Medical Simulation Training Research Articles

Implementation of a high-fidelity simulation programme for year 3 internal medicine trainees (IMT3)

Year 3 Internal Medicine Trainee (IMT3) is a new (in 2021) grade of medical trainee intended to bridge the chasm between the supported environment of being a senior house officer and the more independent role of a medical registrar. We identified an unmet need for simulation experience to develop skills in emergency management, team leadership, and medicolegal/ethical judgement needed by the medical registrar [1]. Medical simulation and human factors training are essential for the development of IMT3s [2]. We created a novel high-fidelity simulation programme to address this training requirement and support this new grade of junior registrars. We designed five scenarios according to current curriculum guidance and Trust human factors framework. These scenarios were: (i) managing a Jehovah’s witness with an upper gastrointestinal tract bleed but lacking capacity, (ii) tricyclic antidepressant overdose, (iii) cardiac arrest in pregnancy, (iv) duty of candour after a fatal medical error, and (v) a hypoxic COVID-19 patient refusing treatment. The scenarios were piloted to a focus group with iterative improvements made. Participants responded to a Likert-type scale on both pre- and post-course questionnaires regarding their perceived confidence in managing difficult clinical and ethical conundrums, and their ability to share decision-making and communicate effectively during these situations. 23 out of 30 (77%) of the Trust’s IMT3s attended the programme which ran from January to May 2022, 22 (96%) of whom have completed both pre- and post-course questionnaires across the six sessions held. Mean course satisfaction and subjective knowledge gained ratings amongst participants following attendance at the course was 4.9/5. There was a 34.9% increase in mean confidence rating towards the management of challenging ethico-legal dilemmas (pre- versus post-course: 6.6/10 versus 8.9/10). Similarly, the average confidence towards the delivery of effective resuscitation in acutely deteriorating patients rose from 7.3 to 8.8/10 (20.5%), while average confidence in sharing decision-making and effective communication increased from 7 to 9/10 (28.6%) amongst the participants. Unclear audio system and lack of handouts were reported as limitations. Pauses in study leave access due to COVID-19 surges posed a challenge to the delivery of sessions and additional sessions were instituted to limit this impact. This is a novel programme for a new grade of doctors. The pilot data suggested that the implementation of a high-fidelity simulation programme appeared to be an effective modality to support the progression of this junior medical registrar cohort. 1. Joint Royal Colleges of Physicians Training Board (JRCPTB). Internal Medicine Training (IMT) Stage 1 ARCP Decision Aid. 2019 (last updated 2022). [Accessed on 4/06/2022]. 2. Joint Royal Colleges of Physicians Training Board (JRCPTB). Rough Guide to Internal Medicine Training: Guidance for training programme directors, supervisors and trainees. 2019 (last updated June 2019) guide to IMT June 2019.docx %282%29.pdf [Accessed on 17/05/2022].

Ultrasound Simulation Training for Radiology Residents-Curriculum Design and Implementation.

Medical simulation training can be used to improve clinician performance, teach communication and professionalism skills, and enhance team training. Radiology residents can benefit from simulation training in diagnostic ultrasound, procedural ultrasound, and communication skills prior to direct patient care experiences. This paper details a weeklong ultrasound simulation training curriculum for radiology residents during the PGY-1 clinical internship. The organization of established teaching methods into a dedicated course early in radiology residency training with the benefit of a multi-disciplinary approach makes this method unique. This framework can be adapted to fit learners at different skill levels or with specific procedural needs.

Fostering complex professional skills with interactive simulation technology: A virtual reality‐based flipped learning approach

