Editing Simulation (section)

==Clinical healthcare simulators==
{{main|Medical simulation}}
'''Clinical healthcare simulators'''<!--boldface per [[WP:R#PLA]]--> are increasingly being developed and deployed to teach therapeutic and diagnostic procedures as well as medical concepts and decision making to personnel in the health professions. Simulators have been developed for training procedures ranging from the basics such as [[blood draw]], to [[laparoscopic]] surgery<ref>{{cite journal  |vauthors=Ahmed K, Keeling AN, Fakhry M, Ashrafian H, Aggarwal R, Naughton PA, Darzi A, Cheshire N, etal |title=Role of Virtual Reality Simulation in Teaching and Assessing Technical Skills in Endovascular Intervention |journal=J Vasc Interv Radiol |volume=21 |issue=1 |pages=55–66 |date=January 2010 |doi=10.1016/j.jvir.2009.09.019 |pmid=20123191 }}</ref> and trauma care. They are also important to help on prototyping new devices<ref>{{cite journal |doi=10.1007/s11837-004-0289-x |author1=Narayan, Roger |author2=Kumta, Prashant |author3=Sfeir, Charles |author4=Lee, Dong-Hyun |author5=Choi, Daiwon |author6=Olton, Dana |title=Nanostructured ceramics in medical devices: Applications and prospects |journal=JOM |volume=56 |issue=10 |pages=38–43 |date=October 2004 |bibcode=2004JOM....56j..38N|s2cid=137324362 }}</ref> for biomedical engineering problems. Currently, simulators are applied to research and develop tools for new therapies,<ref>{{cite journal |vauthors=Couvreur P, Vauthier C |title=Nanotechnology: intelligent design to treat complex disease |journal=Pharm. Res. |volume=23 |issue=7 |pages=1417–50 |date=July 2006 |pmid=16779701 |doi=10.1007/s11095-006-0284-8 |s2cid=1520698 |doi-access=free }}</ref> treatments<ref>{{cite journal |doi=10.4103/0973-1482.29829 |vauthors=Hede S, Huilgol N |title="Nano": the new nemesis of cancer |journal=J Cancer Res Ther |volume=2 |issue=4 |pages=186–95 |year=2006 |pmid=17998702 |doi-access=free }}</ref> and early diagnosis<ref>{{cite journal |vauthors=Leary SP, Liu CY, Apuzzo ML |title=Toward the emergence of nanoneurosurgery: part III—nanomedicine: targeted nanotherapy, nanosurgery, and progress toward the realization of nanoneurosurgery |journal=Neurosurgery |volume=58 |issue=6 |pages=1009–26; discussion 1009–26 |date=June 2006 |pmid=16723880 |doi=10.1227/01.NEU.0000217016.79256.16 |s2cid=33235348 }}</ref> in medicine.

Many medical simulators involve a computer connected to a plastic simulation of the relevant anatomy.<ref>{{cite web |title=Simulation Modalities Available |url=https://cisl.stanford.edu/explore-simulation-based-education/simulation-modalities-available.html |website=Center for Immersive and Simulation-based Learning |publisher=Stanford University |access-date=28 February 2025}}</ref> Sophisticated simulators of this type employ a life-size mannequin that responds to injected drugs and can be programmed to create simulations of life-threatening emergencies.

In other simulations, visual components of the procedure are reproduced by [[computer graphics]] techniques, while touch-based components are reproduced by [[Haptic technology|haptic]] feedback devices combined with physical simulation routines computed in response to the user's actions. Medical simulations of this sort will often use 3D [[Computed tomography|CT]] or [[MRI]] scans of patient data to enhance realism. Some medical simulations are developed to be widely distributed (such as web-enabled simulations<ref>{{cite web | url=http://vam.anest.ufl.edu/simulations/simulationportfolio.php | title=Simulation Portfolio | work=Virtual Anesthesia Machine | access-date=15 May 2016}}</ref> and procedural simulations<ref>{{cite journal | title=A randomized trial evaluating a cognitive simulator for laparoscopic appendectomy | vauthors=Loveday BP, Oosthuizen GV, Diener BS, Windsor JA | journal=ANZ Journal of Surgery | year=2010 | volume=80 | issue=9 | pages=588–594 | doi=10.1111/j.1445-2197.2010.05349.x | pmid=20840399| s2cid=43449399 }}</ref> that can be viewed via standard web browsers) and can be interacted with using standard computer interfaces, such as the [[computer keyboard|keyboard]] and [[computer mouse|mouse]].

===Placebo===
{{Main|Placebo|Placebo in history}}
An important medical application of a simulator—although, perhaps, denoting a slightly different meaning of ''simulator''—is the use of a [[placebo]] drug, a formulation that simulates the active drug in trials of drug efficacy.

