(1)
Flinders University of South Australia School of Medicine, Adelaide, SA, Australia
“The art is long, life is short; the crisis fleeting; experience perilous, and decision difficult”. Hippocrates
Everyone about to undergo a healthcare procedure wants the health professional to be knowledgeable, well-trained, and experienced so that a complication would be unlikely but if one did occur it would be managed quickly and effectively. Practical experience is essential for learning a skill and it may take hours or days to develop competence and learning all the skills of a craft or a profession may take several years. The Greek philosopher Aristotle (384–322 BCE) taught in his Nichomachean Ethics that we learn skills and behaviors through repetitive actions (habituation) and development of expertise, like virtuous behaviors, requires guidance and feedback:
For we learn a craft by producing the same product that we must produce when we learned it; we become builders, for instance, by building, and we become harpists by playing the harp. Similarly, then, we become just by doing just actions, temperate by doing temperate actions, brave by doing brave actions. [1]
There are two parts to learning a skill; learning what to do when everything is normal and working as it should and learning what to do when there is an abnormal condition. Hippocrates (c. 460—c. 367 BCE), known as the father of medicine, summed this up in the Aphorismi, which starts with the phrase, Ars longa, vita brevis. The English rendering of the complete aphorism explains exactly why simulation has to be at the core of practical training of health professionals.
Life is short, the Art is long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate. [2]
In some areas of healthcare the transition from normal to abnormal can be quick and the crisis needs rapid intervention to avoid harm. In these cases “learning by doing” would risk of adverse outcome or in the words of Hippocrates “experience perilous.” The correct procedure to manage these events should be practised through simulation in which the real-world activity is substituted for one in an artificial setting that is realistic but safe. Flight simulation is a well-known example of this way of training where novices can learn the basics of flying and trained pilots can practise managing events that happen rarely but have serious consequences if not dealt with promptly and appropriately. In commercial aviation simulation has become increasingly important in the last 50 years and has been embedded in flight crew training and is used in regular assessment of competence. This was not the case in healthcare.
In the last 50 years simulation has not been routinely used in the education or training of health professionals despite ample evidence that the amount of preventable error and harm from medical care [3] makes admission to hospital many times more dangerous than air travel [4]. Plane crashes are expensive and receive a lot of attention and companies and professional organizations have been willing to cooperate and develop rules and requirements for training using simulation. Pilots would prefer not to be involved in a crash and have actively participated in this development. Healthcare seems to be different partly it seems because patients are injured or die individually and discretely and partly because the risk is borne only by the patient as healthcare providers are not physically harmed by the event. Administrators have been complicit in this failure of training through being overly focused on service provision and less on preventing harm.
Recently there has been increased interest in simulation to improve performance of healthcare professionals but its use has been patchy and uncoordinated. It shouldn’t be this way because more than a hundred years ago simulation was widely used by students and practitioners wanting to learn new techniques and how to avoid loss of life when an uncommon but serious complication presented. This book documents the origins and development of simulation in health professional education and the technology used to create realistic simulators. This has required an exploration of simulation and simulators used as aids for training and education generally. Teaching aids have been included because whilst they were not used in immersive learning they were used to simulate body part or physiological process that would otherwise be hard to see or learn and many were used in experiential learning.
We shouldn’t be surprised that simulation in healthcare has a long history because the value of simulators and simulation was recognized and understood in other fields. What is surprising is that whilst health professionals are generally thought to be smarter than average they have been more than willing to teach and learn on patients. The resurgence in interest in simulation in healthcare education has been broadly met with indifference by healthcare providers and funders.
Liver Simulators
Haruspicy, the inspection of the liver of a sacrificial animal1 for blemishes that could be interpreted as having meanings has been a component of the belief system of many cultures. Clay models of livers (see Fig. 2.1) have been found along a geographical corridor from the Euphrates through Syria and Cyprus to Etruria in what is now Italy. A clay liver model from Babylonia, now in the British museum, dated to 1900–1600 BCE, is thought to have been used in Mesopotamia to forecast the outcome of an illness. Wooden pegs were placed in holes in the model to record the markings on the liver being read.
Fig. 2.1
Clay model of a sheep’s liver 1900–1600 BC (Credit: British Museum)
A bronze model of a sheep’s liver of Etruscan origin was discovered in 1877 near Piacenza in the north of Italy [5]. This simulator is made of bronze and has the gall bladder, caudate lobe, and part of the posterior vena cava sculpted on the inferior surface of the liver which is inscribed with an astrological star map. An accurate interpretation was very important because decisions of great importance were based on the findings. This model ensured consistency of readings and would have been useful for teaching and as a cognitive aid. The Etruscans were thought to be skilled in divination but despite this apparent advantage their culture still experienced a decline from around 500 BCE and they were conquered by the Romans around 100 BCE. The Romans adopted haruspicy and the haruspex (diviner) Spurinna warned Julius Caesar to beware the Ides of March.
Simulation in Roman Military Training
The assassination of Julius Caesar marked the transition of the Roman Republic to the beginning of the Empire. The Republic of Rome had raised armies as required to counter specific threats to the republic and they had a poor record. Reforms instigated by General Gaius Marius led to the creation of a professional standing army that was able to devote time and resources to training. Publius Rutilius Rufus introduced methods of training used in gladiatorial schools including regular fitness training and practise using their swords, spears, and shields on a simple simulator known as the palus. Publius Flavius Vegetius Renatus described how the palus was used in legionary training in De Re Militari (On Military Matters):
They wove their shields from withies, of hurdle-like construction, and circular, such that the hurdle had twice the weight that a government shield normally has. They also gave recruits wooden foils likewise of double weight, instead of swords.
Each recruit would plant a single post in the ground so that it could not move and protruded six feet. Against the pot as if against an adversary the recruit trained himself using the foil and hurdle like a sword and shield, so that now he aimed at as it were the head and face, now threatened the flanks, then tried to cut the hamstrings and legs, backed off, came on, sprang, and aimed at the post with every method of attack and art of combat, as though it were an actual opponent. In this training care was taken that the recruit drew himself up to inflict wounds without exposing any part of himself to a blow. [6]
In training schools the palus could be more substantial and have a carved head (see Fig. 2.2) [7]. The palus offered a safe environment for training and meant that one trainer could supervise several trainees and correct mistakes in technique. There were doubters who thought simulation was inferior to earlier methods of preparing for battle. Valerius Maximus, for example, expressed concern that the quality of training at the palus was inferior to live training [8]. Instead, with the benefit of simulation, the Roman legions became an unstoppable force although this had an unexpected outcome, an empire that was unsustainable. When Vegetatius wrote De Re Militari at the end of the fifth or the beginning of the sixth century CE, the Empire was in serious decline.
Fig. 2.2
Fighting exercises with sword and protective shield—Kampfübungen mit Schwert und Schutzschild [26]
A Battle Simulation and Cadaver Simulators
The palus continued to be used for training in many countries that had been under Roman control and in medieval Europe it was developed into the pell or quintain [9]. In this development the post was replaced by a target or a carved wood figure, typically a Saracen or Turk holding a sword, that could be moved or pivoted when struck. In various guises the quintain was a part of infantry training until rifles made swordsmanship irrelevant [8] although it was still used in cavalry training at the beginning of the twentieth century.
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