Study Design Vol. 1, No. 2 / Jul-Aug 2015 /p.

46-54/ PPCR Journal

Simulation in Medical Education: Brief history and

methodology
F. Jones1*, CE. Passos-Neto2, O. Freitas Melro Braghiroli2
*Corresponding author: Felipe Jones. Research Fellow. Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical
School, 96/79 13th Street Navy Yard, Charlestown, MA 02129, e-mail: [email protected]
Rest of author’s affiliation at the end of the manuscript.
Received August 22, 2015; accepted August 29, 2015; published September 16, 2015.

Abstract:
Background and Aim: Preventable medical errors result in more than 400,000 American citizens each year and are the
third cause of death in the United States, followed by cardiovascular diseases and cancer. The roots of such alarming
statistics may be found in medical education, and innovative educational approaches are necessary. Simulation based
medical education can be a valuable tool for the safe delivery of health care. The purpose of this article is to perform a
brief review the history and methodology of simulation, and highlight its unique importance in the medical teaching and
learning scenario.
Conclusion: Simulation has unique features, since it provides a safe and controlled environment to teach a wide variety
of not only technical abilities but also non-technical skills as well, and it is also a reliable educational assessment method.
Therefore, providing appropriate simulation for medical training is a major path compliant with best educational
standards and ethical principles in the process of medical education.

Keywords: simulation; medical education; simulation-based medical education

DOI: http://dx.doi.org/10.21801/ppcrj.2015.12.8

INTRODUCTION several of these advances, specially simulation-based

Preventable medical errors result in more than 400,000 learning models, leading to a 50% reduction on aircraft
deaths each year in the United States and are the third accidents and spatial conquests (3).
cause of death in this country, followed by cardiovascular Simulation based medical education can be a
diseases and cancer (1). Nonfatal iatrogenesis results in valuable tool for better clinical practice. It provides a safe,
disability in 3.5 million American patients per year (1). controlled environment in which problem-based
One of the main reasons of such alarming statistics may learning is developed and competences are practiced in
be related to the medical education culture. Since the high-standards. Although the use of simulation in medical
Flexner report (2) many advances have been made in education has increased during the last two decades, it
technology and teaching strategies, however, it is still not has happened in an unsystematic manner. The purpose of
unusual for medical students to be taught almost as the this article is to review the history and methodology of
same way they were decades ago. simulation-based technique in the medical education.
Evidence based methodology, patient safety,
andragogy, accessible high-quality media production, HISTORY
computers, smartphones, the Internet, 3D printers, high
and low fidelity mannequins – most of this is basically not The origins of medical simulation
taken into consideration when defining the curriculum Simulation is a technique that replaces and amplifies real
and the pedagogical methods to shape and enhance the experiences. It can evoke and replicate substantial
background of future health care professionals. aspects of the real world in a fully interactive manner (4).
Meanwhile, other high hazardous industries such as In the medical field, one can find its origins in Antiquity,
aviation and spatial engineering were able to embrace when models of human patients were built in clay and
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

