Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA

Medical Simulation
Part 2: The Future Today

Last week, I criticized the current state of skills training for podiatric students and advocated for an increased use of medical simulation. This week, I'd like to discuss simulation training in a little more detail and hopefully provoke our readers with a possible vision for future medical training.

Simulation – The Future Is Here

By no means is simulation a new concept. In fact it's been around for many years in medicine. In some ways anatomical dissection itself is a simulation for the real human. We dissect cadavers during training with the express purpose of gaining knowledge with the intent to apply that knowledge to living human beings. Sounds like simulation to me.

But medical simulation has become increasingly more complex and realistic over recent years. Take, for example, ASTEC, the simulation lab based out of the University of Arizona. These folks teach various medical skills, from running a code to using a laparoscope to fire department training, all using high tech simulations in a very effective manner.

At Western University, we're using simulations in our Essentials of Clinical Medicine class where the students learn how to perform history and physical examinations. As part of the class, the students undergo patient simulations in which they have an encounter with a trained actor and are required to assess and plan treatment for their simulated patient. They are monitored on closed-circuit television and receive immediate feedback from their patient. I didn't receive this type of training during school, but I wish I had. As a result of this course, my students enter their clinical years with a much stronger patient care foundation than I ever did.

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In a similar manner, I've been privileged to run a modified simulation for an interprofessional education pilot program at Western University. During this pilot, we asked a group of students from five different medical programs to individually see a patient educator (a patient with actual disease trained to teach students) and then meet up as a group and create an individualized patient care plan. The simulation was readily accepted by the student participants who enjoyed taking their new knowledge out for a spin.

In the podiatry world, there is one rather glaring current example of simulation: the ACFAS surgical skills courses. I've personally been to several of these and have always found them to be worth every penny. For those who might not have enrolled in these courses, I'll describe the structure. Our national podiatric surgical leaders intersperse short lectures between cadaver workshops covering specific surgical themes during a weekend course. These are excellent workshops, and I highly recommend them, especially if you like hands-on simulation learning.

Of course, nothing is perfect, and medical simulation is not without its difficulties and drawbacks. The first drawback is the cost. High quality medical simulation is expensive. Consider what it must cost a university to have an entire medical simulation department with its associated technologies and labor expenses. Similarly, cadaver limbs are not free, nor are the various instruments necessary to train our students and residents.

A second drawback is the difficulty to set up a simulation lab. Cadaver limbs require special facilities and handling to preserve the specimens for a prolonged time period. Certain precautions are also necessary to prevent disease transmission.

If a lab wanted to avoid the use of cadavers and go with physical models or virtual reality computer programs, they would come up against the third challenge: limits on technology. Highly realistic models still have their limitations, and many of them will not be appropriate for foot and ankle clinical and surgical training.

The National Podiatric Simulation Center

Despite these drawbacks I think it is time we embrace the idea of medical simulation to a much greater extent. I envision a national podiatric center of simulation that is funded by grant money, private donations, industry support, and small contributions from residencies and schools as well as direct income derived from training currently practicing physicians. I know, it's an unlikely dream, but I'm still hopeful.

I see a time when our residents perform hundreds of virtual bunionectomies, flatfoot reconstructions, and triple arthrodeses before ever doing a living patient's surgery. How much better would our training be if we learned how to do dissections or cut bone or learn a new procedure without worrying about hurting a patient? How nice would it be to simulate an operating room in which our students and residents would rotate through different jobs, learning to appreciate the various functions of our surgical support staff? How much faster and more confident would our residents be if they were given a chance to do the surgery before they did the surgery?

Imagine a research arm that develops new technologies and tests those technologies without involving actual patients? This center could fund a research fellow (or maybe several) who could help carry podiatry into the forefront of foot and ankle surgery. In a similar vein, a surgeon with a new procedure idea could request funding for a one-month rotation in which she works through the specifics of that procedure with an entire lab at her beck and call. Want to develop minimal incision methods? Here's your chance in a safe environment.

Biomechanically oriented? Our hypothetical simulation center might contain a high tech gait lab in which the newest theories of foot function may be tested. Our students and residents might learn casting and fabrication of various orthoses. They may learn or even create new methods and technologies that don't even exist yet.

Perhaps our national sim center would have a traveling component that goes to the various podiatry schools and runs through simulations for the students during the week while on the weekend puts on a fee-based regional simulation training course for practicing physicians to hone skills and learn new techniques.

The sky is the limit for the national podiatric simulation center. It only needs the right vision to get it started and the right person to make it happen. Maybe you're that person. Maybe you're the one to carry podiatric simulation training to the next level. The future is here – we just need to make it happen.