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medical students practicing on a doll

Practice Makes Perfect

Behind the scenes with the team who prepares future doctors for patient care  

 

By Liza N. Burby

In one exam room, a 35-year-old female patient is complaining about back pain. She answers a series of questions about her daily routine and health history. Across the hall, what appears to be a man in his 60s is having heart palpitations and asking for something to ease his anxiety.

Andrew Wackett, MD. and Perrilynn Conklin, DNP, RN.

Andrew Wackett, MD, CSC medical director and CSC director Perrilynn Conklin, DNP, RN.

These scenarios could easily be a real-life situation in a hospital setting. But they’re not — yet. Instead, they’re simulated clinical scenes in which every detail is carefully orchestrated, from the scripts to the equipment to the final videotaping. It’s a production with one goal in mind: to prepare the students at the Renaissance School of Medicine in a safe environment for the genuine situations they’ll encounter once they graduate. 

The female patient with back pain is a simulated patient (SP) who is acting based on a script. She’s one of 12 role-playing the same scenario in 12 equally equipped exam rooms with first-year medical students who are preparing for their objective structured clinical exams (OSCEs), performance-based testing used to measure a student’s clinical competence. 

The middle-aged man is a high-fidelity manikin connected to a computer. A simulation facilitator can change his vital signs from a control room and speak for the patient, adjusting responses based on how the interprofessional staff — both nursing and graduating medical students working together — treat the complaints. 

Setting the Stage
The setting is within Stony Brook University Hospital: the Clinical Simulation Center (CSC) of the Renaissance School of Medicine (RSOM). It’s a 13,000-square-foot state-of-the-art training center that’s used as a resource for specialized training of medical, nursing and other healthcare students from the School of Nursing, School of Health Professions Physician Assistant Program, RSOM and by the hospital for the training of residents and staff. 

In the center, students provide simulated care for patients through teaching modules that in addition to the SPs and computerized male, female, infant and child manikins can include partial task trainers (anatomical replicas of human body parts). They practice medical scenarios like performing routine checkups, group interviews and interdisciplinary activities, as well as delivering bad news.

Though the center has been around since 2006, these programs have become more important because today’s healthcare students are facing changing demographics. 

“They need to be prepared to work with all patients, including vulnerable populations like LGBTQ+ patients, people of color, Long Island’s aging population — and an increasing complexity of patient care as more people experience trauma,” said Andrew Wackett, MD, medical director of the CSC and clinical associate professor of emergency medicine.

“You can’t guarantee that every student going through the clinical realm is going to have that opportunity. Whereas if we have a simulated patient playing that role in the center, you can structure it so that every student gets an opportunity to both learn about the case beforehand and then debrief about what they did well and what they could do better afterwards,” said Wackett, who is also vice dean of undergraduate medical education. 

Further, research shows that working in this setting can help reduce practice errors and improve clinical decisions, said CSC director Perrilynn Conklin, DNP, RN.

“The idea is modeled after the airline industry who showed that by using simulation you could make the industry safer. Medicine is trying to do the same thing,” she said. “We can’t exactly measure that, but communication gets better when you practice on a patient who’s not really going through that experience. Then there’s muscle memory because we do many different skills training where they get to practice procedures, know what equipment they need and how to use it.”

And they do that repeatedly, Conklin said. Medical students have their first experience in the CSC during the first week of medical school and then average two to four experiences each month. 

The learning is tailored to be as close to real life as possible, Wackett said. “Simulation exercises will have certain traps set in there, things that we know that people often make mistakes on.”

For example, Conklin said, in the case of the manikin presenting with heart palpitations, a patient would receive several immediate emergency interventions like IV fluids, medications and airway management. This case allows for the providers (medical and nursing students) to work together and practice team communication in an emergency situation where the pressure can lead to errors.

“The objective in simulation is learning, not mistakes,” Conklin said. “It’s to provide a nurturing environment so learners feel they have a safety net in which to learn from the experience.” 

