A man with terminal cancer who has to be told he has only weeks left to live. A disoriented woman, unaware of her surroundings, keeps asking for her daughter. An anxious and confused patient who persistently refuses all treatment, getting increasingly angry with each passing minute. A young man is having an allergic reaction to the peanuts in his nasi lemak. These are just some of the realistic training scenarios that medical students at Duke-NUS Medical School have to go through at the simulation rooms of the Clinical Performance Centre (CPC). “At Duke-NUS, healthcare simulation is embedded across the four years of the curriculum,” explains Ms Kirsty Freeman, lead at the CPC and Fellow for the Society of Simulation in Healthcare. Healthcare simulation is a technique whereby students can develop knowledge, skills and attitudes, often interacting with actors playing the role of patients, or computerised mannequins that replicate clinical scenarios students would encounter in the hospital environment. “It is a powerful tool for the teaching of clinical skills including clinical management, teamwork, decision making and communication skills,” Ms Freeman adds. In line with this philosophy, the CPC has 12 simulation rooms that provide a safe, controlled environment for Duke-NUS students to practise their clinical skills. Designed in conjunction with the clinical faculty from partner hospitals in the SingHealth group, each simulation room is tailored to replicate a medical consultation room as closely as possible so as to accurately simulate a clinical working environment. CPC’s practice mannequins are equipped with state-of-the-art technology that closely mimics human systems, such as artificial breathing and heartbeat noises. PHOTO: DUKE-NUS MEDICAL SCHOOL On top of that, the CPC’s practice mannequins – both part-task trainers and full-bodied simulators alike – are equipped with state-of-the-art technology that closely mimics human systems, such as artificial breathing and heartbeat noises for students to practise auscultation, or a rudimentary circulatory system to facilitate intravenous cannulation. Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope. Intravenous cannulation is a process by which a small plastic tube (a cannula) is inserted into a peripheral vein. Theoretical situations, real people But what truly sets the CPC apart from similar simulation facilities at other medical schools is the heavy use of Simulated Patients (SP): individuals who are rigorously trained to role-play a wide range of patients as realistically as possible during training simulations. According to Ms Freeman, more than 150 individuals are registered with the CPC as SPs. Even from their first year of study, Duke-NUS students regularly train with SPs to develop their clinical communication skills, developing their skills over their time at Duke-NUS to include essential skills like breaking bad news and informed consent, and management of acutely deteriorating patients. For first-year Duke-NUS student Nurul Ain Rejap, her first experience with SPs was when she was attending the college’s open house four years ago and was taken on a tour of the simulation facilities. A veteran first aider with the St John’s Ambulance Brigade for almost 15 years, Ms Nurul already had very positive experiences working with simulated casualties during first aid competitions. As such, she was very excited to hear her open house guides mention the close involvement of SPs in Duke-NUS’ simulated training curriculum. “They talked about a year-long course in Year 1, where students constantly practise with SPs to help prepare them for life in the wards. “I even thought about wanting to apply to be an SP just so I could experience what it would be like!” she says. Students get to learn and apply various interview and communication techniques as they hone their clinical communication skills with Simulated Patients (SPs). PHOTO: DUKE-NUS MEDICAL SCHOOL Soon enough she found herself on the opposite side as a first-year student undertaking the Fundamentals of Clinical Practice module. And when it came her turn to be in the “hot seat”, she found her nerves creeping up on her, even though she was well aware it was a simulation – a testament to the realism of the training environment. “We’d learnt interviewing techniques and how to take the history of a patient the week before, but it was surprisingly nerve-wracking,” she recounts. “But it was also an enjoyable experience, because at that moment in time, I really felt like I was a doctor trying to help a patient.” “Despite knowing the theoretical background behind many of the processes we simulated, being placed under the pressure of both time and place along with my classmates is a vastly different experience,” concurs fellow first-year student Ms Tuleen Sihabi. “Having to simultaneously focus on clinical and communicative skills within a time limit challenged me in a way I would have only been able to experience in a real emergency department.” The simulation rooms are also equipped with audio-visual and recording equipment for the clinical faculty to monitor students. “Being able to perform our duties and send instructions under the watchful eye of the simulation team meant that we could receive immediate, personalised feedback, such as tips on how to improve and what actions to avoid,” Ms Sihabi says. “In clinical settings, small mistakes may lead to grave consequences, and getting feedback is invaluable.” The next step in healthcare education Despite the challenges caused by the Covid-19 pandemic, these simulations crucial to the education of medical students continued running with minimal disruption at the centre. Ms Freeman and her team were quick to introduce tele-simulation using Duke-NUS’ existing online learning infrastructure, letting students continue to learn remotely, even when face-to-face interactions were limited. SPs were also given special training to familiarise themselves with the new online consultation platforms. So successful were these adaptations, in fact, that Ms Freeman and her team are looking to keep virtual learning as a permanent part of the curriculum. On top of that, an increase in the number of available mannequins also meant that a greater number of students was able to continue simulations via small group teaching sessions, in compliance with the latest safety distancing guidelines. Duke-NUS also looks to introduce an all-new procedural skills laboratory next year, which will provide yet more dedicated simulated learning environments for its students to refine their skills. “With the demand on our healthcare system, Duke-NUS is committed to graduating work-ready junior doctors who have the knowledge, skills and confidence to contribute effectively to the healthcare team,” Ms Freeman says. Click here to sign up for Duke-NUS’ Simulated Clinical Learning Experience webinar.