Simulation in Internal Medicine clerkships (Based upon data provided within Torre et al.  study)
Instruction and assessment
Patient safety and care
Consistent and reproducible
Tailored to learner’s level
No risk to patient
Error-forgiving clinical experience
Practice to point of automaticity
Increases patient confidence
The Harvey cardiology patient simulator (CPS), developed by Dr. Michael Gordon in 1968, has been shown to be an efficient and effective tool for teaching cardiac physical exam skills to medical students and Internal Medicine residents [21, 22]. Students using CPS mannequins can develop the ability to recognize normal and abnormal findings with breath sounds, heart sounds, pulses, jugular venous pulsations, and precordial movements. Harvey mannequins have enabled Internal Medicine clerkships to teach and assess medical students’ cardiac physical diagnosis skills . Simulators which demonstrate other physical examination findings are not readily available, but computer-generated simulations can reproduce visual findings well. Virtual reality simulations such as Second Life and other similar products may be helpful in physical examination training and assessment in the future.
According to the AAMC , approximately 76% of medical schools indicated that simulation is used within Internal Medicine clerkships, and approximately 57% of teaching hospitals indicated it is a part of the Internal Medicine clerkship. This places Internal Medicine within the top three disciplines in its use of simulation within medical school and teaching hospital settings .
Torre et al.  in a survey of US and Canadian clerkship directors found that SBME was used by 84% of survey respondents (n = 76/110), with 39% reportedly using it for teaching, 49% for formative assessment, and 38% for summative assessment. For example, partial task trainers (rectal exam, lumbar puncture, venipuncture, arterial blood gas draw) are often used to teach technical skills to third-year medical students during Internal Medicine clerkships . As a result, Graber et al.  reported that patients were more willing to allow medical students to perform procedures such as venipuncture, lumbar puncture, or central lines on them after the students had undergone simulation training.
Standardized patients (SPs) were used by approximately 54% of clerkship respondents. About one-third of clerkships responding reported using SPs for summative evaluations, presumably OSCE exams. Comprehensive simulation programs with evaluation of teamwork (5.6%) and procedural skills (18%) are less common . Survey respondents represented 61% of all eligible schools surveyed.
Several companies have developed virtual cases, which are in common use during third-year clerkships. Virtual cases are often used as supplements or substitutes for actual cases to fulfill clerkship requirements . Software, such as Laerdal MicroSim, is similar to gaming software and allows students to play the role of a physician in emergency or intensive care situations. For example, the software can time student responses during an emergency scenario and give students grades based upon timeliness of responses and ability to follow standard patient protocols. Students may find this software useful when they lack opportunities to practice decision making with seriously ill patients .
Cases involving mannequins are effective for teaching and assessing core curriculum topics during the Internal Medicine clerkship . McMahon et al. have shown that simulators can help students compare and contrast different presentations of similar cases, thus enhancing reflective and metacognitive learning .
Assessment of Technical Skills
Technical skills are typically formatively assessed during clerkships, but students often finish the third and fourth year of medical school without establishing proficiency in many of the skills outlined by the AAMC in its Medical Schools Objectives Project initiative [27, 28]. Technical skills such as airway management, central lines, and ACLS skills are usually formatively assessed, as well, but often not until residency . Objectives related to these skills can easily be added to a medical simulation curriculum.
Assessment: Objective Structured Clinical Exams (OSCEs)
OSCEs, first introduced in the UK by Ronald Harden, MD and FA Gleeson in the 1970s, are used in medical schools around the world to formatively and summatively assess clinical skills of medical students. While the use of OSCEs is widespread in US medical schools, Iqbal et al.  and Troncon  noted that OSCE use is limited in resource-constrained countries, which may not have standardized patient programs or skills labs. Troncon  also pointed out that without competency requirements mandated by accreditation agencies, the case for resource-intense, objective, simulation-based exams may not be there.
While reliability and validity evidence for OSCE-derived scores tends to be strong [31, 32], the psychometric properties related to scores use (reliability and validity) are highly dependent upon the standardization of SP training. As no tool or measure contains reliability or validity [33, 34], OSCEs are not inherently valid or reliable. Like any other tools dependent upon rater training, when SPs or faculty vary in the way they rate learners, reliability and validity of score use suffers . In terms of formative assessment, standardized patient scenarios are also used by medical schools to assess medical students’ communication and history and physical examination skills in preparation for OSCEs and licensure exams. There is evidence that data derived from standardized patient (announced and unannounced) evaluations may be more reliable and valid than faculty observer or patient evaluation data .
Graduate Medical Education
The number of residency programs offering simulation curricula has increased dramatically since the ACGME began mandating simulation learning experiences for all Internal Medicine residents. Across the specialties, approximately 90% of medical schools and teaching hospitals use simulation during the first 3 years of postgraduate training . Once again, Internal Medicine is one of the most common disciplines utilizing simulation instruction in residency training .