The CSC also provides opportunities to practice skills that might not be readily available any other way. Eva Swoboda, MD, the OB-GYN clerkship director for third-year medical students and elective director for the fourth-year medical students, said she uses simulation training in a variety of ways for her students, including scenarios involving a breech delivery or preeclampsia. 

With the advent of more medications and alternative treatments, surgical interventions actually have decreased nationally, and that’s a good thing overall for patient care,” Swoboda said. “But unfortunately for surgical teaching, that’s not so great because you depend on volume to strengthen your surgical skills. Simulation centers have become extremely important in making sure that your residents are well-taught. We couldn’t do anything these days without them.”

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The Development Process

But to do so takes a highly coordinated team of 13 staff members, in addition to Wackett, in a center that was expanded in 2022. It has 20 fully equipped exam rooms that have computer stations with audiovisual monitoring. Eight of these are newer exam rooms with a flexible design to be extended for a simulated family meeting or a consultation. They also have cameras for telehealth scenarios with SPs. In addition, three simulation labs mirror emergency or operating rooms with a software system that allows for simultaneous monitoring, testing and assessment through digital audiovisual equipment and the ability to videotape and remotely view encounters. 

Both the students and SPs are observed through a main control area center that resembles a movie set. This is where the simulation techs use computers and monitors to see what’s happening simultaneously in the 20 exam rooms. They make announcements to tell the students when they can enter the room (they all have to do so at the same time) and give them countdowns for their remaining time, then make sure everyone gets signed in so the recording can begin. It’s a similar technical situation in the simulation labs, where Wackett sits in another control room and he and a colleague speak for the manikins and even adjust the medical equipment remotely.

All activity operates from an initial script. Conklin said each is a case study that starts with a faculty member who has determined something they want to teach their medical and nursing students or residents. They reach out to the CSC where the staff consults with faculty and considers the best way for the student to complete the task: SP, manikin or a hybrid setting with a manikin and an SP. Each script is a team effort. 

“I could write a script, but I may not know when a patient presents with appendicitis exactly what they may be complaining about, so the physician works with me,” said Conklin, a registered nurse. “We may get consultations from other faculty members or other individuals who may have the expertise. For the first transgender case we wrote, we worked with individuals who were transgender so that we had the right terminology. They helped us train the SP so they would know how to react in certain situations or how to respond.”

The scripts — there are currently 250 in a database — are then reviewed by the SP coordinator and educator Denise Antonelle. “I review it from the patient perspective to see what details are missing that the SP should be prepared with just in case the learner should ask the question,” she said.  

Production Time
A significant part of the CSC team is the approximately 100 simulated patients who help to set all this preparation in motion. SPs have been around since the 1960s, but Stony Brook has the oldest program on Long Island. At the CSC, some are actors, but most come from other professions — many are retired teachers — and they range in age from 20 to 82. They get paid at least $22 an hour and can work eight-hour days as often as they’re available.

Antonelle, who hires and trains them, emphasized that being an SP is different than acting. “They’re called simulated patients because they’re not there to entertain; they’re here for educational purposes,” said the former musical theater performer who became an SP in 2011. “They have to memorize scripts that can be 15 pages long and that’s where the ‘standardized’ comes in because we want them to stick to that case. They can’t ad lib and improv. They need to have the same detailed information for every learner who is being tested so that they all have the same experience.”

One of the SPs is 20-year-old Julia DiPucchio, a Stony Brook junior majoring in information systems with a specialization in healthcare. Needing a part-time job, she was drawn to the on-campus opportunity she found on SBU’s job website, Handshake, and has been an SP since her first year.

DiPucchio said she typically plays pediatric and young mom cases. Her first was that of a young mother bringing in her child for what she assumed was an ear infection. Because there were complications, she was told they were admitting the baby to the hospital and contacting Child Protective Services. How the story turns out isn’t part of the script.

