Doctors treated a robot in Trieste, Italy. Is this a scene straight out of a science fiction movie? Not this time. The robot is HAL s5301, one of the most advanced patient simulators in existence. The product of a collaboration between Italian company Accurate, headquartered in Cesena, and American organization Gaumard, HAL s5301 first came to Europe this past May, when it was set up at the University of Trieste's Cattinara Hospital in its Medical Simulation and Advanced Training Center.
HAL s5301 was created to give students the chance to practice key medical techniques used in emergency medicine, intensive care, and surgery. The aim is to simulate the hospital setting: the robot, managed by a "control room," simulates a clinical case proposed by a teacher, and the students try to make the diagnosis in as real-life a scenario as possible. HAL is a humanoid robot that can not only move its arms and eyes and even sweat, but can also speak and recognize tone, thanks to artificial intelligence.
More importantly, it reproduces cardiac, respiratory, vascular, and cerebrovascular physiology. Doctors can apply real tools of clinical practice, like stethoscopes, defibrillators, sensors, probes, and ventilators, to the robot. You can even insert a catheter or do a blood draw. At the end of the session of simulated diagnosis, the debrief allows students and professors to identify errors and highlight corrections and strategies.
The Latest Model
Accurate and Gaumard's robot is just one of the recent examples of an approach used in medical teaching and training in Italy and worldwide. The first steps in the use of simulation in the medical field date back to 1963, when neurologist Howard S. Barrows introduced the use of "simulated patients" in his classes; these were actors who acted out different medical conditions. The first robotic simulators arrived not long after, with the Sim One and Harvey mannequins between 1968 and 1969. Harvey, a cardiology simulator capable of imitating various functions such as blood pressure; jugular, venous, and arterial pulsation; and normal and abnormal heart sounds, was the first great success of simulation in clinical training. It is continually being updated and is still on the market today.
Various studies have indicated that simulators are beneficial, especially for students, in honing individual and team skills in all sorts of specialties. A 1987 study showed that the Harvey simulator improved the diagnostic skills of medical students in some areas. Nowadays, we have proof of the teaching benefits afforded by simulators, covering a wide range of surgical skills and more: from keyhole surgery to stroke management, from venous catheterization to EEG interpretation.
More realistic simulator mannequins, like Gaumard's HAL s5301, newly in use in Trieste, as well as the SimMan (Laerdal, Norway) or METI-HPS (CAE Healthcare, Sarasota, Florida) can now imitate a range of symptoms and vital signs that respond to treatment and can be linked, for example, to software that simulates hemodynamic parameters. They also allow students to repeatedly simulate and train themselves in responding to rare or unexpected events, and even to hone nontechnical skills, such as working as a team, making decisions in an emergency, and communicating.
Educational Worth
Even mannequins without HAL s5301's level of sophistication are an integral part of the medical curriculum in Italy. One example is the four high-fidelity simulators (three adults and one child) in use at University of Turin's Advanced Medical Simulation Center. "High-fidelity scenarios are usually postgraduate training tools, but we also use our high-tech simulators for third-year medical students who learn to take vital signs, read ECG traces, and recognize situations that are clinically unstable," said Grazia Papotti, MD, the center's coordinator. "Different scenarios are simulated using role play to teach students how to tackle physical examinations and approach the diagnostic process, working as part of a team. In their sixth year of study, when they are close to graduating, we switch to SimTo for training in an emergency setting,"
The aim, said Alberto Milan, MD, another coordinator at the center, is to enable students to overcome their self-doubt. "There is a feeling that students can ask questions and make mistakes more freely, which ultimately means they learn at a much faster rate."
And the students seem to support this. Miriam Rosso, who underwent training involving the use of simulators at the University of Turin, told Univadis, "This experience was essential to my learning, because it meant that by the time I got to my hospital placement, I already felt pretty confident in my ability to approach patients and how to correctly distinguish different clinical signs. In my sixth year, the simulated training was even more useful, as the setting was emergency medicine and urgent care. Without a doubt, if I hadn't had training with the simulator, I would have been much more insecure and disoriented during my first shift at the hospital."
