Why simulation is changing education

US partnership helps Center for Education in Medical Simulation make headlines
Mayor, international evaluators applaud new facilities based on WISER guidance

What’s even better than the real thing?

When it comes to health professionals’ high-stakes decisions, simulations indeed deserve their prime place in TMU’s educational landscape.

Do you want a first-time pilot, or one who has managed crises in a flight simulator until their responses are correct and immediate?

Similarly, even the most promising surgical procedures involve a learning curve, with one TMU back surgeon estimating that it takes more than 20 operations to gain reliable skill using new techniques in minimally invasive surgery. Do you want to be one of those 20 patients?

The Center for Education in Medical Simulation is growing to meet these needs at TMU. This center has grown from its CEO’s observations that a lot of training mannequins went unused and that nurses shunned emergency room jobs. Now CEMS has extended its technological and institutional reach even beyond our university — to help the city plan disaster response strategies for the recent Taipei Universiade, and to help learners worldwide with online courses.

Center CEO and Thomas Che-Wei Lin, a physician by training, said TMU’s simulation center is the first Asian center to qualify in two certification categories of the Society for Simulation in Healthcare.

The center applies virtual technology to learning situations using high-end equipment. These technologies include a XVR (eXtreme Virtual Reality) 3D simulation system, the CEMS operating room’s virtual surgical system developed in cooperation with mobile phone maker HTC, a six-dimensional virtual reality imaging system and virtual patients.

TMU clinical education faculty can enhance their instruction by moving from physical models to virtual reality, allowing students to learn how to operate even the most advanced medical technologies well before they progress to patient care. The 727-sq. meter center also has a simulated intensive care unit that opens a new era of virtual-reality teaching.

An opening ceremony took place in May at the CEMS offices in TMU’s Daan campus. Taipei Mayor Wen-Je Ko attended and was briefed on a disaster response system. The mayor, a physician by training, also witnessed simulation training for extracorporeal membrane oxygenation and viewed other medical simulation equipment.

In August, TMU hosted an annual Asian conference on simulation education featuring several US experts. It was organized by CEMS senior advisor Dr. Paul Phrampus, also director of the Peter M. Winter Institute for Simulation, Education and Research (WISER) at the University of Pittsburgh. Dr. Phrampus’s advice has been central to the TMU center’s development since Dr. Lin attended such an event in Hong Kong years ago.

As the conferees gathered nearby in the new Daan Campus’s meeting hall, Dr. Phrampus and Dr. Lin spoke about CEMS’ development and future milestones.

Q: Most people understand flight simulators limit risks that inexperienced pilots might pose to passengers and equipment. But they don’t understand simulation in health services. Can you explain why this can be more important than face time?

Dr. Phrampus: The complexity of health care education is increasing at an astronomical rate — and that’s just the facts and figures of what one needs to know to be a practicing nurse or doctor. And then also [they need] the skills.

As you know, medical science is exploding with new discoveries and so on. So the first piece that I think simulation fits in a big way is transitioning from lecture, lecture, lecture – and people falling asleep in the lecture hall – to actually engaging them in their future profession in a simulated environment where they’re free to explore; they’re free to make mistakes.

And because no can harm comes to a simulated patient, we think that with immersive education and simulation we can accelerate the learning curves. So if it makes their education more efficient…

Q: Didn’t a recent paper based on research at the center find that students learned laparoscopic suturing faster and remembered better when the classroom was ‘flipped’ in a simulation setting than with traditional instructional methods?

Dr. Phrampus: TMU is way ahead of the curve, because Thomas has been a real pioneer here in pushing things forward in the medical school. … He also branched out into the hospital and partnered with nurses and nursing education units.

This has been going on for many years here, and so that puts TMU ahead of the curve particularly when it comes to using simulation directly for patient safety. Simulation is not just for students, but for practicing professionals.

So here is a good place for simulation: education of practicing nurses, practicing physicians, practicing pharmacists – people who touch patients and have the possibility of making a mistake.

Centers like Thomas leads here make that transition easier to the “second world” of simulation [after student training]: the patient safety and practicing professionals.

