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• W1765718098 abstract "Although simulation is now an established educational technique, the lack of consensus on its purpose is evident in the number of different outcomes used in studies of its efficacy [1–5]. In order to understand the place of simulation in education and training, we need to understand clearly what the problem is and why (and perhaps if) simulation is the answer. The literature related to ‘human factors’ [6] gives us insights into why some doctors feel poorly trained to cope with clinical problems and how their performance may be improved [7–9]. Firstly, early studies appeared to demonstrate that human working memory was extremely limited and could only hold around seven items (between five and nine) [10], although more recent studies have demonstrated that it is close to four items (between three and five); that is, we can only hold around four items in our working memory before the next item pushes out the first [11]. Secondly, our ability to process information, or ‘mental capacity’, is also limited [12], and if our rate of processing or ‘mental workload’ approaches capacity, there will be loss of information. This principle is used in the common MP3 codec to compress music for personal music players. The software relies on the fact that all but the most highly skilled listeners are unable to process all of the information contained in music. Part of the process is to predict sections we are unlikely to hear and to delete them [13]; for example, when one frequency is loud, all other frequencies are deleted. Therefore, when listening to an MP3 file, we are listening to music with ‘holes’ in it, but because of our limited capacity, we do not hear the holes. In the same way, when faced with a complex situation or crisis, information is commonly lost without our knowing it [2]. This defines a fundamental problem, that the human mind has a small and fixed ability to process information, that will always limit human performance. The conclusion must be that to avoid poor performance and human error in doctors, we should introduce strategies to reduce mental workload as they have in other industries [12]. The principles of limited working memory and mental capacity, outlined above, contradict the obvious fact that we can deal with the everyday complexities of medical life, without obvious overload. The explanation is that we use schemata [14–16], or internal representations of the world around us. Rather than cognitively processing large amounts of information, our minds are set up to compare reality to internal models – a much more efficient process. Although an oversimplification, schemata can be seen as three types: Sensory schemata allow us to process sensory inputs rapidly to derive meaning from them. For example, when we see a friend, we don’t think ‘blue eyes, brown hair, and a scar on upper lip – that must be Joe’. We look and see Joe. Joe is the internal schemata that is compared with reality and identified. Motor schemata are complex patterns of muscular movement and sensory feedback that allow us to perform complex tasks without conscious input. Most adults do not think about how to walk and experienced anaesthetists do not think about the process of intubation. Abstract schemata are representaions of the meaning of the world. For example, as a trainee anaesthetist, the term ‘malignant hyperpyrexia’ will contain concepts such as hypercarbia, acidosis and pyrexia. For those who have experienced it, it may contain concepts such as anxiety, the need for help and disbelief at how long dantrolene takes to dissolve. Although abstract schemata could be seen as knowledge, the term implies active, functional understanding, rather than simple recall of fact. The conclusion from the above is that the function of an expert in any field is largely dependent on schemata and can be represented as in Fig. 1, with the ability to process information or mental capacity shown as the small central area. This model is supported by a range of observational data in medicine and it is now accepted that medical staff produce a preliminary diagnosis within seconds of encountering a patient and in most cases before any verbal exchange, using a range of information such as posture, movement and clothing in characteristic patterns that match internal schemata of patient states [17]. An example is the ‘Levine fist’, a clenched fist pressed to the chest that has been associated with cardiac chest pain, but that is often not included in textbook accounts of the diagnosis of ischaemic chest pain [18]. Importantly, this process is not easily made conscious and the doctor may not be aware of many – or indeed any – of the key attributes of the patient that led to the initial diagnosis. This is evident in the problem of fixation, where prior influences can lead individuals to focus on one solution (activate one schema) and then go on to ignore what seem in retrospect to be obvious solutions [19]. Rather than being the primary mode of decision making, conscious thought can therefore be seen as a supervisory and fine tuning process. Although there are many studies that describe medical decision making in terms of a hypothetico-deductive model, they are often based on the verbal descriptions of doctors presented with text-based clinical scenarios [20]. Under these conditions, it would not be reasonable to expect that unconscious responses to subtle clinical signs can be detected. Representation of the schemata of an expert, illustrating very well-developed sensory (S), abstract (A) and motor (M) schemata but with limited working memory and mental capacity (C). The development of expertise can therefore be seen as the accumulation of schemata, so that while experts cannot process information faster than novices, they are able to identify problems and solutions by rapidly selecting existing schemata [21]. A traditional academic education focuses on abstract concepts, leading to the pattern seen in Fig. 2. Under these conditions, while students have knowledge, and therefore may be aware of specific conditions, they are unlikely to recognise them and even less likely to respond appropriately. This may explain the distress of newly qualified doctors who are aware of their own weaknesses in the clinical environment, despite successfully completing competence based assessments [22]. Lastly, the practitioner who does not maintain his/her knowledge base is represented in Fig. 3, with a lack of abstract schemata that would limit his/her ability to adapt and develop in response to change. The challenge, therefore, is to define the conditions under which students are likely to develop effective schemata. The evidence points to the need for repeated practice, with constant review of performance, defined by Eriksson as ‘sustained, deliberate practice’ [23, 24] and reflected in Schon’s concept of ‘reflection-in–action’ [25]. A crucial factor in this type of learning is that effective schemata may take 10 years to develop, supported by evidence that the mental workload of trainees completing simple cases decreases over seven years [26]; that is, it takes seven years before the administration of the most simple form of anaesthesia becomes fully internalised and automated. While classroom-based learning and self-directed learning provide essential support to help develop abstract schemata and aid students’ understanding of what they are doing, experience and practice are essential. Although this process might be thought similar to the ‘stimulus-response-feedback’ cycle of behaviourist theory [27], it differs in that it recognises that the effect of any training will have very complex effects on any student. For example, constant repetition of an isolated act will produce skill, but also produce boredom, resentment and an inability to adapt to new situations. Representation of the schemata of a student, illustrating limited sensory and motor schemata that limit the ability to recognise clinical problems and react to them. Representation of the schemata of a lapsed practititoner, illustrating limited abstract schemata that allow normal function, but with a risk of failure with any change in normal working pattern. What is required is therefore a teaching medium that can provide authentic experience and allow students to practise their responses in conditions where formative feedback is available. It is unlikely that any simulated environment can faithfully replicate the complexities of reality and it therefore cannot deliver a complete training course and the necessary schemata in the same way that pilots can be taught to fly a new airliner without any real flight time. Simulation should therefore be seen as a ‘practice ground’ where students can practise their response to specific situations and learn about their own abilities and limitations in a risk-free context. Specific advantages over the clinical environment for learning are shown in Table 1. The aim of simulation is therefore not to ‘teach’ specific skills or knowledge, but to allow the student to gain specific experience and to provide feedback, including strategies to practise during later clinical practice. That is, simulation provides a substitute for clinical experience that may be difficult to gain during normal training. The most crucial aspect of simulation training is both its fundamental strength and its apparent weakness: that it aims to develop highly complex sensory, abstract and motor representations that are subject to many subtle influences and that may take up to 10 years to develop fully. The key to effective use of simulation is therefore likely to be integration into the workplace, as an enhancement to routine clinical training [28, 29]. The high cost of simulation training means that it should only be used where the benefits justify the costs [30]. However, although higher levels of fidelity may lead to better learning, the finding that material learnt at the bottom of a swimming pool is best recalled there [31] suggests that the factors that determine learning are not always obvious. This is reflected in the three descriptions of fidelity: physical fidelity (it looks real); functional fidelity (it works); and psychological fidelity (it has the same effect on the user as the real thing) [32, 33] and linked to the concept of ‘transfer’. If the schemata developed in the simulator do not match reality, then the experience may worsen performance rather than enhance it. We need to determine which aspects of clinical simulation are most important for learning to ensure that not only do students learn, but that that learning transfers effectively to the workplace. Since learning degrades within months if subjects do not have the opportunity to practise, training should be fully integrated into training schemes with the simulation linked to later practice [34] as well as having clear links to published learning outcomes and later assessments, as is done in the current curriculum for trainee anaesthetists in the UK [35]. Supervising clinicians must therefore be aware of their trainees’ simulator training, both to prepare novices to take part and to ensure that the lessons learnt are put to use immediately. It is essential that the procedures practised in the simulator match those in the workplace as closely as possible. Teaching around simple problems, such as cardiac arrest, can follow national guidelines, though ensuring consistency across the real/simulator divide for more complex problems is likely to be more challenging. However, the integration of simulated and real practice may allow us both to assess the performance of staff using existing guidelines and to transfer lessons learned from the simulator to the real world. Teamworking is also an important part of clinical performance and a major cause of morbidity when it is ineffective [36]. The opportunity for team members to debrief and effectively to hold up their own schemata for comparison and debate can provide the opportunity to develop shared understanding, a key to effective team development [37]. The current format of assessments may also be a problem as they rely on decontextualised information along with written responses that are unlikely to assess schemata effectively, focusing on abstract schemata, but not testing sensory or motor schemata. The recognised association between assessment and learning is then likely to drive trainees away from realistic training and toward rote book learning [38]. Further, as we now recognise, schemata take many years to develop effectively, so that it is inevitable that tests based on these methods are unlikely to demonstrate simulation to be any more effective than other techniques. We therefore need to develop more sophisticated assessment techniques that look at performance in realistic situations. Techniques that measure mental workload, in particular, may provide a method of determining whether a trainee has developed effective schemata [26]. However, what the above does not suggest is that professional performance is reduced to a system of rigid guidelines or rules; unthinking practice can never be advocated. The evidence suggests, however, that it is not possible to deal with the complexities of medical practice using conscious cognitive processes [26, 39–41]. What is suggested here is that in order to have the spare capacity to monitor and develop our clinical ability, we need to practise to the point where the routine task becomes almost unthinking or automatic. Cognitive psychology has demonstrated that human capability is much more limited than is generally recognised. In this light, expertise can be seen as the acquisition of sensory, abstract and motor schemata that work to limit our mental workload. Sustained deliberate practice during clinical experience appears to be the most effective method of acquiring schemata, although simulation has a defined role in providing experience not reliably provided by routine practice. However, simulation is likely to be effective only when fully embedded in a clinical training programme and the organisation in which the clinical practice takes place. In order to demonstrate the validity of the theoretical approach described, development of more appropriate assessment tools is required in order to measure the performance of individuals and thereby the effectiveness of their training. There is a real danger that simulation becomes a distinct training entity primarily because it is exciting and popular with trainees. The time has now come to recognise that we are not pilots and that justifying simulation on the grounds that other groups do so is no longer enough. Medical simulation is different and should be one of our key learning resources, but only with a clear rationale, within a curricular framework and with associated assessments that link directly to the intended learning outcomes. No external funding and no competing interests declared." @default.
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• W1765718098 title "What is simulation for?" @default.
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