medical education history

The history of simulation in medical education and

possible future directions
Paul Bradley

INTRODUCTION Clinical simulation is on the point KEYWORDS education, medical ⁄ *history ⁄ trends;
of having a significant impact on health care educa- *patient simulation; forecasting; history, 19th cen-
tion across professional boundaries and in both the tury; history, 20th century.
undergraduate and postgraduate arenas.
Medical Education 2006; 40: 254–262
SCOPE OF SIMULATION The use of simulation doi:10.1111/j.1365-2929.2006.02394.x
spans a spectrum of sophistication, from the simple
reproduction of isolated body parts through to
complex human interactions portrayed by simulated INTRODUCTION
patients or high-fidelity human patient simulators
replicating whole body appearance and variable Simulation has been defined as:
physiological parameters.
ÔThe technique of imitating the behaviour of some
GROWTH OF SIMULATION After a prolonged ges- situation or process (whether economic, military,
tation, recent advances have made available afford- mechanical, etc.) by means of a suitably analogous
able technologies that permit the reproduction of situation or apparatus, especially for the purpose of
clinical events with sufficient fidelity to permit the study or personnel training.Õ1
engagement of learners in a realistic and meaningful
way. At the same time, reforms in undergraduate and Within this definition is included a large range of
postgraduate education, combined with political and activities that are rightly regarded as being a part of
societal pressures, have promoted a safety-conscious the spectrum of clinical simulation.
culture where simulation provides a means of risk-
free learning in complex, critical or rare situations. Simulation, in its many guises, is now widespread in
Furthermore, the importance of team-based and many fields of human endeavour. The history of
interprofessional approaches to learning and health simulation stretches back over centuries. The military
care can be promoted. has been a longterm user of simulation: chess
probably represents one of the earliest attempts at
CONCLUSION However, at the present time the war gaming; jousting permitted knights to hone
quantity and quality of research in this area of med- battlefield skills, and the 18th century Kriegspeil
ical education is limited. Such research is needed to represented a development with more face validity,
enable educators to justify the cost and effort which has led to modern, complex, computerised
involved in simulation and to confirm the benefit of warfare simulations. The modern aviation industry
this mode of learning in terms of the outcomes has developed high-fidelity flight simulation and has
achieved through this process. led on improving the non-technical skills of teams
through crew resource management programmes.
Similarly, the space programme has made extensive
use of simulation for training and testing. The
Peninsula Medical School, Plymouth, UK nuclear power industry, with its adverse experience of
Correspondence: Professor Paul Bradley, Professor and Director of how bad things can be when they go wrong, such as at
Clinical Skills, Peninsula Medical School, Research Way, Tamar Science Three Mile Island and Chernobyl, is another business
Park, Derriford, Plymouth PL6 8BU, UK. Tel: 00 44 1752 437343;
with a major commitment to simulation. What these
Fax: 00 44 1752 517856; E-mail: paul.bradley@pms.ac.uk

254
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 255

Åsmund Lærdal. This cannot be underestimated in

terms of its importance to the field and to humanity
Overview itself. Working with anaesthetists, Lærdal, a Nor-
wegian publisher and toy manufacturer, developed
What is already known on this subject the ÔResusci-AnneÕ, the part-task trainer that was to
revolutionise resuscitation training through the
Simulation is not a new phenomenon in widespread availability of a low-cost, effective training
clinical learning. It has been gradually estab- model.2 Since then, such simulation has evolved
lishing a role in health care education, steadily, with an increasingly sophisticated range of
although there has been limited research of manikins and models used in support of resuscitation
sufficient quality to provide a robust evidence and basic skills training becoming available.
base.
The second movement is quintessentially associated
What this study adds with modern simulation and concerns the develop-
ment of sophisticated simulators dedicated to the
This paper reviews the development and range reproduction of aspects of the human patient. The
of simulation in both undergraduate and earliest of these was the Sim One, developed by
postgraduate education. It describes the Abrahamson and Denson in the late 1960s.3 The
influences that have seen simulation expand manikin had a number of sophisticated features:
across the spectrum of sophistication within
health care education and examines possible ÔIt breathes; has a heart beat, temporal and carotid
future directions. pulse (all synchronised), and blood pressure;
opens and closes its mouth; blinks its eyes; and
Suggestions for further research responds to four intravenously administered drugs
and two gases (oxygen and nitrous oxide) admin-
More quality research is required in this field, istered through mask or tube. The physiologic
as in other areas of medical education, to responses to what is done to him are in real time
establish an evidence base upon which these and occur ‘‘automatically’’ as part of a computer
developments can be based and judged. program.Õ4

