Simulation: Complete dress rehearsal for future clinicians

Students practise their examination skills on a manikin and simulated patients
Simulation at CPC
Students practise their examination skills on a manikin and simulated patients
Students practise their examination skills on a manikin and simulated patients

The doors of the Clinical Performance Centre swing back and the carpeted floor gives way to heavy-duty flooring that makes shoes squeak. The smell of hospital-grade disinfectant permeates the air. From one of the consultation rooms, questions like “Can you breathe easily?” and “Is the mask comfortable?” can be heard. In here, the lines between school and hospital and student and doctor are blurred.

Two Year Four MD students have come back to the campus between clinical rotations to hone their skills and performance before they head to their next clinical postings. They are practising arterial blood gas measurement and fitting a nebuliser. 

Such learning opportunities have always been key to nurturing patient-centred clinicians. COVID-19 has not only limited students’ access to clinical sites but also imposed restrictions on the types of procedures that students can observe and assist with. 

“The COVID-19 pandemic accelerated the roll-out of our pioneering new clinical simulation programme that runs right from year one of the MD programme through to year four,” said Professor Ian Curran, Vice-Dean for Education. “As well as accelerating existing plans, the pandemic has demonstrated the unique value of simulation in reliably providing, safe, authentic clinical learning experiences for our students.”

The simulation programme provides life-like experiences that increase in complexity as the students progress through their training, enhancing existing aspects of the curriculum that focus on clinical and communication skills, professionalism and teamwork. 

“The benefit of simulation is that we can use it to prepare the students for what it is actually like to go out into the workforce,” said Kirsty Freeman, the lead for the Clinical Performance Centre at Duke-NUS and, like Curran, a Fellow of the US Society for Simulation in Healthcare.  

Duke-NUS’ unique simulated patient programme flourishes

When the pandemic forced schools and universities to shift to home-based learning, Freeman and her colleagues shifted gears. Tapping into the School’s existing online learning infrastructure, they rapidly transformed the in-person simulated patient encounters into virtual ones within the space of weeks. As well as the ongoing learning opportunities, final practical examinations, many of which involved simulated patients, also had to be reconfigured at short notice. 

“Because we are so well integrated with the assessments team, we were able to upscale our simulation efforts quickly and adapt the scenarios for our students so they could graduate on time to join the healthcare system when it needed them most,” said Freeman.

To make the transition, simulated patients received special coaching to ensure that they could use the virtual platform confidently and provide insightful feedback to the students on their performances even without being in the same room.

A group of Duke-NUS simulated patients attend a training training session to help them assess students over Zoom

A group of Duke-NUS simulated patients attend a virtual training session to help them assess students over Zoom

“As much as history taking via Zoom, for example, was to solve a pandemic problem, I think that it is one of those things that will continue in our curriculum,” said Freeman.

Expanding the simulated patient encounters into a full virtual patient programme is also on the cards. In the virtual programme, students would get to explore different cases through a computer-based learning journey. Inspired by the Virtual Integrated Patient, which was developed by the Department of Pharmacology at the National University of Singapore’s Yong Loo Lin School of Medicine, Freeman sees that this could allow for more standalone virtual solutions for students to engage with anytime, anywhere. 

“Then, when students come for the session on campus, they’ve already had a chance to apply the knowledge and we can make the most of our precious face-to-face time,” she said.

But simulations are not just an effective tool to train patient-centred doctors. Complex scenarios can also help to prepare students for the teamwork that underpins safe patient care. To this end, Freeman and her team has been developing a series of team-based scenarios, including one where the students gather to manage a critical case in a mock emergency room.

While working under stress and having to think on their feet were some of the key learning points for the students, they enjoyed leaving their textbooks behind and seeing their learning come alive. They also valued the opportunity to make decisions in a safe environment with a full debrief on their performances immediately afterwards.

“Powerful and adaptive simulation techniques and technologies have enabled our students to hone their clinical skills, develop their professional identity, practice important clinical procedures, develop remote consulting skills and be immersed in virtual e-learning environments and programmes—all in a COVID-19 safe environment,” said Curran.

“Our dedicated staff, students and faculty have all risen admirably to the challenge of COVID-19 and we are now looking at consolidating these innovations in an even more ambitious and permanent manner across our MD curriculum,” he added.

Creating a simulation that is greater than the sum of its parts

As the simulation programme is rolled out, Professor Fernando Bello from the School’s Department of Technology Enhanced Learning and Innovation (TELI) hopes to see even more of this integration between in-person and virtual experiences of all kinds.

But Bello, originally an engineer who has spent his career developing technology that educates and engages clinicians, is keenly aware of the hype that surrounds many new technologies. 

“We have to ask ‘Do those technologies help to train better doctors?’ because that perspective is not always present,” said Bello, who was attracted by the School’s commitment to explore novel technology to enhance students’ learning.

One area where the School has made a significant investment in is anatomy learning. The newly completed Immersive Learning Space has been designed for students to pursue self-directed learning as well as attend small-group teaching to gain a deeper understanding of the intricacies of the human body. Students will have access to two 3D high-definition, virtual dissection tables, called Anatomage Tables, as well as 3D printed anatomical models that can be customised to support specific learning objectives. 

Another area that Bello is working on is to integrate technology like augmented and virtual reality into students’ learning experiences. He and the TELI team are exploring the use of these technologies in a range of procedural and clinical contexts. Of particular interest is the addition of realistic touch or haptic interaction in simulators to create fully immersive tactile experiences. 

“When it is well-done, well-designed, the simulation itself becomes sort of transparent. It is a vehicle where those who are participating get so immersed that, for them, it is no longer a simulation but a case that they are dealing with,” he said.

The third strand that Bello is focusing on is how to harness the data that can be gleaned from all these innovations.

“We can generate a substantial amount of data from simulations that we want to analyse to help us provide better feedback and assess students,” he said, “because ultimately, it is not about someone having fun with a VR headset. It is about them learning the right skills and ensuring that those skills translate into real life.”


As for the two Year Four students, they appreciate the extra practice, especially for procedures that they don’t encounter often in the wards. They are also conscious that these skills could be called for anytime, often in situations where they wouldn’t get a second try. 

Getting the chance to hone their skills and teamwork at the Clinical Performance Centre is the closest to the real thing they can get. As they finish up, the next group gets ready to step into their shoes. 

Simulation at CPC

A group of Duke-NUS students step into the shoes of young doctors in this simulation as they practise managing a patient with an allergic reaction