Simulation for Medical Training

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This page originally authored by Oliver Applegarth (2008). Edits by D Findlay (2010), J Rothney and S Jardine (2013), Momoe Hyakutake (2014), Erin Menzies (2015), Troy Seaboyer (2016), and Lisa Dyck (2017).

Click here to view a video on Simulation in Medical Education.

Click here to see a presentation on Medical Simulation.

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Background on the use of Simulation for Medical Training

The first known simulators called Mannequin Simulators were used for Medical Training and were precursors to computer based Simulators. They were created in the early 1960’s - Resusci-Anne used for CPR training and the Harvey Cardiology Mannequin with subsequent sophisticated computer based models designed in the early 1990’s - Sim Man and Sim One Mannequin Simulators.

Using medical simulation tools and techniques, health care professionals can learn treatment protocols and master basic and procedural skills before touching a real patient. Physicians can review, repeat, and reassess their performance and find areas for improvement without compromising patient safety.

A challenge in medical education is to ensure that all students gain exposure to a certain number of procedures and to a variety of clinical scenarios. This is especially challenging with respect to those scenarios that are rare or those in which the patient's life is in immediate danger. Medical simulators allow easy access to a wide variety of clinical scenarios, including rare complications that allow trainees to benefit from observing the reasoning of an expert as they work through difficult situations.

Patient Safety and Medical Simulation

Medical Simulation can aid educators in providing optimal patient care including freedom from accidental injury. Healthcare is not as safe as it should be with deaths due to medical errors exceeding deaths due to motor vehicle accidents. Health care professionals from novice to expert are expected to continuously acquire new knowledge and skills while treating real patients. Simulation offers options for teaching necessary skills as well as supporting improved methods for demonstrating and documenting competencies while keeping patient safe. The Institute for Patient Safety and Medical Simulation is a facility devoted to training new and experienced health care professionals from all specialties. Their model emphasizes (SMART) Synergistic Medical and Resource Team Training and includes consulting services and simulator facility set up services.

Simulated Environments for Medical Training

The use of simulated environments for medical training has grown exponentially over the last decade. There are a number of reasons for this growth in simulation (Ker & Bradley 2007, Issenberg BS, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. 2005, Øhra M. 1998)

  • reduced access to real clinical teaching opportunities - eg. due to limited patient availability and larger number of professionals/students
  • simulation can provide access to a wide range of clinical material that would be difficult to experience relying entirely on patient contacts
  • there is ever increasing evidence that simulation results in actual increase in diagnostic and clinical skills and transfer of skills to the real setting
  • simulation enhances the role of deliberate practice
  • simulation can be scaled to the various levels of expertise from the novice through to the expert (Dreyfus model)
  • simulation offers a way to reduce medical errors and maintain patient safety, especially when learning new behaviours and skills. One can make mistakes in safety. Thus simulation provides a safe and accessible way to assess professional competencies. Also with the increase in new diagnostic and management technologies that require high technical expertise- eg. endoscopies – simulation offers maintenance of patient safety and opportunities for repeated, deliberate practice
  • simulation provides an ideal opportunity for teaching of non technical skills eg team work, leadership, communication skills etc

With technology improving rapidly, simulation has become common place in hundreds of schools around the world. It is seen in many medical sub-specialties and is incorporated into many areas of both undergraduate and graduate medical education. Currently it is used to teach Anesthesiology, Emergency Medicine, Surgery and Intensive Care Medicine.

In 2009 in the USA legislation was put forward to enhance the use of medical simulation in civilian settings across medical, nursing, allied health, podiatry, osteopathy and dentistry; however the bill was never passed. The Enhancing Simulation Act of 2009.

McGaghie 1999 (in Ker & Bradley 2007 p 2) defined simulation as "any person, device or set of conditions that attempts to present problems authentically". Ker & Bradley 2007 identify that simulation can be viewed as a continuum from low fidelity to high fidelity (where fidelity is the extent to which the simulation matches the appearance and behaviours of the real system) and also as a continuum from low levels to high levels of authenticity.


In medicine this simulation continuum can include (Zif, et al. 2003; Ker & Bradley 2007):

Low-tech approaches: Paper based cases

Low-tech simulators: Models or mannequins used to practice simple physical maneuvers or procedures (eg. venepuncture arm, CPR model).

