The Last Word: Simulation Training

By Miss Lara Watson , Miss Priyanka Chadha and Mr Nihull Jakharia-Shah / 17 Nov 2017

Ms Priyanka Chadha, Miss Lara Watson and Mr Nihull Jakharia-Shah debate the use of simulation training in aesthetics

Simulation ‘is the imitation or representation of one act or system by another’ and, according to the Society for Simulation in Healthcare, a global organisation that seeks to improve performance in patient care through simulation, in a training and educational environment, it ‘is a bridge between classroom learning and real-life clinical experience’.1

As technology becomes more advanced and affordable, the potential for its use has transitioned into training for minor procedures, including those within the aesthetic sector. 

However, many aesthetic practitioners still have mixed views on the value of simulation-based training over the traditional approach of graded practice on real-life patients. Thus, the debate around the value of simulation models must be re-evaluated to determine its true value within the aesthetic specialty.

Traditional training

The traditional teaching method for clinical skills, which is based on real-life patient experience, has been documented in literature as covering the following five steps:2

  1. Students learn basic knowledge relating to the condition requiring the treatment, the relevant anatomy and instrumentation required.
  2. Students observe the procedure being completed, providing them with an overview and enabling self-evaluation.
  3. The students observe the procedure again with step-by-step explanation by a supervisor. This provides an opportunity to break the procedure into key steps and allows students to ask questions.
  4. The students talk through the procedure whilst the supervisor conducts it. This ensures a student’s understanding of the skill and the steps of the procedure prior to attempting it themselves.
  5. Students can perform the procedure under close supervision.3

Throughout the aforementioned steps, constant feedback and coaching should be given.

This traditional model is becoming increasingly challenged by educational providers due to concerns surrounding patient safety and its efficacy as the best method for acquiring clinical skills, especially for complex and intricate procedures such as injectable aesthetic procedures.4

Simulation training

Simulation models are commonly used throughout medicine for both surgical and non-surgical procedures. For example, simulation arms are regularly used for venipuncture and cannulation practice, which are used in almost every medical school. Simulation models are also widely used in aesthetic training courses as they can be easier to acquire than real-life patients. 

The latest Health Education England training requirement recommendations state that trainees must observe, practice and be assessed in simulated clinical environments.5 However, it does not explicitly specify whether this should be on real-life patient volunteers or simulation models. 

There are numerous simulation models available for aesthetics training. These vary in sophistication and, therefore, in price and availability. 

High fidelity head and neck models, with muscles and additional structures, are generally used for injectable training. Nylon thread, human hair and goat skin can be added for hair transplant training.6 Silicon pads or cattle skin are often used for suturing, excision, flap surgery and skin graft training; and fruits or vegetables with thick peels can be used for dermabrasion training.13 Models resembling any part of the body can be ordered, however, in our experience, the above are the most commonly used on aesthetic training courses.

Advantages

Studies demonstrate the benefit of simulation training on skill acquisition in addition to the psychomotor performance of trainees, for instance, the manipulation of tools, dexterity, grace and speed of movement when conducting the procedure.7-11 

A major advantage is that it creates a low-pressure, risk-free environment in which to learn. As students are practicing on simulation models, there is no risk to patients and simulation can allow practitioners to be better prepared when dealing with real-life patients by having prior experience of performing the procedures, thus increasing patient safety.12 

Although it can be argued that simulation training does not completely emulate real-life scenarios, in our experience, there is a difference between a clinician treating a patient who only has theory knowledge without prior practical experience in performing the task, versus one who has practiced the procedure numerous times on a simulation model. The latter clinician is likely to be arguably better prepared and perform the procedure safely.7

Simulation also provides an easily accessible learning opportunity. With the traditional training model, students rely on the availability of specific clinical scenarios, such as patients with certain conditions, to ensure they receive adequate practice and exposure. With simulation training, once the simulation model has been purchased, scheduled training sessions can be undertaken at any time for as long as one desires, enabling more convenient teaching as you do not have to manage the real-life models or wait for access to one with a particular condition. 

Additionally, the fact that simulation allows trainees to practice various procedures on specific parts of the body without relying on different patients to request these procedures is especially valuable for more rare or complex procedures, for which clinical practice would be difficult to come by and the stakes would be higher, for example, treating complications.1

Trainees can also create more personalised learning as they can focus on elements of the task they find most difficult, practicing it as many times as they need to, without having to repeat the entire process each time. 

Although practicing the entire process on a real model helps to emulate the true clinical scenario more effectively, it is a benefit to focus on specific aspects of the task once a general familiarity/competence has been gained. Hand positioning, needle angulation and use of the microcannula, for example, can be rehearsed in a controlled setting without incurring risk or discomfort to a patient. 

Disadvantages

The biggest disadvantage of simulation training is the fact that it is a simulation. Although clinical scenarios can be artificially manufactured, they will never truly reflect real-life experiences. 

