tion in the next ten years, instead of asking “why?” or even “how?”, the most
appropriate question is “why on earth not?”.
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	Simulation in Critical Care Medicine: The Next Ten Years
	Introduction
	The Danger of Complacency
	Engineering a Better Simulation Experience
	Updating our Understanding of Simulation
	Simulation and Adult Education Theory
	Simulation and Error Mitigation
	Simulation as an Agent of Culture Change
	Conclusion
	References