The introduction of hi-tech equipment in medicine entails a need to train new skills and the continuous need to maintain a necessary competence level. Simulator training in medical education opens possibilities for training without the use of real patients, and simulator training has a long history in medicine. One example is the medical (mechanical) mannequin described by Hieronymus Fabricius ab Aquapendente (1533–1619) in 1582 [1
], which was used in the teaching of correction of dislocations and in the skills of making prosthesis in the 17th
century. Another example is the French-American surgeon Alexis Carrel who was awarded the Nobel Prize in physiology and medicine in 1912 for his work on vascular suture and organ transplants. Carrel intensively practiced lace-making in order to develop and maintain his skills [2
However, it is not before modern times that simulators have come to have significant impact on health care education across professional boundaries and on all levels of teaching [3
]. It has shown a substantial potential and generated great enthusiasm. Simulation provides a means of risk-free learning in complex, critical or rare situations as well as promoting team-based and interdisciplinary approaches to learning in health care [3
]. Furthermore, simulation can play a significant role in outcome assessment and accreditation [5
There has been an increasing demand for documenting the outcome of teaching methods. As simulation typically is resource demanding, and due to the recent focus on evidence in health care, the need to document the effectiveness and efficiency (cost-effectiveness) of simulation has become pressing.
Many studies show improvement of short term retention of knowledge and skills [7
]. However, there are challenges with demonstrating the outcome of such results in clinical practice with real patients [10
]. "Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus" [12
]. Few studies show long-term retention of skills and knowledge, effectiveness in terms of patient outcome, or cost-effectiveness of simulation as an educational tool [4
There are many challenges with proving effectiveness and efficiency of educational measures, such as simulation, e.g. to decide on endpoints [14
], to validate instruments [15
], and to design good studies (that avoid measuring enthusiasm and biases). Moreover, there are non-technical premises of simulation outcomes, such as social and psychological aspects which strongly influence simulation outcome, e.g. active and motivated participants, safe and constructive learning atmosphere, participants match, and competence in simulation learning [16
]. Correspondingly, individual mood and personality is important for the performance of the trainee, the trainer, and the assessor [18
All these challenges need careful attention in order to provide evidence of the effectiveness and efficiency of simulation. However, is it worth the effort? Does simulation have the potential for increasing the outcome of education and training? In the same manner as it is wise to confer with Einstein's (special) theory of relativity before trying to travel faster than the speed of light, it is wise to investigate whether and why simulation has the potential of improving education in technology based health care before we start measuring its effectiveness and efficiency. Therefore the key issue in this article is to investigate if and why simulation can improve learning effectiveness and efficiency in complex hi-tech contexts in health care.
There appear to be many good reasons why simulations can be effective and efficient, e.g. that simulation provides the opportunity to do practice situations that seldom occur in practice or that expose the patient to unacceptable hazard. Some of these reasons are theoretical, hypothetical, or argumentative, as there is little empirical evidence of their importance. Issenberg and colleagues have reviewed the literature on empirical studies on the outcome of simulation [12
] and have identified the features and uses of high-fidelity medical simulations that can lead to effective learning:
- Simulation facilitates feedback, which is important for learning.
- Repetitive practice is a key feature involving the use of high-fidelity simulations in medical education.
- Simulators can capture a wide variety of clinical conditions.
- High-fidelity simulations provide a controlled environment where learners can make, detect and correct errors without adverse consequences.
- Integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum is an essential feature of their effective use.
- There is a range of task difficulty levels in simulation-based medical education, which is important for effective learning.
- Adaptability of high-fidelity simulations to multiple learning strategies is an important factor in educational effectiveness.
- Simulations provide reproducible, standardized educational experiences where learners are active participants, not passive bystanders.
- Simulation facilitates team work and interdisciplinary approaches.
These studies highlight features that clearly are important in order to generate outcome in the use of simulators. However, they do not guarantee that simulation will be effective and efficient. On the contrary, they presuppose that simulation can be so. It is exactly this premise that is the issue of this article: can simulation be effective? Addressing this question will also lead to answers to the question of why and how simulation can be effective and efficient. Knowing why simulation can be effective can direct our efforts to increase its outcome.