Building Patient Simulators That Represent Patient Populations

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Most people know about simulation manikins. If you haven’t practiced on one, you would probably recognize the fake patients that are used in disaster drills and medical training to help students, physicians, nurses, first responders, and other providers learn how to diagnose and treat “plastic” patients before they practice on real ones.

The new working prototype will be available in three skin tones: light, medium, and dark.

Have you ever noticed that nearly all simulation manikins have something in common? They’re white males.

“Why for the last 60 years have all manikins been white when the patients we care for, particularly in large medical institutions, are not all white?” asks Barry Issenberg, M.D., director of the Gordon Center for Simulation and Innovation in Medical Education and professor of medicine and medical education at the University of Miami Miller School of Medicine.

Barry Issenberg, M.D.

“Harvey,” the world’s first cardiopulmonary simulator, was created in 1968 by Michael S. Gordon, M.D., Ph.D., at the Miller School. The school — more specifically, the Gordon Center — is still the world’s only academic medical institution that develops, builds, and sells medical simulators. A Texas-based company handles the distribution.

“Beginning in the 1990s, more and more was written about the lack of diversity in textbooks, models, and descriptions, and how that can have an impact on how we perceive our patients and what is normal,” said Dr. Issenberg. “Perception matters.”

A Shift in Attitudes

Harvey was created as a male for a couple of reasons: the first was modesty. Back in the 1960s, when Harvey was in development, a live model was required to lie naked on a table while a group of exclusively male physicians, engineers, and mold-making technicians stood around. Everyone back then felt more comfortable with a male model. The second reason was a practical one. “They needed the largest possible body for the mechanics to fit under the chest to do the breathing,” said Dr. Issenberg. “So, they found a large torso-to-legs ratio” in a fourth-year medical student who was a competitive swimmer.

The cast for Harvey's body being made from a Miller School student and Olympic swimmer in 1973.

In the real world, however, patients are of all races, ethnicities, and genders. “Students had to suspend their disbelief,” Dr. Issenberg said. For years, he said, no one saw anything wrong with that. Then, in 2020, a shift happened in the political and racial climate of the country that spurred the development of the Miller School’s Task Force on Racial Justice.

The first three cardiology simulators that were made. The sculptor used the face of President Lyndon Johnson, Time magazine’s 1967 "Man of the Year,” as the model for the eldest man.

“I was on the task force, and patient representation was one of the issues we identified. We wanted to walk the walk,” said Dr. Issenberg.

The new working prototype will be available in three skin tones: light, medium, and dark.

The Future Is Female (and XR)

Next up in the evolution of Harvey? “We will be developing a female model,” said Dr. Issenberg. (Though a name hasn’t been decided upon yet, they are thinking of calling her “Hailey.”)

“More than half the population are women,” he said. “Heart disease is underrecognized in women, who often present differently than men, and it's been shown they have worse outcomes than men because of the presentations.” Men tend to perform cardiac exams on women less well than other women do, he added, “because men don't know how to navigate a breast ... They are uncomfortable.”

Future models, which are expected to be available in the next few years, will incorporate extended reality technology. “If I go to Harvey in the future, I will wear goggles and Harvey will appear as any age, any gender, any skin tone,” said Dr. Issenberg. “Not just for moral and ethical reasons, but for very practical and scientific reasons.”

More evidence that diversity and inclusion lead to better outcomes.

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