===Improving patient safety===
Patient safety is a concern in the medical industry. Patients have been known to suffer injuries and even death due to management error, and lack of using best standards of care and training. According to Building a National Agenda for Simulation-Based Medical Education (Eder-Van Hook, Jackie, 2004), "a health care provider's ability to react prudently in an unexpected situation is one of the most critical factors in creating a positive outcome in medical emergency, regardless of whether it occurs on the battlefield, freeway, or hospital emergency room." Eder-Van Hook (2004) also noted that medical errors kill up to 98,000 with an estimated cost between $37 and $50&nbsp;million and $17 to $29&nbsp;billion for preventable adverse events dollars per year.

Simulation is being used to study patient safety, as well as train medical professionals.<ref name=":0">{{cite journal|last1=Groves|first1=Patricia S.|last2=Bunch|first2=Jacinda L.|last3=Cram|first3=Ellen|last4=Farag|first4=Amany|last5=Manges|first5=Kirstin|last6=Perkhounkova|first6=Yelena|last7=Scott-Cawiezell|first7=Jill|date=19 October 2016|title=Priming Patient Safety Through Nursing Handoff Communication: A Simulation Pilot Study|journal=Western Journal of Nursing Research|volume=39|issue=11|language=en|pages=1394–1411|doi=10.1177/0193945916673358|pmid=28322631|s2cid=32696412|issn=0193-9459}}</ref> Studying patient safety and safety interventions in healthcare is challenging, because there is a lack of experimental control (i.e., patient complexity, system/process variances) to see if an intervention made a meaningful difference (Groves & Manges, 2017).<ref>{{cite journal|last1=Groves|first1=Patricia S.|last2=Manges|first2=Kirstin|date=24 August 2017|title=Understanding Nursing Handoffs: Safety Scholarship in Nursing|journal=Western Journal of Nursing Research|volume=39|issue=11|language=en|pages=1391–1393|doi=10.1177/0193945917727237|pmid=28835189|issn=0193-9459|doi-access=free}}</ref> An example of innovative simulation to study patient safety is from nursing research. Groves et al. (2016) used a high-fidelity simulation to examine nursing safety-oriented behaviors during times such as [[change-of-shift report]].<ref name=":0" />

However, the value of simulation interventions to translating to clinical practice are is still debatable.<ref name=":1" /> As Nishisaki states, "there is good evidence that simulation training improves provider and team [[self-efficacy]] and competence on manikins. There is also good evidence that procedural simulation improves actual operational performance in clinical settings."<ref name=":1">{{cite journal |vauthors=Nishisaki A, Keren R, Nadkarni V |title=Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety |journal=Anesthesiol Clin |volume=25 |issue=2 |pages=225–36 |date=June 2007 |pmid=17574187 |doi=10.1016/j.anclin.2007.03.009 }}</ref> However, there is a need to have improved evidence to show that [[crew resource management]] training through simulation.<ref name=":1" /> One of the largest challenges is showing that team simulation improves team operational performance at the bedside.<ref name=":2">{{cite journal|title=Empowering Sustained Patient Safety|journal=Journal of Nursing Care Quality|volume=30|issue=3|pages=240–6|language=en-US|doi=10.1097/NCQ.0000000000000103|pmid=25479238|year=2015|last1=Stewart|first1=Greg L|last2=Manges|first2=Kirstin A|last3=Ward|first3=Marcia M|s2cid=5613563}}</ref> Although evidence that simulation-based training actually improves patient outcome has been slow to accrue, today the ability of simulation to provide hands-on experience that translates to the operating room is no longer in doubt.<ref>{{cite journal |author1=Zendejas B |author2=Brydges R |author3=Hamstra SJ |display-authors=etal |title=State of the evidence on simulation-based training for laparoscopic surgery: A systematic review |journal=Ann Surg |volume=257 |issue=4 |pages=586–93 |date=2013|doi=10.1097/SLA.0b013e318288c40b|pmid=23407298|s2cid=25367431 }}</ref><ref>{{cite journal |vauthors=Pandey VA, ((Wolfe JHN)) |title=Expanding the use of simulation in open vascular surgical training |journal=J Vasc Surg |volume=56 |issue=3 |pages=847–52 |date=2012|pmid=22836105|doi=10.1016/j.jvs.2012.04.015|doi-access=free }}</ref><ref>{{cite journal |vauthors=Palter VN, Grantcharov TP |title=Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room |journal=Ann Surg |volume=259 |issue=3 |pages=443–48 |date=2014 |doi=10.1097/sla.0000000000000254|pmid=24503910 |s2cid=43162924 }}</ref>

