What impact can simulations have in advancing medicine?
Simulation, defined broadly, refers to an artificial representation of a real-world object, event or process [1, 2]. The representation of organ systems and pathology through art, literature and theatre, can be viewed as the earliest predecessors to medical simulation .
The majority of studies to date discuss the impact of medical simulation in regard to education and training. Simulations [Figure 1] are increasingly supplanting didactic methods as a means of both learning and assessment. Professor Gaba, in the vanguard of ‘simulation-based medical education’ (SBE), has categorised the types of technology used [Figure 1].
Simulation-based medical education (SBE) is a fairly nascent field. In contrast, the field of medical research has long utilised simulation techniques (i.e. animal models, tissue cultures). Recently, some have attempted to define ‘simulation-based medical research’ (SBR) as a distinct research strategy [5, 6].
Simulations can also be therapeutic, which, for the purposes of this essay, will be termed ‘simulation-based medical treatment’ (SBT). Like SBE, SBT is also just emerging and its impact has yet to be ascertained.
To assess the impact that SBR, SBE and SBT will have in advancing medicine it is helpful to understand the impact they have had thus far. Delineating these trends is important as immersive, high fidelity, integrated, AI-driven experiences erase our ‘banana peel suturing’ past [7, 8].
Figure 1: Types of technology used in simulation-based medical education (SBE). Data extracted from Gaba 2004, The future vision of simulation in healthcare .
What impact can simulation-based research (SBR) have in advancing medicine?
The aforementioned definition of simulation can be problematic when assessing its impact on medical research. Under this definition, seminal in vivo [9, 10] and in vitro studies  that constitute medical first principles, even the use of computational tools , would all be considered ‘simulation’. By this logic, nearly all medical research would fall under the umbrella of SBR, rendering this category obsolete.
Nevertheless, recent studies have attempted to argue for SBR as a distinct research strategy, and to characterise its various designs [5, 6]. Although these design distinctions work adequately when applied to healthcare processes, and closely mirror the types identified by Gaba [Figure 1], they fail to encompass the array of simulations available (animal models, cell lines) when applied more generally to medical research. These difficulties in distinction are reflected in SBR reviews to date; definitions for SBR are nebulous and the rationale underlying the selection criteria for an ‘SBR study’ is obscure [5, 6].
It can be argued that properly characterising SBR is important given its profound potential for streamlining healthcare processes. An example of SBR in action is the ‘SIMUL8 for Healthcare’ simulation software currently used, by John Hopkins  and the NHS  etc., to audit processes and test change. Yet it is nigh impossible for SBR to account for the inordinate number of variables that occur in reality, as such, results from SBR will rarely be conclusive.
What impact can simulation-based education (SBE) have in advancing medicine?
The first known use of patient actors for SBE was in 1963. Initially, Barrow’s use of standardised patients (SPs) to evaluate trainee performance was met with derision, making headlines: “Hollywood Invades USC Medical School” . However, contemporaneous advances in andragogy , and the desertion of Locke’s ‘tabula rasa’ theory , led to rapidly growing support for experiential learning/deliberate practice .
Now, SBE has become a fundamental component of medical training, as dictated in ‘Outcomes for Graduates’ . The 2014 ASPiH summary report found 60% of hospitals and 81% of higher education institutions use SPs . 77% of hospitals and 80% of higher education institutions use simulator manikins. Approximately half of all hospitals and higher education institutions possess an advanced sim suite .
The impacts of SBE [Table 1] in advancing medicine are often taken for granted, as demonstrated by a dearth of evidence in the literature. Additionally, heterogeneity in reporting, in simulation methods, in debriefing designs and in teaching topics has impeded data pooling for systematic review [21-24]. Nevertheless, outcomes are generally positive [21, 22].
Table 1: Impacts of SBE (simulation-based medical education) on stakeholders.
Increasing fidelity drives the evolution of SBE – manikins , ever more realistic, are now giving way to high-fidelity, virtual reality (VR) clinical settings, replete with interactive staff and patients. HEE East of England mandates that all foundation year doctors receive VR training  and delivery is expanding to a further 18 NHS Trusts .
OMS (oxford medical simulation) is providing clinical training scenarios using VR, complete with automated, personal feedback. OMS is currently available in 80% of NHS trusts with 100,000+ sessions run in 2020 . Moreover, OMS costs merely a tenth of traditional simulation methods .
Yet VR, like traditional means of simulation [Figure 1], requires the pre-empting of dialogue to script scenarios. These limitations can be largely overcome through the incorporation of artificial intelligence (AI). AI speech engines can communicate naturally with the user, responding to countless variations in questioning . AI can also give highly granular feedback, e.g. on stethoscope placement, micro-expressions, and decision time [36, 37]. However, AI black box phenomena, whereby complex algorithms outpace us, are the latest concern .
What impact can simulation-based treatment (SBT) have in advancing medicine?
SBT is the use of simulation, namely VR, as a means of treatment. Arguably, the ‘placebo effect’ (can be therapeutic, although often unintended ), is its primitive ancestor.
VR/simulation treatments are now being rolled out across NHS Trusts, heralding a novel field of care. One NHS pilot is offering VR treatment to patients suffering from acrophobia  following the results of a 2018 RCT demonstrating VR’s effectiveness . Other pilots include VR use in youth mental health facilities  and in patients undergoing ‘awake’ limb surgery .
The unforeseeable uptake of simulation in the 60s led to radical changes in medical education, yet heterogeneity in methods has made assessing the lasting impact difficult. Now, actors and manikins are being replaced by VR/AI technologies, the latter providing high-fidelity scenarios, lower costs, and quality feedback.
Although the epistemology underlying simulation is strong, quality evidence on impact is required. This can be somewhat resolved by reaching a consensus on terminology and selection criteria for SBR, SBE and the burgeoning field of SBT.
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