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Learning through simulation

A group of third-year students crowds into a room at the Yale Center for Medical Simulation (YCMS), listening to a description of the robotic manikin lying on a nearby bed. When the group hears that the manikin’s pupils can dilate and constrict in response to stimuli, one student eagerly pulls a cell phone from his pocket and taps a few buttons, producing a light to shine into the manikin’s face. A collective murmur ripples through the students standing next to him as they observe the phenomenon, and a few linger behind as the group moves to the next room, waiting for a turn to see for themselves.

This short introduction to the manikins is only the beginning for these students; they will soon be spending much more time here. In the fall of 2015, third-year medical students began to use simulation throughout their clerkships, leading weekly case presentations and practicing technical skills at the new center, which opened in January 2015.

Before simulation became an available educational tool, medical students learned primarily through apprenticeship. “You walked around the hospital and learned from whomever you were working with—residents, faculty, attendings—in the real clinical setting,” said Leigh V. Evans, M.D., HS ’02, associate professor of emergency medicine, and executive director of YCMS. “The problem is, there are so many things you’re working with that you’re just too junior, too inexperienced, to practice. And then when it comes your time, usually when you’re an intern, you start by trial by fire.”

In medical school training, simulation allows students to hone their communication, leadership, and clinical decision-making skills in a safe, nonthreatening environment, away from flesh-and-blood patients. Instead of being thrust onto the hospital wards armed largely with textbook knowledge, students can learn on the robotic manikins. “We want you to practice, so when you’re there for the real thing, you’ll be confident, you’ll have the skills, and you’ll know what to do,” Tiffany Moadel, M.D., FW ’15, director of medical student simulation at YCMS, told the students on their first day.

The new center has four simulation rooms: a trauma resuscitation room; an emergency room/intensive care unit; a pediatric resuscitation room; and a multipurpose “procedural suite” used as an operating and delivery room. The manikins residing there—SimMan, SimMom, SimBaby, and SimNewB—produce realistic heart, lung, and bowel sounds as well as a palpable pulse and responsive pupil size. Students also use partial-body “task-trainers” at the center to practice procedures like lumbar punctures, intubation, chest tube insertion, IV placement, urinary catheterization, and nasogastric tube insertion.

Beyond placing tubes and monitoring vital signs, students learn primarily from the manikins during case studies, following a model that Evans started 10 years ago in the surgery and emergency medicine clerkship. Students previously worked through 24 case studies over a 12-week period in a small office with a single manikin. Staff programmed the manikin to present with a patient’s symptoms and “spoke” as the patient through a microphone-and-speaker system; students alternated leading teams to diagnose and treat the patient. Evans developed every case based on real patients she had seen in the emergency department, using the patient’s history, laboratory results, and radiology images sans identifying information.

Now, nearly every clerkship has a simulation module. Residents and faculty have helped develop hundreds of simulated cases, and Evans is always looking for more: “When I see a patient in the emergency department and I think it’s an interesting case, something that I’ve learned from,

I take that case and make it into something that the students and residents can be exposed to,” she said. “I’d love for the faculty to get into that mentality: When they see a case, let us know about it, and we’ll make it into a case so that everyone can learn from that patient as well.”

To build the new simulation curriculum, Moadel worked with the clerkship directors and selected scenarios from the case bank relevant to each discipline. No case shows up more than once in the curriculum, and students agree not to discuss cases outside the center in order to ensure that each learner receives the same experience. In teams of four to six students, they work through the 15-minute scenarios and then participate in a faculty-led debriefing session, in which they discuss communication, teamwork, and clinical management of each case. The students are graded only on attendance and participation; the center creates a safe, low-risk learning environment to encourage students to learn from their mistakes as well as their successes. “I remember as a medical student how much I enjoyed simulation,” said Moadel. “You remember the cases. It’s different from passive learning where you sit and read a textbook or an article. If you do a simulation case and you make a mistake, you remember that forever.”