Simulation is a synthetic representation of a real-world process with sufficient reliability to facilitate learning through contemplation and practice without the hazard, innate in a real-life experience 1. Simulation is derived from the Latin word ‘Simulare’ which means to copy 2 Simulation is considered at present a fundamental part of the contemporary medical education system, be it graduation or post-graduation. Nowadays, simulation is a useful accompaniment to medical education as pre-exposure to necessary clinical skills as exposure in the real clinical setting may be insufficient. A medical student is expected to acquire certain basic skills by the end of graduation and thereafter pursue learning skills throughout life even after formal education is completed. A trainee is expected to learn patient-centered and process skills (teamwork, information management, self-directed learning, and patient advocacy) in their undergraduate curriculum. It is often found that in a clinical area, a trainee does not get uniform clinical exposure, thereby it is impossible to learn all the necessary skills (Friedman C, Purcell E, Swanson 1992).

Besides issues like medico-legal issues, patient safety, and patient discomfort pose a serious threat to a trainee to practice and get suitable skills even if he gets a suitable patient to learn from. In the current situation, simulation provides an alternative environment to the real patient and trainees get an opportunity to learn a wide range of skills for mastering and practice with the achievement of specific learning goals and objectives. In such a situation learning can place in a dedicated teaching environment rather than in a patient care environment. 3 Clinical skills and performance are considered core proficiency and are crucial to professionalism in medical practice for successful patient care. This can enable the students to learn themselves with clinical examination and hands-on- training by using models and simulators before examining the patients directly. Simulation-based medical education (SBME) has been introduced in the health care field and now it is becoming one of the popular teaching modalities for refining patient safety and care 4.

The three objectives of SBME are:

A. Executing a clinical skill.

B. Practicing the clinical skill under observation.

C. Performing clinical skills individualistically and self-assuredly.

Maastricht university of Netherlands first opened clinical skill laboratory in the year 1974. Over the last 25 years, the use of SBME and skill laboratories has seen a vast advance in medical education. The principle of “See one, Do one and Teach one” is still followed in certain countries. SBME is an educational interposition that links the gap between the “See one and Do one” in clinical practice to stress on psychomotor domain and to focus on the quality of medical care and the patient’s safety.

The introduction of SBME is considered advantageous over the traditional style of medical education as it provides medical students and the” simulated patients”, a safe environment to commit errors and to learn the right technical skills. Clinical simulation resembles a clinical scenario. It is one of the different modes in “health care education” that is usually offered to learn the competency and technical skills necessary to treat the patients to bring out a successful outcome. 5

The different skills that are to be instructed to pupils amid the early stage of their medical learning are recorded and each ability is applied within the skill lab. They are classified as “Diagnostic skills, ‘Performing skills”, “Resuscitative skills” and “High fidelity skills”. The skills are instructed during the training session before the candidate performs it on the patient. The students are made to learn and practice repeatedly so that afterward they are made to perform individually under the professional’s guidance and supervision. The trainers instruct and insist on them constantly about the skills, the medical students can acquire the skill and perform them individually. Since the students are given repeated practice of the skills, they can perform on the patients independently with utmost confidence. This enhances the learner to become a proficient health care professional instead of acquiring only theoretical knowledge.6

The main benefit is that clinical circumstances and outcomes of medical emergencies can be planned, can be detected and then can be replicated and at the same time understanding can be established. The particular clinical questions can be rehearsed by the students and can be replicated several times until they are satisfied and confident about the procedure. Here for training and understanding purposes, clinical circumstances are made so the practice of new competencies is possible without requiring a real patient role. 7

Simulators are broadly classified into two categories: 1. High-fidelity simulators and 2. Low-fidelity simulators. The fidelity of a simulator is determined by the degree to which it offers realism over characteristics like visual signs, tactile characteristics, feedback abilities, and user interface with the learner.

Firstly, learning objectives are defined followed by feedback from the faculty members and trainees are obtained. Best- suited simulators are identified. The preparatory phase consists of arranging infrastructure, procuring the simulators, maintenance, funding, and manpower. 10

Preparation of blueprint: This is prepared for the training session by specifying textbooks, international guidelines and checklists. The number of trainers is allocated based on the students’ strength and the type of the skill to be taught. The resource persons have to be trained based on the total training hours of the session 11.

Evaluation Phase: The student’s performance is evaluated based on their responses using a checklist. At the end of the session the drawbacks and strengths of the session is assessed 12.

Darla Brown once said, "By making this doctor, I have not harmed my patients." It offers a very safe and confident environment for both patients and learners. Medical students' knowledge and confidence are reinforced through clinical skills lab work and simulation training making SBME, a valuable tool during the preclinical phase. The principles of adult active learning are reinforced and learners encounter a variety of clinical cases and rare situations. Simulation-based training integrates clinical and basic medicine. It also improves clinical outcomes, learning and training in appropriate clinical skills for medical students. 14, 15

Daniel et al., conducted a study with medical students (n 85) from 2nd and 3rd year MBBS curriculum in which an audiovisual instruction followed by high fidelity mannequins were provided during an Adult and child CPR training session. Pretest and Post-test self-assessment questionnaires were given. Simulation-based training improves the knowledge and skill of medical students 37.

Hermann-Werner et al. (n94). organized a randomized controlled experiment among 4 group of students. One group was trained with TRAD model (Traditional See One, Do One) other group was trained with BPSL (Best Practice model). These groups were monitored every 3 and 6 months. The study found that the BPSL group was advanced to the TRAD groups for several complex skills when examined both immediately and after a follow-up period of three and six months. 38.

Al Suwaidi et al. (n84) described the influence of the simulation in acquiring clinical skills using “Kirkpatrick’s Evaluation Framework. First group of students (n= 49) were offered “interactive learning tutorials” and the second group of students (n=35) were given simulation sessions to discuss the clinical vignette. After the session, the second group of students responded effectivity of the simulation session 39.

Swami et al. (n24) divided into two groups of students. One group tested each other's chests and the other group tested with their ‘SimMan’ model of high fidelity. The two groups then switched places and the groups switched subjects. Three tests were performed (pretest, mid- test, and post test). The study showed that knowledge and ability to perform chest exercises increased significantly, as did students' test performance and confidence levels. 40.

Over the year’s models with Simulation machinery evolved along with medical procedures. It has gained rapid advancement in last few years beginning from part assignment trainers to highly advanced computer-guided simulators with innovative technologies. More difficult devices have come into the market and Simulation is refined to a more advanced stage 41. It has offered its hand in clinical practice and health care deliverance, particularly in the field of patient protection and evaluation 42. As a part of professional learning, the Skill laboratory is taking place as an integral part of the medical curriculum offering both technical and non-technical skills to medical students 43. Medical professionals acquire knowledge and many skills such as professionalism, self-evaluation, management, communication, and teamwork through SBME. With proper learning objectives, designing the clinical skill program with efficient teaching faculty and equipment, the SBME is a boon to medical students 44.