Simulation has become a growing component of educational and research strategies in healthcare over the past two decades. One reflection of this is the number of simulation centers dedicated to housing simulated clinical spaces, equipment, and personnel to support these endeavors (see Fig. 4.1) (1). The exponential curve on this graph reminds us that healthcare simulation is a relatively new field, and best practices are currently being defined and refined. This rapid growth is also reflected in the development and membership of simulation societies and conferences that foster networking and sharing of new developments. An important example in the field of pediatrics is the International Pediatric Simulation Society who in 2014 celebrated their sixth annual meeting, that is, International Pediatric Simulation Symposium and Workshops (IPSSW).

It is interesting that after hundreds (or really thousands) of years of rarely using surrogates (actors, manikins) in education in medicine, nursing, and allied health, there has been such a paradigm shift. It raises the question of why simulation is now considered such an important component element of the healthcare curriculum.

One of the first major shifts in medical education paradigms occurred with the Flexner Report of 1910. After a detailed examination of the curriculum, facilities, finances, faculty, and clinical resources of medical schools in the United States, Abraham Flexner made a detailed report to the sponsoring Carnegie Foundation that included insightful observations that remain relevant today. He observed: “On the pedagogic side, modern medicine, like all scientific teaching, is characterized by activity. The student no longer merely watches, listens, memorizes; he does.” He continued, “An education in medicine nowadays involves both learning and learning how; the student cannot effectively know, unless he knows how.” “Out and out didactic treatment is hopelessly antiquated; … The lecture indeed continues of limited use.” Ironically, much of his reference was to the “active learning” in the basic science (Anatomy and Chemistry) laboratories. He strongly felt these subjects were better learned in an active manner (dissecting rather than reading from an Anatomy atlas). He highlighted that the success of a medical curriculum is integrally linked to the relationship between a medical school and its hospital and clinic population. He emphasized medical schools, most specifically Johns Hopkins University School of Medicine (Baltimore, MD), that moved their students from the classroom and basic science laboratories after 2 years into the clinical environment, as defining best practices in medical education (2). Subsequently, this became the model of the modern medical school that stood for another century.

Sir William Osler (3) has been quoted as having said, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” These two men stressed that one must get out of the classroom to truly learn medicine, or more specifically “to learn how.” The apprentice model ruled healthcare education for the next 100 years, didactic knowledge gained in the classroom followed by intense bedside experiences, where the skills of taking a history, listening to patients, conducting a physical
exam, and performing procedures were learned by first watching senior clinicians before attempting. In fact, Osler was known for examining his patient’s microbiology specimens and conducting his own autopsies so that he understood every aspect of his patient’s diseases. Learning at the bedside, on patients, was the norm and bedside teaching revered.

The learning during this period is accurately reflected by a phrase that was common at the time: “see one, do one, teach one” (4). There was no expectation that students would learn clinical skills in a laboratory, prior to performing them on actual patients. While there are clearly reports of leading edge, iconic human patient simulators being developed and utilized in medical education in the 1960s and 1970s, very few simulators were developed for healthcare education prior to the 21st century, partially due to low demand (5). In marked contrast, the airline and aeronautic industries were developing sophisticated simulators to intensely train pilots and flight teams prior to flying actual planes in an attempt to avoid catastrophic errors (6).

In 1999, the Institute of Medicine released a report entitled “To Err is Human: Building a Safer Healthcare System.” The report estimated that 98,000 patients died each year within U.S. hospitals secondary to errors (7). The fact that medical errors were a leading cause of death sent shock waves through the medical system. This was part of a cascade of international literature that highlighted problems with healthcare systems and called for higher quality of care and attention to patient safety. One of the causes of errors emphasized was fatigue; that physician trainees were working >100 hours per week contributed to errors. This resulted in regulatory requirements to limit physician trainee work hours. As a result, trainees were protected from excessively long workweeks, but the reduction in patient care and follow-up limited the educational experience these duties provided. In addition to less time for patient care, other changes in the education of healthcare trainees in the last decade include a concerted effort to make medical care more transparent and more patient- and family-centered as well as a progressive expectancy to disclose errors, to allow family presence during critical events, to respect requests for senior clinician involvement in procedures, etc. All of this translates to a sea of change in terms of how we educate our healthcare trainees.

