History of Medical Simulation
In the medical field, one can find its origins in Antiquity, when models of human patients were built in clay and stone to demonstrate clinical features of diseases and their effects on humans. Such simulators were present across different cultures, and even enabled male physicians to diagnosis women in societies where social laws of modesty used to forbid exposure of body parts. In 18th century France, Angélique Marguerite Le Boursier du Coudray (1712-1794) used a cloth birthing simulator to teach her techniques to midwives and surgeons. About the same time, Dr. Giovanni Antonio Galli (1708-1782) developed a birthing simulator for training his students and midwives in Bologna, Italy. Obstetric simulators, called obstetrical phantoms, were available in the early part of the 20th century.
On the other hand, historical data document the use of animals in the training of surgical skills since the Middle Ages throughout modern times. While the unsystematic use of inanimate and live simulators is reported along the history of medicine, the origins of medical simulation as we know nowadays comes from other science: aviation.
In 1929, Edwin Albert Link had invented the first flight simulator, a prototype named “Blue Box”. The simulator was a fuselage-like device equipped with a cockpit and controls. The capacity to reproduce flying motions and sensations allowed Link to teach his brother to fly during the same year.
The rationale behind the Blue Box provides support to state why simulation became successfully applied in many human endeavors. The flight simulation creates a controlled and safe environment where trainees are exposed to high-risk conditions that could be rarely experienced otherwise. In addition, the process is standardized and can reproduce settings of various levels of complexity, which allows pilots with different levels of skills to achieve flight expertise.
In the early 1960s, Peter Safar described the efficacy of mouth-to-mouth cardiopulmonary resuscitation. Encouraged by his work, Ausmund Laerdal, a plastic toy manufacturer, designed a realistic simulator to teach mouth-to-mouth ventilation. He named the mannequin Resusci-Anne, inspired by a popular European history of a young girl that was found dead floating on the River Seine, back in the late 1890s. Later, Laerdal was advised by Safar to include an internal spring attached to the mannequin’s chest wall, which permitted the cardiac compression simulation. This was the birth of the most widely used CPR mannequin of the 20th century.
Sim One is a starting point for true computer controlled, mannequin simulators, particularly for simulation of the entire patient. Conceived by Dr Stephen Abrahamson, an engineer, and Dr Judson Denson, a physician, at the University of Southern California in the mid-1960s. The simulator was a remarkably lifelike mannequin, controlled by a hybrid digital (with ‘‘4096 words of memory’’) and analogue computer.
In 1968, during the American Heart Association Scientific Sessions, Doctor Michael Gordon from the University of Miami Medical School presented Harvey, the Cardiology Patient Simulator. The mannequin can reproduce almost any cardiac disease by varying blood pressure, heart sounds, heart murmurs, pulses and breathing.
Resusci-Anne and Harvey represent cornerstones of the beginning of modern era medical simulation. After their development, many other types of simulators were developed for education and training. All of them share a common characteristic: the use of technology to achieve a more effective learning experience.
However, modern simulation is not only based on lifelike mannequins. The use of actors to portray patient encounters was first reported by Howard Barrows in 1964. Barrows started to systematically use healthy actors to simulate patient’s signs and symptoms, in order to teach and assess his students. The standardized patient was born, an umbrella term for situations where a person is trained to simulate a clinical case or an actual patient is trained to present his or her illness in a standardized way.
As technology improved during the 1980s and 1990s, software and computerized systems that can mimic physiologic responses and provide real feedback were produced. At Stanford University, a group led by David Gaba developed the comprehensive anesthesia simulation environment (CASE). The rationale of the CASE simulator was to incorporate the aviation model of crew resource management for the sake of teamwork training in a realistic environment.
Recently, even more realistic environments were introduced through the development of virtual reality simulation. In 2007, medical schools created forums in an internet-based world called “Second Life”. This virtual life tool provided an environment where students could practice history taking and clinical examination skills.