Simulation, as defined by the Association of American Medical Colleges (AAMC), is “a method used in healthcare education to replace or amplify real patient experiences with scenarios designed to replicate real health encounters, using lifelike mannequins, physical models, standardized patients, or computers.”¹ Although simulation has roots in aviation and warfare training, it also has significant applicability in the realm of healthcare.

When the Institute of Medicine published To Err Is Human, a landmark 1999 paper revealing that medical errors were associated with between 44,000 and 98,000 preventable patient deaths, an increased emphasis emerged on the need for patient safety and to reduce the number of mistakes made while caring for patients.² Simulation is an educational modality that is seen to enhance both patient safety and learning³ by providing a controlled and constructed environment for medical professionals of all training levels to improve their technical skills, such as laparoscopic techniques as well as communication and interpersonal team-based skills. As evidenced by the creation of an academic society dedicated to this area, the initiation of a simulation journal, and a growing body of research around its use in medical education, the interest in and use of simulation has increased dramatically since the 1990s.⁴

Simulation, in the most general terms, is simply a teaching technique. By understanding the varying capabilities of simulators, the environments in which each type can be used, and their unique challenges, we can better employ simulators to accomplish intended learning objectives. Simulation is beneficial to the obstetric (OB/GYN) hospitalist because it provides a standardized and safe, yet interactive and experiential learning environment for trainees that can be adapted to the curricular needs of residency and fellowship programs. In particular, simulation can enhance technical and functional expertise through hands-on training as well as problem-solving and decision-making skills based on interpretation of changing patient states. In addition, simulation allows the hospitalist to explore systems and patient safety issues in real time, without putting patients at risk, and provides opportunities for complex, multidisciplinary healthcare teams to practice working together in unity.

This chapter will provide a brief description of simulator fidelity, the simulator sites, and the pros and cons of each. It will also offer concrete examples of ways in which simulation can be used to address several common OB emergencies and help illustrate how simulation can address educational objectives.

In relation to medical simulation, simulation fidelity describes the level of realism or authenticity to which a model approaches an actual real-life situation, and this fidelity has been described as a continuum.^5,6 The lowest levels of fidelity may be represented by verbal or written stems, as with case studies or oral board exams. At these levels, participants are asked to make clinical decisions and verbally describe goals and actions to demonstrate their knowledge and clinical reasoning.

The highest levels of fidelity typically utilize a standardized patient, or live actor, to have clinicians perform a physical exam. In general, simulators with higher levels of fidelity tend to be more costly. However, simulators with the highest level of fidelity (i.e. standardized human patients) are limited in what procedures can be performed on them, as practicing unnecessary and invasive procedures on an actor can both pose an ethical dilemma and constitute a danger to the “patient.”

Although there may be a tendency to think that cost is proportionate to effectiveness, it is important to stress that high-fidelity simulators are not necessarily more effective, and costs for simulation can come from a variety of hidden sources beyond the cost of the actual simulator.⁷ What is essential is that clear learning objectives are created so that the correct simulator can be utilized in the right environment to maximize learning opportunities.

Several examples of simulator fidelity are provided in Table 19-1. In some instances, a combination of simulators of varying fidelity may be used together to enhance learning, and this is called a hybrid. One example of a hybrid simulator is a standardized patient wearing a cloth uterine model with a prolapsed cord to allow physical exam and inspection of the perineum, in addition to direct questioning.

In addition to how lifelike the simulator is perceived to be, other aspects of the simulation can be more or less realistic, including environmental fidelity (i.e. the physical space looks like an exam or triage room), equipment fidelity (i.e. equipment is similar to that actually used in the clinic), and physical fidelity (i.e. the model feels, and acts, like human tissue). An important distinction should be placed on the difference between physical fidelity and psychological fidelity. Thus far, our discussion has focused on the physical aspects of simulation fidelity. In contrast, psychological fidelity is a concept that focuses on how likely the simulation evokes behaviors or skills seen as necessary to accomplish goals in the real-life situation.⁸

This aspect of simulation is incredibly important, as it is a key component of the educational process involving simulation, as described by Maran and Glavin (2003).⁶ As they note, three fundamental components are part of using simulations for the purpose of education: deliberate practice, reflection, and feedback. Simulation as an activity allows the deliberate practice of both simple and complex actions in a reproducible environment where errors of both diagnosis and management can evolve in a risk-free manner for learning purposes. The educational opportunity may involve individuals or teams of any skill level. For clarity, the term multidisciplinary training is used when describing simulations involving teams from different departments working on the same simulation, both separately and in parallel. In contrast, when teams from different departments participate in simulation activities to enhance their ability to work together through communication and team enhancement strategies, the term interprofessional training is used instead.

