Patient practice: Simulation training prepares medical students for real patients

It's the second week of orientation, and new medical students are crowded into the learning theater, buzzing with anticipation. Next on the agenda is the introduction to an exercise that is, by design, light on details — all they know is that in two days, before they have sat for a single lecture or cracked open an anatomy book, they will each face the first patient encounter of their medical school journeys.

“This is an opportunity for you to try on your professional identities for the first time,” Cathy Grossman, M.D., director of the Center for Human Simulation and Patient Safety, tells the M.D. Class of 2029.

Each year, Grossman greets the M1s during orientation and introduces them to the concept of simulation training. She explains that across all four years of the M.D. program, they will engage in simulated medical scenarios to develop their clinical and communication skills in preparation for real patients.

Their first ever simulation is just days away. Grossman keeps the description intentionally vague, to retain the integrity of the scenarios and ensure that each student has an authentic first experience in the Sim Center. It's a rite of passage for all first years at VCU School of Medicine, and she encourages them to go in with an open, curious mind.

“It will not be graded and there’s no right answer,” she informs the roomful of high-achieving students. “But I want you to extend yourself and your peers grace, now and in the future, if you feel you aren’t quite perfect in the scenario.”

Two days later, small groups of M1s exit the Sim Center’s replica clinical exam rooms with collective exhales. Some are wide-eyed and quiet while others chatter excitedly, and the tension release is palpable. With this first experience under their belt, they will soon begin classes with a deeper understanding of what is to come in the next four years.

M1 Cameron Keeley-Parker said he had no idea what to expect when he and a group of six peers entered the exam room, but he was impressed by how realistic it felt.

“It was a little awkward and I feel like I have big shoes to fill,” Keeley-Parker, who holds the Penroase S. Forman Scholarship, said. “But it was also reassuring to be with my peers, who I think feel similarly, and receive feedback that will be valuable later down the line.”

Confidence through consistency

Medical simulations, which range from performing basic physical exams to triaging trauma patients to diagnosing cancer, increase in complexity and intensity as students progress through the M.D. program. The scenarios often involve manikins, which are realistic, human-like models that can speak, breathe, blink and display vital signs in reaction to treatment. These allow students to practice more invasive skills like intubating, inserting a central line or administering medications without involving human models.

For aspiring emergency medicine physician and M4 Guiliano Melki, working with simulation models has been instrumental in building confidence in high-pressure, fast-paced settings. Practicing in a realistic setting has helped him develop a sense of muscle memory, he said, which he trusts he can tap into during real patient interactions.

“In the emergency department, everything is going 100 miles an hour, and it can be easy to get overwhelmed in that environment,” Melki said. “But I feel like I can rely on my training, even when things get hectic.”

For example, when he and a group of classmates entered a hospital room in the Sim Center, a manikin was simulating the role of an unresponsive patient. Being unable to communicate directly with the patient presented an extra barrier in identifying a diagnosis and treatment, he said, and when the first dose of medication had the opposite effect he and his team anticipated, finding a solution took some trial and error. One of Melki's many takeaways was that even with the correct treatment, sometimes a patient’s symptoms will get worse before they get better.

“Everyone worked as a team to figure out how to help this patient. Someone was trying to communicate to him while someone else was administering medication,” Melki said. “It really taught me to trust my instincts.

Medical students also work with standardized patients (SPs), trained actors who simulate patient interactions and give feedback based on the simulation’s learning objectives. During SP encounters, students practice less invasive procedures like blood pressure monitoring, along with communication skills and bedside manner. Melki said these interactions are especially impactful when it comes to sharing unexpected information with patients and their families, like diagnosing a miscarriage, cancer or brain death.

“It can be a really awkward experience, especially when you’re breaking bad news,” Melki said. “You’re training to deliver the facts while not sounding robotic, and have empathy while not giving false hope. It’s a fine line.”

For preclinical medical students like Rebecca Doan, SP simulations are practice for their upcoming clinical rotations. Doan, now an M2, recalled how nervous she was before the first graded simulation, which involved taking an SP’s blood pressure. She studied hard before the session but said nothing could have prepared her for performing the task on an actual person.

“Even with all that studying, it wasn’t real until I was in that room.” Doan said. “Navigating those conversations isn’t something you can learn from a book.”

Room for discovery

The Sim Center also serves as a safe place for students — especially M1s and M2s — to explore interests or get a head start on specialties. Students have access to the space during open hours to practice their ultrasound skills on human models, and student interest groups (SIGs) are encouraged to reserve one of the center’s 20 rooms to host workshops highlighting different skills.

Doan has attended sessions held in the Sim Center by the emergency medicine SIG, where she learned how to intubate and perform a lumbar puncture on adult and pediatric manikins — skills that she wouldn’t have otherwise been exposed to until clinical rotations.

“It’s a low pressure, low stakes environment to learn something new in, especially something that is pretty difficult like intubation,” Doan, a recipient of the Vigneshwar Family Scholarship, said. “If I want to keep practicing, I always have the option of going to another workshop.”

As someone who has always enjoyed working with her hands, Doan is leaning toward a surgical specialty. In the Sim Center, she has already gotten a peek into that future at suturing workshops, where she practiced different wound closures and knots on artificial skin.

“You can sample different things or really lean into something, if you’re already pretty sure of what you want to pursue,” Doan said. “I feel like, whatever specialty I go into, thanks to my practice time in the Sim Center, I’ll be more confident on my first day of residency.”

Prepared by practice

Reflecting on that very first simulation during orientation, Doan now thinks of it not just as an introduction to the Sim Center, but a baseline to measure her academic growth over the past year of medical school.

“I feel like we were such babies then compared to now,” Doan said. “If I could go back, there are definitely things I would have done differently, and I think recognizing that shows how much I’ve learned. I would love to try that same simulation again and see how I do and how my approach has changed.”

Melki echoed Doan’s sentiment and noted that VCU residents who graduated from other medical schools frequently remark on how much the clinical students know already. With his own residency rapidly approaching, Melki said he’s ready to hit the ground running thanks to simulation training.

“I think it’s a testament to how successful this model of learning is,” Melki said. “VCU graduates pretty strong performing interns, without sacrificing medical knowledge. It’s a privilege to get that kind of education.”