AbstractIt has always been a challenging issue to develop complex professional skills accompanied with sufficient professional knowledge and correct judgement. Previous studies have indicated that students have more opportunities for practice in flipped learning contexts. Basically, complex professional skills training is often risky in different real‐world applications. Therefore, most medical training lessons are done through case discussions, interpretation of mannequins, and watching videos. Such learning models are, however, not only ineffective, but students fail to solve real problems without sufficient drills. The advanced progress of 3D simulation technology provides good opportunities to solve these problems. Virtual reality (VR) provides simulations for real clinical scenarios, offering medical students the chance to practice standard complex medical skills repeatedly, as well as thinking about and responding to clinical problems in VR, where they can obtain immediate feedback from VR learning systems. Thus, to enhance medical students' complex medical skills, the study proposes a virtual reality‐based flipped learning approach. To investigate the effectiveness of the proposed approach, a quasi‐experimental design was conducted with two groups in a lumbar puncture course for postgraduate year (PGY) residents of a hospital The experimental group with 39 students was conducted with virtual reality‐based flipped learning (VR‐FL), while the control group with 37 students was managed by traditional flipped learning (T‐FL). The results showed that the complex medical skills of the experimental group were significantly better than those of the control group. In addition, the experimental group showed higher learning motivation and self‐efficacy. It can be inferred that VR‐FL has a positive impact on complex medical skills for PGY residents. Educators and researchers should consider integrating VR technology with learning strategies in medical simulation training. Practitioner notesWhat is already known about this topic Flipped learning provides opportunities for medical students to practice professional technical operations to enhance students' knowledge and skills. Virtual reality (VR) situates students in a simulated environment that enables them to have deep experience regarding the learning contexts. What this paper adds A virtual reality‐based flipped learning approach is proposed to facilitate students' complex professional skills. In addition to promoting students' learning motivation, the results showed that the proposed approach is able to promote students' complex professional skills and self‐efficacy. Implications for practice and/or policy It is potentially worth using the VR technology in flipped learning to facilitate learners' knowledge and professional skills. VR‐FL is a potential learning strategy for implementing experiential learning activities; especially in improving students' ability to integrate knowledge and professional technology applications, as well as enhancing students' self‐confidence in performing professional technology. It is worth promoting the VR‐FL approach to strengthening skill practice since students use cell phones individually, without gathering in the same classroom. It can prevent infectious diseases prevention in schools.

Medical emergency training for doctors and nurses in psychiatry: A quality improvement study.

We evaluated the impact of medical emergency simulation training on self-reported attitudes, confidence level and knowledge amongst psychiatric doctors and mental health nurses. Before and following Essential Life Support (ELS) simulation training for medical emergencies, pre and post-questionnaires were employed. Paired t-tests were used to analyse change in self-reported attitudes, confidence in self and the team, and theoretical knowledge. In 37 participants we found significant improvement in doctors and nurses attitudes (t = 2.168 p < .05 and 2.651 p < .05) and doctor's confidence t = 3.711 p < .001) following training. Knowledge increased for all participants and was significant for doctors (t = 2.112, p < .041). Comments supported training. Many doctors and nurses in mental health feel inadequately prepared and lack confidence in themselves and their colleagues to respond to medical emergencies. A structured simulation course was useful to change attitudes and increase confidence and knowledge which could benefit the team and patients.

Comparing the Psychological Effects of Manikin-Based and Augmented Reality-Based Simulation Training: Within-Subjects Crossover Study.

BackgroundPatient simulators are an increasingly important part of medical training. They have been shown to be effective in teaching procedural skills, medical knowledge, and clinical decision-making. Recently, virtual and augmented reality simulators are being produced, but there is no research on whether these more realistic experiences cause problematic and greater stress responses as compared to standard manikin simulators.ObjectiveThe purpose of this research is to examine the psychological and physiological effects of augmented reality (AR) in medical simulation training as compared to traditional manikin simulations.MethodsA within-subjects experimental design was used to assess the responses of medical students (N=89) as they completed simulated (using either manikin or AR) pediatric resuscitations. Baseline measures of psychological well-being, salivary cortisol, and galvanic skin response (GSR) were taken before the simulations began. Continuous GSR assessments throughout and after the simulations were captured along with follow-up measures of emotion and cortisol. Participants also wrote freely about their experience with each simulation, and narratives were coded for emotional word use.ResultsOf the total 86 medical students who participated, 37 (43%) were male and 49 (57%) were female, with a mean age of 25.2 (SD 2.09, range 22-30) years and 24.7 (SD 2.08, range 23-36) years, respectively. GSR was higher in the manikin group adjusted for day, sex, and medications taken by the participants (AR-manikin: –0.11, 95% CI –0.18 to –0.03; P=.009). The difference in negative affect between simulation types was not statistically significant (AR-manikin: 0.41, 95% CI –0.72 to 1.53; P=.48). There was no statistically significant difference between simulation types in self-reported stress (AR-manikin: 0.53, 95% CI –2.35 to 3.42; P=.71) or simulation stress (AR-manikin: –2.17, 95% CI –6.94 to 2.59; P=.37). The difference in percentage of positive emotion words used to describe the experience was not statistically significant between simulation types, which were adjusted for day of experiment, sex of the participants, and total number of words used (AR-manikin: –4.0, 95% CI –0.91 to 0.10; P=.12). There was no statistically significant difference between simulation types in terms of the percentage of negative emotion words used to describe the experience (AR-manikin: –0.33, 95% CI –1.12 to 0.46; P=.41), simulation sickness (AR-manikin: 0.17, 95% CI –0.29 to 0.62; P=.47), or salivary cortisol (AR-manikin: 0.04, 95% CI –0.05 to 0.13; P=.41). Finally, preexisting levels of posttraumatic stress disorder, perceived stress, and reported depression were not tied to physiological responses to AR.ConclusionsAR simulators elicited similar stress responses to currently used manikin-based simulators, and we did not find any evidence of AR simulators causing excessive stress to participants. Therefore, AR simulators are a promising tool to be used in medical training, which can provide more emotionally realistic scenarios without the risk of additional harm.

