‍Introduction

We can observe in the modern world the need for clinical simulations. With the constant development in medicine, we wish doctors would make fewer mistakes, state more accurate diagnoses and be skillful in procedures. However, access to real-life-based training is limited because of different reasons. The latest one can be the COVID-19 pandemic and strict sanitary rules. For two years, medical students’ participation in clinical practice was sparse. Another cause is the safety of patients, and it is evident that some procedures require previous experience to provide the best-quality help for a person. In given circumstances, a place was made for virtual simulators, websites, and applications. They offer comprehensive clinical-problem training in a safe environment.

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Clinical simulation can be defined as a technique, not a technology, to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner [1]. In an article from 2004, Gaba et al. described the possible benefits of simulation teaching, underlying unknowns, and challenges. Now we know how rapidly the development of the modern educational model went. The majority of medical universities use simulated patient classes, and even broader possibilities can be found online. 

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How do we learn from medical simulations?

Simulations are suitable for students at every level of education. Scenarios can be predictable, standardized, and safe [2]. They aim to repeat the same skills and become confident in basic situations. A crucial part of the simulation is debriefing. This is a point when we learn from mistakes and gain conclusions for the future [3]. Reflecting on the mistakes is a part of the learning cycle, enabling us to create ideas on how we can improve activity. Learning through experience is one of the most effective ways to develop [4]. During the discussion few points should be examined, timing, facilitation, conversational structures, and process elements [3]. It is beneficial to perform debriefing after the simulation or during. It can be guided by the third person or by participants themselves. In order to gain an advantage, debriefing is structured into three categories, essential elements, conversational techniques, and debriefing adjuncts [3]. ‘Debriefing with good judgment is a superior custom. The instructor tries to understand the student’s thoughts, determine what led to actions, and illuminate reasons that stand by made decisions [5]. 

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Sim bodies, medical mannequins imitating a patient

Generally, we can divide medical simulations into the ones supported by a simulated patient, a person who requires social interaction, and another based on the medical simulator, a device that lets us train manual skills. In the last years, various models of sim bodies have been introduced [2]. More than 50 years ago, one called Resusci Anne was made by a Norwegian company. They specialized in CPR mannequins [6]. Another example is SimOne, which offers a broad range of obstetric-gynecology mannequins. The next step to the birthing simulator is Noelle. It imitates the delivery process, starting with auscultating fetal heart sounds [7]. Students can practice maneuvers for troublesome conditions, for example, shoulder dystocia. Even the third stage of labor can be trained; the mannequin has a uterus that can imitate a postpartum hemorrhage. It illustrates how far technology went in sim body experience. Systems that are now built enter the virtual reality area. These simulators enable specific surgery skills training that inpose no danger to the patient. A feature that may be beneficial even for experienced doctors is the possibility of uploading actual patient CT data. Programm will recreate surgery settings in the 3D format, and surgeons can practice risky procedures [8]. 

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In what medicine fields is there a place for a simulation?

One can argue that every medical field may benefit from using simulations as a training tool. It is favorable even for a domain like psychiatry, where it is unyielding to see the possibility of a simulator [9]. What is worth underlining is that not only do doctors benefit from the practice, but it also shows assistance to patients [9]. Well-prepared doctors perform procedures faster, reducing the risk of the processes [10].

In the case of surgical training, we can deliberate if old-fashioned ways of learning are not enough and if being absorbed into new technology will not be detrimental. However, it is safe to state that training with simulators exceeds the outcomes comparing practice on cadavers. A course for orthopedic trainees was conducted to see if these two methods are much different from each other [11]. The object of practice was shoulder operation. In the final tests, the group trained on the VR simulator performed a task in a short time and statistically significantly rarer scratched the humerus cartilage. 

The operation which requires a lot of practice and is highly specialized is colorectal surgery. As the cases of the various colon and rectum diseases are prevalent in the population, surgical treatment is in need [12]. Virtual simulators had the advantage over physical models in that trainees could freely repeat the steps of a procedure without wasting resources. They get an objective assessment and instant feedback. Besides, the simulator enables the choice of the level of difficulty. It lets doctors develop their skills starting from the primary knowledge point. 

