Small-town doctors don't deliver babies very often, but to keep their skills current—and to avoid catastrophic medical mistakes—they can practice deliveries with childbirth simulators at the University of Washington School of Medicine.

On another simulator there, physicians can practice putting a catheter into the big veins of the chest and neck, a procedure that's employed for many reasons but can result in complications, says Dr. Paul Ramsey, the medical school's dean.

If a four-year branch campus of the UW medical school is developed here, as is being discussed, simulators would be integrated into the curriculum heavily—and also could become an important new business focus in Spokane, although not right away, Ramsey says.

"I don't think we'll see a focus on this in a three- or four-year period, but over a 10- or 15-year period, I do believe we'll see a focus," he says. "In the long run, it's likely that there will be spin-off companies and intellectual property that will be created. What is developed from the R&D will result in companies, smaller than typical companies at first, but then they will begin to grow."

"The potential for simulation in health care is tremendous," says Ramsey. "As the flight simulator has improved quality and safety for the pilots in the airline industry, simulation in health care has that same potential. We want to be certain the physician has the right skills. There's tremendous potential to improve quality of care, safety of care, and have a significant impact on cost of care."

Dr. Brian Ross, executive director of the medical school's Institute for Simulation and Interprofessional Studies, says, "The people involved in simulation at the UW probably have more years in it than people at any other place. We have a huge amount of intellectual power."

In December, a task force of leaders from the UW, Washington State University, and businesses and health-care institutions here concluded that it would be feasible to establish a four-year branch campus of the UW medical school in Spokane.

Two months earlier, UW President Mark Emmert told the annual meeting of Greater Spokane Incorporated that the UW medical school is a national leader in medical simulation—and wants to "take the best of what we do in Seattle and add to it some more interesting and innovative twists" in Spokane.

Medical simulation is a growth industry, says the Newport News, Va., Daily Press, which is published in a hotbed of simulation development in medicine and other fields.

Medical simulation has a further financial impetus in that it can reduce malpractice claims, says Steve Dawson, of Massachusetts General Hospital, in Boston.

Last year, Dawson told a symposium that the hospital's malpractice insurer had found in a 15-year analysis of its claims that simulation had made a huge difference in its losses—"and as a result we now get a bonus back on our premium if we are simulation trained."

Emmert also told the GSI audience that Spokane would be a "great place" for developing medical simulation tools, and Ramsey says that's true for several reasons, "one being the high quality of health care in Spokane for many years. It is a high-quality group of professionals and hospitals in Spokane. Spokane is a leader in the application of information technology in health care."

Because Inland Northwest Health Services' electronic health information system includes the records of the Spokane area's hospitals and many of its medical practitioners, development of simulators in Spokane "can be informed by the data that can come from what's happening in health care," Ramsey says. The INHS system includes the records of some 40 hospitals, 6,000 practitioners, and 3.5 million patients in the West.

The presence of the WWAMI program here also would be good for development of simulators, Ramsey says. WWAMI, which stands for Washington, Wyoming, Alaska, Montana, and Idaho, is a system of medical education run by the UW Medical School that serves students from the five states.

In all, about 4,800 physicians are involved in the WWAMI faculty, Ramsey says.

"Over the coming years, we plan to ask administrative leaders of the WWAMI program at all major sites, including Spokane, to work together on development and implementation of simulation programs," Ramsey says. "We will seek grant funding from federal programs and private nonprofit foundations to support this work. By coordinating the work across many sites, we believe that the expensive research and development can be handled in a more cost-effective manner."

Medical simulation has grown so rapidly that last year, 3,200 people attended the annual meeting of the national Society for Simulation in Healthcare, up from about 150 people at the first such meeting 15 years ago, Ross says.

"It is exciting to be involved in this," he says. "It really is new. It really has taken hold."

Yet, he says that while simulators are proliferating in medical education, the field is wide open for many more of the machines to be employed.

"There needs to be more simulation companies," says Ross, who's a native of North Idaho's Silver Valley. "There are not enough simulation companies to bring those prices down."

Ramsey says that simulators can cost anywhere from under $50,000 to more than $2 million. "Many areas of surgery are becoming minimally invasive; to simulate that can be relatively expensive," he says.

Ross, who's an anesthesiologist, says that one of the chief ideas behind simulation is to give medical students a chance to practice a procedure on a simulator before they perform it on a patient.

"The first time I did anesthesia, I did it on a patient, which is not a model the public likes," Ross says. "We have to move away from the model of 'do one on the patient the first time.'"

The ISIS center, which was formed in 2005, has simulators for practicing spinal taps, orthopedic procedures on the shoulders and knees, sutures, and many other procedures, Ross says.

One human-like simulator can breathe, twitch, dilate the pupils of its eyes, produce a heartbeat and pulse, and recognize hundreds of different drugs that a student might administer depending on the symptoms he or she observes, Ross says.

The simulator can produce 60 different physiological parameters that students might need to monitor, can transmit as its own voice the voice of an instructor who's speaking via a microphone in another room, and can simulate kidney failure, diabetic responses, and other urgent conditions.

A life-size newborn baby simulator at ISIS has a heartbeat in its umbilical cord like a real baby, has lips and hands that will turn blue if it has breathing problems, and will go into seizures if a practitioner does the wrong things.

In some settings, teams of doctors and nurses who perform surgeries go through simulations together to improve communication between the group, Ross says. He says that 70 percent of medical errors occur because of communication failures between the members of such teams. "Ultimately, a doctor or a nurse gives the wrong drug, but it's the system that doesn't work."

Other types of simulation involve role-playing. In one, anesthesia students have "consent" and "do-not-resuscitate" discussions with an actor who is playing the role of a patient who's about to have surgery, Ross says. Those conversations are observed and recorded, and the students are graded on them. Then, after the simulated surgery, the student must talk to another actor who is playing the role of a family member—and must make appropriate disclosures about what has happened during the surgery, including disclosing adverse developments, Ross says.

Ramsey says the UW medical school sometimes buys simulators from companies that make them, but also makes some of its own.

"We have through our own engineering group a lot of in-house R&D capabilities," Ramsey says. "There are only a few other medical schools in the country that have their own engineering groups, with computer science, and electrical engineering, and mechanical engineering."

At this point, simulators are probably most useful for medical residents, who have completed four years of medical school and are gaining experience in clinical settings to complete their training, Ramsey says.

"In the long run, we believe this will be more cost effective for education," he says. He adds that an experienced physician often oversees a student who's using a simulator, and one of the advantages of simulators is that in many cases students can perform a procedure even if their overseer can't be present. That way, students stay on schedule in their training, and their instructors go over the recorded results later.

Both Ramsey and Ross say simulators can enable experienced practitioners to improve skills that have gotten rusty and to bring their capabilities back up to a certain level of proficiency.

"The time will come when simulations will be a lifelong part of being a health-care professional," Ramsey says.