Role play and Simulated/standardized patients: Role play with doctors role playing both doctor and patient roles, and the use of actors trained to role-play patients allow for training and practice in assessment of history taking, physicals, developing management plans and communication skills.

Screen-based computer simulators: Programs to train and assess clinical knowledge and decision making . Examples include: perioperative critical incident management, problem-based learning, physical diagnosis in cardiology, and acute cardiac life support.

Complex task trainers: High fidelity visual, audio, touch cues, and actual tools that are integrated with computers. Virtual reality devices and simulators that replicate a clinical setting. Examples include: ultrasound, bronchoscopy, cardiology, laparoscopic, surgery, arthroscopy, sigmoidoscopy, and dentistry.

Realistic patient simulators: Computer-driven, full-length mannequins. Simulated anatomy and physiology that allow handling of complex and high-risk clinical situations in lifelike settings, including team training and integration of multiple simulation devices.

Simulated environments: Simulated wards or surgical theatres or intensive care environments.

Games and Virtual reality: 3D virtual environments with virtual patients. This includes the virtual world - Second Life.

Computer-Based Simulation

Computer-based simulation programs have been an integral part of medical education since the 1960s. As technology advances and improves, so do the uses of this modality. Computer technology has allowed for a vast array of programs that can simulate such things as the physiology, pharmacology and detailed human anatomy.

Anatomy and Physiology Simulation tools

Sample image from Visible Human project

The Visible Human Project

The Visible Human project, based out of the US National Library of Medicine, was the culmination of many institutions efforts to fully image the human body. The Visible Human Projectis a database of CT scan images of complete human anatomy that allows users an interactive exploration of the human body without the need for dissection of a cadaver. The Visible Human dataset is also freely available for developers to use in new projects.

Virtual Dissection Table

The Virtual Dissection Table is a life-sized model of the human body displayed on a table structure so that the the viewer stands over the model as one would in a real dissection. The virtual body can be dissected in many different ways, including removing one body structure (ie. muscles), in order to view the relationships of the remaining structures (ie. veins and bones). MRI and CT images of the various views are available, allowing users to flip back and forth between views.

See a TED talk on the virtual dissection table by one of the developers; Virtual Dissection Table TED talk

Zygote Body

Zygote Body is a free, online (no downloads needed), fully manipulable anatomy tool. Originally developed in Google Labs, the tool was migrated to Zygote Body in January 2012.

http://www.zygotebody.com

Second Life: Virtual Patients in a Virtual World

Second Life is a popular online game started in 2003 that has created a virtual world in which "residents" use Avatars to negotiate their online environment. Recently, Second Life has begun to be utilized by Universities and medical schools to create simulated courses, patient encounters and even symposiums on disease (see Attending Medical School in Virtual Reality).

A simulated patient in Second Life

Simulation for Surgical Training

Laparoscopic box trainer by 3D-Med

The use of simulation in surgical training is not a new phenomenon. For centuries, surgeons have used cadavers and animal models for practicing their skills. However, the legal, ethical, financial and resource intense nature of these models restricts its frequency of use. In addition, these models are limited in their ability to model pathology (Choy & Okrainec, 2010). Recent changes in practice, particularly the widespread use of minimally invasive surgery, has made simulation an attractive teaching tool. One type of minimally invasive surgery is laparoscopy. This involves creating a pneumoperitoneum and operating within the abdominal cavity using long rigid instruments through small keyhole incisions. Laparoscopy requires a different set of technical skills in comparison to open surgery. These skills include the ability to manipulate three-dimensional objects while watching a two-dimensional image, use of long rigid instruments, overcoming the fulcrum effect, and the increased use of visual cues in addition to force feedback during surgery. The fulcrum effect occurs because long instruments are used through a narrow opening. The narrow opening acts as a fulcrum, which requires the operator to manipulate the handle of the instrument in the opposite direction so the tip of the instrument moves towards the intended direction. This section will focus on laparoscopic simulators, as they are the most commonly encountered simulator in surgical education.