Validity is another concept essential to simulation theory; this focuses on how well the simulated task is subjectively viewed as teaching or testing the desired educational goal. Content validity refers to how well the simulation covers content relevant to the proposed situation. Construct validity relates to how well the simulation establishes the degree to which a participant is able to perform a task (not surprisingly, experts should outscore novices). Face validity concerns how realistic the simulation appears to the participant.^9,10

By taking into consideration these aspects of fidelity and validity, the instructor can start to decipher what level of realism is necessary to accomplish the desired educational goals. Further, individual simulations may have key features and can be part of a larger educational curriculum, which often builds upon prior modules. In this manner, comprehensive and complex simulation programs can be established.

Having an amazing, high-fidelity mannequin simulator with the capability to give birth and hemorrhage can seem very appealing. However, does that advanced technology actually translate into better learning? Among the most common simulated scenarios in OB (including hemorrhage, maternal code, shoulder dystocia, and eclampsia), is there evidence that high fidelity is better? Some cited advantages for using a high-fidelity birthing simulator include that the simulator and intended complication are more lifelike, with improved ability to suspend disbelief; the increased variety of scenarios that can be used with the same model; and the increased ability to simulate procedures such as breech extractions or operative deliveries. The disadvantages of using high-fidelity simulators include high cost, the need for technical training to use the simulators, difficulty transporting the simulators, the lack of studies supporting the cost-effectiveness of its use. Similarly, the researched evidence of benefits for using high or low-fidelity models in obstetric simulations has been limited.¹¹

Although many simulations in OB can be accomplished with relatively low-fidelity and low-cost models, one example advocating for a high-fidelity model would be in the simulation of shoulder dystocia. A multicenter study in the United Kingdom compared a high-fidelity training mannequin that incorporated force perception training to a traditional, low-fidelity mannequin. Although there was improvement in both groups, with increased successful delivery rates, when compared to the low-fidelity training, the high-fidelity mannequin had a higher successful delivery rate (72% vs. 94%) and significantly lower total applied force used during the training (2030 Newton seconds vs. 2916 Newton seconds).¹² Similarly, another study in the United Kingdom noted an increase in brachial plexus injury, which was possibly related to the low-fidelity training model or improper simulation training.¹³ Despite these findings, low-fidelity shoulder dystocia training still showed improvements in communication and teamwork training.¹⁴

There are other examples where low-fidelity and high-fidelity simulation training have both shown similar improvements, such as in cardiac resuscitation, postpartum hemorrhage, eclampsia, and neonatal resuscitation.^15,16 Therefore the decision to use low- or high-fidelity simulators should be thoughtfully guided by the purpose and learning objectives of the simulation.

For smaller facilities, it is still feasible to plan simulation training with low-fidelity and/or low-cost resources. Since fidelity is also used to describe the amount of realism in the environment, equipment, or psychology of a simulation, the cost of reproducing each element varies.¹⁷ For example, using a birthing simulator at a simulation lab for training may provide high-fidelity equipment, a moderate-fidelity environment, and moderate psychologic fidelity, whereas an in situ simulation with role-playing may offer low-fidelity equipment, a high-fidelity environment, and moderate psychologic fidelity. A review comparing high-fidelity simulation to low-fidelity simulation in areas such as heart auscultation, basic surgical skills, and training in critical care showed improvement in performance and transferable skills with both types of fidelity simulations. However, when comparing high and low fidelity, the improvements with high fidelity were typically only modestly better, and often not statistically significant.¹⁷

Other low-cost options may be carried out by educational videos that demonstrate skills with a simulator, a hybrid simulator such as a standardized patient or patient actor with a pelvic model, or a laparoscopic box trainer. The most important starting point in developing simulation-based training is to identify clear learning objectives for the learners, and then to match the simulation to represent those goals. Similarly, if multiple departments are involved in the simulation, overall team goals should be clearly described as well as the goals for each individual department.

There is a growing medical conundrum surrounding medical education, especially for those in training. As evidence regarding the consequences of fatigue and sleep deprivation mounts, the push toward limited work hours for medical students and residents has affected medical education significantly. As the number of trainees has increased and the number of hours spent on training has decreased, this has resulted in decreasing opportunities for GYN surgeries. This trend will also likely continue as more patients select medical therapies over surgical interventions due to the advancements of noninvasive options.¹⁸ Overall, these changes make it more difficult for residents to gain firsthand experience and include an adequate breadth of cases in their experience to ensure adequate surgical skills and competency. More recently, data suggests that surgeons with a higher volume of cases, such as laparoscopies and hysterectomies, have improved outcomes when compared with surgeons of a low volume of cases.^19,20 As patient safety and quality of care continue to be priorities at medical facilities in the United States, the need to establish a balance between educational value and patient safety of surgical cases actively brings simulation opportunities to the forefront.