stone to demonstrate clinical features of diseases and manufacturer, designed a realistic simulator to teach
their effects on humans. Such simulators were present mouth-to-mouth ventilation (7). He named the
across different cultures, and even enabled male mannequin Resusci-Anne, inspired by a popular
physicians to diagnosis women in societies where social European history of a young girl that was found dead
laws of modesty used to forbid exposure of body parts floating on the River Seine, back in the late 1890s.
(5). In the 18th century Paris, Grégoire father and son Resusci-Anne enabled physicians to practice
developed an obstetrical mannequin made of human hyperextension of the neck and chin lift, two techniques
pelvis and a dead baby. The phantom, as the mannequin of airway obstruction management that every healthcare
was named, enabled obstetricians to teach delivery professional must know nowadays. Later, Laerdal was
techniques which resulted in a reduction of maternal and advised by Safar to include an internal spring attached to
infant mortality rates (6). On the other hand, historical the mannequin’s chest wall, which permitted the cardiac
data document the use of animals in the training of compression simulation. This was the birth of the most
surgical skills since the Middle Ages throughout modern widely used CPR mannequin of the 20th century (7,6).
times (7). While the unsystematic use of inanimate and In 1968, during the American Heart Association
live simulators is reported along the history of medicine, Scientific Sessions, Doctor Michael Gordon from the
the origins of medical simulation as we know nowadays University of Miami Medical School presented Harvey,
comes from other science: aviation (6,7). the Cardiology Patient Simulator (7). Harvey was named
after Doctor W Proctor Harvey, professor of cardiology at
Brief history of nonmedical simulation Georgetown University during Gordon’s cardiology
In 1929, Edwin Albert Link had invented the first flight fellowship, and who is credited for first applying modern
simulator, a prototype named “Blue Box”. The simulator technology to the practice of 20th-century medicine
was a fuselage-like device equipped with a cockpit and through the use of phonocardiographic records to
controls (8). The capacity to reproduce flying motions illustrate the nature of auscultatory findings (10). The
and sensations allowed Link to teach his brother to fly mannequin can reproduce almost any cardiac disease by
during the same year. After succeeding this innovating varying blood pressure, heart sounds, heart murmurs,
idea, Link named the prototype as a “Pilot maker” and pulses and breathing. Its efficacy as an educational tool
started to commercialize it, but the Blue Box only has been proved throughout time, henceforth it has been
interested amusement park operators. In 1934, several applied for training and assessment of trainees in various
American postal carriers’ crashes were documented as medical schools, residency programs and emergency
consequence of poor meteorological conditions. At that departments (6,7).
moment, the President of the United States of America Resusci-Anne and Harvey represent cornerstones of
(Theodore Roosevelt) hired the US Army Air Corps the beginning of modern era medical simulation. After
believing that they would address the US postal mail their development, many other types of simulators were
needs. The result was the same: bad weather conditions developed for education and training (6,7). All of them
leading to fatal accidents. Shortly after, the Link Simulator share a common characteristic: the use of technology to
started to gain national attention. The Army Corps achieve a more effective learning experience.
purchased six trainers, and soon the simulator became a However, modern simulation is not only based on
mandatory part of pilot training in many countries (6,9). lifelike mannequins. The use of actors to portray patient
The rationale behind the Blue Box provides support encounters was first reported by Howard Barrows in
to state why simulation became successfully applied in 1964 (11). In the early 1960s, during his last year as a
many human endeavors. The flight simulation creates a neurology resident at the New York Neurological
controlled and safe environment where trainees are Institute, Barrows ran into David Seegal, a professor of
exposed to high-risk conditions that could be rarely neurology that used to sit down and do a detailed
experienced otherwise. In addition, the process is assessment of his resident’s performance during a patient
standardized and can reproduce settings of various levels encounter. He was impressed with Seegal’s capability to
of complexity, which allows pilots with different levels of evaluate interview skills, physical examination
skills to achieve flight expertise. techniques, and clinical thinking. In that same year,
Barrows observed that patients can get extremely
Modern era of medical simulation annoyed when they participate in repeated clinical
assessments by trainees, and that they could even modify
In the early 1960s, Peter Safar described the efficacy of
neurological findings. Soon after he got his first academic
mouth-to-mouth cardiopulmonary resuscitation (7).
position and inspired by these observations, Barrows
Encouraged by his work, Ausmund Laerdal, a plastic toy
47
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