Types of laparoscopic simulators

In general, laparoscopic simulators can be categorized into two groups; low fidelity simulators and high fidelity simulators. Fidelity in simulation is the measure of how faithful an object is to what it is supposed to represent. The box trainer, also termed partial task trainer or video trainer, is a low fidelity simulator. The basic construct is that of a box with several holes in it for instrument insertion. The trainee uses the space inside the box as if it is the inside of the abdominal cavity to manipulate objects while observing their actions on a screen. The box trainer has several advantages. They are more portable and relatively inexpensive in comparison to high fidelity simulators. The trainee also uses the same instruments used in real operations and receives real haptic feedback during training. Haptic feedback is the proprioceptive feedback that the trainee receives when handling objects. Their limitations include the lack of internal assessment tools within the simulator itself and its inability to recreate an entire procedure.

LapMentor is a virtual reality laparoscopic simulator by Simbionix.

Virtual reality laparoscopic simulators are an example of a high fidelity simulator. Using complex technology, they are able to offer the trainee an opportunity to practice whole procedures, parts of procedures, as well as specific surgical tasks. These simulators are often linked to a computer platform that allows measurements of performance metrics, record and track progress, allow interactions between teachers and trainees in an asynchronous fashion, and provide feedback. The trainees and teachers can also manipulate the complexity of cases, allowing the trainee to progress as their skill level improves. Some of these also have the ability to provide haptic feedback, which was previously a criticism of this type of simulator. However, its expensive nature is prohibitive.

Designing an effective surgical simulation environment

Education through simulation, particularly in the field of surgery, has seen an exponential increase. This is propelled by several factors:

  1. Patient safety concerns
  2. Technological advancements
  3. Decrease in trainee work hours
  4. Increasing complexity of surgical cases

These are all practical reasons to shift away from an emphasis on in-operative training to simulation. However, the main goal of simulation should be to assist in turning trainees into better surgeons. If we are going to use simulation to replace some of the time spent on in-operative training, we must implement it in such a way that enhances the trainees’ learning. The creation of an effective simulation environment is essential for this goal. In this section, we will use the principles of effective learning environments to evaluate and provide guidance for creating an effective surgical simulation environment.

These principles were developed based on extensive research on learning and educational environments (Chickering & Gamson, 1987). Effective educational environments must fosters the following principles:

  • Encourages contacts between students and teachers
  • Develops reciprocity and cooperation among students
  • Use of active learning techniques
  • Prompt feedback
  • Emphasize time on task
  • Communicate high expectations Respect diverse talents and ways of learning

Contact between student and teachers

Contact between trainees and teachers allows for coaching and scaffolding through feedback. Both are essential components for effective learning (Jonasse, 1999). With low fidelity simulators, there is a great potential for interaction between the trainee and teacher. As there is no internal system of assessment and feedback, an external observer, in most cases a teacher, is necessary for trainees to get the full benefit of simulation. This creates an environment where the trainee can interact with the teacher one-on-one. Though this is an advantage, it can also be a hindrance because this is demanding on the teacher’s time. And, with more trainees practising at the same time, the interaction time is shortened.

With high fidelity simulators, contact between the trainee and teacher can become minimal. Instruction, tutorials, tips and feedback are often integrated within the simulator. The teacher is able to monitor trainee progress through the system and can interact with them in an asynchronous fashion using built-in messaging systems. Though this can be seen as an advantage from a resource point of view, interaction with teachers is a valuable element of learning as they are able to impart not only technical knowledge but also clinically applicable knowledge based on their vast experience. Interaction can also help solidify the construction of knowledge within the trainee (Jonasse, 1999).

Develop reciprocity and cooperation among students

At the current time, most simulators are designed for one operator. However, laparoscopic surgery is heavily dependent on surgical assistance provided by another operator, particularly for more complex cases. In this situation, communication and interaction with others becomes an important factor in the success and proficiency of the operation. Therefore, regardless of the type of simulator used, it would be important to incorporate a cooperative component to the surgical simulation curriculum. In addition, the trainee may make greater gains in their progress by working with more capable peers, per Lev Vygotsky’s “zone of proximal development” theory (Vygotsky, 1978).

Active learning

Both low and high fidelity simulators require the trainee to think, analyze and perform tasks. Therefore, both types employ active learning(Bonwell & Eison, 1991). This is further enhanced by implementing reflective thought and increasing complexity of tasks and procedures, which requires a greater degree of analysis and repetition by the trainee.

Prompt feedback

Feedback can serve many functions. This may include focusing and maintaining the attention of the trainee; outlining clear goals; drawing on learned knowledge; providing guidance; initiating practice; and providing informative, contextual and objective information (Cannon-Bowers, Bowers, & Procci, 2010). Feedback will depend on the type of simulator used.