The addition of core competencies by the ACGME has provided opportunities to utilize simulation for competency evaluation in a structured environment. Some of the competencies can be difficult to evaluate and remediate, including interpersonal and communication skills, professionalism, and systems-based practice [36–38]. With SBME, residents have opportunities to practice in risk-free environments and engage in patient encounters which would have high procedural risks or are infrequent events (i.e., ACLS code, weapons of mass destruction, mass causality scenarios) in real clinical settings.
Procedural skills have traditionally been taught within a “see one, do one, teach one” paradigm, which places patients at significant risk for complications and may increase frustration with operators and/or procedures. Standardized patients have allowed certain bedside procedures (starting an IV, phlebotomy, and electrocardiogram) to be performed on them for medical education, but most of these are examples of low-risk, frequently utilized procedures for hospitalized patients. The more complex procedures (lumbar puncture, central venous catheterization, paracentesis, and thoracentesis) all have a higher risk associated with them and are infrequently performed by general Internal Medicine physicians.
SBME allows trainees to improve their performance with procedures prior to clinical practice. Central venous catheterization (CVC) has been one of the most studied procedures within simulation, and studies that have shown improvement with ultrasound-guided SBME training was superior to traditional training [39, 40]. Evans et al.  showed postgraduate year 1 and 2 (PGY-1 and PGY-2) physicians, when given a structured, competency-based simulation training protocol, improved CVC insertion performance with regard to success at first cannulation . Simulation-based curricula for CVC has also been associated with improvement in catheter-related bloodstream infection . Barsuk et al.  found that SBME-trained residents had fewer catheter-related bloodstream infections within the intensive care unit after participating in a central venous catheter insertion skills simulation curriculum . Simulation with partial task trainer models allows trainees the opportunity to learn the overall procedure with sterile techniques in an environment which will not interfere with patient safety or quality of care. Procedural skills activities can be used to evaluate resident competencies such as medical knowledge, patient care, systems based practice and communication skills with the addition of trained SPs to evaluate informed consent or delivery of bad news.
Hospital Teams and Infrequent Events
SBME also allows graduate trainees to practice infrequent events (i.e., ACLS code, weapons of mass destruction, mass causality scenarios) in a controlled environment, allowing for adaptation according to the skill level of the learner. As the learner advances within her/his medical training, simulation allows for diversity of experiences and complexity of the simulation scenario. Starting residency training can be a challenging period for individuals and specifically being on the code team increases trainee anxiety. The American Board of Internal Medicine requires residents to be competent in advance cardiac life support (ACLS) for certification. Simulation allows trainees to become more competent with ACLS while decreasing the stress associated with infrequent events which have life-altering consequences . In addition, the utilization of multidisciplinary teams during code training can improve a trainee’s competency in teamwork skills , an aspect of systems-based practice, and improve learner’s professionalism and communication skills . Multidisciplinary teams often consist of members who are responsible for the code teams within the institution (i.e., nurses, pharmacists, respiratory therapists, and physicians). Evaluation of team dynamics can be performed with tools such as the Mayo High Performance Teamwork Scale [10, 46]. This team training helps to improve technical skills of the practitioner but also works to emphasize teamwork within the institution.
In GME, other uses of SBME include the teaching and assessment of patient communication. Simulation scenarios can be developed to highlight the physician-patient relationship. Learning objectives and learning activities can target ethical dilemmas, including those encountered when dealing with advanced directives  and breaking bad news. Unannounced standardized patient visits to the resident clinic have been used within a number of GME programs, including the University of Texas Medical School at Houston. The scenarios can be viewed in real time or videotaped so that the resident has the opportunity to later watch their interactions with standardized patients. This gives residents some insight into their own medical interviewing and physical examination skills. Simulated scenarios are somewhat unique because they can be designed to include and evaluate all six competencies (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice).
Internal Medicine residency programs have struggled with teaching and assessing systems-based practice , practice-based learning and improvement, and communication skills and professionalism . McGaghie et al.  have used medical simulation to teach systems-based practice skills to Internal Medicine residents and have discovered that the simulation experience is irreplaceable. Simulation education offers an excellent opportunity to perform observed competency-based education and assessment.
GME Final Thoughts
The utilization of SBME within graduate medical education is increasing , with numerous opportunities for improvement in patient care. Studies have shown not only the improvement of resident procedural skills performance but also improved communication and professionalism within multidisciplinary teams [49–51]. The number of programs offering simulation curricula has increased dramatically since the ACGME began mandating simulation learning experiences for all Internal Medicine residents.
Practicing Physicians and CME
The field of continuing medical education (CME) has also embraced SBME to enhance education during CME conferences. A review of CME activities by Marinopoulos et al.  showed that effective CME includes live conferences, conferences with multiple media offerings, multiple opportunities to build new knowledge through repeated exposure to new information, and opportunities to interactively engage in new practices . SBME utilizes all four effective CME approaches during most scenarios. The American College of Physicians (ACP) utilizes simulation activities during their annual meeting by offering the Waxman Clinical Skills stations. These sessions are well attended and have been a popular addition to the annual meeting since 2001. Simulation stations engage participants in a variety of procedural skills; physical exam improvement stations including cardiac, breast, or pelvic exam; and a variety of standardized patient scenarios. Simulation has become a strong and integral part of medical education and will continue to be a critical element in physician education, not only during medical school or residency training but also for lifelong learning.