However, the Sim One failed to achieve acceptance,

despite promising early reports of its effectiveness in
groups have in common is that, for each of them, training. This was largely because the need for
training or systems testing in the real world would be anything other than apprenticeship-based training
too costly or too dangerous to undertake. It is not had not yet been defined and, secondly, because the
surprising therefore that the medical profession cost of the technology at the time did not permit
should take steps to adopt the principles of high- more than one example to be produced. In the
reliability organisations. Indeed, what may be more 1980s, the feasibility of producing high-fidelity simu-
surprising is how long it has taken to get here. lators was resurrected by two groups, the first at
Stanford University and the other at the University of
Florida. The former group, led by David Gaba,
THE HISTORY OF CLINICAL developed the comprehensive anaesthesia simulation
SIMULATION environment (CASE)5 and the latter, led by Michael
Good and JS Gravenstein, developed the Gainesville
Clinical simulation does, in fact, span the centuries; anaesthesia simulator (GAS).6 The CASE was later to
for example, models have long been used to help be commercialised as Medsim and the GAS eventually
students learn about anatomical structures. The became the Medical Education Technologies, Inc.
modern era of medical simulation has its origins in (METI). The Stanford team focused significant
the second half of the 20th century. Three distinct attention on the development of team-based working
movements can be identified that have spurred the in realistic simulation environments and incorpor-
development of clinical simulation. ated the aviation model of crew resource manage-
ment into the anaesthesia crisis resource
The first, which occurred slightly earlier than the management (ACRM) curriculum, leading to signi-
high-fidelity simulation developments and at the near ficant developments in clinical team-based training.7
opposite end of the spectrum, concerns the work of These simulators and some European counterparts

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256 medical education history

(from Holland, Denmark and the UK) form or have continuing medical education after higher specialist
formed the basis for today’s modern moderate to training and the drive to revalidation has also been a
high-fidelity simulator (Table 1). They have been at significant part of this process. This has seen a rise in
the forefront of the development of high-fidelity the use of simulator methodologies in both under-
simulation; led by the anaesthesia community these graduate and postgraduate education. Although
manikins have been central to the understanding and much of this learning is at the lower end of the
development of simulation-based learning and train- simulation spectrum, increasing attention is being
ing to date. paid to high-fidelity simulation as a means of provi-
ding safe, protected, educationally sound experience
The third major movement has been that of medical to undergraduate students, postgraduate trainees and
education reform, which, in the latter part of the established practitioners. Indeed, it has been argued
century, began an ongoing process that continues that these changes are long overdue and that they
today. Some of this change has been driven by represent an essential element of an ethically cogni-
worldwide recognition of the need for students to be sant education.15
prepared as effective junior doctors after their
undergraduate education.8–11 The recognition of
information overload within the undergraduate cur- DRIVES TO SIMULATION
riculum, at the expense of the learning of clinical and
communication skills, has seen the widespread adop- Figure 1 shows the major drives of the late 20th
tion of programmes in clinical skills learning and the century behind the adoption of simulation. The
development of clinical skills education facilities to movements that have provided the impetus towards
support that learning.12–14 Changes to postgraduate the use of simulations are varied but they resonate
training have also come about as the need to adopt a throughout many health care systems.
sounder educational approach, coupled with a more
streamlined process, has emerged. The need for It has been widely recognised that students have been
ill-prepared for their roles as young doctors. In
addition to their well documented deficiencies in a
range of skills,16–19 there have been reports of stress
Table 1 Features of a modern moderate to high-fidelity human patient resulting from inadequate preparation for their
simulator
roles.20 These skill deficiencies have occurred along-
Complete human body
side a changing pattern of health care delivery, which
Capable of ÔspeechÕ has seen significant changes to the clinical experi-
Structure and function ence of undergraduates.21,22 In the postgraduate
Complete integrated physiology ⁄ pharmacology model (high-
fidelity)
arena, working time restrictions have raised concerns
Open ⁄ close mouth Trismus about junior doctor training23–25 and the move
Realistic airway Pharyngeal oedema towards a more streamlined, shorter duration of
Respiratory chest Appropriate anatomical
(± abdominal landmarks
higher professional training has also caused concern
wall movements
Lungs capable of ± consumption of O2,
spontaneous, assisted or exhalation of CO2 and uptake Medical
mechanical ventilation of anaesthetic gases education
Tongue swelling Difficult airways reform
Synchronised breath Bowel sounds
sounds
Monitoring
Pulses palpable
Resuscitation movement
Synchronised with heart sounds
Blood pressure measurable
Variety of physiological outputs to standard monitors
Pulse oximetry
Procedures Anaesthetic simulator
Defibrillation Pneumothorax
decompression
Cardioversion Cricothyroidotomy
External pacing Pericardiocentesis 1950 1960 1970 1980 1990 2000
Venepuncture Chest drain insertion
Cannulation Intramuscular injection
Urinary catheterisation Figure 1 The major movements of the late 20th century
driving the adoption of simulation