Emergency medicine is a field where quick and confident actions are required. There is no place for hesitation when a patient is deteriorating. That states a problem for young adepts. They need experience and practice to be able to train in real-life situations. Taking into account that hemorrhagic shock is the main preventable cause of death [13], learning how to control them. Pilot studies emerge [14] to recognize the most effective model of practicing this skill. They developed the prototype of the lower extremity with high accuracy and implemented four scenarios, one for each type of blood vessel. The pressure needed to cease the bleeding varies depending if a vessel is an artery or vein and internal or external. Final year medical students and doctors could try this simulator. Results have shown that students applied much higher pressure than needed, even on the low-pressure external vein bleeding. This sets an example that practical training is necessary for young adepts to demonstrate how one should apply theory in real life. 

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Do medical simulations reflect reality objectively?

The issue that may accompany simulated patient training is the simplicity of the case [15]. Created scenarios need to be more straightforward so students can state the expected diagnosis. However, situations in clinical practice are usually more confusing and tricky. The study carried out by Scott et al. aimed to check how students will cope with the scenarios which bring uncertainty to the situation. As expected, simulation was considered more challenging compared to the usual one. They were discouraged by unclear diagnoses and bewildered in the diagnosis process. What can be done in this area is adjusting scenarios of simulations to be compound and surprising. They will additionally familiarize students with the feeling they will encounter during future practice.   

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Students’ mental health benefit

Nowadays, medical students face a lot of stress and pressure during their studies. An unclear and intricate path after graduation adds anxiety as well. Whereas, to perform well with patients and procedures, confidence and self-belief are required. Classes in the clinical setting demand knowledge, proficiency in chosen skills, and adequate communication with patients and make especially young students nervous [16]. It was shown in the study [16] that previous training in the simulation environment reduced the level of anxiety and boosted confidence in students. Simulation is good preparation for clinical practice; it stabilizes students’ mental firmness and enables them to deliver better medical treatment to real-life patients later. 

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Gamification, a way to improve academic performance?

Training platforms can obtain different forms. It may be a game, mobile application, virtual patient scenarios, or a combination [17]. Now when medical schools also include educational platforms into the curriculum, it is worth observing how it will benefit the learning process. Now we know that virtual patient simulations increase learning results and improve engagement in a topic. The main advantages of digital learning are remoteness, practicing independently where we are, thorough analysis of progress, and immediate feedback. According to the ongoing study [17], the notable benefit of the virtual patient is the opportunity to make risk-free healthcare decisions, which later will have implications in the real-world setting. 

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Classic educational programs are not enough

Despite the still modernized curriculum and wide usage of medical databases, millions of patients are misdiagnosed yearly [18]. A wise way to improve the performance of students and then physicians is to establish diagnostic reasoning by implementing simulated patients. After undergoing a course of diagnosing common symptoms like abdominal pain and loss of consciousness, an increase in the correct diagnosis statement was accordingly 27% and 32% [18]. The course included lectures and three virtual patient cases. Additionally, practice with simulated patients helps students distinguish essential and irrelevant information. It was shown that [19] students who used tools for clinical reasoning before were more thorough in gathering patient data than inexperienced ones. 

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Conclusion

Medical simulations, including simulated patient scenarios or simbodies, enhance student performance. They prepare them for clinical practice, in safe settings, with no harm to the patients. Obviously, they cannot substitute real-life physician training, but the wide range of possibilities they include opens prospects for modernizing and intensifying pre-clinical education. Fast development in medical sciences raises the bar for young adepts, and expansion of new technology should be used to assist their education with great benefit.  