Internal Medicine: Certification
While Internal Medicine has been relatively slow to adopt simulation for high-stakes testing when compared with the field of anesthesiology [5, 53], its use is increasing. Simulation is used in high-stakes testing for Internal Medicine specialty certification in Canada. Physicians are required to rotate through and pass a standardized patient physical exam station and an ethics and communication skills station . In the USA, simulation-based virtual reality (VR) training for cardiac stenting was approved by the Society for Cardiovascular Angiography and Interventions, the Society for Vascular Medicine, and the Society for Vascular Surgery . The American Board of Internal Medicine (ABIM)  also utilizes VR simulation; VR simulation is used for self-evaluation of medical knowledge within its maintenance of certification program for interventional cardiology diplomats (ABIM web site). A number of studies have been completed in recent years regarding the use of virtual reality training for carotid stenting [54, 56, 57]. In these studies, there was a significant part of the learning curve that could be accomplished using virtual reality training. The shift in procedural skills training to include the virtual reality format offers significant opportunities for acquiring these technical skills and providing enhanced patient care.
As SBME is such a powerful tool for educating learners and observing performance, it would be logical to assume that SBME is used frequently within Internal Medicine faculty development. Yet, it is not incorporated to the degree we might expect. Significant barriers to adoption include cost of equipment and space, especially for resource-poor medical schools, and the time it takes to prepare for training. Although many faculty members support simulation training, another barrier is resistance that some faculty may have toward new ways of teaching. Seasoned Internal Medicine physicians may be less familiar with technology and as a result be apprehensive about incorporating high-fidelity mannequins, virtual reality, virtual patients, and other technology-driven simulation. These faculty members, who were taught within traditional apprenticeship models, often lack experience working with simulation equipment and/or computers and would rather not rely on new equipment when training young physicians.
The development of realistic clinical scenarios is also time-consuming for faculty and can be very expensive for institutions . There may be technical limitations in terms of what can be simulated with current simulation mannequins, without the addition of standardized patients. Many of the current mannequins work best for anesthesia and ACLS-type scenarios. Faculty may be more inclined to embrace SBME as a teaching modality and the required faculty development if they can understand the utility of SBME for teaching patient safety and the newer more difficult general competencies . Faculty who embrace SBME must be supported by their academic institutions and offered faculty development to be effective in developing advanced skills .
McGaghie et al.  emphasized that one of the areas of greatest need is faculty expertise. In order to be successful, there are several key components, including faculty training in the use of equipment, institutional support, and faculty motivation to succeed . Research groups have emerged in many specialties studying best practices for the use of simulation . With all the rapid changes in medical education, one thing remains constant and is evident in the research related to SBME: the need for faculty development to move faculty learners from novice to expert levels . While physicians might agree with that concept in practice, not all are willing to acknowledge the value of experiential learning through the use of simulation. In our opinion, the lack of experts, age of Internal Medicine faculty, need for faculty development, and distrust of technology are major barriers that must be overcome. For Internal Medicine to improve its education of medical students, residents, and practicing physicians, Internal Medicine faculty must embrace SBME and learn the skills necessary to teach SBME effectively.
Finding a Champion
Successful programs have a faculty person who is passionate about SBME. SBME requires planning, imagination, and a willingness to experiment with new ideas and new technology. Many times, faculty champions are junior faculty members who are innovative and adaptable enough to appreciate the potential of SBME and be comfortable with the technology. However, this person must have enough authority to make curricular changes and time dedicated to program enhancement. This does not exclude the more seasoned faculty member, but the skill set does need to match the job. The person in charge needs to be a champion and must be given the time and resources to ensure program success.
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The course administrator for the overall educational unit (e.g., clerkship director, residency program director) must be involved in planning the simulation curriculum or be willing to delegate planning to the simulation director. The overall goals and objectives of the program must fit with the objectives of the clerkship and/or residency program and align with institutional objectives.
The best place to start is with the current curriculum. Our institution utilized the CDIM clerkship curriculum to evaluate the Internal Medicine clerkship curriculum. Our review of that curriculum revealed medical problems and procedures which were not consistently taught. Those problems formed the basis of the first undergraduate simulation curriculum. For example, students were not consistently performing supervised IM recommended procedures, so those procedures were targeted for teaching at the simulation lab. In the lab, we could observe techniques and ensure students understood the indications, contraindications, and complications of the procedures. These procedures are now commonly tested on our OSCE. We also believed our students were not being observed performing history and physical examination skills and that bedside cardiac skills needed to be improved. One day devoted to standardized patient scenarios was added to the SBME curriculum. The sessions allow us to review history and physical skills and give faculty and standardized patient feedback to students. A progressive course utilizing the Harvey mannequin was incorporated into the clerkship’s simulation curriculum as well.
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