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 257

about the amount of direct clinical experience it is However, it is only over the last 40 years or so that
possible to provide.26,27 In the light of decreasing simulation has emerged as a gathering force in the
time available for higher training, the case has been development of medical education and has become
made for planned exposure to simulated cases to increasingly recognised as having great potential in
ensure that sufficient material is covered.28 Such delivering elements of health care education.
approaches are underwritten by the drive to clinical
governance that has emerged over the past decade;
this requires strategies that support education and SIMULATOR TYPES
training in support of quality improvement.29 Simi-
larly, the publications To Err is Human30 and An The technologies that have been at the heart of the
Organisation with a Memory31 have brought the agenda drive to incorporate simulation are not all high-
of patient safety to the fore and stressed the need for technology in nature or computerised. Most simula-
an institutional approach to overcoming institu- tors in use today are at the low-technology end of the
tional, individual and cultural barriers; within this spectrum and are used in the high-volume, basic skills
approach the inclusion of simulation is readily learning arena associated with undergraduate and
apparent, with lessons from the domain of anaes- early postgraduate health care professional develop-
thesia providing significant guidance.32 Within these ment. Table 2 shows how the range of simulators can
development models, significant emphasis is placed be categorised.36,37
on effective team working and, with the drive to
interprofessional education,33,34 it is also apparent
that these factors further stimulate simulation as a PART-TASK TRAINERS
vehicle for progressing these agendas and preparing
a workforce that exhibits capability and not simply These models are meant to represent only a part of the
competence.35 As well as these drivers, there are also real thing and will often comprise a limb or body part
important background factors acting continuously on or structure. These are usually used to aid the acqui-
the systems. These include not only societal expec- sition of technical, procedural or psychomotor skills,
tations and political pressures from governments, but such as venepuncture, ophthalmoscopy and catheter-
also the profession itself as it strives to meet the isation; there are more sophisticated part-task simula-
demands of modern day health care. tors, such as the Harvey and the Simulator-K, which are
high-fidelity cardiovascular systems designed to help
Figure 2 shows the background to learning through learners recognise common auscultatory cardiac find-
clinical simulation and the factors that drive it. ings,38,39 as well as trainers designed to develop basic
and sophisticated surgical techniques. They allow the
learner to focus on the isolated task, but can be used in
Societal Political combination to enhance the learning experience: for
example, a female pelvic examination trainer may be
expectation accountability
used along with an anatomical model of the pelvis to
Failure of traditional learning
reinforce learning of the underlying anatomy. Some
modes
provide feedback (visual, auditory or printed) to the
Changing clinical Clinic al learner on the quality of their performance (e.g.
experience Learning governance simple clicking to represent adequate depth of chest
through
Shorter time in simulation Patient safety
training enabled by agenda
new Table 2 Classification of simulators36,37
technologies
Working time Interprofessional
Part-task trainers
restrictions learning
Computer-based systems
Team-based learning and Virtual reality and Precision placement
haptic systems Simple manipulation
working
Professional Complex manipulation
Simulated patients
regulation Simulated environments
Integrated simulators
Instructor-driven simulators
Figure 2 Drives and background to learning through clin- Model-driven simulators
ical simulation

