medical simulation medical simulation medical simulation, or more broadly, healthcare simulation, is a branch of simulation related to education and training in medical fields of various industries. simulations can be held in the classroom, in situational environments, or in spaces built specifically for simulation practice. it can involve simulated human patients (whether artificial, human or a combination of the two), educational documents with detailed simulated animations, casualty assessment in homeland security and military situations, emergency response, and support for virtual health functions with holographic simulation. in the past, its main purpose was to train medical professionals to reduce errors during surgery, prescription, crisis interventions, and general practice. combined with methods in debriefing, it is now also used to train students in anatomy, physiology, and communication during their schooling. an nshq instructor shows a sof medic the proper procedure for controlling a mannequin. history link trainer. modern-day simulation for training was first utilized by anesthesia physicians to reduce accidents. when simulation skyrocketed in popularity during the 1930's due to the invention of the trainer building link trainer for flight and military applications, many field experts attempted to adapt simulation to their own needs. medical simulation was not immediately accepted as a useful training technique, both because of technological limitations and because of the limited availability of medical expertise at the time. however, extensive military use demonstrated that medical simulation could be cost-effective. additionally, valuable simulation hardware and software was developed, and medical standards were established. gradually, medical simulation became affordable, although it remained un-standardized. by the 1980's software simulations became available. with the help of a ucsd school of medicine student, computer gaming world reported that a surgeon (1986) for the apple macintosh very accurately simulated operating on an aortic aneurysm. others followed, such as life & death (1988). in 2004, the society for simulation in healthcare (ssh) was formed to assist in collaboration between associations interested in medical simulation in healthcare. the need for a "uniform mechanism to educate, evaluate, and certify simulation instructors for the health care profession" was recognized by mcgaghie et al. in their critical review of simulation-based medical education research. in 2012 the ssh piloted two new certifications to provide recognition to educators to meet this need. modern medical simulation the american board of emergency medicine employs the use of medical simulation technology in order to accurately judge students by using "patient scenarios" during oral board examinations. however, these forms of simulation are a far cry from high-fidelity models that have surfaced since the 1990s. due to the fact that computer simulation technology is still relatively new with regard to flight and military simulators, there is still much research to be done about the best way to approach medical training through simulation, which remains un-standardized despite having been embraced generally by the medical community. that said, successful strides are being made in terms of medical education and training, although a number of studies have shown that students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means. the council of residency directors (cord) has established the following recommendations for simulation: simulation is a useful tool for training residents and ascertaining competency. the core competencies most conducive to simulation-based training are patient care, interpersonal skills, and systems-based practice. it is appropriate for performance assessment but there is a scarcity of evidence that supports the validity of simulation in the use for promotion or certification. there is a need for standardization and definition in using simulation to evaluate performance. scenarios and tools should also be formatted and standardized such that em educators can use the data and count on it for reproducibility, reliability, and validity. the association of surgeons in training has produced recommendations for the introduction, availability, and role of simulation in surgical training. clinical skills and simulations centers (cssc) for medical simulation the two main types of medical institutions that train people through medical simulations are medical schools and teaching hospitals. according to survey results from the association of american medical colleges (aamc), simulation content taught at american medical schools spans all four years of study, while hospitals utilize simulations during the residency and subspecialty period. internal medicine, emergency medicine, obstetrics/gynecology, pediatrics, surgery, and anesthesiology are the most common areas taught in medical schools and hospitals. the aamc reported that the majority of medical schools and teaching hospitals centralize their simulation activities at a single physical location, while some use decentralized facilities or mobile simulation resources. most of the medical training institutions own their own facilities. often, medical school cssc locations include rooms for debriefs, training exercises, standardized exam and patient rooms, procedure rooms, offices, observation area, control rooms, classrooms, and storage rooms. on average, a medical school dedicates 27 rooms of its cssc to training with simulations. medical simulation centre design & operations a medical simulation centre is an educational centre in a clinical setting. the key elements in the design of a simulation center are building form, room usage, and technology. for learners to suspend disbelief during simulation scenarios, it is important to create a realistic environment. it may include incorporating aspects of the environment not essential in simulation activities, but that play a big role in patient safety. for instance, many reports show that patient falls and injuries occur in the hospital bathroom, so the simulation rooms were designed with bathroom spaces. a successful simulation center must be within walking distance of the medical professionals who will be using it. often, clinical and medical faculty are responsible for the day-to-day operations of simulation centers, typically in addition to other responsibilities. however, the technology that has emerged within medical simulation has become complex and can benefit from the utilization of specialists. in 2014, society for simulation in healthcare introduced the certified healthcare simulation operations specialist (chsos) certification. the chsos certification endeavors to standardize and authenticate the minimum competencies to be demonstrated by simulation center operations specialists. debriefing & education in medical simulation example