Virtual Alternatives
As with any technology, simulator mannequins have been met with criticism. Above all, robots tend to be costly. HAL s5301 costs around $100,000. Add to that $16,000 in service costs, and you can generally expect to pay up to $250,000 dollars for a realistic simulator.
Can similar results be achieved without spending so much money? Maybe. One aspect still to be clarified in scientific literature is whether the use of simulators translates into better patient outcomes. The few systematic reviews available find no statistically significant advantage of training with simulators, compared with traditional teaching, when it comes to patient outcomes in endoscopy or in the surgical field.
In the case of the University of Turin, we have to make do for now with perceived competence, but more in-depth studies analyzing quantifiable skill acquisition are on the horizon. "By analyzing a large amount of scientific data collected to date (from March 2021 to July 2023 we have trained 3500 medical students), we can show that students significantly improve their perceived competence for each of the practical tasks for which they undergo training. We will also try to obtain objective measurements and to compare our students with cohorts of students who have undergone traditional training without simulation techniques,” said Papotti.
It is interesting to note that, when comparing different types of simulation technology, virtual reality techniques seem, at least in some cases, to be as useful as mannequins, and are 22 times cheaper. A 2021 randomized pilot study found no differences between robotic mannequins and virtual reality simulations in managing emergency medicine cases. A 2023 study on diagnostic bronchoscopy had similar results.
Conversely, at least two studies, one from 2021 and the other 2022, showed that students were more comfortable and found it more informative to practice with human-simulated patients than with robots, which were perceived as being less realistic.
However, it must be said that even during simulation using mannequins, it is still possible to add verbal human feedback, as Papotti confirmed. "In some cases, we can simulate making the mannequin speak using a tutor or actor's voice from the control room. Some mannequins let you do this directly; for others, we make do by tying a small amplifier under the bed.
"The student is fully aware that it isn't the mannequin talking, but this method is nearly always more effective in helping them immerse themselves in the scenario and relate fully with their pretend patient. This is excellent practice: the students begin to understand how difficult it is and how careful they must be when choosing the language they use and the tone they take when communicating with their patients."
Being Too Precise
Finally, there is a risk that simulations could be misleading, as feared in a 2015 debate on the topic. Indeed, neither mannequins nor other simulation methods are capable of correctly imitating all symptoms and types of illness. For example, in the field of neurology, human simulators cannot correctly imitate epileptic seizures, aphasia, or stroke. An actor imitating an epileptic seizure will, in reality, be acting out seizures recognized by an expert eye to be psychogenic. These are different and require alternative treatment to that used for epileptic seizures.
Conversely, a mannequin runs the risk of being too "honest" in its imitation of symptoms, without the ambiguities doctors are faced with in real life. The risk of "mistraining" also results from the imperfect anatomic accuracy of mannequin simulators, as has been shown in various studies. For example, one 2021 study on premature neonate respiratory tract simulators found numerous differences between infant anatomy and the simulated one, which may lead to medical students being taught — and therefore putting into use — excessively intensive ventilation techniques, potentially endangering patients.
Medical students are aware of these limitations, as Miriam Rosso noted: "As realistic as these clinical cases are, they remain somewhat standardized (they hardly include all of the comorbidities that 'real' patients have on a daily basis), and interaction with the patient is reduced (taking their history, accurately investigating their pain, et cetera)."
Therefore, to ensure that students receive a full and accurate learning experience, simulator mannequins must only be used by appropriately trained teachers, who are capable of understanding and maneuvering around the potential limitations of simulators, said Papotti. "To ensure high-quality training, even tutors will need specific training, monitoring, and support in the use of such devices. The technology is complex and requires care and skill.
"It's my belief that, if a student learns incorrectly, the cause will never be the simulator's lack of realism, but rather a failing on the part of the person who planned the activity or supported it as a tutor or facilitator. Tutors must always provide honest feedback on which aspects are most and least realistic. They must have a wealth of experience in the field and put it to good use."
This article was translated from Univadis Italy, which is part of the Medscape professional network.
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