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258 medical education history

compression in cardiopulmonary resuscitation). particularly in undergraduate communication skills

Although it is not part of their original purpose, they learning. The SP may be a professional actor trained
can be imaginatively used along with simulated to present a history and sometimes to mimic physical
patients (SPs) to provide learners with realistic clinical signs, or a patient who has received training to
scenarios in which both technical and communication present his or her history in a standardised, reliable
skills are combined.40 manner. They have also been used in assessment as
replacements for real patients and as assessors
themselves.41 Occasionally, the learners themselves
COMPUTER-BASED SYSTEMS may act as SPs through role-play.42

Multimedia programmes The recreation of the environment in which the

activity is going to take place is common in simula-
U-Medic is a CD-ROM based multimedia programme tion and clinical skills centres. Within reason, the
that partners the Harvey and presents an extensive ability to situate the activity in a realistic environment
cardiovascular curriculum incorporating cardiac aus- would be expected to increase the learner’s engage-
cultation and cardiovascular imaging in its presenta- ment with the simulation and to enhance the
tion. Programmes such as this, incorporating audio suspension of disbelief. Although, for team training
and video, are used in a fairly commonplace manner in particular, it might be argued that training in situ
as adjuncts to formal teaching and learning. within the normal clinical environment can provide
individuals and systems with real experience upon
Interactive systems which to reflect, the impact on clinical activity and
the distraction of ongoing work may create too much
These systems often provide the user with an inter- peripheral distraction to learning.
face that presents physiological or pharmacological
variables that can be manipulated through the user’s
actions, providing feedback on decisions made and INTEGRATED SIMULATORS
actions taken.
These simulators combine a manikin (usually a whole
Virtual reality and haptic systems body) with sophisticated computer controls that can
be manipulated to provide various physiological
More sophisticated application of computer tech- parameter outputs that can be physical (such as a
nology is encountered in virtual reality (VR) and pulse rate or respiratory movements) or electrical
haptic systems. Virtual reality refers to the recreation (presented as monitor readouts). These parameters
of environments or objects as a complex, computer- may be automatically controlled by a physiological
generated image; haptic systems refer to those and pharmacological model incorporated within the
replicating the kinaesthetic and tactile perception. software or may respond to instructor inventions in
Often VR and haptic systems are combined with some response to actions of learners. The sophistication of
form of part-task trainer; the products that are these simulators and their costs vary. The METI and
currently available support vascular access training, the Medsim are high-fidelity simulators that have
endoscopy training and laparoscopic surgical tech- been at the forefront of work in anaesthetic simula-
niques. Kneebone describes a subcategorisation of tion. More recently, the SimMan, a moderate-fidelity
computer-based VR simulators: precision placement simulator, has become available at a much lower cost,
(e.g. vascular access), simple manipulation (e.g. enabling an unprecedented growth in the use of this
sigmoidoscopy) and complex manipulation (e.g. level of simulation.
anastomosis).37 He also describes a higher level of
integrated procedures, which are in keeping with
fully integrated, high-fidelity simulators. WHY USE SIMULATION?
All this being said, we are still left with the question:
SIMULATED PATIENTS AND why use simulation? The proponents for simulation
ENVIRONMENTS make a reasoned and cogent argument for the use of
simulation. Simulation provides a safe, supportive
Simulated patients have over the last two to three educational environment.43 It allows users at all
decades become commonplace in medical education, levels, from novice to expert, to practise and develop

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 259

skills with the knowledge that mistakes carry no

penalties or fear of harm to patients or learners. It Table 4 Potential application of simulation
encourages the acquisition of skills through experi-
ence,44 ideally in a realistic situation or environment, Routine learning and rehearsal of clinical and communication
and can stimulate reflection on performance.45 skills at all levels
Routine basic training of individuals and teams
Learners can develop at their own rate and individual Practice of complex clinical situations
learning and rates of learning styles can be accommo- Training of teams in crisis resource management
dated. Simulation can facilitate on-demand learning Rehearsal of serious and ⁄ or rare events
Rehearsal of planned, novel or infrequent interventions
and scenarios can be created as required.46 Further- Induction into new clinical environments and use of
more, training through simulation may facilitate the equipment
transfer of skills to the real world setting of the clinical Design and testing of new clinical equipment
Performance assessment of staff at all levels
environment. It also has the potential to be a valuable Refresher training of staff at all levels
formative and summative assessment tool. The poten-
tial benefits of simulation are shown in Table 3.