Low fidelity simulators do not have the ability to provide feedback themselves. Feedback is dependent on an external observer, such as a peer or teacher. Thus, the content, quality and educational merit of the feedback will also vary. This can be standardized with the use of global assessment scales such as the Objective Assessment of Technical Skills (OSATS)(Reznick, Regehr, MacRae, Martin, & McCulloch, 1997). This was developed by University of Toronto and has been extensively studied and used in surgery. A modification of this scale has been developed specifically for laparoscopy (Gumbs, Hogle, & Fowler, 2007).

Many high fidelity simulators have performance metrics built within them. They will analyze variables such as degree of tissue injury, economy of motion, number of attempts, time to completion, theoretical blood loss, and accuracy. After the completion of each task or procedure, these metrics are displayed. Most programs also keep a record of the users past performance metrics for comparison. This allows for prompt, measurable and direct feedback. However, it is up to the user to analyze, interpret and make changes based on this data. As such, for a novice trainee, this type of feedback may be suboptimal and lead to frustration and disengagement. It is important for the teacher to review each trainee’s progress and provide further coaching if necessary.

Emphasize time on task

As stated by Chickering & Gamson (1987), “time plus energy equals learning” (p5). Creating a well thought out curriculum with clearly stated goals and dedicated time to train is pivotal. Much research has been conducted to design an effective curriculum and the Surgical Skills Curriculum developed by the American College of Surgeons in collaboration with the Association of Program Directors in Surgery is one such example. This curriculum is free and can be assessed on the American college of Surgeons website (see external links).

Communicate high expectations

According to Chickering & Gamson, higher expectations of trainees leads to higher performance (1987). With this in mind, regardless of the type of simulator used, it is important to have well defined goals and expectations for trainees. As with time on task, a well-organized curriculum or program would facilitate this aim. In addition, effective communication of these expectations is also necessary.

Respect diverse talents and ways of learning

Trainees enter surgical programs with various backgrounds, strength, weaknesses and ways of learning. It is important to foster these differences in a learner-centred approach to achieve effective learning (Anderson, 2011). Therefore, the simulation curriculum should be designed to cater to different skill levels and learning modalities. Ideally, video, audio, book and human resources should be in place to foster an effective simulation environment.

In the low fidelity simulators, providing various tasks that are differentiated by complexity can allow the trainee to progress through them at their own pace. However, other resources will need to be provided in the environment, as the simulator itself does not have this capability.

With high fidelity simulators, effective audio-visual aids are included within the system. It can also provide didactic lessons. However, depending on the trainee`s learning aptitudes, they may require other resources.

Summary

An effective learning environment for surgical simulation can be achieved with both low and high fidelity simulators. The choice of simulator will be dependent on several factors, such as resource availability. Regardless of the simulator, it is important that it be coupled with an organized curriculum with clear goals. The curriculum should incorporate collaboration among the trainees, variation in complexity of tasks and procedures, and mechanisms for prompt feedback. In addition, the simulation environment should include various resources of different modalities for students to use in order to enhance their learning.

The Use of the High Fidelity Patient Simulators

A High-Fidelity Simulator

There are many High-Fidelity Simulators available on the market. For an example of a HPS see METI HPS (Human Patient Simulator). Each is slightly different but certain underlying characteristics can be said to be familiar with all.

  • They are mannequin based
  • They are fully interactive
  • They are programmable and are able to replicate many complicated and dynamic clinical scenarios
  • They offer physiological feedback based on actions taken by the performers

As an example of the rapid acceptance of HPS, Morgan (2002) notes that in 1999 there were 97 operational high fidelity simulators, whereas within three years, by 2002, there were 158.

Teaching Non-Technical skills Through Simulation

Recent research has shown that patient outcome during times of critical care can be related not only to the proper performance of technical skills such as intubation, intravenous insertionand fluid resuscitation, but also due to non-technical skills. Included in these skills are such concepts as teamwork, communication, leadership, delegation of tasks and resource utilization. Work in this area within medicine is an extension of that in the aviation industry showing how breakdowns in communication can quickly lead to a poor outcome during in-flight crises.