Dr. Lin: [Simulation] is high-engagement education, so it must be a small group. We’re improving simulation instructional methods [in partnership with] the University of Pittsburgh and the Gordon Center for Research in Medical Education at the University of Miami.

Dr. Phrampus: One another advantage that Thomas brought to TMU is he turned this center in the last 5 or 6 years into a beacon of leadership for faculty development. The dirty little secret in health-care education is that none of us are really educators; we’re all just doctors and nurses and pharmacists and respiratory therapists – but some of us get assigned to teach. (laughter) What we need to do is fuse education for principles and education for skills. For normal clinical folks, we can get them up to a level of competency to come in the simulation lab and be very effective. He [Thomas] adopted that model quite a while ago; that’s why he’s got so many instructors, that’s why they run so many programs at his center.

Dr. Lin: You have to attend our training faculty training course; we have several courses. They can teach in pairs, then individually; they can design a course. … [Simulation offers] ways of teaching the same stuff faster. [As faculty grow] familiar with the message of simulation education, we can help each specialty.

The dental school [has had] the best simulation program … We hold their hand and say ‘Let’s convert your good idea in dentistry into an immersive learning process.’

In the end, step by step, we nurture ideas, and we get them [faculty] to focus on efficiency and effectiveness in the ultimate outcome.

Dr. Phrampus: We don’t want to get sidetracked by simulation; people can get enamored with the theatrics and get confused and think that that’s the part that’s effective. So the job of a well-trained faculty development center is to help people navigate those potential risks of getting hooked on the technology and keep them on message, focusing on the needs.

Q: What inspired you? Can you share your path to leadership in this field?

Dr. Lin: My first experience to teach using simulation? I’m an emergency physician, so we focus a lot on resuscitation. Maybe 8 years ago I was the ACLS instructor; at that time I thought I knew simulation very well!

They used a mannequin in the past, so I thought, ‘If you use a mannequin, you’re teaching with simulation.’ But besides mannequins I found many more things! So I listened to Paul’s speech, then took his course in Hong Kong to gain a more comprehensive idea.

I applied [simulation] in my daily work, and then one day the vice president asked [me to]expand this [simulation] at Taipei Medical University Hospital. Hospital accreditation focuses on patient safety issues, so we developed courses that also focus on some patient safety issues.

One day [former TMU President Yun Yen] asked if I can design a similar simulation education [program for TMU], so we standardized patient training [and expanded this]. Also, once we established our center we needed someone to guide us, so we invited Paul as our senior advisor.

For years [the center was located] in a small basement space, but Paul said not to worry about that: ‘The fundamental job is to make a logical structure. If you have the faculty, you don’t need a castle.”

Q: Where do you see Taiwan having strengths? Where can we add to medical simulation?

Dr. Phrampus: I think that Thomas is already starting that leadership process by adopting a framework to become a center of excellence in faculty development for medical education. But he also went through the enormous task of getting his center accredited by the Society for Simulation in Health Care.

The other thing I think is really exciting is [that] in general the medical and nursing communities are a little bit closer in terms of the way they interact. My interactions have been at the Taiwan Society for Emergency Medicine and so on; having that ability to put together a small network is relatively easy [in Taiwan], and I think is a big strength.

In terms of faculty development he’s not only done great work here in Taiwan, but he’s also recruited lots of people as well put on conferences like this one and others.

The other thing that I think is extraordinary about TMU and the hospital system is the support they’ve given to him. [Dr. Lin] modeled it after my center — and I’m not saying my center’s the basic model, but we’re in a similar situation where we are partnered directly with the University of Pittsburgh and the UPMC health system.

So that’s why we cross that mission back and forth between students and practicing professionals. [People need to] hear the patient safety side of it: how does this apply to work inside real hospitals where real people are caring for patients? Because most people know about medical simulation for students but not practitioners, that’s I think a very unique theme of CEMS.

And he’s gotten tremendous support… Without leadership support this stuff goes nowhere. What has brought this center to become such a roaring success: the leadership pays attention to making sure there’s a sustainable program in place.

Q: What can you foresee as future developments in simulation and for CEMS?

Dr. Lin: We’ve been working hard on online courses about simulation-based medical education. … Materials and everything are ready, but we will try to look for some grants to help; then we can do it maybe next year.

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