Role of advanced simulation in undergraduate and postgraduate medical education


  • Vincenzo Fodale
  • Olivia Penna
  • Antonio Amato
  • Rosario Bruno
  • Vincenzo Francesco Tripodi
  • Eugenio G. Vadalà
  • Giuseppe Guzzo
  • Maria Gabriella D’Arrigo
  • Carolina Giordano
  • Maria Rosa Signer
  • Francesco Squadrito



Medical simulations, early clinical contact, undergraduate medical education, postgraduate medical training.


Medical simulations are effective education complements for medical training, demonstrating effective learning, level of participation, and improvement in knowledge, skills and attitudes. In undergraduate medical education, simulation provides the potential for valid, cost-benefit teaching and assessment of clinical skills, especially clinical reasoning skills, bridging the gap between theory and practice. Simulation as a training tool in postgraduate medical training is a practical method to provide a kind of educational realistic significance for practicing specialty in order to improve quality of care and patient safety. In particular, simulation is an excellent opportunity to implement reports of security which can be considered a true strategy in order to minimize clinical risk and ensure appropriate levels of quality in daily clinical practice.


Sevdalis N, Hull L, Birnbach DJ. Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. Br J Anaesth. 2012;109 Suppl 1: i3-i16.

Rall M, Dieckmann P. Safety culture and crisis resource management in airway management: general principles to enhance patient safety in critical airway situations. Best Pract Res Clin Anaesthesiol. 2005;19: 539-57.

Bosse G, Schröder T, von Heymann C, Spies C. Berliner Simulations training (BeST) – the concept of anesthesia simulation. Anasthesiol Intensivmed Notfallmed Schmerzther. 2007;42:740-4.

Vincent C, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. BMJ Qual Saf. 2014;23(8):670-7.

Grube C, Schaper N, Graf BM. Man at risk. Preventive strategies and risk management for patient safety. Anaesthesist. 2002;51:239-47.

Sullivan DL, Chumbley C. Critical thinking a new approach to patient care. JEMS. 2010;35(4):48-53.

Timmermann A, Eich C, Nickel E, Russo S, Barwing J, Heuer JF, et al. Simulation and airway managemen. Anaesthesist. 2005;54:582-7.

Chilkoti G, Mohta M, Wadhwa R, Saxena AK. Problem-based learning research in anesthesia teaching: current status and future perspective. Anesthesiol Res Pract 2014;263948.

Rall M, Dieckmann P, Manser T, Zieger J, Unertl K. Simulation as strategy for risk minimizing in anesthesia. Anasthesiol Intensivmed Notfallmed Schmerzther. 2004;39:240-7.

Iwata K, Gill D. Learning through work: clinical shadowing of junior doctors by first year medical students. Med Teach 2013;35(8):633-8.

Goldie J. Teaching professionalism in the early years of a medical curriculum: a qualitative study. Med Educ. 2007;41:610-7.

Parekh A, Thorpe T. How should we teach undergraduates in simulation scenarios? Clin Teach. 2012;9(5):280-4.

Issenberg SB. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27:10-28.

Moreno-Ger P, Torrente J, Bustamante J, Fernández-Galaz C, Fernández-Manjón B, Comas-Rengifo MD. Application of a low-cost web-based simulation to improve students' practical skills in medical education. Int J Med Inform. 2010;79(6):459-67.

Gesundheit N. The use of virtual patients to assess the clinical skills and reasoning of medical students: initial insights on student acceptance. Med Teach. 2009;31:739-42.

Oliven A, Nave R, Hasson-Gilad DR, Baruch A (). Medical students' views on the use of virtual patients for teaching and assessment of clinical knowledge and reasoning. Harefuah. 2013;152(5):257-61.

ISTUD Foundation. Frontal Lesson. c2014. Available from:

Weller JM. Simulation in undergraduate medical education: bridging the gap between theory and practice. Med Educ. 2004;38:32-8.

Hallikainen J. Teaching anaesthesia induction to medical students: comparison between full-scale simulation and supervised teaching in the operating theatre. Eur J Anaesthesiol. 2009;26:101-4.

Tokunaga J, Takamura N, Ogata K, Setoguchi N, Matsuoka T, Sato K. Preparation of simulation programs regarding excess-dose drug administration and acute-phase condition changes and its evaluation by students. Yakugaku Zasshi. 2011;131(4):655-9.

Ray SM, Wylie DR, Shaun Rowe A, Heidel E, Franks AS. Pharmacy student knowledge retention after completing either a simulated or written patient case. Am J Pharm Educ. 2012;76(5):86.

Halm BM, Lee MT, Franke AA. Improving toxicology knowledge in preclinical medical students using high-fidelity patient simulators. Hawaii Med J. 2011;70(6):112-5.

Skoy ET, Eukel HN, Frenzel JE. Comparison of low- and higher-fidelity simulation to train and assess pharmacy students' injection technique. Am J Pharm Educ. 2013;77(2):33.

Vukin E, Greenberg R, Auerbach M, Chang L, Scotten M, Tenney-Soeiro R, et al. Use of simulation-based education: a national survey of pediatric clerkship directors. Acad Pediatr 2014;14(4):369-74.

Ernst KD, Cline WL, Dannaway DC, Davis EM, Anderson MP, Atchley CB, et al. Weekly and consecutive day neonatal intubation training: comparable on a pediatrics clerkship. Acad Med. 2014;89(3):505-10.

Kim SJ, Oh J, Kang KA, Kim S. Development and evaluation of simulation-based fever management module for children with febrile convulsion. Nurse Educ Today. 2014;34(6):1005-11.