One of the largest factors that might impact the ability to have training impact the work of practitioners at the bedside is the ability to empower frontline staff (Stewart, Manges, Ward, 2015).<ref name=":2" /><ref>{{citation|doi=10.1111/nuf.12161|pmid=27194144|title=Maximizing Team Performance: The Critical Role of the Nurse Leader|journal=Nursing Forum|volume=52|issue=1|pages=21–29|year=2017|last1=Manges|first1=Kirstin|last2=Scott-Cawiezell|first2=Jill|last3=Ward|first3=Marcia M|doi-access=free}}</ref> Another example of an attempt to improve patient safety through the use of simulations training is patient care to deliver just-in-time service or/and just-in-place. This training consists of 20&nbsp; minutes of simulated training just before workers report to shift. One study found that just in time training improved the transition to the bedside. The conclusion as reported in Nishisaki (2008) work, was that the simulation training improved resident participation in real cases; but did not sacrifice the quality of service. It could be therefore hypothesized that by increasing the number of highly trained residents through the use of simulation training, that the simulation training does, in fact, increase patient safety.

===History of simulation in healthcare===
The first medical simulators were simple models of human patients.<ref name="medicalSimulationHistory">{{cite journal |author=Meller, G. |title=A Typology of Simulators for Medical Education |journal=Journal of Digital Imaging |volume=10 |issue=Suppl 1 |pages=194–196 |year=1997 |url=http://www.medsim.com/profile/article1.html |url-status=dead |archive-url=https://web.archive.org/web/19991127134420/http://www.medsim.com/profile/article1.html |archive-date=27 November 1999 |doi=10.1007/BF03168699 |pmid=9268881 |pmc=3452832 }}</ref>

Since antiquity, these representations in clay and stone were used to demonstrate clinical features of disease states and their effects on humans. Models have been found in many cultures and continents. These models have been used in some cultures (e.g., Chinese culture) as a "[[medical diagnosis|diagnostic]]" instrument, allowing women to consult male physicians while maintaining social laws of modesty. Models are used today to help students learn the [[anatomy]] of the [[musculoskeletal]] system and organ systems.<ref name="medicalSimulationHistory" />

In 2002, the [[Society for Simulation in Healthcare]] (SSH) was formed to become a leader in international interprofessional advances the application of medical simulation in healthcare<ref name=Riley2008>{{cite book|author=Richard H. Riley|title=Chapter 38: Society for Simulation in Healthcare by Raemer, Dan IN: Manual of Simulation in Healthcare|url=https://books.google.com/books?id=oABbAg2sjxYC&pg=PA532|year=2008|publisher=Oxford University Press|isbn=978-0-19-920585-1|pages=532–}}</ref>

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.<ref name=pmid20078756>{{cite journal |vauthors=McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ |title=A critical review of simulation-based medical education research: 2003–2009 |journal=Medical Education |volume=44 |issue=1 |pages=50–63 |year=2010 |pmid=20078756 |doi=10.1111/j.1365-2923.2009.03547.x |s2cid=228055 }}</ref> In 2012 the SSH piloted two new certifications to provide recognition to educators in an effort to meet this need.<ref name=StruijkASPE2013>{{cite journal |author=Struijk, Jennie |title=Certified Healthcare Simulation Educator (CHSE) – an update for ASPE |date=11 April 2013 |journal=Association of Standardized Patient Educators News |url=http://aspenews.org/2013/04/11/certified-healthcare-simulation-educator-chse-an-update-for-aspe/ |access-date=27 December 2015}}</ref>

===Type of models===
====Active models====
Active models that attempt to reproduce living anatomy or physiology are recent developments. The famous [["Harvey" mannequin]] was developed at the [[University of Miami]] and is able to recreate many of the physical findings of the [[cardiology]] examination, including [[palpation]], [[auscultation]], and [[electrocardiography]].<ref name=pmid19103813>{{cite journal |vauthors=Cooper Jeffery B, Taqueti VR |date=December 2008 |title=A brief history of the development of mannequin simulators for clinical education and training |journal=Postgrad Med J |volume=84 | issue=997 |pages=563–570 |pmid=19103813 |pmc=1765785 | doi=10.1136/qshc.2004.009886|doi-access=free }}</ref>

====Interactive models====
More recently, interactive models have been developed that respond to actions taken by a student or physician.<ref name=pmid19103813/> Until recently, these simulations were two dimensional computer programs that acted more like a textbook than a patient. Computer simulations have the advantage of allowing a student to make judgments, and also to make errors. The process of iterative learning through assessment, evaluation, decision making, and error correction creates a much stronger learning environment than passive instruction.