Learning opportunities outside the operating room are being recommended more often to train laparoscopic surgical skills. Training outside of the operating room reduces the risk of adverse surgical events because it allows inexperienced surgeons to develop surgical skills through practicing repetitive motions and hand-eye coordination without putting patients at risk. In 2006, a systematic review showed learners for laparoscopic colorectal procedures could acquire similar clinical results in a simulated setting when supervised by an expert. Although the data was inconsistent for measures such as decreased operating room time or observer assessment of laparoscopic skills, the evidence supports skill transfer in a safe and effective way for inexperienced surgeons as well as a decrease in errors by surgeons trained in a simulation-based environment.²¹

Although box trainer simulators (Fig. 19-1) have been most commonly used as training tools for laparoscopic skills, with the advancement of technology, the use of virtual reality (VR) simulators has become actual reality. In Australia, studies on VR simulators have shown them to be effective in acquiring laparoscopic skills compared to no additional training.²² When comparing the VR simulator to the traditional laparoscopic box trainer in training inexperienced surgeons to a predetermined skill level, the data for the box trainer showed steady improvement over time, whereas those who trained on the VR simulator initially declined in skill; however, at the end of the 6-month study period, the skills of VR simulator–trained professionals were equivalent to those trained on the box trainer.²³

Depending on how readily available this technology becomes, VR may offer more flexibility in training surgical skills, especially as haptics, or the ability to apply tactile sensation and control to virtual modalities, advances. Another creative way that VR simulation has been used in Australia is for credentialing. More specifically, VR was used to evaluate the skills of practitioners during laparoscopic salpingectomy for ectopic pregnancy and salpingo-oophorectomy. A study of this found simulator-credentialed surgeons had shorter procedure times and improved self-assessed confidence in performing the procedure.¹⁸ This simulation technology could be applied to ensure that surgeons have a predetermined level of laparoscopic skills before graduation, or to credential new physicians for privileges at a hospital.

Medical simulation can take place in a number of locations. Although a variety of simulation sites may not be available to simulation instructors, a brief analysis of each type of site will help determine the most appropriate and cost-effective ones for desired goals and objectives.

SIMULATION CENTERS

A simulation center is a dedicated simulation space, often with multiple simulators of varying fidelity and advanced audiovisual equipment available for recording. Space in which the actual simulations occur is often outfitted to resemble actual clinical environments, such as the operating room or a patient’s hospital room. Rooms for debriefing participants and control rooms to direct the simulators are also present. These centers are costly to create, requiring significant primary capital for equipment and space development. They are also expensive to maintain because they require support staff familiar with simulation technology, regular equipment, software updates and disposable materials. These centers are ideal for providing a controlled environment for standardized training of multiple participants and do not impede actual patient care environments. However, since they are not actual clinical work spaces, they do not always capture the same sense of realism or have the ability to test systems that may currently be in place in the actual work area. They can be used for scheduled periods of time, often for a fee, so they may be more accessible if available.

IN SITU SIMULATION

In situ simulation is simulation that takes place in a clinical work environment, such as the OB ward. A simulator or standardized patient is brought into a clinical unit to create a temporary simulation. Because simulation in this manner takes place in an actual clinical setting, it has a high degree of environmental fidelity, can be used to test systems and practices currently in place, and can cross multidisciplinary lines if multiple units are asked to participate. Significant limitations to this form of simulation include delays or cancelations based on clinical need, especially if there is not a separate team of participants free of clinical duties available to engage in the activity. In addition, since these sessions are likely to be based on hospital clinical schedules, it is difficult to ensure that all members in the test subject area will get adequate exposure.

MOBILE SIMULATION

Mobile simulation refers to a simulation lab or environment created in a mobile space, such as a trailer or bus. This allows the simulation center to be brought to the participants, and a temporary simulation environment is created in a parking lot or field. Access to this technology may be somewhat limited because these mobile spaces share the same start-up and maintenance fees as a dedicated center. Moreover, due to their smaller size, they are often unable to have the same capacity as a dedicated space, which limits the number of participants. This kind of technology may be ideal in less population-dense areas, where a community of medical facilities can share resources. Again, because this is a generalized and artificial environment, it is unlikely to allow participants to test systems and practices, but it can be scheduled to allow all participants to engage in a standardized simulation activity.

COMPUTER-BASED SIMULATION

Computer-based simulation allows the participants to engage in simulation activities on a computer or online. This form of simulation is the easiest to assign to participants, and it can be performed when most convenient for them. Significant resources are required to develop this kind of environment, but once it is created, it can be accessed or purchased readily. Computer-based simulation is ideal for psychological testing and processing, but it typically does not allow hands-on activities.