of a medical simulation the origins of debriefing can be traced back to the military, whereby upon return from a mission or war game exercise, participants were asked to gather as a group and recount what had happened. these gatherings had the primary intention of developing new strategies to use in future encounters; these gatherings also provided a learning opportunity for other members of the team who were not present at the events being debriefed. in the field of psychology, debriefing is used in the processing of traumatic events. here, the emphasis is on the narrative; in a facilitator-led environment, participants reconstruct what happened and review facts, share reactions, and develop a shared meaning of the events. the aim is to reduce stress, accelerate normal recovery, and assist in both the cognitive and emotional processing of the experience. in all instances, debriefing is the process by which people who have gone through an experience are intentionally and thoughtfully led through a discussion of that experience. debriefing in simulation is a critical component of learning in simulation and is necessary to facilitate change “on an individual and systematic level”.: e287 it draws from the above-mentioned forms of debriefing, but the emphasis here is on education. debriefing in education can be described as a “facilitator-led participant discussion of events, reflection, and assimilation of activities into cognitions produce long-lasting learning”. more specific descriptions of debriefing can be found, such as the following in relation to debriefing in healthcare simulations, described by cheng et al. (2014): “...a discussion between two or more individuals in which aspects of a performance are explored and analysed with the aim of gaining insights that impact the quality of future clinical practice”.: 658 or another regarding debriefing in gaming, by steinwachs (1992), “…a time to reflect on and discover together what happened during game play and what it all means.": 187 debriefing in medical simulation medical simulation is often defined as, “a technique (not a technology) to replace and amplify real life experiences with guided ones, often “immersive” in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion”. this definition deliberately defines simulation as a technique and not a technology, implying that simulation is greater than the technology or tools which it adopts. also note the use of the word guided in the definition, further implying that the interactions which occur in a simulated environment are not left solely to those persons immersed in the simulation, but that a “guide” also be present. this guide may be virtual in nature, such as prompts from a computer program, or may be physically present, in the form of an instructor or teacher. the human guide is often referred to as a “facilitator”. it is this facilitator who guides the debriefing which occurs after a simulation scenario has been completed. when these elements are present, the simulation is often referred to as “instructional simulation", "educational simulation,” or “simulation-based learning”. favorable and statistically significant effects for nearly all knowledge and process skill outcomes when comparing simulation and debriefing versus simulation with no intervention (in healthcare) has been shown. when applied in a capacity to further professional development, simulation and debriefing may be referred to as “simulation-based training”. simulation, debriefing, & education theory experiential learning, which draws from prominent scholars such as john dewey, jean piaget, and carl rogers, among others, underpins simulation-based learning. often referred to as “learning by doing”, or more broadly, a “theory of experience”, experiential learning theory states that experience plays a central role in human learning & development. the six principles of experiential learning theory align with educational simulation. the six principles are: engaging students in a process that enhances learning. this includes “feedback on the effectiveness of their learning efforts,” (p. 194) and focus on the process, not the outcome. students have prior beliefs and ideas. a process which draws these beliefs & ideas out, with the intent of re-examining & re-testing them against a topic in order to accommodate new ideas, will lead to learning. learning is a process which cycles between reflection and action, feeling and thinking. “conflict, differences, and disagreement are what drive the learning process” (p. 194); the resolution of these is what leads to learning. learning happens in interactions between the person and the environment which surrounds them. learning is more than cognition; it also involves thinking, feeling, perceiving, and behaving. learning is grounded in constructivist philosophy; “learning is the process of creating knowledge”.: 194 simulation also aligns with guided discovery learning. developed by jerome bruner in the 1960s, discovery learning also stems from the work of jean piaget and can be described as a learning environment where there is little to no instructor-guidance. guided discovery learning, on the other hand, continues to place learners in a discovery environment, but where an instructor is available to help guide learning via coaching, feedback, hints, and/or modeling. both experiential & discovery learning are based on constructivist philosophy. broadly, constructivism is based on the belief that learning is an active process whereby learners make sense of new knowledge by building upon their prior experiences; each person has a unique set of experiences which frame their interpretation of information. debriefing frameworks while many models for debriefing exist, they all follow, at a minimum, a three-phase format. debriefing models can be divided into two categories: the “three-phase debriefing structure,” and the “multiphase debriefing structure”. three-phase debriefing structure a benchmark in all forms of facilitator-guided, post-event debriefing conversational structures, the three conventional phases of debriefing are: description, analysis, and application. frameworks which make use of the three-phase debriefing format include debriefing with good judgment, the 3d model, the gas model, and diamond debrief. description also labelled as “reaction,” "defusing," "gather," and "identify what happened," the description phase of debriefing sees simulation participants describing and exploring their reactions, emotions, and overall impact of the experience. it is the opening phase of systematic reflection, enabled by a facilitator who poses key questions such as: “how did that feel?” “how did that go?” “can you take us through the scenario as it unfolded?” a facilitator is to keep asking these questions of the learners until they feel confident that all participants have voiced their understanding of the situation. the point of the description phase is to