Acknowledging both the changes in medical education, the shifting culture of the physician, as well as the changes in healthcare and science, multiple groups revisited the Flexner Report at its centenary and used that opportunity to issue new guidelines for medical education [2, 5]. The International Association of Medical Science Educators (IAMSE) surveyed leaders in medical education, including the national organizations of multiple basic science specialties. The consensus of the various groups was that basic science studies should be early and throughout the 4 years of medical school to improve knowledge retention. They advocated for increased integration of the basic and clinical sciences, with an emphasis on feedback and mastery of knowledge, rather than having basic sciences front loaded into the medical school curriculum. In one suggested approach, which they termed “ICE” (Ideas, Connections, and Extensions), students are first introduced to an idea, they then connect that idea with other teachings to place it within a contextual framework, and finally they extend the teaching by applying it to real-life examples. One of the suggested methods to improve the basic science and clinical integration is via the use of simulators [5].

The Carnegie Foundation, who commissioned the original Flexner Report, also chose to review the state of medical education at the 100-year anniversary of Flexner’s seminal work. Central themes in the commission’s recommendations were the need to make the learning process more learner centric, the “integration of formal knowledge and clinical experience, and the development of habits of inquiry and improvement” [2] (Fig. 40.2). Many of their recommendations, including connecting formal teaching to clinical experiences, providing challenging problems and giving students the ability to participate in authentic care, and incorporating teamwork into the curriculum, are well suited to simulation. Simulation lends itself to integration of basic science and clinical work and promotes both teamwork and scientific inquiry by engaging learners in challenging problems and giving them tools with which to participate.

Medical simulation is most often associated with clinical education; indeed, the earliest examples of medical simulation involved obstetric mannequins, and mannequins designed to teach airway and resuscitation, which have existed since the 1950s [14, 15]. In the intervening years, the field of simulation has seen vast improvements in the fidelity and accuracy of these models, and its use has become widespread in medical education. A 2010 survey of 90 medical schools by the AAMC showed that 84 and 91% of respondents used simulation in the 1st year and 2nd year courses, respectively. Per the survey, the most common courses in which simulation was employed were Clinical Skills, Introduction to Clinical Medicine, and Physical Diagnosis, suggesting that while simulation use is widespread in the preclinical years, it is still predominantly being used to enhance clinical medicine experiences rather than for basic science education (Fig. 40.3). Less than half of the schools surveyed used simulation in nonclinical subjects such as anatomy, pharmacology, and physiology [6].

To some degree, simulation in preclinical education is not a new concept. Anatomy courses, in which students dissect cadavers to learn the relationships between physical ­structures, have been a part of medical education for centuries. Physiology and pharmacology courses have long employed animal labs to simulate the physiologic responses to pharmacologic and physiologic intervention. These animal labs are particularly useful for augmenting lecture material by demonstrating core physiologic concepts, such as cardiac and pulmonary function, and the physiologic responses to perturbations to homeostasis. Students must generate hypotheses, manipulate variables, and observe and record their effects; the labs allow participants to integrate core concepts and appreciate the interrelatedness and unpredictability of live bodies [16]. Animal labs are not without their limitations—they are expensive and time-consuming, employ an animal surrogate to teach about the human body, and are fraught with ethical considerations. They present a large amount of data quickly, requiring students to focus on numerous variables simultaneously [16]. Should students miss a critical feature of the experiment, it is difficult to go back and redo that portion. There are a finite number of interventions (such as drugs) that can be performed per session—and if a mistake is made, the organ cannot be “reset.” There are limitations on the measurements, which can be performed on an organ—especially within the economic constraints of the student laboratory. Due to changing cultural attitudes towards vivisection, some students have difficulty focusing on the goals of the experiment [16], whereas others have found that a large majority of students exposed to a dog laboratory found it to reinforce lecture material, despite approximately 20% of students reporting discomfort in using dogs to demonstrate pharmacologic concepts [17]. As technologic capabilities have expanded, high fidelity and computer simulators seemed ideal replacements for these animal labs.

Simulation for clinical education, both in clerkship training, residency, and postresidency, has been extensively studied, with the earliest published report from 1969 [18]. A recent meta-analysis, spanning 20 years of data, showed that simulation-based medical education with clinical practice was superior to traditional medical education for acquisition of skills that ranged from laparoscopy and central venous catheter insertion to advanced ACLS and cardiac auscultation [19]. As the equipment and expertise have become more widespread among medical school and training programs and faculty have become adept at their use, it is no surprise that they have moved into the preclinical years.

Problematically, research on simulation in the preclinical years is sparse and typically consists of reports from one center. A 2007 conference on Educational Research rated simulation the highest priority for educational research (out of 11 possible options) [20]. One key item discussed by researchers is the need for simulation use to be integrated throughout the medical school curriculum, so that students are able to develop expertise over time [21] and benefit from repetitive practice [7]. While these statements refer to task-based simulation, it can be inferred that by introducing simulation earlier, students can develop more general simulation skills: teamwork, facility with mannequins and computers, and familiarity with terms and devices. Students’ reflections on their first encounters with patients reveal them to be anxious and insecure—fearful of all there is to remember, a belief that they have insufficient knowledge and skills and guilt over using patients for “practice” [22]. Using simulated patient encounters, even if their primary role is to cement and supplement basic science concepts, may relieve some of that anxiety. A major challenge to integrating simulation more fully into the preclinical years is well-designed, well-­validated simulators and simulations that educators will accept as a suitable replacement or function to enhance existing practices and educational activities.

There are some benefits of using computer models to teach basic science:

Whereas simulation in clinical years, especially simulation related to acquisition of procedural skills, has been studied extensively, simulation in preclinical education has not. Most published data has been on individual schools’ experience with simulation and/or small, single-center pilot studies, and the published literature includes data on computer- and mannequin-based simulation. However, there have been similar themes that run across these accounts and provide a useful framework for discussion of simulation in basic science education.

Overall, students rate simulation experiences very highly, believing them worthwhile and recommended for future courses and other students (Table 40.2).

Numerous studies, across multiple centers and fields of study, show students believe that simulators enhance and improve their knowledge of physiology [6] and allow them to more easily grasp concepts [26] and see realistic changes [26]. Students and teachers who have used computer modeling to simulate renal and cardiovascular physiology have reported improved integration and understanding of physiologic processes and assisted in conceptualizing “whole-body homeostasis” when combined with traditional lecture-based learning [28]. When computer simulation has been applied to neurophysiology to demonstrate membrane potentials, a large majority of students believed that the program increased their understanding [29]. While such self-efficacy data represent “soft” outcomes on the surface, having students believe in their own education is a major challenge to educators in many fields. Almost universally, simulation improves student confidence in themselves and in the instruction they received. That alone can be a victory for educators.