Simulators have proven to be valuable assets in teaching medical practitioners crisis resource management. Orsanu and Connolly (1993) have suggested that the unique problem with an environment such as the operating room is that it is not static, but rather it is dynamic. While classical modes of medical education have sought to teach a rigid diagnosis and management regime, the following characteristics need to be understood and practiced to ensure a good clinical outcome (adapted from Gaba 2001):

  • Problems and goals that are ill-defined can compete with one another
  • The environment is dynamic and full of uncertainty
  • Intense time pressure exists
  • Action/feedback loops are tightly coupled
  • The stakes are high
  • Personnel operate under strong organizational and cultural norms

Simulators allow for the creation of a risk-free environment in which such non-technical aspects can be practiced in multiple scenarios with full interactive capability between multiple performers. Recent programs centred on crisis resource management have become a fundamental part of the undergraduate medical curriculum at many medical schools (see Anesthesia Crisis Resource Management at Stanford School of Medicine)

Interprofessional education,defined as education that occurs about, with and from multiple health professions is well-suited to simulation training. Brock (2013) discusses the value of a simulation exercise among medical, nursing, pharmacy and physician assistance students in building a life-like model of working on an interprofessional health team.

Problem-based learning is very common in medical training, and lends itself to simulation scenarios. In a problem-based learning approach, non-technical skills are learned right alongside and completely integrated with learning technical skills, underscoring the value of each component. Problem-based learning is often taught in groups, which may or may not be interprofessional, and is easily transferred to a simulation exercise.

Watch a short YouTube video on the benefits of using simulators in medical training.

The High Fidelity Simulator as an Evaluative Tool

Traditionally, clinical medical education has relied on Objective Structured Clinical Examination (OSCE) on the Human Patient to evaluate the performance of medical students in the clinical area. Institutions are looking to broaden the scope of testing medical students to include OSCE on the Virtual Patient (VP) or HPS.

  • The results of a study performed by Oliven et al (2011) compared the use of OSCE on the Human Patient to the Virtual Patient. The results of the study indicated that OSCE on the Virtual Patient showed increased reliability as well as possessing multiple uses such as practice tool for both training and examination preparation.
  • Conclusions for the successful implementation of OSCE on the VP presented by Oliven et al (2011) include:
    • a well designed system tested in pilot trials
    • convenient use of the of the OSCE VP allowing students to practice at their own time and pace while promoting learning in a clinical environment rather than relying on textbooks
    • VP should not replace bedside teaching but rather enhance or complement it by providing additional case scenarios and unique ones not previously encountered
    • VP needs to be user friendly in order to motivate students to use the simulator in their free time without the need for direct guidance

High Fidelity Simulators have classically been seen as purely self-reflective due to the high stress environment of learning in clinical situations , resulting performance anxiety, and the difficulty in quantifying the outcomes observed. However, there has been considerable recent work which attempts to utilize the HPS as an evaluative tool in medical training. It has been suggested that simulators could be a critical aspect of re-certification, as in the airline industry.

  • Savoldelli (2006) examined senior anesthesia residents using a standard oral exam format utilized by the Royal College of Physicians and Surgeons of Canada for certification. He compared this to a similar clinical scenario examined in a simulated environment. He showed discrepancy between the outcomes, suggesting that the simulator may hold importance in being able to "evaluate hands-on technical skills that are too easily communicated orally".

It has also been suggested that "ill-defined" learning objectives, such as crisis resource management, may be evaluated with some validity.

  • Kim (2006) has created a global checklist score to examine the effectiveness of evaluating non-technical skills. He showed that this score has a high degree of construct validity and inter-rater reliability, suggesting that this score can effectively and quantifiably evaluate these non-technical skills within a simulated environment.

Feedback is an essential and integral part of simulation, without it, it is unlikely that simulation will be effective. Simulators that are equipped with evaluation tools can help learners to self assess and monitor their progress. In addition it also appears to slow the decay of acquired skills. The source of the feedback may be delivered by the simulation tool itself, by media tools eg. like video, or by facilitators, peer groups or the learner themselves. However evidence suggests that the source of the feedback is less important than its actual presence. (Issenberg et al 2005, Ker and Bradley 2007, Fanning and Gabba 2007)