Simulating dynamic facial expressions of pain from visuo-haptic interactions with a robotic patient

Medical training simulators can provide a safe and controlled environment for medical students to practice their physical examination skills. An important source of information for physicians is the visual feedback of involuntary pain facial expressions in response to physical palpation on an affected area of a patient. However, most existing robotic medical training simulators that can capture physical examination behaviours in real-time cannot display facial expressions and comprise a limited range of patient identities in terms of ethnicity and gender. Together, these limitations restrict the utility of medical training simulators because they do not provide medical students with a representative sample of pain facial expressions and face identities, which could result in biased practices. Further, these limitations restrict the utility of such medical simulators to detect and correct early signs of bias in medical training. Here, for the first time, we present a robotic system that can simulate facial expressions of pain in response to palpations, displayed on a range of patient face identities. We use the unique approach of modelling dynamic pain facial expressions using a data-driven perception-based psychophysical method combined with the visuo-haptic inputs of users performing palpations on a robot medical simulator. Specifically, participants performed palpation actions on the abdomen phantom of a simulated patient, which triggered the real-time display of six pain-related facial Action Units (AUs) on a robotic face (MorphFace), each controlled by two pseudo randomly generated transient parameters: rate of change beta and activation delay tau . Participants then rated the appropriateness of the facial expression displayed in response to their palpations on a 4-point scale from “strongly disagree” to “strongly agree”. Each participant (n=16, 4 Asian females, 4 Asian males, 4 White females and 4 White males) performed 200 palpation trials on 4 patient identities (Black female, Black male, White female and White male) simulated using MorphFace. Results showed facial expressions rated as most appropriate by all participants comprise a higher rate of change and shorter delay from upper face AUs (around the eyes) to those in the lower face (around the mouth). In contrast, we found that transient parameter values of most appropriate-rated pain facial expressions, palpation forces, and delays between palpation actions varied across participant-simulated patient pairs according to gender and ethnicity. These findings suggest that gender and ethnicity biases affect palpation strategies and the perception of pain facial expressions displayed on MorphFace. We anticipate that our approach will be used to generate physical examination models with diverse patient demographics to reduce erroneous judgments in medical students, and provide focused training to address these errors.

Blood, sweat, trauma-and the value of medical simulation training.

Blood, sweat, trauma-and the value of medical simulation training.

Multi-Shape Free-Form Deformation Framework for Efficient Data Transmission in AR-Based Medical Training Simulators

Augmented reality medical training simulators can provide a realistic and immersive experience by overlapping the virtual scene on to the real world. Latency in augmented reality (AR) medical training simulators is an important issue as it can lead to motion sickness for users. This paper proposes a framework that can achieve real-time rendering of the 3D scene aligned to the real world using a head-mounted display (HMD). Model deformation in the 3D scene is categorised into local deformation derived from user interaction and global deformation determined by the simulation scenario. Target shapes are predefined by a simulation scenario, and control points are placed to embed the predefined shapes. Free-form deformation (FFD) is applied to multiple shapes to efficiently transfer the simulated model to the HMD. Global deformation is computed by blending a mapping matrix of each FFD with an assigned weighting value. The local and global deformation are then transferred through the control points updated from a deformed surface mesh and its corresponding weighting value. The proposed framework is verified in terms of latency caused by data transmission and the accuracy of a transmitted surface mesh in a vaginal examination (VE) training simulation. The average latency is reduced to 7 ms, less than the latency causing motion sickness in virtual reality simulations. The maximum relative error is less than 3%. Our framework allows seamless rendering of a virtual scene to the real world with substantially reduced latency and without the need for an external tracking system.

