History of simulation

Simulation is the imitation or enactment of something anticipated. As a form of communication and education, simulation has been used by peoples all over the world for thousands of years. The Incas began their corn planting season with a reproduction of corn plowing performed by those of royal blood. This inaugural ritual promised a rich harvest and reiterated the importance of respect to their deities and proper care of the earth (Bauer, 1996). Eventually, the idea of simulation migrated into the educational aspect of medicine. Theologians of ancient Mesopotamia were some of the first to reproduce examples of human anatomy. Believing the liver to contain the soul of a being, priests created clay liver models and in fact, some of the liver nomenclature today gets its origin from the Babylonians of 2000 BC (Martins & Martins, 2013). The 18the century produced a more relevant teaching tool. A hospital in Pistoia, Italy, used a model of the female torso crafted from leather and wood to illustrate the basics of childbirth. In a populace fraught with labor complication, the obstetric phantom -as it would come to be called - allowed midwives and doctors to practice a delivery with the “baby” in a variety of positions, hopefully leading to fewer deaths (Lawrence, 2001). These developments continued as medicine advanced but the true origin of medical simulation as we know it began in a different field entirely.

Aviation had struggled with training pilots safely on the ground since its genesis. Variations of flight simulators were tested and found wanting throughout the early 1900s until the invention of the “Blue Box” (Allen, 1993). In 1929, Ed Link, a young pilot with extensive engineering experience, created a prototype of the cockpit and controls with which he had trained. The ability to replicate the movements and environment enabled Link to teach his brother to fly without leaving the ground. This triumph inspired him to rebrand the simulator “Pilot maker” and he attempted to market his invention. It held little value to anyone other than amusement parks as a novelty. That changed in 1934 when multiple postal airplane carriers crashed due to bad weather. President Roosevelt turned the US postal service over to the US Army Air Corps, hoping for better results. Unfortunately, the outcome was the same with several fatal crashes due to storms and harsh weather. Looking for new training methods, the Army Corps purchased six of Link’s simulators and they soon were integrated as a mandatory part of the training curriculum (Jones et al., 2015). The advantage of the Blue Box was its ability to replicate the difficult and dangerous situations pilots would encounter in a safe environment. Participants could receive feedback in a timely manner that might save their life later. The same principle could be applied to any number of fields and medicine soon saw its value.

The 20th century ushered in a new era of medical developments. The success of Link’s simulator led to increased interest in simulated educational experiences that were more reflective of real-life scenarios. Rescue Annie made her debut in 1960. A mannequin created by Laerdal Medical, Rescue Annie was first used to practice mouth-to-mouth ventilation and later chest compressions (Aebersold, 2016). Anesthesia led the medical field in simulation advances. In the years after Rescue Annie’s creation, Sierra Engineering Company produced Sim One, one of the first anesthesia simulators (Abrahamson & Wallace, 1980). In 1968, Harvey was introduced to the world of cardiology. He was a mannequin named after Dr. W. Proctor Harvey who could replicate most cardiac diseases by altering blood pressure, pulse, murmurs, heart sounds, and breathing (Jones et al., 2015). In 1986, the Comprehensive Anesthesia Simulation Environment (CASE) was invented by altering a mannequin to suit the needs of the trainings. Dave Gaba and Abe DeAnda, the creators, later renamed their product the MedSim Eagle Simulation when they partnered with CAE-Link Corporation in the 1990s (Aebersold, 2016).

Even with all these improvements, the military had a relative monopoly on simulation before the 1990s with 80% of the simulation work occurring under their umbrella. That began to shift in the mid 1990s as the gaming industry became more involved in the high quality graphics and generated increased demand. The Society in Europe for Simulation Applied to Medicine (SESAM) was founded in 1993 but the US didn’t begin their foray into simulation organizations until the emergence of the Simulators in Anesthesiology Education two years later. In 1998, the SAE conference was co-sponsored by the Society for Technology in Anesthesia, showing again anesthesia’s commitment to simulated education (Rosen, 2008). As years passed, this organization bore other names including Society for Simulation in Medicine before settling on Society for Simulation in Healthcare. The journal of this group was spearheaded by Dr. Gaba, the same man who created an anesthesia mannequin in the 1980s. He served as editor-in-chief for years and spent more than 30 years advocating for and developing simulation-based learning (Cooper et al., 2016).

Another aspect of simulation education that didn’t receive its accolades immediately was standardized patients. A standardized patient or SP is a “ ‘patient-actor’ who has been trained to consistently portray a specific patient role, outlined by a script devised by topic content experts” (Wilbur et al., 2018). First originated by Dr. Howard Barrows over 55 years ago, the standardized patient can be used to assess a student’s clinical skills (Barrows, 1993). The replicability of the SP made comparison and individual grading far easier than clinical assessments with real patients. It took several years for the idea of SPs to catch on nationwide. However, by the early 2000s, SPs had been integrated into not just medical school curricula but also nursing and nurse practitioner schools (Ebbert DW & Connors H, 2004). Another advantage of a simulated clinical experience is the ease of interprofessional collaboration. Good communication and understanding of the roles of different professions is critical to improved patient safety and quality of care (Palaganas, 2013).

In the years since its arrival on the mainstream medical curriculum, simulation education has skyrocketed in popularity. Over 70% of anesthesia programs use some form of simulation in their training. In fact, the American Board of Anesthesiology certification require an aspect of simulation-based education as it is considered a central pillar of certification (Singh et al., 2013). This shift is seen across the board with similar requirements in other specialties like general surgery (Stefanidis et al., 2015). Pediatrics rely heavily on simulation to hone skills needed in neonatal resuscitation while obstetrics has used it to practice uncommon procedures. Simulation training on shoulder dystocia has led to a four-fold reduction in injury to the neonate (Singh et al., 2013). This pattern of successful education is the culmination of thousands of years of practice. Simulation is the natural continuation of humanity’s imagination and ingenuity. High fidelity simulation allows clinicians to practice everything from basic interview skills to complex procedures in a realistic setting. In 2000, the Institute of Medicine published a series of articles called To Err is Human, calling attention to the alarming statistics of human error in medicine. The explanation was good people with good intentions working in a flawed system (Kohn et al., 2000). The hope of simulation education is to eliminate some of those errors by providing a low risk environment in which healthcare providers can sharpen clinical skills. The ongoing progress in simulated healthcare trainings and the commitment of providers to use the most effective form of education create the opportunities to provide higher quality care to patients everywhere.

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