started to systematically use healthy actors to simulate There are indeed aspects of extrinsic motivation and
patient’s signs and symptoms, in order to teach and reflection that play a central role in medical education
assess his students (12). The standardized patient was that are not classically addressed by andragogy (23) –
born, an umbrella term for situations where a person is other theories, such as Transformative Learning, are
trained to simulate a clinical case or an actual patient is alternatives that address some of such aspects. The main
trained to present his or her illness in a standardized way point, however, seems to be the adoption of a student-
(12). directed model, which is being consistently shown to
As technology improved during the 1980s and yield good results both in improving knowledge and
1990s, software and computerized systems that can increasing engagement (22,24–27). Facing a student with
mimic physiologic responses and provide real feedback a list of classes and chapters goes against the direction of
were produced. At Stanford University, a group led by recent effective approaches that take in account adult
David Gaba developed the comprehensive anesthesia learning theory.
simulation environment (CASE) (13). The initial Simulation may play a central role in a student-
prototypes combined commercially available technology, directed learning model (28,29). It helps to create a clear
such as a Machintosh computer, a mannequin and “need to know”, since it mimics real life situations and
waveform generators to simulate a patient during the gives students the chance to practice procedures – both
process of anesthesia (Figure 4). The rationale of the within the safety of a controlled environment and the
CASE simulator was to incorporate the aviation model of possibility to determine in advance the nature of the cases
crew resource management for the sake of teamwork to be addressed. Thus, it becomes possible to cover in an
training in a realistic environment. After the success with ordered manner the most important diseases (namely,
CASE, Gaba’s group advocated for the implementation of the most prevalent and acute conditions that may require
SBME into the anesthesia crisis resource management immediate interventions), overcoming the expected
curriculum, which led to significant advances on team- variability of real scenarios in a hospital setting. Various
based training (4,14). objectives can be accomplished by adopting simulation,
Recently, even more realistic environments were as described more thoroughly later in this review, but in
introduced through the development of virtual reality all cases it can be tailored to meet the adult learning
simulation. In 2007, medical schools created forums in an assumptions.
internet-based world called “Second Life”. This virtual life A critical aspect of simulation is constant feedback
tool provided an environment where students could (23). This task is mainly done through debriefing, which
practice history taking and clinical examination skills
(9,15,16). Therefore, the use of simulation has been
shown to have many advantages: SBME allows repeated
practice of clinical skills and exposure to rare but high-
risk scenarios; and it reduces the inconvenience of using
real patients for teaching purposes and is also a valuable
tool for assessments of medical competences and
performance (17–19).

WHY TO STIMULATE

Adult Learning Theory

Andragogy, the science related to adult education, is not a
new field of study. Several authors have proposed
different approaches and principles, most of them based
on the key aspects of improving motivation and providing
adequate guidance (20–22). To accomplish this task, it is
important to recognize the differences between
andragogy and pedagogy. Malcom Knowles put forth the
main assumptions that should be considered when
developing educational plans for adults (Figure 1). The
spectrum from pedagogy to andragogy is a continuum
Fig.1. The characteristic of adults learning process
that manifests itself differently in different situations.
48
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

must be seen as a unique opportunity to reinforce the survey on 449 coordinators of emergency medicine and
core assumptions of adult learning, as well as provide critical care programs showed that 39% of these reported
external motivation and stimulate guided reflection. the use of recently deceased patients to practice invasive
Understanding how the experience affects future practice procedures, such as intubation, thoracotomy,
is a crucial step to improve performance (30). Simulation cricothyroidotomy, central venous line placement,
by itself does not guarantee learning, but within the pericardiocentesis, among others (34,35). The classic
proper environment, it is a tool of paramount importance medical pretext for using patients as commodities is the
for modern curricula oriented by the adult learning societal need to have well trained professionals in life-
theory (31). saving techniques (36). On the other hand, simulation
offers options for practicing invasive procedures rarely
Ethical Issue seen otherwise, helping to mitigate these ethical
In 2000, the National Institute of Medicine report To Err dilemmas.
is Human brought up to light that the number of deaths
due to medical errors exceeded those from breast cancer Error Management and Error Prevention
and AIDS combined (38). More recent epidemiological Medical practice is characterized by a constant pursuit of
studies suggested that 400,000 American patients die perfection. During medical school and residency, trainees
each year due to medical errors and that it is the third strive for an error-free practice in an environment where
cause of death in the US (1). A recent international Patient mistakes are not well accepted (37). As a result,
Safety Movement calls for raising safety and quality of physicians have difficulties in dealing with error and
healthcare (17,32). admitting them as well (37). Besides its advantages as a
The increased demand for patient safety has pushed teaching and learning tool for conventional medical skills,
educational institutes to rethink the medical education simulation is also a useful approach to provide
system. The current model of medical training has competence in new areas. Among the proposed changes
remained unchanged during the past hundred years. to achieve a safer healthcare system, the report To Err is
Based on apprenticeship model, trainees are exposed Human recommended simulation as an educational
early to patients in medical school, and pass through technique on error management and error prevention
increasing levels of difficulty in patient care. In such (17,38,39).
hierarchical system, clinical decisions are shared among Error management involves understanding the
attending physician, senior residents, and students. nature and cause of errors in order to avoid further
Although the final decision relies on the physician, mistakes (40). The concept comes from the Crew
trainees are taught “handson”. This can be problematic Resource Management training of the aviation field. Pilots
considering the practice of risky procedures, and training are trained on how to change conditions that induce
of complex and critical problems (17). errors and also on nontechnical skills that can prevent
One of the main bioethical principles taught to all them, such as optimal communication and teamwork
healthcare professionals worldwide is the “primum non behavior (41). Although medicine has lagged behind on
nocere” or, in English, “first do not harm” (33). However, the development of errorcontrol practices, simulation is
it is inevitable that trainees will occasionally cause an innovative approach of learning based on mistakes. It
preventable injuries to patients. From the ethical has the potential to improve performance in core
viewpoint, such injuries are only justified when all effort competences such as: knowledge, communication skills,
is made to minimize patient harm (22). Simulation team work, patient care, clinical skills and
provides an innovative approach to medical education, in professionalism (42). Therefore, simulation-based
which trainees can practice medical skills to be better medical education has the potential to provide
prepared for clinical encounters, potentially reducing professionals with the correct attitude and skills to
such risks. prevent and cope with errors in medical practice (43).
Other major ethical concern in modern medicine
approached by simulation is the respect of patient Skills evaluation
autonomy. Current standards of informed consent Changing the concept of standard evaluation to an
establish the patient´s right to make their own decisions analytical learning process is not an easy task. When
about their healthcare, which includes accepting or Professor Harden published his objective structured
rejecting their treatment by a trainee (34). However, clinical examination (OSCE) (44), he was not only turning
training of medical procedures by students in recently public a remarkable method for evaluating different skills
dead or sedated patients is a common practice (34-36). A domains. But OSCE is the perfect complement for
49
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