The Biological Signal Visualization Algorithm for Heart Surgery Simulator

<p class='IJASEITAbtract'>This paper introduces a bio-signal visualization algorithm for developing a cardiovascular medical virtual training simulator. It provides opportunities for practitioners and specialists who have complicated medical practice to perform enough training exercises. To reimplement the current study operation situation as much as possible, we implemented an algorithm that can easily identify each biological signal based on the patient monitoring system by visualized. In the future, combining physical engines with valid verification of whether they are suitable for actual medical staff and building simulations. That is identical to actual surgical conditions will enable more scenarios for patient diagnosis and more training programs in various healthcare fields. It produces talented individuals with specialized skills for medical personnel by training in multiple health care fields and more patients' conditions. In addition, for emergencies and emergencies in a real surgical environment, patterns through pulse rate/blood pressure changes were implemented when certain values were entered. Users could be given various situations through the WebSocket communication method as a shield to provide them with specific situations (sudden blood pressure reduction, pulse rate rise, and breathing anxiety) suitable for each training scenario. Also, our method interacts with the user in real-time, keeps the signal uninterrupted and continuous when it gives signals such as a particular situation.

Accreditation of specialists with higher medical and pharmaceutical education

The issue of reforming not only the healthcare system as a whole, but also the system of training medical and pharmaceutical personnel is relevant today. The main direction of the National Project "Healthcare" is the solution of the issue of providing healthcare institutions with qualified personnel, the introduction of a system of continuing medical education (the National Project "Healthcare", the federal project "Providing medical organizations of the healthcare system with qualified personnel"). In this regard, the requirements for persons who have mastered educational programs and are engaged in medical activities on the territory of Russia have changed. Admission to medical activity, according to modern trends, should be objective, uniform and universal throughout the country. The aim of this article is familiarization of specialists with higher medical and pharmaceutical education with the legislative framework and methodology for conducting the accreditation procedure for specialists. Primary, primary specialized and periodic accreditation is a complex organizational, methodological and engineering process that requires a competent approach in terms of planning, organization and implementation. The training of employees of accreditation centers according to the programs of training specialists in medical simulation training, as well as close interaction with the accreditation commission, certainly allows us to solve these problems and flawlessly ensure that all stages of accreditation of specialists are carried out.

Simulation Training and Coordination of the Results of Mastering Educational Programs in a Medical University

Trends to improve international quality standards for medical education dictate the need for the proper application of methods for coordinating the results of the development of educational programs.The introduction of methodological approaches for coordinating the results of mastering educational programs, as well as the founding of two medical simulation training centers and their functional integration into the educational system of the Yerevan State Medical University after M. Heratsi served as a serious help for improving the quality of educational services.

P‐3.6: A training system for the rescue process of acute and severe diseases based on AR

China is one of the countries with the most serious natural disasters in the world. Hidden dangers and risks of all kinds of accidents are intertwined and superimposed, and the factors affecting public safety are increasing. It is urgent to strengthen the construction of emergency medical rescue capacity. During the nineteenth collective learning of the Central Political Bureau, general secretary Xi Jinping stressed that we should strengthen the capacity building of aviation emergency rescue and improve the airspace guarantee mechanism for emergency rescue. As the most important aerial medical evacuation platform, helicopter has the advantages of fast response, strong mobility, wide rescue range, direct arrival at the first line of treatment, etc. it has become an important means of modern rescue, and also the only way to open life treatment in case of land damage. From the international experience, the helicopter emergency medical system established by most developed countries plays an important role in disaster relief and anti‐terrorism. China has a large population, complex terrain and uneven regional development. In case of disasters, the casualties are often more severe and the demand for treatment is more urgent. It is urgent to establish an aviation medical emergency rescue system suitable for the national conditions and with helicopters as the main carrier, and accelerate the research and development of key technical equipment.In recent years, more and more people realize the necessity and benefits of the application of interactive technology for aviation medical simulation training in major events and disasters. Interaction refers to the transmission and exchange of intelligence, data, data and technical knowledge in all aspects of nature and society. From the perspective of information theory, local chronicles are a tangible text information carrier, which collects all kinds of information in a certain region. Interactive technology is to use certain means to achieve the purpose of interaction, and gradually enter the era of multi field application! In thefield of aviation medical rescue, it is in urgent need of penetration and integration.This paper mainly develops an AR emergency rescue process training system. Through the creation of data sets, action recognition based on computer vision and deep learning, the selection of recognition model and action capture, the action is recognized based on AR, and then 22 joint points of human hand and upper arm skeleton are taken to label the data space position. Through the above learning results, we can get the real‐time hand recognition based on depth information Upper arm skeleton output. Neural network is used to recognize human skeleton action. The skeleton information coordinates are imported into RNN neural network for deep learning. Finally, based on the complementarity of CNN and LSTM, combined with the idea of dual stream structure network, the action recognition is carried out.