Simulation has several potential applications at all educational innovations without sound evidence for
levels of the professional development of individuals, their efficacy.47 The field of simulation is similarly
as well as in supporting professional practice and under the microscope for the same reason. As
continuing professional development. As a tech- Table 5 shows, the field itself is theory-rich48 and
nique, simulation can support undergraduates in the such an abundant conceptualisation of learning
acquisition of a range of basic clinical (history should help us understand how learning is taking
content, physical examination and procedural) and place and how it can be supported through simula-
communication skills. Teamwork and interprofes- tion.
sional learning can similarly be the subject of
simulated activities. It also has the potential to both It is evident that the literature on simulation is
support and quality assure ongoing professional growing rapidly (Fig. 3); however, the evidence
development. Some of these applications are out- emerging from the literature is limited. A recent ÔBest
lined in Table 4. Evidence Medical EducationÕ (BEME) review of
effective learning through high-fidelity simulation
However, despite the rhetoric and the recognised identified only 109 articles (from 670) that were
potential of simulation to be used widely in support sufficiently robust to be included in the process.49
of health care education at all levels and across all The chief findings of the successful elements of high-
disciplines, this is not likely to be realised without fidelity mediated learning are summarised in
evidence to support the widespread adoption of this Table 6. It is apparent that much of what has been
technique. and is being written is limited in scope to reporting
evaluations, usually at the lower end of the Kirkpa-
trick criteria,50 in common with much medical
THEORY AND RESEARCH education literature.51

The medical education community has been much

criticised of late for adopting and implementing POSSIBLE FUTURE DIRECTIONS
There are needs for research that has a better
methodological base and for medical education to
Table 3 The benefits of simulation36
learn from other disciplines. This applies to the
Risks to patients and learners are avoided
Undesired interference is reduced
Tasks ⁄ scenarios can be created to demand
Skills can be practised repeatedly Table 5 Relevant learning theories48
Training can be tailored to individuals
Retention and accuracy are increased Behaviourism
Transfer of training from classroom to real Constructivism
situation is enhanced Social constructivism
Standards against which to evaluate Reflective learning
student performance and diagnose Situated learning
educational needs are enhanced Activity theory

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260 medical education history

600 researchers appropriate approaches. Neither should

be viewed as superior to the other; rather they should
500
be aligned with the appropriate theoretical stance to
400 provide different and complimentary research per-
spectives proving different, but equally relevant,
300 evidence regarding the learning facilitated by the
simulated processes in all their guises.48 The prob-
200
lems pertaining to small sample sizes need to be
100 overcome through collaboration between educa-
tional institutions.
0
1963 1968 1973 1978 1983 1988 1993 1998 2003
Assuming that evidence will be forthcoming, what
Figure 3 Cumulative growth in simulation literature direction will clinical simulation take? It seems likely
(Source: Boston Simulation Centre) that the three movements described earlier will
coalesce and that the process will continue to grow
and have an important part to play in the future. It is,
however, important not to think of simulation as
Table 6 The features of high-fidelity simulation that affect learning49 disintegrating into separate low-fidelity ⁄ high-fidelity
dichotomies with SPs somewhere else off the scale.59
Providing feedback
Allowing repetitive practice
The level and type of simulation will need to be
Integrating within curriculum adapted to the educational needs of the learner and
Providing a range of difficulties the design and intended outcomes of the pro-
Being adaptable; allowing multiple
learning strategies
gramme; for example, high-fidelity simulation with
Providing a range of clinical scenarios the METI is inappropriate for developing learner
Providing a safe, educationally supportive skills in breaking bad news and learning team-based,
learning environment
Active learning based on individualised needs
non-technical skills is unlikely to be facilitated
Defined outcomes through the use of an upper limb intended for
Simulator validity as a realistic recreation of venepuncture!
complex clinical situations