Pillow MT, Stader D, Nguyen M, Cao D, McArthur R, Hoxhaj S. Perceptions of basic, advanced, and pediatric life support training in a United States medical school. J Emerg Med. 2014;46(5):695-700.

Shah A, Carter T, Kuwani T, Sharpe R. Simulation to develop tomorrow's medical registrar. Clin Teach. 2013;10(1):42-6.

Lake CL. Simulation in cardiothoracic and vascular anesthesia education: tool or toy? Semin Cardiothorac Vasc Anesth. 2005;9:265-73.

Wong AK. Full scale computer simulators in anesthesia training and evaluation. Can J Anaesth. 2004;51:455-64.

Newell B, Fibuch E, McCartney M. Simulation in anesthesiology: A key element in the new recertification process. Mo Med. 2013;110(2):139-41.

McIvor W, Burden A, Weinger MB, Steadman R. Simulation for maintenance of certification in anesthesiology: the first two years. J Contin Educ Health Prof Fall. 2012;32(4):236-42.

Byrne AJ, Greaves JD. Assessment instruments used during anaesthetic simulation: review of published studies. Br J Anaesth. 2001;86:445-50.

Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. Reconsidering fidelity in simulation-based training. Acad Med. 2014;89(3):3873-92.

Schwid HA. Anesthesia simulators-technology and applications. Isr Med Assoc J. 2000;2:949-53.

Hartwell DA, Grayling M, Kennedy RR. Low-cost high-fidelity anaesthetic simulation. Anaesth Intensive Care. 2014;42(3):371-7.

Cumin D, Merry AF. Simulators for use in anaesthesia. Anaesthesia. 2007;62:151-62.

Hotchkiss MA, Mendoza SN. Update for nurse anesthetists. Part 6. Full-body patient simulation technology: gaining experience using a malignant hyperthermia model. AANA. J. 2001;69: 59-65.

Davis DP, Buono C, Ford J, Paulson L, Koenig W, Carrison D. The effectiveness of a novel, algorithm-based difficult airway curriculum for air medical crews using human patient simulators. Prehosp Emerg Care. 2007;11:72-9.

Lorello GR, Cook DA, Johnson RL, Brydges R. Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth. 2014;112(2):231-45.

Kulcsár Z, O'Mahony E, Lövquist E, Aboulafia A, Sabova D, Ghori K, et al. Preliminary evaluation of a virtual reality-based simulator for learning spinal anesthesia. J Clin Anesth. 2013;25(2):98-105.

Hu J, Lim YJ, Tardella N, Chang C, Warren L. Localized virtual patient model for regional anesthesia simulation training system. Stud Health Technol Inform. 2007;125:185-90.

Struys MM, De Smet T, Mortier EP. Simulated drug administration: an emerging tool for teaching clinical pharmacology during anesthesiology training. Clin Pharmacol Ther. 2008;84:170-4.

Hassan Z, DiLorenzo A, Sloan P. Teaching clinical opioid pharmacology with the Human Patient Simulator. J Opioid Manag. 2010;6(2):125-32.

Bouillon TW. Hypnotic and opioid anesthetic drug interactions on the CNS, focus on response surface modeling. Handb Exp Pharmacol. 2008;182:471-87.

Schädler D, Heinrichs W, Mönk S, Elke G, Zick G, Scholz J. Simulation training for German anaesthesiologists - case scenarios and training results. Anasthesiol Intensivmed Notfallmed Schmerzther. 2008;43:474-7.

Park CS. Simulation and quality improvement in anesthesiology. Anesthesiol Clin. 2011;29(1):13-28.

ASA Workgroup on Simulation Education White Paper. ASA Approval of Anesthesiology Simulation Programs. Final Version July 18, 2006. Available from:

Clarke S, Horeczko T, Cotton D, Bair A. Heart rate, anxiety and performance of residents during a simulated critical clinical encounter: a pilot study. BMC Med Educ. 2014;14(1):153.

Bilotta FF, Werner SM, Bergese SD, Rosa G. Impact and implementation of simulation-based training for safety. Scientific WorldJournal. 2013;7:652956.

Han H, Resch DS, Kovach RA. Educational technology in medical education. Teach Learn Med. 2013;25 Suppl 1:S39-S43.

Michael M, Abboudi H, Ker J, Shamim Khan M, Dasgupta P, Ahmed K. Performance of technology-driven simulators for medical students-a systematic review. J Surg Res. 2014;192(2):531-43.

Ringel N, Bürmann BM, Fellmer-Drueg E, Roos M, Herzog W, Nikendei C. Integrated Peer Teaching of Communication and Clinical Skills How to Train Student Tutors? Psychother Psychosom Med Psychol. 2015 Mar 20. [Epub ahead of print] PMID:25794354.

Happel CS, Lease MA, Nishisaki A, Braga MS. Evaluating simulation education via electronic surveys immediately following live critical events: a pilot study. Hosp Pediatr. 2015;5(2):96-100.

Grall KH, Stoneking LR, DeLuca LA, Waterbrook AL, Pritchard TG, Denninghoff KR. An innovative longitudinal curriculum to increase emergency medicine residents' exposure to rarely encountered and technically challenging procedures. Adv Med Educ Pract. 2014;5:229-36.

Isaranuwatchai W, Brydges R, Carnahan H, Backstein D, Dubrowski A. Comparing the cost-effectiveness of simulation modalities: a case study of peripheral intravenous catheterization training. Adv Health Sci Educ Theory Pract. 2014;19(2):219-32.

Eason MP. Simulation devices in cardiothoracic and vascular anesthesia. Semin Cardiothorac Vasc Anesth. 2005;9:309-23.

Lussi C, Grapengeter M, Schüttler J. Simulator training in anesthesia. Applications and value. Anaesthesist. 1999;48:433-8.






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