simulation as it provides an objective way to analyze 1. Low-technology: relatively low-cost models or

performance and substantiate feedback – a fundamental mannequins used to teach basic knowledge or particular
step for continuous improvement (45,46). psychomotor skills (Figure 2 and 3).
Since its first release, OSCE has grown worldwide to 2. Screen-based computer simulators: software for
become an indispensable part of health care students and training and assessment of clinical knowledge and
professionals’ evaluations (47–50). In fact, several decision making.
countries require some clinical skills test, most of them on 3. Standardized patients: actors trained to play patients,
the OSCE format, to provide medical license or specialty which enables training and assessment of history taking,
degree. physical examination, communication skills, and
A particularly important aspect of OSCE is the professionalism (Figures 4 and 5).
possibility to analyze separately different skill domains. 4. Complex task trainers: computer-based simulators
From history-taking to communicating skills, imaging used for high-fidelity training of procedures.
interpretation to technical procedures, throughout 5. Realistic patient simulators: computer-based
different scenarios, OSCE allows each domain to be mannequins used for high-fidelity replication of complex
explored and individually evaluated. and high-risk clinical conditions in lifelike settings.
As any evaluation method, OSCE has limitations. Despite there are different simulation
Validity, reliability, objectivity and feasibility are major methodologies with wide applicability (Table 2), there is
criteria that must be considered when analyzing a no right or wrong template for a simulation exercise.
method of assessment. Despite some controversial Several combinations of techniques are possible
findings, OSCE generally demonstrates good capability of depending on who the target population, previous
actually evaluating a representative sample of achieved background and the specific educational goals of the
subjective matter and other educational objectives (51– activity. On the other hand, financial resources may be an
53). Consistency drops when stations are in reduced important restriction when defining modalities, but not
number or little time is used. Other aspects that affect an unsurpassable one. One of the arts of simulation is
reliability are training of patients, staff organization, and tailoring educational objectives according to available
fatigue after long periods of examination (for the student, resources, a process in which innovation and student
patient, and/or examiner) (54,55). Structured checklist participation may play a central role. As an example, the
configures an acceptable way to standardize evaluation, Academic League of Trauma and Emergency Medicine of
providing examiners are trained in adequate manner. A Bahia (LAEME, in Portuguese) is an institution with 10
possibly important drawback relies on the resources years of existence composed by medical students of the
required to properly apply OSCE. It is fundamental to Federal University of Bahia (UFBA), Brazil. The group
consider the number of students, available staff and promotes simulation sessions that uses a mix of relative
patients, space, time, and financial investment. There are, low-cost mannequins with students that simulate
however, less costly alternatives that may be applied patients to create a relative complex environment in
(51,56–59). which students are trained on decision making, history-
Simulation appears as a fundamental part of taking, clinical examination, procedure techniques, and
evaluation in medical schools through OSCE. To obtain teamwork and communication skills (Figures 4 and 5).
better results, it should be carefully planned and
combined with other assessment methods.