Figure 4 shows a representation of a broad-based

clinical simulation movement. This envisages wide-
continuum of simulation as much as it does to other spread adaptation by many target groups and disci-
aspects of medical education.52–55 Medical education plines. Low to high-fidelity simulation is supported
is an expensive undertaking; like other aspects of
health care it demands attention to the cost justifi-
cation of the outcomes of the process; without such
evidence, simulation, for example, is unlikely to
persuade those who manage the funding of the
potential benefits. Without commitment to an evi-
• Coalescence of movements
dence base, at best simulation will retain a peripheral • Undergrad, post grad and continuing medical education
place in education and training; at worst the process • Multiple disciplines use routinely
will stagnate for the lack of forceful argument in its • Interprofessional learning
• Team-based learning
favour. • Full range of simulation continuum used
• Technological advances to combine whole body
The need for outcomes-based education is increas- manikins, virtual reality and computer - based
physiological/pharmacological modelling
ingly accepted in general medical education56,57 and • Revalidation and reaccreditation
in clinical skills learning58 – simulation is no excep-
tion to this. Having defined outcomes facilitates the
investigation of the interventions intended to pro-
duce learning and the achievement of these out-
comes.
2000 2010 2020

In terms of the research methods that support the

investigation of learning through simulation, both Figure 4 Representation of the future, broadening base of
the scientific and interpretative paradigms offer learning through simulation

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 261

across the full continuum. Such an uptake of simu- 6 Good ML, Gravenstein JS. Anaesthesia simulators and
lation would have major consequences for health training devices. Int Anesthesiol Clin 1989;27:161–6.
care education and delivery institutions. The vision 7 Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA.
for simulation in the future has been explored Simulation-based training in anaesthesia crisis resource
management (ACRM): a decade of experience. Simu-
eloquently and honestly by Gaba60 but the final
lation Gaming 2001;32(2):175–93.
outcome remains to be seen.
8 General Medical Council. Tomorrow’s Doctors: Recom-
mendations on Undergraduate Medical Education. London:
GMC 1993.
CONCLUSION 9 Association of American Medical Colleges. Learning
objectives for medical student education – guidelines
Clinical simulation is a technique that enables the for medical schools: Report 1 of the Medical School
learning and training of individuals and teams Objectives Project. Acad Med 1999;74:13–8.
through the re-creation of some aspect of the real 10 Accreditation Committee. Assessment and Accreditation of
clinical situation. It exists as a spectrum of educa- Medical Schools: Standards and Procedures. Canberra:
tional activities involving not just technological and Australian Medical Council 2002.
11 World Federation for Medical Education. Global Stand-
computerised facilities, but including important
ards for Quality Improvement. Copenhagen: WFME 2003.
human interactions. These interactions may be one-
12 Bligh J. The clinical skills unit. Postgrad Med J
to-one (e.g. as role-plays or with SPs), within teams 1995;71(842):730–2.
or between teams. It is important not to disinteg- 13 Bradley P, Bligh J. One year’s experience with a clinical
rate simulation into a dichotomy between low- and skills resource centre. Med Educ 1999;33(2):114–20.
high-fidelity, but to regard it as a continuum with 14 Dacre J, Nicol M, Holroyd D, Ingram D. The develop-
roles to fulfil at all levels of seniority within and ment of a clinical skills centre. J R Coll Physicians Lond
between professional groups. However, the evi- 1996;30(4):318–24.
dence to date that has appeared in the literature 15 Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based
tends to be of a low-level evaluative nature, weak in medical education: an ethical imperative. Acad Med
methodology and of limited generalisability. Robust 2003;78(8):783–8.
16 Carter R, Aitchison M, Mufti G, Scott R. Catheterisa-
research is required to underpin simulation as a
tion: your urethra in their hands. BMJ 1990;301:905.
worthwhile educational strategy. This research
17 Cartwright MS, Reynolds PS, Rodriguez ZM, Breyer
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whole spectrum of the efficacy and effectiveness of dural skills training. Med Educ 2005;39(4):437.
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