Pictures of Health

By Mary Hoff

What do carving decay from a tooth, counseling the owner of a sick cat, starting an IV, and performing endoscopic surgery have in common? All are skills health professional students can practice at the University of Minnesota using simulation-based educational experiences.

From actors who pose as patients, to computer-operated manikins, to virtual reality software, simulations offer students valuable opportunities to hone the manual dexterity, critical thinking, problem solving, and other capabilities they’ll need in their future careers.

“Simulations, when well executed, can really accelerate the learning curve on knowledge and skills,” says Jane Miller, director of the Academic Health Center’s Interprofessional Education and Resource Center (IERC), which offers simulation opportunities to students from a variety of health professional programs. With the help of simulations, Miller says, students can practice procedures and techniques over and over until they perfect them, getting skill-building feedback each time. They also can make—and learn from—mistakes before they find themselves in literal life-or-death situations. The ultimate goal: better patient care.

“It might be high effort, but it’s also high yield,” she says. “And it’s fun—fun for everybody.”

Acting Out

Once a week, from September through April, retired banker Dennis Maetzold spends a good chunk of his day in an exam room at the University of Minnesota, pretending he’s in need of medical attention. Sometimes a medical student will tend to him. Other times it’s a nursing, dental hygiene, or pharmacy student. A couple of times it’s even been a student from the College of Veterinary Medicine, and he’s talked about his make-believe golden retriever’s make-believe ailments instead of his own.

Maetzold is one of some 200 individuals who serve as standardized patients in the IERC’s clinic simulation program. Some days he’s simply a “warm body” on whom instructors can demonstrate procedures and students can practice them. But often Maetzold is given a specific script, with symptoms and a personality to portray. As students examine him, either for practice or as part of a test, he’ll ask questions and act cranky, pleasant, confused, or whatever the script dictates. A videotape records the session so the student can review, reflect on, and learn from it.

Todd Sorensen, associate professor of pharmacy, uses the standardized patient program to give third-year students a chance to do a patient assessment with a preceptor watching on a video monitor in another room rather than being with the student, standard procedure in the past.

“I’ve really noticed a difference in the way students handle the assessment,” Sorensen says. “They don’t automatically turn to the preceptor for visual cues. They have to take on a higher sense of responsibility.” Fourth-year veterinary student Holly Hommerding has been through the veterinary client simulation half a dozen times. She says it was unnerving but also hugely helpful.

“It’s a great way for us to get the feel of things, to be able to work on our communication skills,” Hommerding says. “It was a wonderful contribution to how I interact with clients now.” Other programs also use roleplaying for teaching. The School of Nursing’s Adolescent Actor program, for example, trains teens who then serve as surrogate patients for graduate nursing students and pediatric, internal medicine, and child psychiatry residents.

“It gives the trainees exposure to adolescent interviewing that they wouldn’t get anywhere else,” says Scott Harpin, instructor for the program.

Smart Dummies

Of course, not everything can be practiced on a real, live person. At IERC, students early in their health professional education use tabletop models of body parts to learn and practice procedures such as diagnosing ear disorders, performing rectal exams, and drawing blood. The Medical School’s SimPORTAL facility, which provides simulation training for residents, fellows, and continuing medical education students in surgery, emergency medicine, and anesthesia, has facilities for practicing surgical procedures using animal tissue, and video trainers for honing endoscopy skills. It also provides surgery students and surgeons an opportunity to practice transurethral resection of the prostate (TURP), removal of the prostate, using a sophisticated virtual-reality computer simulation developed by AHC clinical director of simulation programs and SimPORTAL Director Robert Sweet. Urologic surgery fellow Kishore Thekke Adiyat has used the TURP simulator and also performed the surgery in patients. He says both students and surgeons will benefit from using the simulation device. “Definitely it’s going to be helpful,” he says. “It’s like going onto the real TURP machine.”

When it’s time to practice procedures that involve the entire body, students and instructors in both IERC and SimPORTAL can turn to SimMan or StanMan, lifelike, computer-driven manikins. These guys will take just about anything lying down—in fact, that’s what they’re designed to do. But not without reacting. Controlled by sophisticated computer software that can be programmed to act out scenarios and respond to treatment, these “smart dummies” breathe, gag, go into cardiac arrest, and more.