METHODOLOGY OF SIMULATION-BASED
MEDICAL EDUCATION

Defining goals and modality

Several conditions are associated with creating an easier
and more effective strategy of learning in a simulation
environment (Table 1) (60). The effectiveness of medical
simulation depends on the appropriate application of its
methodology and on the knowledge of its different
modalities.
The simulation modalities can be classified into five Table 1. Conditions associated with learning facilitation in
major groups (17,34): simulation
50
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

Figures 2-3: Low-cost mannequin for central venous line placement. Figures 4-5: LAEME members performing trauma
simulatios
Trainees should be presented to all materials and
How the medical simulation session work resources that may be used during simulation, as well as
According to Pazin et al (2007), a simulation session is become familiarized with terms and singular aspects of
characterized by the presence of four core components simulation – such as which decisions should be explicitly
(Figure 6). The first component is termed “exposure”, mentioned, what aspects of physical examination will be
which consists of the trainees’ introduction to the measured or told by the trainer and others. Such
problem ahead, and it is also referred as “briefing”. The systematic approach avoid unexpected breaks in the
second element is “sequence”, defined by a progressively virtual reality pact, an agreement with all involved
escalating complexity during the session, which helps the personnel that commits them to immerging into the
trainees to build upon consolidated knowledge, and scenario and provides the concentration and emotional
allows them to have a better performance throughout the binding that are essential to educational success (61).
exercise (61). The third core component is named
“feedback”, and it refers to the continuous exchange of
information between trainer and trainee. This process
takes place during and/or after the simulation session,
and the instructor must be observant of the trainees’
abilities and performance in order to guide the learning
process. Finally, the last component is “repetition”, which
provides improved retaining of knowledge learned
during a session (61).

Preparation
The preparation of a simulation session involves the
creation of a welcoming and positive learning Figure 6: The five major components of a stimulation exercise.
environment.

51
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

Table 2. Examples of applications of simulation-based medical education

audiovisual tools helps trainees to analyze, synthesize,

Conduction and evaluate the experience in order to be able to apply
Dealing with the trainee during simulation is a dynamic the lessons in future events. Debriefing provides learners
and complex task. There are different ways to approach an opportunity to learn from their mistakes, and
this task and there is no single best method. The decision therefore is the one of the ways in which many of the
on if or how to perform an intervention, whether or not to advantages of simulation occur, as previously discussed.
help with clues, how flexible to be with various types of It is also applied following real clinical settings, and it has
conduct deviations, when to stop, allowing, forbidding or been successfully implemented in obstetrics (62),
forcing a “patient” to die, are all key aspects that should be resuscitation (64), and critical care (65).
addressed when defining how the trainer will guide the
scenario. These decisions should be taken according to CONCLUSION
learning objectives and trainee preparation (61). The To Err is Human report highlighted the need to
When using sophisticated manikins, it is usually improve patient safety on medical practice. The first step
necessary to sketch a flowchart with all possible pre-set to provide a better quality of care begins on how
scenarios. This may be useful also for training healthcare professionals are trained. Simulation has the
standardized patients and for less experienced trainers. characteristic of providing a safe and controlled
environment that suits learner centered approaches. In
addition, it can mitigate traditional ethical dilemmas of
Debriefing medical training by reducing patient exposure to
Debriefing is the most important component of a inexperienced trainees. Simulation also has unique
simulation session. It refers to a moment in which the features, such as the ability of being tailored to train
trainee is guided through a process of reflective thinking, technical skills or other abilities and attitudes such as
by discussing his or her performance in the exercise (62). teamwork, communication skills and leadership, as well
The goals of a debriefing session is to give the opportunity as being a reliable assessment method through OSCE.
to the trainees to conceptualize the learning goals set by More than that, as it enables learning from mistakes,
the trainers, and gain insight toward a better simulation has the potential to change a traditional
understanding of the event and its application on future medical difficulty of dealing with error. Therefore,
experiences (63). providing simulation-based training is a path compliant
There is no gold standard approach to the debriefing with best educational standards and ethical principia that
session. However, it is recognized that the trainer must should be adapted according to each institution’s
act as a facilitator, and his or her ability to assess the singularities.
trainees’ skill is fundamental for the learning process
(63). In addition, facilitators must create a Author Affiliations
nonthreatening environment that promotes active 1 Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital,
Harvard Medical School, 96/79 13th Street Navy Yard, Charlestown, MA
participation of trainees through the use of open-ended 02129, USA
questions and positive reinforcement (63). The use of
52
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

