What is integrated cognitive simulation? How is it changing the face of teaching and learning in the healthcare sector?

For many of us, the best way to learn is to have a go: to take as many turns as we need to get it right. Practice makes perfect. But what if having a go has consequences? What if getting it wrong has higher stakes that can’t be resolved by simply pressing the restart button?

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John Windsor: On a mission to democratize medical education.

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Imagine having a missionary as your father. Or moving to a foreign country as a small child and going to school in a remote rural area. Or learning about medicine from the age of 9, standing on a box by your father’s operating table. Any one of those life experiences would probably give you a very different perspective on the world, but for Professor John Windsor, one of the brains behind the SIMTICS product, they were all fundamental parts of his life until he was fifteen years old!

“I grew up in northern India and did all of my primary and secondary schooling there,“ says Professor Windsor. “My father went out in 1963 to set up a heart unit in a post-graduate institute, and thus helped establish that specialty in India.  He went on to work as a general surgeon in mission hospitals for twenty years.”

It’s no wonder John has such an interesting worldview, and such a passion for making education accessible and available to all, regardless of geographic location or economic circumstances.

As well as the wonderful climate and the spectacular Himalayas, he also remembers the principles he learned. “Under my dad’s influence I grew up understanding the importance of healthcare and community development, and that educational opportunities were precious. It was a wonderful upbringing, to be honest.”

When he finished secondary school John returned to New Zealand, completed a double major in physiology and biochemistry and then enrolled in preclinical medical school at the University of Otago. He later transferred to the University of Auckland and qualified as a medical doctor before training as a general surgeon. He then completed a two-year fellowship in hepato-biliary and pancreatic surgery in Edinburgh, working under Sir David Carter.

Back in New Zealand, he was encouraged to pursue an academic career. In 1992 he founded the Pancreas Research Group, which has been at the centre of his research endeavor, and in 1994 he was appointed as Senior Lecturer of Surgery at the University of Auckland and as a Consultant Surgeon at the Auckland Hospital.

Around this time, the advent of the laparoscopic revolution was putting significant pressure on traditional approaches to surgical training.  John set up the first Surgical Skills Centre in New Zealand to address this need.  Later, in 2007, he raised $2 million and, in partnership with Mercy Ascot Integrated Hospitals Ltd, he designed a purpose-built facility: the Advanced Clinical Skills Centre. This has become a world-class environment for skills research and training.

Windsor seems tireless; on top of all his surgical, academic and research work, over the last 5 years he has published 112 of 235 manuscripts, raised $6m in grants and given over 100 invited talks, including Visiting Professorships to Harvard, Oxford, Karolinska, Singapore, Capetown, Johannesburg and Delhi.

How did a surgeon come to develop an online simulation technology like SIMTICS?

The lessons learnt during his early life in rural India, the years of providing and managing skills training, and experience with using physical simulators and training centers have all played a significant role in John’s thinking. From this the approach to ‘integrated cognitive simulation’ – to be accessible anywhere – was developed, in partnership with two other doctors.

John’s interest in virtual learning began back in the early 2000’s when he met George Oosthuizen, a surgeon who had recently moved from South Africa to New Zealand. Before he could practice in his newly adopted country, Oosthuizen had to become a student again and retake his fellowship exam.

“George found studying inefficient and exasperating. Even as an experienced physician he had to find books and journals from libraries, videos on the internet, advice from colleagues, diagrams from elsewhere… He shared his frustrations and this led us to ask: could we use technology to bring together all of the necessary materials in one place to promote more efficient learning and knowledge retention?” John explains. “As we explored this idea further, we realized that there was an opportunity to incorporate modern educational theory and practice with appealing media like computer graphics and video to make the learning experience more interactive, effective, and enjoyable.

With the help of some programmers, they mocked up a basic product framework, then got to work on their first procedure prototype: a laparoscopic appendectomy. As the lead subject expert, John had a starring role, performing and narrating the steps for the video portion.

Laparoscopic appendectomy simulation
The first version of the SIMTICS simulator – to learn laparoscopic appendectomy

The company gained support from an Auckland based business incubator and gradually attracted investors. To ensure commercial viability, the growing team branched out from surgical procedures into the wider healthcare market with a range of medical procedure simulations. Later they developed three suites of simulations for ultrasonography and radiography, and eventually more clinical procedures for medical assistants and entry-level nursing students. Dental Assisting and updated Basic Life Support modules are the latest addition to the catalog.

Cognitive learning is valuable and needs greater emphasis.

In developing the content, the team focused on the cognitive learning required for procedures, since this is a layer of knowledge that can be easily addressed by technology, outside of the clinical setting. It is also thought that cognitive knowledge represents up to 75% of the skills required for the safe performance of procedures. Cognitive knowledge doesn’t replace hands-on, psychomotor skills learning, but it is a critical part of the required learning that can be addressed separately, even while the learner is working alone, and without equipment.

