Using Simulation-Based Training to Improve the Procedural Skills of Oncology/Hematology Fellows

A Conversation With Rodrigo B. Cavalcanti, MD, MSc, FRCPC

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The big advantage of simulation learning is that it accelerates the learning curve for trainees and exposes them to uncommon medical situations within a safe environment.
— Rodrigo B. Cavalcanti, MD, MSc, FRCPC

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Simulation-based education in medicine programs implemented in cancer centers for oncology/hematology fellows recreates real-world patient experiences and provides a safe—and stress-free—learning environment in which trainees can enhance their clinical and procedural skills in a variety of areas. These areas include communication and technical skills, such as chemotherapy writing; patient interaction; performance of and/or interpretation of bone marrow biopsy and aspiration; lumbar puncture; and paracentesis and thoracentesis procedures. Simulation-based instruction is so crucial to improving fellowship training and, ultimately, patient care that the Accreditation Council for Graduate Medical Education (ACGME) requires all fellows to have access to training using simulation.

“The committee does not expect each program to use a simulator or have a simulation center,” according to the ACGME’s procedural requirement. “Simulation means that learning about patient care occurs in a setting that does not include actual patients.” This type of learning could include standardized patient encounters, patient simulators, procedure simulators, electronic simulation of codes, and other clinical scenarios.

To learn more about the benefits of simulation training for hematology/oncology fellows, The ASCO Post talked with Rodrigo B. Cavalcanti, MD, MSc, FRCPC, Associate Professor in General Internal Medicine and Director of the General Internal Medicine Training Program at the University of Toronto and Director of Scholarship at The HoPingKong Centre for Excellence in Education and Practice–University Health Network in Toronto, Canada.

Optimizing Patient Safety

How is simulation used for medical instruction and the assessment of knowledge of hematology/oncology fellows?

The ultimate goal of a simulation-based curriculum is to optimize patient safety by allowing oncology trainees to gain proficiency by what we call deliberate practice, which refers to repeatedly practicing a procedure on a standardized model before having to do it in the clinical environment on actual patients. Simulation-based training also allows instructors to assess their fellows’ clinical and procedural skills in a more standardized way than in the clinical setting, where patient needs vary and the opportunities for training are not always consistent.

Objectives and Components

What resources does an oncology center need to establish a simulation-based training program?

Making an investment in simulation training can be significant both financially, to obtain equipment and staff the initiative, and operationally, to design a dedicated area in the institution to house the simulation facility.

To determine what resources might be necessary, the center should outline the learning objectives of the program. The objectives should include defining the key components required to teach communication and procedural skills using simulation; identifying methods that can be used to assess competency using simulation; and developing a model for a simulation-based procedural skills and communication curriculum in the cancer center’s program.

If a cancer center has not developed its own simulation-based curriculum, it can partner with an established simulation center to obtain the necessary resources for simulation instruction. One of the key components is to establish a valid checklist of procedural requirements, so the clinical supervisor can assess the trainee’s skills in the six core competencies: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning, and systems-based practice.

More Effective Communication

How can simulation-based training be used to improve oncologists’ communication skills?

Most people tend to think of simulation training as a bench-top model to hone procedural skills such as performing a bone marrow biopsy, but using simulation to improve communication skills, for example, to deliver bad news to patients and families, is an even more powerful training tool. A study has shown that using a curricular module on “breaking bad news” in which a role-playing exercise was used to communicate a diagnosis of cancer to a cancer survivor volunteer was an effective method of teaching medical students how to communicate bad news.1

This type of simulation can also be used to help physicians communicate more effectively with patients from different cultural and religious backgrounds and give physicians an appreciation of the unique needs of their patients.

Accelerating the Learning Curve

How common are simulation-based programs in oncology centers?

I am not certain how many centers have implemented programs, but simulation as a learning tool in the oncology setting is well established in specialties such as surgery and anesthesiology, which require highly technical skills. Simulation in anesthesiology is now an integral part of resident education and one of the ACGME’s requirements for resident graduation.

The big advantage of integrating simulation-based training into oncology education is it accelerates the learning curve for trainees and exposes them to clinical situations they might not come across frequently, but need to be prepared for, so there is a big role for simulation in clinical quality improvement.

Debate Over Models

Should there be a dedicated area in a hospital for simulation-based instruction?

That is an area of debate. The classic model is a centralized simulation center, where all the equipment is located and where trainees go to practice their skills. A newer model that is emerging is the idea of embedded simulation, or in situ simulation, where simulators are close to the clinical area, so trainees can practice procedures such as paracentesis, which is commonly performed at the bedside and has the potential for serious complications, to improve their level of procedural competence.

I can’t emphasize enough the importance of providing this type of training for fellows. Critics of simulation-based learning argue that real-life clinical exposure provides the training young physicians need to develop their procedural skills. But the big advantage of simulation learning is that it accelerates the learning curve for trainees and exposes them to uncommon medical situations within a safe environment. ■

Disclosure: Dr. Cavalcanti reported no potential conflicts of interest.


1. Baer AN, Freer JP, Milling DA, et al: Breaking bad news: Use of cancer survivors in role-playing exercises. J Palliat Med 11:885-892, 2008.