“It’s not so much about the diagnosis process or symptoms; it’s more about the communication aspect, which is what we really focus on as SPs,” said DiPucchio, who is from Sterling Heights, Michigan. “Knowing the outcome could cause a bias that might impact the student’s grading.”

What she likes most about doing this, in addition to fitting well into her schedule, is that it’s rewarding, especially when she hears from the students, she said. “There are times when they’ve told me, `I hope you know that what you’re doing is just so important to us.’” 

There are also bad news cases, and for Tom Sirianni, 62, a retired police officer from Suffolk, there are times when he learns six different times that his wife’s esophageal cancer is no longer treatable. Those are the emotionally draining days, when he said Antonelle makes the SPs take a break along with chocolates and a coloring book.

“I enjoy it, but I also do it because everyone’s had the experience of that doctor who has no bedside manner, and you don’t like the way you’re treated. I think that this SP program maybe prevents somebody from turning into that doctor,” said Sirianni, who has done 65 different cases over eight years working about 12 days a month.

Camille Chan, a fourth-year medical student from San Francisco, is one of those students who said working with an SP had been helpful throughout her training. Over four years, she’s had at least 50 sessions with them. She said, “It always feels nerve-wracking standing outside the door before my encounter starts, even though I know these patients are actors.” 

As an MD/MA candidate for class of ’24, Chan plans to go into emergency medicine, so her SP encounters might include a script where they must act like they’re in acute pain or discomfort. “This is a great challenge for us, as we learn to respond to acute distress and figure out strategies to safely calm the patient and stabilize them enough to get more information. I think this is really important to the field of emergency medicine.” 

Chan has also had about 40 simulation sessions in the CSC code rooms with manikins for acute health crises and resuscitation efforts. She said this has helped her to practice working as part of an emergency medicine team.  


The Debrief 

Before every simulated encounter, students — who in many cases have memorized a 100-question checklist — have an orientation with a CSC staff member. The goal is to remind them of the steps they need to take, like wearing a mask and nonsurgical gloves, introducing themselves, paying attention to their body language and remembering how to ensure the patient’s comfort.

The review process after these simulations depends on the type of encounter. Conklin said when they complete an SP activity, they can debrief with a fourth-year teaching assistant or in a group with faculty. Chan said what’s also useful about the debrief is that students often get to return to the exam room to receive feedback from the SP regarding communication skills and body language. They also get to review their video and self-evaluate with mentors or faculty.

“This way we can talk about things that went well and areas where we can improve,” she said. “It’s always strange to watch myself in the encounter videos. However, it is super helpful because I get to see how my body language plays out during the encounter — like my eye contact, how I respond to patients’ answers, how I show empathy.”

After a manikin simulation session, Conklin said, it’s traditional to meet as a group with faculty and debrief. “It’s during the debriefing process that the most learning occurs. During skills practice with simulated task training (like CPR manikins), the faculty is present teaching the skills and then watching to give immediate feedback to the learner on their skills technique.”

The Wave of the Future
Students aren’t the only ones within the hospital who use simulation exercises. Physicians and staff might participate to practice delivering bad news to patients. The CSC has also been used with Emergency Medicine residents to simulate a trauma patient scenario. “This can be done in the center, or sometimes we bring our equipment/manikins to the actual ER or hospital unit to complete an ‘in-situ’ experience to bring more realism to the activity and practice in the actual environment,” Conklin said.

These are two examples of ways Conklin said the CSC is in the process of expanding the use to other healthcare schools. The target is for all healthcare students to have the opportunity to train using simulation technology and the introduction of more virtual reality/mixed reality technology. So far, the School of Dental Medicine and the School of Health Professions Physical Therapy Program have already completed a few simulations. Other programs, including the School of Health Professions EMS, Respiratory Therapy and Athletic Training Programs, have also inquired about the incorporation of simulation in their training programs.

According to Conklin, this interprofessional education is the wave of the future. “The simulation provides an excellent environment for this type of education to occur and is so important as it allows for hands-on learning in a real-life environment with no risk to patients or learners.”