The idea that cognitive learning is highly valuable and needs to be given greater emphasis originally came from the world of sport. Not only do high-performing athletes practice to achieve excellent physical performance, they also mentally rehearse their event or activity, running every single aspect through their minds beforehand. The movie, Rush, about Formula One drivers, brings this to life with a scene where driver James Hunt lies down and ‘mentally’ drives his car around the course, steering and pressing pedals in his mind, before his next race.

The SIMTICS product also achieves Oosthuizen’s dream of having everything in one place for learning a medical procedure. It allows learners to read, watch, explore in 3D, practice, and test their skills, all from the same interface.

At the heart of SIMTICS is a web-based simulator. This is what allows the learner to do their mental rehearsal of each new skill or procedure. Each module covers one type of healthcare procedure, from lumbar puncture or administering an intradermal injection, to ultrasound assessment of the aorta or performing radiography of the chest. The simulations require the learner to cognitively learn and understand the steps of that procedure, then perform it online just as if they were doing it in real-life. For instance, in a SIMTICS simulation, the learner has to prepare, position the patient, select and move instruments and consumables, place them correctly, and in some cases operate virtual equipment. For people studying sonography or radiography, SIMTICS is a bit like having a real imaging machine at home or in the classroom – at a tiny fraction of the cost. No consumables are needed, either.

As well as interactive simulations, each SIMTICS module contains a step-by-step video demonstration, a text description of the procedure, explorable 3D anatomy, and a quiz to test theoretical knowledge. The product does not dictate a pre-set ‘one-size-fits-all’ sequence of learning, so these components can be accessed in any order. “We home-schooled our five children,” says Professor Windsor, “and through that I came to appreciate the value of individualized learning, and providing choices in order to match learning opportunities with learning styles. And regardless of that, everyone gains by being able to experience and absorb the same information in different formats.”

The built-in SIMTICS logbook continually tracks study hours, quiz and simulation completion times, and scores. It even records the errors made in the simulations, so students know what to work on in order to improve their score. When SIMTICS is used in education institutions and work-teams, the logbook data can also be accessed by instructors and supervisors.

Making education available anywhere, anytime.

The desire to find the most cost-effective and accessible education solutions has been a strong driver for someone who grew up in one of the poorest and most remote parts of the world. “Coming from a missionary background in rural India, I know how important it is to find a generalizable and sustainable approach to education, that can be accessed regardless of geographical location. The SIMTICS product is one of my contributions to achieving that mission.”

SimTutor currently has a catalog of over 170 SIMTICS modules, covering ultrasound scanning procedures and protocols, radiographic positioning, dental assisting, medical assisting, basic life support, and common medical procedures. For more information about SIMTICS, check out www.simtics.com.

And if you’re interested in creating your own simulations and interactive training activities using the same tool that powers SIMTICS simulations, you can find out more at www.simtutor.com

There’s no such thing as the perfect clinical training environment – e-simulations bridge the gap

While a healthcare educator’s dream might be of labs available whenever and wherever students want them, fully-equipped sim centers, and patients obliging with the right symptoms for the procedure of the week during student externships, this is seldom the reality.

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Online simulations: a critical element in creating engaging healthcare curricula for high schools

What does it take to provide a healthcare curriculum at high school that engages students and prepares them for work? Paulette Diener is an RN with 25 years’ experience, a HOSA Advisor, and has been teaching Health Care Science at high school for the last 12 years in the state of Georgia. Finding the SIMTICS online simulations for clinical skills at a HOSA conference was a standout moment for her in her drive to create excellent learning experiences for her students: ‘Oh, my gosh, I was so excited that there was a resource like this available!’
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How to engage medical assisting students with skills simulations

Medical Assistant Director and Instructor, Nicole Carter, is always looking for new ways to engage her students.  One of the founders of the non-profit training institution, Latin American Youth Center Career Academy (LAYCCA) in Washington DC, Nicole says her work is hard but fun and the wins make it all worthwhile. But before you can have wins with students, you have to have engagement.

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Learning sonography through e-simulation: A non-believer turned believer

– By Angelique Praat –

We wouldn’t be overstating the case to say that Shelly Zimbelman was initially skeptical about teaching the clinical skills of her profession using computer-based simulations. Her first reaction was unequivocal: “There is no way you can simulate an ultrasound scan of a patient by using just a computer and a mouse!”

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From the frontline: how SIMTICS helps ultrasound professionals stay on top

By Angelique Praat

Working as an ultrasound technologist in a small radiology department brings challenges and opportunities. Cristina Adriano works for a Medical Group/Imaging Center in San Bernardino County, California. In her job, she isn’t surrounded by other ultrasound professionals every day. So she makes her own opportunities to stay on top of the field.

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