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1. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004 Oct;13 Suppl 1(Suppl 1):i2-10. doi: 10.1136/qhc.13.suppl_1.i2. PMID: 15465951; PMCID: PMC1765792.
2. Herrera-Aliaga E, Estrada LD. Trends and Innovations of Simulation for Twenty First Century Medical Education. Front Public Health. 2022 Mar 3;10:619769. doi: https://doi.org/10.3389/fpubh.2022.619769. PMID: 35309206; PMCID: PMC8929194. 
3. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More Than One Way to Debrief: A Critical Review of Healthcare Simulation Debriefing Methods. Simul Healthc. 2016 Jun;11(3):209-17. doi: https://doi.org/10.1097/SIH.0000000000000148. PMID: 27254527.
4. Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015 Apr;10(2):106-15. doi: https://doi.org/10.1097/SIH.0000000000000072. PMID: 25710312.
5. Simon R, Raemer D, Rudolph J. Debriefing Assessment for Simulation in Healthcare (DASH)© Rater's Handbook. Center for Medical Simulation, Boston, MA (2010)
6. https://pl.wikipedia.org/wiki/Resusci_Anne
7. https://www.gaumard.com/s550 
8. https://www.3bscientific.com/ca/voxel-man-ent-full-system-virtual-reality-simulator-1022080-voxel-man-ent-full,p_1581_30885.html 
9. Piot MA, Dechartres A, Attoe C, Jollant F, Lemogne C, Layat Burn C, Rethans JJ, Michelet D, Cross S, Billon G, Guerrier G, Tesniere A, Falissard B. Simulation in psychiatry for medical doctors: A systematic review and meta-analysis. Med Educ. 2020 Aug;54(8):696-708. doi: https://doi.org/10.1111/medu.14166. Epub 2020 Jun 9. PMID: 32242966.
10. Meling TR, Meling TR. The impact of surgical simulation on patient outcomes: a systematic review and meta-analysis. Neurosurg Rev. 2021 Apr;44(2):843-854. doi: https://doi.org/10.1007/s10143-020-01314-2. Epub 2020 May 13. PMID: 32399730; PMCID: PMC8035110.
11. Huri G, Gülşen MR, Karmış EB, Karagüven D. Cadaver versus simulator based arthroscopic training in shoulder surgery. Turk J Med Sci. 2021 Jun 28;51(3):1179-1190. doi: https://doi.org/10.3906/sag-2011-71. PMID: 33421972; PMCID: PMC8283431.
12. Sankaranarayanan G, Parker L, De S, Kapadia M, Fichera A. Simulation for Colorectal Surgery. J Laparoendosc Adv Surg Tech A. 2021 May;31(5):566-569. doi: https://doi.org/10.1089/lap.2021.0096. Epub 2021 Apr 22. PMID: 33891496; PMCID: PMC8126420.
13. Johansson P.I., Ostrowski S.R., Secher N.H. Management of major blood loss: An update. Acta Anaesthesiol. Scand. 2010;54:1039–1049. doi: https://doi.org/10.1111/j.1399-6576.2010.02265.x.
14.  Larraga-García B, Pérez-Jiménez A, Ros-Dopico S, Rubio-Bolívar J, Quintana-Diaz M, Gutiérrez Á. Design and Development of a Hemorrhagic Trauma Simulator for Lower Limbs: A Pilot Study. Sensors (Basel). 2021 May 31;21(11):3816. doi: https://doi.org/10.3390/s21113816. PMID: 34073020; PMCID: PMC8198904.
15.  Scott A, Sudlow M, Shaw E, Fisher J. Medical education, simulation and uncertainty. Clin Teach. 2020 Oct;17(5):497-502. doi: https://doi.org/10.1111/tct.13119. Epub 2020 Jan 6. PMID: 31903672.
16. Yu JH, Chang HJ, Kim SS, Park JE, Chung WY, Lee SK, Kim M, Lee JH, Jung YJ. Effects of high-fidelity simulation education on medical students' anxiety and confidence. PLoS One. 2021 May 13;16(5):e0251078. doi: https://doi.org/10.1371/journal.pone.0251078. PMID: 33983983; PMCID: PMC8118241.
17. Krishnamurthy K, Selvaraj N, Gupta P, Cyriac B, Dhurairaj P, Abdullah A, Krishnapillai A, Lugova H, Haque M, Xie S, Ang ET. Benefits of gamification in medical education. Clin Anat. 2022 Sep;35(6):795-807. doi: https://doi.org/10.1002/ca.23916. Epub 2022 Jun 8. PMID: 35637557.
18. Dekhtyar, Michael, Park, Yoon Soo, Kalinyak, Judy, Chudgar, Saumil M., Fedoriw, Kelly Bossenbroek, Johnson, Khadeja J., Knoche, Craig F., Martinez, Lisa, Mingioni, Nina, Pincavage, Amber T., Salas, Rachel, Sanfilippo, Fred, Sozio, Stephen M., Weigle, Nancy, Wood, Sarah, Zavodnick, Jillian and Stern, Scott. "Use of a structured approach and virtual simulation practice to improve diagnostic reasoning" Diagnosis, vol. 9, no. 1, 2022, pp. 69-76. https://doi.org/10.1515/dx-2020-0160
19. Plackett R, Kassianos AP, Timmis J, Sheringham J, Schartau P, Kambouri M. Using Virtual Patients to Explore the Clinical Reasoning Skills of Medical Students: Mixed Methods Study. J Med Internet Res. 2021 Jun 4;23(6):e24723. doi: https://doi.org/10.2196/24723. PMID: 34085940; PMCID: PMC8214179.