The factors described above aligned in a manner analogous to what Gladwell (8) referred to as The Tipping Point, “that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.” Simulation is spreading like wildfire through healthcare, and pediatrics in particular. In another of his works entitled “Outliers: The Story of Success,” Gladwell refers to seminal work by Anders Ericsson where he methodically analyzed what it takes to become a world-class expert in a field, that is, chess, athletics, music, etc. He is widely quoted as demonstrating that it takes 10,000 hours of practice at one’s specialty to become a true expert (9,10). However, Ericsson clearly states that “practice” is not sufficient; it is “deliberate practice” that is the key. In healthcare, the physician who is seeing patients day to day is not in deliberate practice, that is, “game time” is more effective if performance is analyzed, feedback given, and that time used to implement feedback and improve performance. A key ingredient to success is a coach who is invested in, and cares about, their students’ success, observes them, gives specific feedback on performance with tips targeted at addressing deficiencies, and provides practice that deliberately focuses on narrowing identified gaps. Simulation can be used to provide “deliberate practice” and debriefing with direct feedback, important tools to improve healthcare education and training.

Weinstock et al. (11) described why simulation is relevant for those who care for children, and coined the phrase the “pediatric training paradox.” In addition to the factors listed above, the relative rarity of high stakes, high-risk events such as cardiac arrest or difficult airway management in children results in less “hands-on” practice of procedures and teamwork that are made more difficult by the small size, limited space for a team around the patient and heightened emotions related to the vulnerable population. We encounter the problem of very difficult procedures, which require the most amount of practice for proficiency, are the least available to practice. Simulation has the potential to provide a student with efficient practice of rare events despite decreased trainee hours, low incidence, or seasonality of disease. If we acknowledge that simulation has become an important tool in our educational toolbox for pediatric critical care medicine, we can address how to best approach and optimize its use (Table 4.1).

Reflecting on Flexner’s words, “An education in medicine nowadays involves both learning and learning how,” we find similarity in work that psychologist George Miller proposed in 1990 for assessing clinical competence using what is now referred to as Miller’s Pyramid. This pyramid has four levels; at the base rather than “learning and learning how” Miller (12) uses the language “knows” and “knows how,” followed by “shows how” and “does” (see Fig. 4.2). This is our ultimate
goal, that our frontline clinicians can demonstrate the required knowledge and skills through answers on Multiple Choice Questions tests, in physical demonstration in a safe setting (simulated clinical environment), and ultimately at the bedside (the top of Miller’s Pyramid). This pyramid emphasizes the importance of hands-on, experiential learning in which the learner demonstrates to the teacher that they have mastered the appropriate skills and knowledge. Another important paradigm for evaluating the effectiveness of a training program is Kirkpatrick’s (13) four steps, or “levels,” first proposed in the 1950s and subsequently refined. The four levels Reaction, Learning, Behavior, and Results are used as a progressive chain of evidence on the effectiveness of a training program (see Fig. 4.3) (14). Ultimately, we should target our educational and training programs to the top of Miller’s Pyramid (the learner is able to perform what was taught in a clinical environment) and Kirkpatrick’s Results level (assessment of whether the training program improves clinical outcomes).

Donald Schön, in his book Educating the Reflective Practitioner, states “Professional education should be redesigned to combine the teaching of applied science with coaching in the artistry of reflection-in-action.” This statement emphasizes the role of the educator in guiding the student through the process of continual critical evaluation of their own performance by “coaching” them during their active learning experience (15).

We have reviewed the rationale and underlying goals of simulation training and will now focus on the essential elements for designing simulation curriculum. One of the most important principles is that the students involved in healthcare simulation are adult learners, and teaching adults is different from teaching children. Malcolm Knowles popularized the term andragogy, originally introduced by the German professor Alexander Knapp. Knowles initially defined andragogy as “the art and science of helping adults learn,” and pedagogy as “the art and science of teaching children.” However, he felt this was too simplistic and ultimately saw them as two ends of a spectrum of educational approaches that extends from those used for learners who are dependent on the teacher for direction and priorities to learners that are self-directed. He realized that both the age of the learner as well as the content being taught might influence the learner’s needs (16

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