2 Medical student of Medical School of Bahia, Federal University of 20. Knowles MS, III EFH, Swanson RA. The Adult Learner: The Definitive
Bahia, Salvador, Brazil. Classic in Adult Education and Human Resource Development.
Routledge; 2014. 402 p.
21. House JD, Burns EA. A study of the use of adult learning theory in medical
Conflict of interest and financial disclosure instruction. Fam Pract Res J. 1986;5(4):241–6.
The authors followed the International Committee or 22. Shanks D, Wong RY, Roberts JM, Nair P, Ma IWY. Use of simulatorbased
Journal of Medical Journals Editors (ICMJE) form for medical procedural curriculum: the learner’s perspectives. BMC Med
Educ. 2010;10:77.
disclosure of potential conflicts of interest. All listed 23. Abela JC. Adult learning theories and medical education: a review. 2009;
authors concur with the submission of the manuscript, 24. Tan NCK, Kandiah N, Chan YH, Umapathi T, Lee SH, Tan K. A controlled
the final version has been approved by all authors. The study of team-based learning for undergraduate clinical neurology
authors have no financial or personal conflicts of interest. education. BMC Med Educ. 2011;11:91.
25. Spencer JA, Jordan RK. Learner centred approaches in medical
education. BMJ Br Med J. 1999 May;318(7193):1280–3.
REFERENCES 26. Ten Eyck RP, Tews M, Ballester JM. Improved medical student
1. James JT. A new, evidence-based estimate of patient harms associated satisfaction and test performance with a simulation-based emergency
with hospital care. J Patient Saf. 2013;9(3):122–8. medicine curriculum: a randomized controlled trial. Ann Emerg Med.
2. Flexner A. Medical Education in the United States and Canada Bulletin 2009 Nov;54(5):684–91.
Number Four (The Flexner Report). Carnegie Bulletin. 1910. p. 364. 27. Sperling JD, Clark S, Kang Y. Teaching medical students a clinical
3. Tegtmeyer K, Ibsen L, Goldstein B. Computer-assisted learning in critical approach to altered mental status: simulation enhances traditional
care: from ENIAC to HAL. Crit Care Med. 2001;29(8 Suppl):N177–82. curriculum. Med Educ Online. 2013;18:1–8.
4. Gaba DM, DeAnda A. The response of anesthesia trainees to simulated 28. Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical
critical incidents. Anesth Analg. 1989;68(4):444–51. education. Med J Armed Forces India. 2012 Apr;68(2):167–72.
5. Meller G. A typology of simulators for medical education. J Digit imaging 29. Akaike M, Fukutomi M, Nagamune M, Fujimoto A, Tsuji A, Ishida K, et al.
Off J Soc Comput Appl Radiol. 1997;10(3 Suppl 1):194–6. Simulation-based medical education in clinical skills laboratory. J Med
6. Rosen KR. The history of medical simulation. J Crit Care. 2008;23(2):157– Investig JMI. 2012;59(1-2):28–35.
66. 30. Kaufman DM. Applying educational theory in practice. BMJ Br Med J.
7. Cooper JB, Taqueti VR. A brief history of the development of mannequin 2003 Jan;326(7382):213–6.
simulators for clinical education and training. Postgrad Med J. 31. Gaba D. The future vision of simulation in health care. Qual Saf Health
2008;84(997):563–70. Care. 2004 Oct;13(Suppl 1):i2–10.
8. Edwin Link [Internet]. [cited 2015 Aug 10]. Available from: 32. Patient Safety Movement [Internet]. Available from:
http://www.nationalaviation.org/link-edwin/ http://patientsafetymovement.org/
9. Singh H, Kalani M, Acosta-Torres S, El Ahmadieh TY, Loya J, Ganju A. 33. Smith CM. Origin and uses of primum non nocere--above all, do no
History of simulation in medicine: From resusci annie to the ann myers harm! J Clin Pharmacol. 2005;45(4):371–7.