Debriefing Assessment for Simulation in Healthcare

The Centre for Medical Simulation has devised a tool called Debriefing Assessment for Simulation in Healthcare (DASH). Debriefing is defined by The Centre for Medical Simulation as “a conversation among two or more people to review a simulated event or activity in which participants explore, analyze and synthesize their actions and thought processes, emotional states and other information to improve performance in real situations”. Although there are few comprehensive studies focusing on debriefing in healthcare, a systematic review of high fidelity simulators revealed debriefing as the most important feature of medical based education (Fanning et al, 2007). Debriefing during simulation can encompass three stages:

  • description
  • analysis
  • application

Facilitators are important in order to keep participants focused and directed towards moving forward past the first phase by keeping students focused on the global perspective instead of their own emotional accounts of what they believe actually occurred (Fanning et al, 2007). Another type of Debriefing Assessments occurs in Operating Rooms throughout the world. Nursing has helped promote and implement the Surgical Safety Checklist created by the World Health Organization (WHO) to promote safe surgery while decreasing the number of sentinel events during surgery. The Surgical Safety Checklist is an example of a successful initiative that has used the concept of briefing and debriefing pre and postoperatively on the Human Patient. Training for the Surgical Safety Checklist in Nursing has been done with low tech simulators and role play/simulated standardized patients.

Conditions for Effective Simulation

Issenberg et al 2005 in a meta analysis identified a range of conditions that impact on the effectiveness of simulation. These included:

  • provision of feedback (identified by 47% of the research);
  • repetitive practice (identified by 39% of the research)
  • curriculum integration (identified by 25% of the research)
  • range of task difficulty level (identified by 14% of the research)
  • adaptability to multiple learning strategies (identified by 10% of the research)
  • capture of a wide variety of clinical conditions (identified by 10% of the research)
  • use of simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences controlled environment (identified by 9% of the research)
  • active and not passive participation in reproducible, standardized educational experiences (identified by 9% of the research)
  • clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills (identified by 6% of the research);
  • simulator validity (identified by 3% of the research

Criticisms of HPS Simulation

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Simulators, especially HPS and fully developed simulation labs, are resource intensive and time consuming. The upfront costs are expensive, as is set up and long-term maintenance. This also impacts on access for all learners.

Research on whether high fidelity simulation is actually a more effective teaching strategy than low fidelity simulation training is fraught with challenges. In comparing the two educational modalities, one must control for the quality of instructional design and teaching skills, length of time in training, and level of evaluation, among many other factors. Cook et al. (2012) completed a systematic review and meta-analysis of the effectiveness of technology-enhanced (high fidelity) simulation compared to other instructional methodologies such as lectures, standardized patients and small group discussion. Their research showed that technology-enhanced simulation does in fact outperform lower-fidelity instructional methods, but also acknowledges the challenges of making such comparisons. Cost is an especially difficult issue to address, as many studies that assess the impact of cost do not accurately measure the cost of low-fidelity training (ie. faculty time, local resources). Cook et al. suggest using simulation only in higher learning levels to alleviate cost burdens.

de Giovanni, Roberts and Norman (2009) found that low fidelity simulation can be as effective as high fidelity in both transfer of skills to the real setting and to the actual increase in diagnostic and clinical skills. To ensure effective transfer to real patients the most appropriate elements of simulation must be identified by a careful analysis of the critical tasks. Thus high fidelity is not necessarily better than low fidelity - it is what is most appropriate for learning the task.

Bligh & Bleakley 2006 argue for a critical approach to simulation research with a focus on cultural theory of simulation, rather than on education theory. They also argue for the development of appropriate models that blend simulation with real world practice.

Implications for Educators

“Simulation has its place and is very valuable in medical education but identifying that place and taking care not to create new educationally redundant spaces is important. Simulation can act as a crucial bridge between structured classroom learning and the emergent issues of the complex clinical learning environment. Too much of a good thing can be dangerous and it is important to remember that the core of medicine is the relationship between a patient and his or her doctor. No amount of practice can replace the real thing. Teaching and learning at the bedside, in the clinic and in the home must remain the very heart of medical education.” (Bligh & Bleakley 2006 p 612)

See Also

External Links

Stop Motion Video

Wiki Stop Motion Artifact added by Lisa Dyck (2017): Click here to view a video on Simulation for Medical Education

Debriefing Healthcare Simulations; An Animated Report by Troy Seaboyer; https://youtu.be/Kt1hiei2P0w

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