In a society that regards the health of the patient with utmost importance, it is an odd fact that the most common mode of medical teaching for physicians is to learn through on-the-job training — creating an environment that puts the patient at risk. Until recently, on-the-job training was the only way to learn medicine. Physicians and nurses could only practice treatments when patients entered the hospital with their ailments, and experience with rare situations was only available to those who were in the right place at the right time. Now, with the development of simulation tools and simulation teaching centers, like the newly opened Patient Safety and Training Center at the Dartmouth Hitchcock Medical Center (DHMC), the nature of medical training is quickly changing.

A neonatal intensive care simulation unit at the DHMC simulation center.

A neonatal intensive care simulation unit at the DHMC simulation center.

The Tools
The only simulation tool available for medical training in the past was the actor. An actor would be hired to play the part of the patient and answer questions based on a script. This mode of simulation is still used in medical schools today, but it clearly does not suffice for training on physical medical procedures. Additionally, without alternatives a curious situation arises in which physicians begin to want patients with more problems in order to gain the training they need. To fulfill this need, artificial task trainers and mannequins were created.

Task trainers grant medical professionals the ability to practice isolated procedures in a low stress environment. These trainers, which are replicas of isolated portions of the body, allow for focused task practice without the distraction of other factors that may influence the procedure (1). Although helpful for textbook procedures, they are not realistic. Task trainers are separated portions of the body, and do not prepare students for real, complex medical situations involving the entire body. This insufficiency of task trainers led to the creation of high-tech mannequins.

Simulation mannequins made by several companies such as Meti, Laerdal, and Gaumard Scientific were created with the aim of eliminating patient risk in medical training by providing a lifelike replacement for the patient (2, 3, 4). The high-tech mannequins created by these companies allow for more holistic training and can be programmed in multiple ways to show a variety of symptoms and reactions to procedures.

One of the most recent mannequins created is the iStan released by Meti in June 2008 (2). The iStan, jointly funded by the U.S. Army Research Development Engineering Command and the U.S Army Medical Research and Material Command, was originally created as a more portable and versatile simulator for use in combat scenarios (2).

Unlike previous mannequins that were build from the outside in — by putting wired parts within a hard rubber shell — the iStan was built from the inside out — branching from an accurate skeletal frame (2). Many upgraded features make the iStan more realistic, such as its life-like bodily secretions and sweating, jugular vein distention, bilateral chest movement and flail chest, real breath, heart and bowel sounds, movable skeletal structure, and vocal ability (2). The outer cover for the iStan was based on a real human cast, making the structure more accurate both anatomically and visually, unlike the unrealistic previous models such as the HPS by Meti and Keri by Simulution (2, 5). The new mannequin can complain, cry, and even drool, giving feedback for every procedure that is done to it (2). The iStan represents a new generation of simulation mannequins that are coming closer to eliminating the need for patient risk in medical training.

The focus Meti put on making the mannequin look as realistic as possible — from its portable, unplugged structure to the texture of its skin — creates a more human connection between the mannequin and students, allowing for a more complete simulation training experience. By consulting educators in the fields of medicine, nursing, disaster medicine, emergency response, and the military, Meti and similar companies have succeeded in making a new generation of medical simulation tools that allow for a higher level of preparedness and safety (2). They have opened a door to training without patient risk, and with the ability to test hypothetical high-risk situations before they become a reality.

The Facilities
As important as the simulator mannequins are, training for real medical situations would not be possible without a realistic setting to train in. Simulation centers offer what mannequins cannot — an environment in which physicians, nurses, and staff can fine-tune the cooperation and speed needed to respond effectively to the reactions of the patients that the mannequins replace.

The most recent simulation training center opened last November at DHMC. An 8,000 square-foot facility, the center itself is the size of a small hospital and offers a realistic and versatile environment for simulation learning, unlike other centers that only cater to specific specialties (6). The center, a result of three years of planning, has a Neonatal Intensive Care Unit, a Pediatric Intensive Care Unit, an adult critical care unit, a birthing room, and an operating room that caters to the learning needs of nurses, medical students, hospital volunteers, housekeepers, and physicians alike (6).


An adult critical care simulation unit at the DHMC simulation center.

The hospital’s aim in creating the new center was to bring simulation teaching, which has been active in DHMC for ten years, to an on-site location that would provide a multidisciplinary and multimodal approach to medical training (6).

The center’s design and construction brings together the best elements from several of the most prominent simulation centers such as Riverside Methodist in Ohio and Mayo Clinic in Minnesota, as well as new elements unique to DHMC (6). Taking advice from these other centers, DHMC’s medical board focused on providing a space with plenty of room for storage at an on-site location to convenience busy physicians and clinicians who take courses at the center (6).

The center offers courses in sedation and rescue, anesthesia crisis resource management, intubations, ACLS, PALS, and airway management among others (7). The courses use mannequins, patient actors, and task trainers to refine performance of specific procedures, cooperation and speed in the OR, patient communication, safe transportation, and care of medical equipment (7).

The Future
With the formation of multidisciplinary simulation centers that make use of upgraded simulation tools, the future of medical training is changing. The need for patient risk in on-the-job training is diminishing as more realistic ways to replicate hospital situations are developed. Simulation enables medical professionals to drastically increase the level of patient safety in hospitals.

1. Simulation Development and Cognitive Science Lab (2008). Available at (18 December 2008).
2. METI: Medical Education Technologies, Inc. (2008). Available at (17 December 2008).
3. The Next Generation of Laerdal Simulation (2008) Available at (19 December 2008).
4. Gaumard Simulators for Health Care Education (2008). Available at (18 December 2008).
5. Simulution: Practice Made Perfect (2008). Available at (19 December 2008).
6. A. Leland, Personal interview, 1 December 2008.
7. Dartmouth-Hitchcock Simulation Center (2008). Available at (15 December 2008).