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Simulation in preclinical medical student education: getting started
  1. Emily M Hayden1,2,
  2. James A Gordon1,2
  1. 1Gilbert Program in Medical Simulation, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Division of Medical Simulation, Department of Emergency Medicine and MGH Learning Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Emily M Hayden, Department of Emergency Medicine Faculty Offices, Massachusetts General Hospital, 0 Emerson, Suite 3B, Boston, MA 02144, USA; emhayden{at}

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High-fidelity patient simulation allows deliberate practice1 of clinical skills, and is now commonly deployed as an educational platform for trainees, staff and teams across healthcare. In our medical school simulation laboratory, we focus primarily on the preclinical education of medical students, prior to their patient-care rotations. This approach may seem counterintuitive at such an early stage of training, but we find it powerful as a platform to teach basic biomedical science.2 ,3 In this brief practice report, we review core principles of our approach for readers who wish to pursue further work at the interface of healthcare simulation and basic science education.

Which cases to select?

Many medical educators have historically viewed mannequin simulation as useful only for code cases; however, we use such cases sparingly and instead run simple cases of common medical symptoms (eg, shortness of breath). When we write our cases, we keep them as ‘textbook’ as possible and avoid the temptation to make the case more complicated which can distract the novice student from the pathophysiology.

Even when viewed as an adjunct to teaching basic biomedical concepts, it is important to account for the emotional impact of simulation on the student. In the beginning of our simulation programme, we would allow the patient to die during a routine simulation case. However, we found that death of the simulated patient was not only deeply unsettling to some students but also unpredictably shifted the focus of any teaching session to the topic of death and dying. We now favour progression to extreme critical illness with pass off to an operating room or intensive care unit team. This provides an important level of emotional protection to the novice student,4 while still preserving the realism and original objectives of the simulated encounter.

What set-up is required?

Many simulation centres have separate control rooms and more realistic examination rooms for the mannequin, all designed in an attempt to transfer skills to the clinical practice environment.5 For preclinical simulation, we have found that novice students can reliably engage with minimal adjuncts. In particular, we have found that a simple vital signs monitor together with blinking eyes, chest rise and a conversational patient voice (through a speaker projecting by the head) provide enough animation to engage students. While other basic accessories to cases (nasal cannula or intravenous fluid bag) can also be helpful for preclinical student engagement, we typically do not rely on the procedural capabilities embedded in many simulation mannequins (eg, intubation). Since the students' point of view and thought pathways can be unpredictable, we have found it more efficient not to preprogram the cases into the mannequin software. Instead, we encourage our instructors to customise case progression in real time during the live session. However, if the case was being used for summative assessment, preprogramming is one common approach to maintain case standardisation.

As for managing student participation, we have found that more than five students at the mannequin bedside are cumbersome. We traditionally have run simulation sessions with 10 students in the simulation room itself: half of the group cares for the patient around the bedside, while the other group of five watches. The groups swap roles for a new patient, or they pass off care for the same patient who then experiences a new symptom. For larger groups in a bigger classroom equipped with a simulator, the rotational approach can continue as time allows, with five new students selected from a larger audience. This revolving format accommodates for multiple learning style preferences within a student cohort, including hands-on and observational experiences.

Instructional approach and debriefing

We view the medical simulation laboratory as an environment for participants to use and grow their knowledge through action. The more that an instructor guides the students, the less the simulation allows the students to care for the patient, and precludes them from practicing the skill of simultaneously conversing with the patient, creating a differential diagnosis and constructing a management plan. In the simulation laboratory, there is no imperative to correct students or trainees in real time before they make a wrong choice. While there is a role for instructor guidance to keep the case progressing, the simulation session is predominantly a student-driven exercise where the instructor quietly observes with curiosity. This then sets the stage for immediate instructor-led debriefing where the majority of critical teaching guidance will occur.

For preclinical students, we feel it is more important for students to understand the rationale behind a management step than to know the details of a specific clinical care protocol. For example, we would rather have the students verbalise that they want a medication that can block electrical signals at the atrioventricular node than to know that adenosine is used to treat supraventricular tachycardia. However, if this case was being used in a pharmacology class, then knowing the name of the drug would be appropriate. Many clinical instructors are predisposed to move through standard-of-care clinical protocols during a simulation session, expecting the students to specify the details of a treatment plan as a baseline for discussion. While the students appreciate this information, preclinical simulation sessions in our curriculum are primarily designed to focus on the basic science that informs therapeutic choices.


Immersive clinical simulation can provide preclinical medical students a powerful learning experience; however, it represents a unique hybrid between traditional and novel teaching approaches. We hope that this brief practice report of approach is helpful to readers working to integrate basic and clinical science education across the health professions.


The authors would like to acknowledge the enthusiasm from all of our instructors, especially all current and former simulation fellows.


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  • Contributors EMH made substantial contributions to the conception and design of this work, drafted the work, approved the final version to be published and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JAG made substantial contributions to the design of this work, critically revised the work, approved the final version to be published and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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