Modern technologies in teaching obstetrics. About students' attachment to simulation training

The authors of this article describe the experience of applying of simulation technologies in the curriculum in a medical university. The article discusses the methodology of practical training in obstetrics on the platform of a simulation center. The article also presents the results of the study that reveals students ' opinion about the role of the medical simulation training and its place in the educational process.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Extended-Reality Technologies: An Overview of Emerging Applications in Medical Education and Clinical Care.

Construction and Application of Computer Virtual Simulation Teaching Platform for Medical Testing

At present, virtual simulation experimental teaching has become the mainstream experimental teaching method in colleges and universities. Compared with the traditional classroom experiments, virtual simulation experiment teaching is not limited by time and space, and there is no need to worry about the risk of experiment. Students only need to wear VR devices through computers or mobile phones to enter the virtual simulation lab for experiments. The realism and interactivity of virtual simulation technology allows students to immerse themselves in it. Based on this situation, this paper discusses the construction and application of medical laboratory computer virtual simulation training teaching platform

An Investigation on the Perceptions of Practicing Interdisciplinary Health Professionals on Rapid Cycle Deliberate Practice Simulation.

Rapid cycle deliberate practice (RCDP) is a relatively new method for delivering simulation for a structured algorithm-based clinical content. We sought to understand how a group of practicing emergency medicine healthcare professionals would perceive RCDP as a learning method. This was a qualitative study of participants' reactions to RCDP simulation during an orientation process to a new freestanding emergency department using grounded theory. Focus groups were held after simulation sessions to investigate the participants reactions to RCDP as well as the experience of multiple professions participating. Two investigators independently coded the focus group transcripts to detect themes and developed a list of codes, which were then confirmed by consensus. Data were organized into themes with contributing codes. Thirty-one individuals participated in the focus groups including physicians, nurse practitioners, nurses, respiratory therapists, and patient care technicians. Four themes were detected: the procedural components of RCDP, the behavioral response to RCDP, learning through RCDP, and RCDP as interprofessional experience. The participants view of emotions and interruptions and pauses had discrepant interpretation. Participants received RCDP simulation positively. Initial negative reactions to the interruptions and pauses of RCDP dissipated as the simulation progressed. Ultimately, learners agreed that RCDP was extremely effective as compared with traditional simulation for medical resuscitation training because of the authenticity of the multidisciplinary aspect. This suggests that RCDP may be an effective tool for continuing education of practicing healthcare professionals.

ALTERNATING MAGNETIC FIELD GENERATOR FOR THREE-DIMENSIONAL POSITION TRACKING OF MEDICAL TREATMENT EQUIPMENT FOR TRAINING

In recent years, the incidence of cardiovascular disease is high due to the aging population and westernization of dietary habits, what encourages researching new methods. Most cardiovascular procedures use the catheter. In the procedure using a catheter, a long time of training is required to lower the procedure risk. So, a medical training simulator is being developed. In the actual procedure, the position of the catheter is confirmed by a C-arm using X-ray, but there is a risk of over exposure to radiation if the X-ray device is used until training. To solve this problem, in previous studies, the position of the catheter was tracked using a permanent magnet. However, the method of permanent magnet has a high error value due to the shape of the external magnetic flux density and the interference of environmental magnetic field. In this paper, an alternating magnetic field generator is proposed for 3D position tracking of medical equipment for training. An electromagnet with an optimal shape was designed through finite element analysis. The designed electromagnet is implemented and tested to confirm the performance. Through the location tracking experiment, an equation to estimate the distance between the electromagnet and the Hall sensor in 3D space was derived by linear regression recursive method. Through the derived equation, it was possible to track the position of the electromagnet at any position in the 3D space. Unlike previous studies using permanent magnets, the proposed alternating magnetic field generator has an isotropic shape with an external magnetic flux density according to the same distance. So, it is possible to reduce errors in position and distance, and minimize the effect of environmental magnetic fields by using an alternating magnetic field.