A successful encounter or treatment requires building a good rapport with the patient, having good communication and clinical judgement. This is especially important for aesthetic practitioners as patient satisfaction is arguably the most important outcome, unlike with the public sector, where clinical outcome and financial expenditure factor more heavily into the overall success of a treatment.13 

The occurrence of patient distress or discomfort, haematoma formation and hypersensitivity reaction for example, cannot be replicated in currently accessible simulation training models which, therefore, carries some limitation to the scope of simulation in aesthetics. However, all scenarios can be mimicked to some extent and exposure to this before being in a real-life situation will, more often than not, result in increased confidence from the clinician and better outcomes for the patient.14

Tying into the argument surrounding the artificial nature of simulation-based training is the need to develop the ‘aesthetic eye’. Simulation models do not provide sufficient exposure to the variety of aesthetic outcomes that can occur from administering products. Each patient will respond differently and varying quantities and sites of injection will yield different results, which will not be reflected when a student consistently trains on a simulation model.

Simulation training is also expensive compared to clinical learning. The equipment alone can cost thousands of pounds for a simulation head and neck. Following this, there is a cost of maintaining the equipment and hiring specific areas. Simulation is also only as useful as the participant’s engagement. 

Although simulation allows students to practice certain elements of procedures, this can lead to neglect of other aspects such as patient communication. 

The learning process for students is also dependent on the quality of the feedback given by supervisors, therefore, the efficacy of simulation training is reliant on having high quality, engaged supervisors.15 

Finally, its use as an assessment tool can only be a surrogate for real-life clinical assessment. This problem presents due to two main factors; that simulation can never truly emulate real-life scenarios and students will be aware that the scenarios are simulations. The latter disrupts a true evaluation as the simulation fails to capture the emotional elements of a clinical scenario such as stress, anxiety and natural doctor-patient rapport. 

However, the initial problem can be minimised through two methods; firstly, as simulation models become more sophisticated, over time they will more closely emulate real-life scenarios, for example models that can bleed to emulate complications. 

Secondly, the introduction of a validated national simulation training programme with a specific and thorough outline of what needs to be examined and how to examine it using a simulation, would enforce the validity of simulation-based training in aesthetic medicine. No validated programme exists yet, and further discussions with healthcare regulatory bodies is needed to produce this for the future.

Conclusion

There are disadvantages to simulation training, namely the cost and the artificial nature of the experience, however, as a means of supplementing the learning of simple aesthetic procedural skills, simulation training can provide an effective learning experience that preserves patient safety. 

We believe simulation-based training has a significant place in the future of training in medical aesthetics, however, as there are limitations to this type of training, it is our opinion that the optimum training programme would include a combination of both simulation training and supervised training on real-life models.

Disclosure: Miss Priyanka Chadha and Miss Lara Watson are directors of the training academy Acquisition Aesthetics, which offers simulation-based training combined with supervised training on live models. Mr Nihull Jakharia-Shah is the educational and academic lead for Acquisition Aesthetics. 

References

  1. Society for Simulation in Healthcare. About simulation. <http://www.ssih.org/About-SSH/About- Simulation>
  2. George JH, Doto FX. A simple five-step method for teaching technical skills. For the Office-based Teacher of Family Medicine. 2001;33(8):577-8
  3. Society for Simulation in Healthcare. What is simulation? 2009. <http://www.ssih.org/About-SSH/ About-Simulation>
  4. Grantcharov, Teodor P, and Richard K Reznick. ‘Teaching Procedural Skills.’ BMJ : British Medical Journal, 336.7653 (2008): 1129–1131
  5. HEE, ‘PART ONE: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery’, Health Education England, 2015. <https://www. hee.nhs.uk/sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20one%20 update%20v1%20final%20version_0.pdf>
  6. Khunger, Niti, and Sushruta Kathuria. ‘Mastering Surgical Skills Through Simulation-Based Learning: Practice Makes One Perfect.’ Journal of Cutaneous and Aesthetic Surgery. 9.1 (2016): 27–31.
  7. Grantcharov TP, Kristiansen VB, et al., ‘Randomised clinical trial of virtual reality simulation for laparoscopic skills training’. Br J Surgery, 2004;91:146-50
  8. Aggarwal R, Grantcharov TP, et al., An evidence-based virtual reality training program for novice laparoscopic surgeons. Ann Surg, 2006;244:310-4
  9. C.-A.E. Moulton, A. Dubrowski, et al., Surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg, 244 (3) (2006 Sep), pp. 400-409.
  10. E.D. Grober, S.J. Hamstra, K.R. Wanzel, et al. Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill. J Urol, 172 (1) (2004 Jul), pp. 378-381
  11. L.P. Sturm, J.A. Windsor, et al., A systematic review of skills transfer after surgical simulation training. Ann Surg, 248 (2008), pp. 166-179
  12. E.D. Grober, S.J. Hamstra, K.R. Wanzel, et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg, 240 (2) (2004), 374-381
  13. Kosowski TR et al. ‘A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009 Jun;123(6):1819-27
  14. Moorthy, K., Vincent, C., & Darzi, A. (2005). Simulation Based Training. British Medical Journal, 330, 493-494
  15. Brooks, N., Moriarty, A., & Welyczko, N. (2010). 

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