BMJ  2005;330:1319 (4 June), doi:10.1136/bmj.330.7503.1319

Filler

bmjlearning.com

Simulators

Doctors should learn in the same way that pilots do. They should train and test their skills in simulators. In that way they could make mistakes and climb a steep learning curve quickly without harming anyone—so it would be good for patients and doctors alike.

How many times over recent years have you heard something like this? Some feel that the analogy has been stretched too far and that doctors and pilots do completely different jobs and so cannot learn in the same way. But before we look at the drawbacks of simulators let's first consider their advantages.

Proponents of simulators damn learning by experience: they say that it is time consuming, dangerous, and expensive.¹ Learning with simulators is quicker and safer. Certainly simulators are effective at eliminating risk and allow the learner to learn through repeated failure and eventual success.¹ In simulations you can experience complications that would take you a lifetime of clinical practice to just see, never mind learn how to deal with. Thus, learning and experience can be accelerated. Simulations can also allow us to integrate our knowledge and skills more effectively than by reading a book or sitting in a lecture hall—these methods are best for gaining knowledge. Like many other e-learning experiences, online simulations satisfy the "Martini criteria"—you can do them any time or any place. They can also be a better way of assessing performance than written exams.

What, then, are the downsides of learning via simulations? Virtual reality can never be reality, and caring for a virtual patient on a computer can never be the same as caring for a patient sitting in front of you. So should we make simulators as close to real life as possible? Absolute realism is not always the best option. To learn about how to care for a patient with depression online, you don't need to drive to your virtual surgery in your virtual car—in fact, these can distract from the learning experience. Some simulators can overwhelm the learner with information and cause them to throw up their hands and give up.

At BMJ Learning, we have found that we don't need to reproduce a virtual hospital to produce effective simulations. However, although too much emphasis on physical fidelity can be a distraction, psychological fidelity (that is, patients doing and saying things that are credible) is essential. For that reason, our simulations (which we call interactive case histories) involve patients with common conditions and common complications of these conditions. The simulations then train and test your skills on important aspects of these conditions such as diagnosis, treatment, and prognosis.

One of our newest case histories introduces you to a series of patients with abnormal liver function tests. The module's author, Anand Reddy, says that "a recent large population based study showed that apparently healthy people with liver function tests at the upper end of normal had markedly increased mortality from liver disease."² Another study showed that 8% of US citizens without overt liver disease have unexplained abnormalities of their liver function tests, possibly reflecting increased prevalence of fatty liver.³ To find out how best to care for patients with abnormal liver function tests just click on www.bmjlearning.com.

BMJ Learning (bmjlearning{at}bmjgroup.com)

References

1. Epic Group. White paper: Simulations and e-learning. www.epic.co.uk/content/resources/white_papers/sims.htm (accessed 19 May 2005).
2. Kim HC, Nam CM, Jee HS, Han KH, Oh DK. Normal serum aminotransferase concentration and risk of mortality from liver diseases: prospective cohort study. BMJ 2004;328: 983-90.[Abstract/Free Full Text]
3. Clark JM, Brancati FL, Diehl AM. The prevalence and etiology of elevated aminotransferase levels in the United States. Am J Gastroenterol 2003;98: 960-7.[CrossRef][ISI][Medline]

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