medical center. Neurosurgery. 2013;73(SUPPL. 4):9–14. 34. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-Based Medical Education:
10. S. Kimara March M. W. Proctor Harvey. Texas Hear Inst J. An Ethical Imperative. 2003;783–8.
2002;29(29):182–92. 35. Moore GP. Ethics seminars: the practice of medical procedures on newly
11. Barrows HS, Abrahamson S. The Programmed Patient: a Technique for dead patients--is consent warranted? Acad Emerg Med. 2001;8(4):389–
Appraising Student Performance in Clinical Neurology. Journal of 92.
medical education. 1964. p. 802–5. 36. Iserson K V. Postmortem procedures in the emergency department:
12. Barrows H. An orverview of the uses of standardized patients for using the recently dead to practise and teach. J Med Ethics.
teaching and evaluating clinical skills. Academic Medicine: Journal of the 1993;19(2):92– 8.
Association of American Medical Collegesournal of the Association of 37. Leape LL. Error in Medicine. JAMA J Am Med Assoc. 1994; 272(23):1851–
American Medical Colleges. 1993. p. 443–51. 7.
13. Gaba DMAD. A comprehensive anesthesia simulation environment: re- 38. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer
creating the operating room for research and training. Anesthesiology. health system. Washington, DC: National Academy Press; 1999.
1988;69:387–94. 39. Leape LL, Berwick DM. Five years after To Err is Human: what have we
14. Gaba DM, Lee T. Measuring the workload of anesthesiologist. learned? JAMA J Am Med Assoc. 2005;293(3):2384–90.
Anesthesiol Analg J. 1990;71:354–61. 40. Fernandez E, Williams DG. Training and the European working time
15. Chu LF, Young C, Zamora A, Kurup V, Macario A. Anesthesia 2.0: internet- directive: A 7 year review of paediatric anaesthetic trainee caseload data.
based information resources and Web 2.0 applications in anesthesia Br J Anaesth. 2009;103(4):566–9.
education. Curr Opin Anaesthesiol. 2010;23(2):218–27. 41. Helmreich RL. On error management: lessons from aviation. BMJ.
16. Beard L, Wilson K, Morra D, Keelan J. A survey of health-related activities 2000;320(7237):781–5.
on second life. J Med Internet Res. 2009;11(2):1–22. 42. Sukalich S, Elliott JO, Ruffner G. Teaching medical error disclosure to
17. Ziv A, Small SD, Wolpe PR. Patient safety and simulation-based medical residents using patient-centered simulation training. Acad Med J Assoc
education. Med Teach. 2000;22(5):489–95. Am Med Coll [Internet]. 2014;89(1):136–43.
18. Reznick R, Blackmore D, Dauphinee W, Rothman A, Smee S. Largescale 43. Ziv A, Ben-David S, Ziv M. Simulation based medical education: an
high stakes testing with an OSCE: Report from the Medical Council of opportunity to learn from errors. Med Teach. 2005;27(3):193–9.
Canda. Academic Medicine. 1996. p. s19–21. 44. Harden RM, Gleeson FA. Assessment of clinical competence using an
19. Sutnick a I, Stillman PL, Norcini JJ, Friedman M, Regan MB, Williams RG, objective structured clinical examination (OSCE). Med Educ. 1979
et al. ECFMG assessment of clinical competence of graduates of foreign Jan;13(1):41–54.
medical schools. Educational Commission for Foreign Medical 45. Hawkins SC, Osborne A, Schofield SJ, Pournaras DJ, Chester JF. Improving
Graduates. JAMA. 1993;270(9):1041–5. the accuracy of self-assessment of practical clinical skills using video
feedback--the importance of including benchmarks. Med Teach.
2012;34(4):279–84.
53
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research
 Vol. 1, No. 2 / Jul-Aug 2015 /p. 46-54/ PPCR Journal

