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Healthcare Simulation in the Post-Mannequin Era

[This, which I co-authored with Dr. Robert Szczerba of Lockheed Martin, is cross-posted from the original entry on my corporate Z Shift blog, where it was in turn posted after originally being published on the Intelligent Hospital Today website.]

In 2010, Apple Inc. CEO Steve Jobs used the words "post-PC era" to describe the impact of new computing devices such as tablet computers. (1) In this description, he was clear that personal computers (PCs) would remain with us for a long time to come. By "post-PC era," Jobs meant the era in which PCs are no longer the focal point of computing for most people.

In a manner similar to the early PC market, the healthcare industry has mainly focused on the interactions with a single technology: the mannequin. When healthcare professionals use the terms "simulation" and "simulation center" to describe how they train clinicians, what they typically mean is "mannequin" and "mannequin center."

Good reasons exist for this. The focus of a clinician's work is, by definition, interacting with patients, and the mannequin is the best technology currently available for the immersive simulation of patients, providing for both input (clinician actions) and output (patient responses) using a variety of mechanisms. Mannequin technology is well-understood, and studies across a variety of clinical task domains have validated the value of mannequin-based training. (2, 3)

Yet with this in mind, we believe that the focus on the mannequin for clinician training is retarding progress in the evolution of healthcare simulation technologies in general, impacting our ability to significantly improve patient safety and the overall quality of care.

We believe that the focus of healthcare simulation can, should, and must switch away from the mannequin and toward the software-based simulation of clinical systems, which integrates virtual patients, clinicians, devices, settings, and processes. Moving our focus away from hardware and toward software will enable more rapid progress in fidelity, functionality, and price-performance.

To illustrate our point, it is useful to examine the history of flight simulation, which serves as the leading example of how training via simulation can improve real-world performance in complex environments.

Four decades ago, creators of flight simulators began to shift their development approach in a way that would profoundly impact the future of aviation. Prior to this time, flight simulators had been based upon simple analog electronics. However, computer developments in the 1960s offered the opportunity to move the task of the simulation of flight from analog electronics to computer software, with the software controlling a physical simulator. This is not dissimilar from how mannequins have worked since the first modern computer-controlled mannequin, Sim One, was introduced in 1967. (4, 5)

After switching to software-based technologies, the next generation of flight simulators used computer graphics to replace the mechanical and video-based systems heretofore used to display terrain to simulator-based pilots. Prior to this change, a typical high-end flight simulator would have included a "model board," a large physical model of terrain, over which a computer-controlled camera would "fly," providing images to the pilots.

While model boards provided a reasonable method of providing imagery given the technology of the time, they were ultimately limiting. Simulators could only "fly" over terrain that had been physically modeled. The model boards took up substantial space and required effort to handle. A model board could only be used by one flight crew in one simulator at a time. The view through the camera was limited by the degrees of freedom provided by the camera control mechanism.

The change to computer-generated graphics removed these limitations and more. Any environment that could be imagined could be drawn algorithmically, from any viewpoint, in a variety of simulated conditions. Further, this development eliminated flight simulation's last remaining dependency upon hardware for user interaction. Although flight simulators continued to make use of physically simulated cockpits and motion control systems, these were no longer essential. A flight simulator could be defined purely in terms of software and interacted with using mass-market input devices such as keyboards and mice. The result of this was that the rate of improvement in the fidelity of flight simulators was limited only by increases in computer processing power, which has grown exponentially since the invention of digital computing. (6)

Around this time, one other development took place that dramatically impacted the evolution of flight simulators. The introduction of personal computers in the late 1970s enabled anyone to develop or extend flight simulator technology. The first amateur flight simulator for a popular personal computer was released in 1980. (7) While it was primitive, within a decade, its successors were capable enough to be certified for pilot training. By the 2000s, entrepreneurs and hobbyists had released tens of thousands of add-ons that extended the functionality of multiple flight simulators.

With this history in mind, we re-examine healthcare simulation.

In flight simulation terms, healthcare simulation is approximately at the model board level of the early 1970s. Mannequins are computer-controlled, but rely on expensive, proprietary hardware for user interaction. The focus of healthcare simulation development is on improving the interactivity and fidelity of mannequins themselves. This would be as if the only focus of flight simulation today were on making better cameras and more realistic-looking model boards.

We do not claim that mannequins are going away. As with PCs in the post-PC era, the post-mannequin era will be one in which mannequins play an important but not central role. In the post-mannequin era, the mannequin will be seen as one of many possible methods of enabling user interaction with rapidly improving simulations of clinical system-of-systems. (8) As a result, we expect to see less investment in proprietary mannequins and associated hardware, and more investment in the research, development, and deployment of software simulations. (9)

Given current practices in the larger software development community and the certain involvement of academia, we expect that most useful and popular software simulations of clinical systems will be partly or fully open. This will move responsibility for the advancement of healthcare simulation away from a relatively small group of for-profit firms and toward the broadest possible community, including healthcare researchers and providers. Experience with prominent open software projects (10) suggests that this will have a dramatic and positive effect on the pace of development and the quality of the results.

The next generation of healthcare simulation has the potential to revolutionize the practice of medicine, from improving the quality of care to reducing overall waste and errors. However, for this "evolution to revolution" to occur, the industry needs to stop thinking in mannequin-centric terms and start thinking in terms of the holistic software simulation of clinical systems, with the mannequin as one piece of a much larger puzzle. To the extent that the healthcare industry adopts this attitude, it will enable dramatic advances in simulation for healthcare, and we will usher in a new era: the post-mannequin era.


1. Steve Jobs at D8: Post-PC era is nigh. CNET News Web site. Full text. June 1, 2010.
2. Issenberg SB, Mcgaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher. 2005;27(1), 10-28. Abstract. Full text (PDF).
3. Murin S, Stollenwerk NS. Simulation in procedural training: at the tipping point. Chest. 2010;137(5):1009-1011. Full text.
4. Denson JS, Abrahamson SM. A computer-controlled patient simulator. JAMA. 1969;208(3):504-508. Abstract.
5. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Quality and Safety in Health Care. 2004;13(suppl 1):i11-i18. Abstract. Full text (PDF).
6. Kurzweil R. The law of accelerating returns. Kurzweil Accelerating Intelligence website. Full text. March 7, 2001.
7. Flight Simulator history introduction. simFlight Web site. Full text. February 20, 2005.
8. Boosman F, Szczerba RJ. Simulated clinical environments and virtual system-of-systems engineering for health care. Interservice/Industry Training, Simulation and Education Conference (I/ITSEC) 2010. Abstract. Full text (PDF).
9. Kneebone RL. Practice, rehearsal, and performance: an approach for simulation-based surgical and procedure training. JAMA. 2009;302(12):1336-1338. Abstract.
10. Lerner J, Tirole J. Some simple economics of open source. Journal of Industrial Economics. 2002;50(2):197-234. Abstract. Full text (PDF).


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