====Computer simulators====
[[File:3DiTeams percuss chest.JPG|right|thumb|[[3DiTeams]] learner is [[Percussion (medicine)|percussing]] the patient's chest in virtual [[field hospital]].]]
Simulators have been proposed as an ideal tool for assessment of students for clinical skills.<ref name="pmid17626526">{{cite journal |vauthors=Murphy D, Challacombe B, Nedas T, Elhage O, Althoefer K, Seneviratne L, Dasgupta P |title=[Equipment and technology in robotics] |language=es|journal=Arch. Esp. Urol. |volume=60 |issue=4 |pages=349–55 |date=May 2007 |pmid=17626526 |doi=10.4321/s0004-06142007000400004|doi-access=free }}</ref> For patients, "cybertherapy" can be used for sessions simulating traumatic experiences, from fear of heights to social anxiety.<ref>{{cite news| url=https://www.nytimes.com/2010/11/23/science/23avatar.html?_r=1&ref=science | work=[[The New York Times]] | title=In Cybertherapy, Avatars Assist With Healing | last=Carey | first=Benedict | date=22 November 2010 | access-date=27 February 2020 | archive-url=https://archive.today/20111002063514/http://www.nytimes.com/2010/11/23/science/23avatar.html | archive-date=2 October 2011 | url-status=unfit}}</ref>

Programmed patients and simulated clinical situations, including mock disaster drills, have been used extensively for education and evaluation. These "lifelike" simulations are expensive, and lack reproducibility. A fully functional "3Di" simulator would be the most specific tool available for teaching and measurement of clinical skills. [[Game engine|Gaming platforms]] have been applied to create these virtual medical environments to create an interactive method for learning and application of information in a clinical context.<ref name=DukeMag>{{cite magazine |author=Dagger, Jacob |magazine=[[Duke Magazine]] |title=The New Game Theory: Update |volume=94 |issue=3 |date=May–June 2008 |url=https://alumni.duke.edu/magazine/articles/new-game-theory-update |access-date=27 February 2020 |url-status=live |archive-url=https://web.archive.org/web/20090609042857/http://dukemagazine.duke.edu/dukemag/issues/050608/depupd.html |archive-date=9 June 2009}}</ref><ref name=SteinbergCNN>{{cite journal |author=Steinberg, Scott |title=How video games can make you smarter |journal=Cable News Network (CNN Tech) |date=31 January 2011 |url=http://www.cnn.com/2011/TECH/gaming.gadgets/01/31/video.games.smarter.steinberg/index.html?_s=PM:TECH |access-date=8 February 2011 |archive-url=https://web.archive.org/web/20110207205453/http://articles.cnn.com/2011-01-31/tech/video.games.smarter.steinberg_1_video-games-interactive-simulations-digital-world?_s=PM:TECH |archive-date=7 February 2011 |url-status=live}}</ref>

Immersive disease state simulations allow a doctor or HCP to experience what a disease actually feels like. Using sensors and transducers symptomatic effects can be delivered to a participant allowing them to experience the patients disease state.

Such a simulator meets the goals of an objective and standardized examination for clinical competence.<ref name="pmid18402731">{{cite journal |vauthors=Vlaovic PD, Sargent ER, Boker JR, etal |title=Immediate impact of an intensive one-week laparoscopy training program on laparoscopic skills among postgraduate urologists |journal=JSLS |volume=12 |issue=1 |pages=1–8 |year=2008 |pmid=18402731 |url=http://openurl.ingenta.com/content/nlm?genre=article&issn=1086-8089&volume=12&issue=1&spage=1&aulast=Vlaovic|archive-url=https://archive.today/20130103122531/http://openurl.ingenta.com/content/nlm?genre=article&issn=1086-8089&volume=12&issue=1&spage=1&aulast=Vlaovic |url-status=dead |archive-date=3 January 2013 |pmc=3016039 }}</ref> This system is superior to examinations that use "[[Simulated patient|standard patients]]" because it permits the quantitative measurement of competence, as well as reproducing the same objective findings.<ref name="pmid18462603">{{cite journal |vauthors=Leung J, Foster E |title=How do we ensure that trainees learn to perform biliary sphincterotomy safely, appropriately, and effectively? |journal=Curr Gastroenterol Rep |volume=10 |issue=2 |pages=163–8 |date=April 2008 |pmid=18462603 |doi=10.1007/s11894-008-0038-3 |s2cid=41259893 |url=http://www.current-reports.com/article_frame.cfm?PubID=GR10-2-2-03&Type=Abstract |url-status=dead |archive-url=https://web.archive.org/web/20090122094330/http://www.current-reports.com/article_frame.cfm?PubID=GR10-2-2-03&Type=Abstract |archive-date=22 January 2009}}</ref>