Cardiac patient simulators

Clinical examination is vital in cardiology. Ify Mordi and Stephen Leslie discuss a novel way of developing the necessary skills

Many industries have embraced simulator technology to impart knowledge and practical skills. However, the use of simulator technology in the training of doctors has been slower in development.

Simulators have been designed for specialties such as emergency care, paediatrics, and anaesthetics. Smaller ones can be used to teach specific skills, such as airway management, cannulation, and cardiopulmonary resuscitation.^{w1 w2} High fidelity manikins in simulation centres, alongside facilitated case management, videotaped scenarios, and debriefing, can develop cognitive as well as psychomotor skills in a controlled environment where error has no adverse patient consequences. This article considers simulators designed to teach cardiac examination.

Despite considerable advances in diagnostic imaging, accurate clinical examination remains important for the diagnosis of cardiological conditions.^w3 However, the auscultatory skills of doctors may be less well developed nowadays compared with the past.^{w4 w5} This could be because of less time spent teaching auscultation,^w6 or greater reliance on diagnostic tests such as echocardiography.^w7 Nevertheless accurate auscultation remains an important component of clinical medicine.

Comprehensive cardiac patient simulators include Harvey (University of Miami), Cardiology Patient Simulator "K" (Kyoto Kagaku, Japan) and Stan The Human Patient Simulator (Medical Education Technologies), each with different features.

The simulators are life sized manikins developed to aid the education and assessment of medical students, doctors, and allied healthcare professionals.^w8-w11 Harvey, for example, can simulate up to 30 cardiac conditions. In addition to heart sounds and murmurs, simulators can reproduce other clinical signs, including praecordial impulses, peripheral pulses, blood pressure, jugular venous waveform, and respiration. These clinical parameters change automatically according to preprogrammed clinical diagnoses. Some of the simulators can talk, allowing more interactivity.

How to use simulators

Simulators can be used in many ways-teaching in large lectures, to small groups, or one to one. They can be also be used to teach all grades of medical students, doctors, and other paramedical groups. For maximum effect it is useful to have a tutor or facilitator who is familiar with the clinical conditions and the signs. Integration with commercial packages, including CD Rom and PowerPoint presentations, can improve teaching. A recent review identified features that increase the educational effectiveness of learning through simulation (box 1).^w12

Harvy used with U-Medic teaching package (reproduce with the permission of Dr Gordon, University of Miami Miller School of Medicine).

Are simulators worth it?

Because many simulators have been developed only recently, robust evidence of educational benefit is not available for them all. However, the principles of simulator teaching can be applied. Harvey, for example, has been shown to improve medical students' test scores in terms of knowledge and clinical skills.^{w16 w20-w23}

Real patients were unable to detect any differences in the attitudes of students who had been taught on Harvey. This suggests that skills taught on a simulator are transferable to the bedside with no apparent detrimental effect on the students' interaction with real patients.^w21 But it is important that it is seen as one component of a multifaceted approach to clinical teaching. The inability to exhibit the full range of clinical signs is a big limitation.

One study of junior doctors found no difference in performance after a simulator training regime,^w24 indicating that benefits seen in medical students may not be directly transferable to other groups. Also, long term studies have not assessed the retention of skills learnt using simulators.

Simulators can be expensive (table). For example, Harvey costs about $60,000 (29,000 pound; 41,000 euro), with additional teaching programmes costing up to $16,500. This may be prohibitive for smaller institutions. However, simulators are efficient because many students can be taught with one machine. Unlike patients, they are always available and they exhibit recognisable clinical signs. Newer simulators are lighter, making them more portable and raising the possibility of sharing simulators among institutes. In addition to the purchase costs, there may be considerable recurring costs for accommodation and technical support in maintaining simulators.

Examples of comprehensive cardiac and resuscitation simulators

The British Heart Foundation has provided a Harvey simulator in each medical school in the United Kingdom. Despite this, the use of Harvey in some institutes may be limited and the teaching of tutors ad hoc. Should medical schools be encouraged to provide more simulator based teaching? This may depend on the results of further studies to investigate longer term outcomes of simulator teaching and its potential for revalidation of healthcare professionals.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

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