46. Wang EE. Simulation and adult learning. Dis DM. 2011 Nov;57(11):664–
78.
47. Nguyen LN, Tardioli K, Roberts M, Watterson J. Development and
incorporation of hybrid simulation OSCE into in-training examinations to
assess multiple CanMEDS competencies in urologic trainees. Can Urol
Assoc J. 2015 Feb;9(1-2):32–6.
48. Berkenstadt H, Ziv A, Gafni N, Sidi A. Incorporating simulation-based
objective structured clinical examination into the Israeli National Board
Examination in Anesthesiology. Anesth Analg. 2006 Mar;102(3):853–8.
49. Guttormsen S, Beyeler C, Bonvin R, Feller S, Schirlo C, Schnabel K, et al.
The new licencing examination for human medicine: from concept to
implementation. Swiss Med Wkly. 2013;143:w13897.
50. Lillis S, Stuart M, Sidonie, Stuart N. New Zealand Registration
Examination (NZREX Clinical): 6 years of experience as an Objective
Structured Clinical Examination (OSCE). N Z Med J. 2012;125(1361):74–
80.
51. Barman A. Critiques on the Objective Structured Clinical Examination.
Ann Acad Med Singapore. 2005 Sep;34(8):478–82.
52. Carraccio C, Englander R. The objective structured clinical examination:
a step in the direction of competency-based evaluation. Arch Pediatr
Adolesc Med. 2000 Jul;154(7):736–41.
53. Sloan DA, Donnelly MB, Schwartz RW, Felts JL, Blue A V., Strodel WE. The
use of objective structured clinical examination (OSCE) for evaluation
and instruction in graduate medical education. J Surg Res. 1996
Jun;63(1):225–30.
54. Brannick MT, Erol-Korkmaz HT, Prewett M. A systematic review of the
reliability of objective structured clinical examination scores. Med Educ.
2011 Dec;45(12):1181–9.
55. Setyonugroho W, Kennedy KM, Kropmans TJB. Reliability and validity of
OSCE checklists used to assess the communication skills of
undergraduate medical students: A systematic review. Patient Educ
Couns. 2015 Jun;
56. Frye AW, Richards BF, Philp EB, Philp JR. Is it worth it? A look at the costs
and benefits of an OSCE for second-year medical students. Med Teach.
1989;11(3-4):291–3.
57. Feickert JA, Harris IB, Anderson DC, Bland CJ, Allen S, Poland GA, et al.
Senior medical students as simulated patients in an objective structured
clinical examination: motivation and benefits. Med Teach. 1992;14(2-
3):167–77.
58. Poenaru D, Morales D, Richards A, O’Connor HM. Running an objective
structured clinical examination on a shoestring budget. Am J Surg. 1997
Jun;173(6):538–41.
59. Carpenter JL. Cost analysis of objective structured clinical examinations.
Acad Med J Assoc Am Med Coll. 1995 Sep;70(9):828–33.
60. Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner JM, Petrusa ER,
et al. Simulation technology for health care professional skills training
and assessment. JAMA. 1999;282(9):861–6.
61. Pazin Filho A, Romano MMD. Simulacao: Aspectos conceituais. Rev Fac
Med Ribeirao Preto. 2007;40(2):167–70.
62. Cho SJ. Debriefing in pediatrics. Korean J Pediatr. 2015;58(2):47–51.
63. Fanning RM, Gaba DM. The role of debriefing in simulation-based
learning. Simul Healthc. 2007;2(2):115–25.
64. Couper K, Perkins GD. Debriefing after resuscitation. Curr Opin Crit Care
[Internet]. 2013;19(3):188–94.
65. Clay AS, Que L, Petrusa ER, Sebastian M, Govert J. Debriefing in the
intensive care unit: a feedback tool to facilitate bedside teaching. Crit
Care Med. 2007;35(3):738–54.

54
Copyright: © 2015 PPCR. The Principles and Practice of Clinical Research