Motion Smoothness Metrics for Cannulation Skill Assessment: What Factors Matter?

Medical training simulators have the potential to provide remote and automated assessment of skill vital for medical training. Consequently, there is a need to develop “smart” training devices with robust metrics that can quantify clinical skills for effective training and self-assessment. Recently, metrics that quantify motion smoothness such as log dimensionless jerk (LDLJ) and spectral arc length (SPARC) are increasingly being applied in medical simulators. However, two key questions remain about the efficacy of such metrics: how do these metrics relate to clinical skill, and how to best compute these metrics from sensor data and relate them with similar metrics? This study addresses these questions in the context of hemodialysis cannulation by enrolling 52 clinicians who performed cannulation in a simulated arteriovenous (AV) fistula. For clinical skill, results demonstrate that the objective outcome metric flash ratio (FR), developed to measure the quality of task completion, outperformed traditional skill indicator metrics (years of experience and global rating sheet scores). For computing motion smoothness metrics for skill assessment, we observed that the lowest amount of smoothing could result in unreliable metrics. Furthermore, the relative efficacy of motion smoothness metrics when compared with other process metrics in correlating with skill was similar for FR, the most accurate measure of skill. These results provide guidance for the computation and use of motion-based metrics for clinical skill assessment, including utilizing objective outcome metrics as ideal measures for quantifying skill.

Development of a novel global rating scale for objective structured assessment of technical skills in an emergency medical simulation training

BackgroundMedical simulation trainings lead to an improvement in patient care by increasing technical and non-technical skills, procedural confidence and medical knowledge. For structured simulation-based trainings, objective assessment tools are needed to evaluate the performance during simulation and the learning progress. In surgical education, objective structured assessment of technical skills (OSATS) are widely used and validated. However, in emergency medicine and anesthesia there is a lack of validated assessment tools for technical skills. Thus, the aim of the present study was to develop and validate a novel Global Rating Scale (GRS) for emergency medical simulation trainings.MethodsFollowing the development of the GRS, 12 teams of different experience in emergency medicine (4th year medical students, paramedics, emergency physicians) were involved in a pre-hospital emergency medicine simulation scenario and assessed by four independent raters. Subsequently, interrater reliability and construct validity of the GRS were analyzed. Moreover, the results of the GRS were cross-checked with a task specific check list. Data are presented as median (minimum; maximum).ResultsThe GRS consists of ten items each scored on a 5-point Likert scale yielding a maximum of 50 points. The median score achieved by novice teams was 22.75 points (17;30), while experts scored 39.00 points (32;47). The GRS overall scores significantly discriminated between student-guided teams and expert teams of emergency physicians (p = 0.005). Interrater reliability for the GRS was high with a Kendall’s coefficient of concordance W ranging from 0.64 to 0.90 in 9 of 10 items and 0.88 in the overall score.ConclusionThe GRS represents a promising novel tool to objectively assess technical skills in simulation training with high construct validity and interrater reliability in this pilot study.

The Wakayama-Immediate Stroke Life Support Course: Achieving Successful Training on the Stroke Emergency System without using Mechanical Medical Training Simulators.

Background:The Immediate Stroke Life Support (ISLS) course run in Wakayama (Wakayama-ISLS course) is an off-the-job training course for understanding the initial treatment of acute stroke. A total of 22 Wakayama-ISLS courses have been held in Wakayama Prefecture since 2008. To begin with, the case presentation was performed using human-like, mechanical manikins for simulation training. However, as the course progressed, we found the students paying great attention to the display monitor, and less to the patients' neurological status.Methods:From the fourth Wakayama-ISLS course onward, we conducted the group work with the facilitators pretending to be patients, i.e., without medical training manikins.Results:When the facilitators acted as patients, the students gained a more realistic and expressive perception of neurological symptoms. As a result, they expressed a high level of satisfaction with the course in the questionnaire sent immediately afterwards, regardless of their profession or prior experience. Moreover, as we did not need to transfer medical training simulators, we were able to carry out three ISLS courses at locations some distance from Wakayama city on a low-cost basis. This also enabled the regional medical staff in rural hospitals to participate in the courses easily.Conclusion:The Wakayama-ISLS course without medical training manikins is an entirely feasible off-the-job training course, which provides training on fast and excellent treatment of acute stroke problems based on clinical practice. The course has the potential to spread not only across Japan but throughout the world, including to developing countries, given the cost perspective.