In one unique simulation exercise, advanced medical students and baccalaureate nursing students get a chance to practice communication and teamwork as well as medical skills as they respond together to a manikin-based medical emergency in a realistic emergency room setting that’s part of the SimPORTAL facility. After going through the exercise, participants sit down with faculty and review videotapes of their work.

“The vitals that they can see, the voice they can interact with, make it so real for them that they forget that it’s a simulation,” says Mary Ann McNeil, administrative director of the Department of Emergency Medicine. That, she says, makes for better responses in an actual emergency.

“We all know that learning translation is all that matters, how you act at the patient’s side is the only thing that matters,” she says. “This—the closest you’ll ever come outside of a real patient to a real situation—is the way to go.” One of the manikins periodically takes a field trip to Twin Cities hospitals, where health-care teams role-play a simulated critical event in the actual rooms where real patients would be, then view a videotape of the event and critique their communication with each other. Later, simulation lead developer William Riley, of the Division of Health Policy & Management in the School of Public Health, shows video clips of the exercise to dentistry, public health, medicine, nursing, and pharmacy students in the AHC’s interprofessional teamwork class. Class members then discuss the effective and ineffective communication they see.

“It becomes clear to them that a team of experts is not [necessarily] an expert team,” Riley says. By observing what professionals do right and what they could do better, he says, the students gain an awareness of the barriers to interdisciplinary communication that can threaten patient safety and develop strategies for surmounting those barriers in their future careers.

Torsos and Teeth

Folks who don’t like the sound of a dental drill would not appreciate the new simulation room on the fourth floor of Moos Tower nearly as much as the dental students do. Here, up to 100 drills whine in unison as the students practice their skills on replaceable teeth inside the mouths of lifelike heads.

Before this facility opened last May, students worked on disembodied, denture-like sets of teeth attached to sticks. The new models have torsos, lips, and teeth, and the stations students are working at have the same lights, water supply, and drills you’d find in a real dentist’s office. Instructors can demonstrate procedures on camera at a station in the front of the room while students follow along on individual monitors.

Down the hall is the Advanced Simulation Laboratory, scheduled to open in early 2008. Here students will be able to practice procedures on even more sophisticated models, using drills with infrared sensors that feed information about their every move into a sophisticated training and evaluation software program. The machine will project a virtual image of the activity on a screen, give students a goal, let them try it, then provide feedback in the form of a numerical grade and visual comparisons of what they were supposed to do and what they actually did.

“With simulation, students learn almost twice as fast as they do in a regular lab,” says Judith Buchanan, associate dean for academic affairs with the School of Dentistry.

Buchanan emphasizes that even with the new simulation opportunities, dental students will get plenty of face time with real, live patients—the ones with saliva, personalities, and plentiful plaque. They’ll just get there sooner and in better shape.

“We want real life,” she says. “This is just a means for us to feel more comfortable with them earlier.”

On the Grow

With analyses showing benefits, from improved performance of students to enhanced patient safety and better use of faculty time, the use of simulation in health professional education is on the grow. A new AHC Simulation Center under Miller’s direction is scheduled to open early in 2008. The new facility will allow more student access to manikin simulations and will add more opportunities for interdisciplinary training in realistic inpatient settings, from intensive care unit rooms to surgical suites. It will also provide a resource for piloting new simulations, such as a new simulation program Miller and colleagues are developing that simulates giving injections into the joints.

SimPORTAL’s Sweet, meanwhile, is leading an array of efforts to advance simulations through the Center for Research in Education and Simulation Technologies (CREST). His research group is part of a multiinstitutional study to validate the TURP simulation, and is working on developing a virtual reality version of laparoscopic kidney surgery that simulates the precise feel of the various manipulations involved, from cutting to suturing. CREST is also spearheading research aimed at modeling material properties of various types of tissues, paving the way for even more realistic computer-based surgical simulations. Sweet’s dream is to someday be able to provide the realistic surgery simulations online, so students can practice and professionals can refresh their skills wherever they can access the Internet.

Miller underscores that simulations will never completely replace hands-on experience with patients. But, she adds, they certainly have their place.

“You never forget what you do,” she says.  “[With simulation] you can do it over and over again.”