Trainees carry out a laparoscopic procedure on Leonardo – Photo: Nasim Muinov for GIZ Uzbekistan

Enabling trainees to practice real life scenarios in simulated environments has brought Uzbekistan’s medical training into a new era.

It’s 10.40 am and in the Centre of Development of Professional Qualification of Medical Professionals a patient called Leonardo is having his appendix removed by medical staff. The procedure is going well when suddenly his blood pressure starts to drop and his pulse weakens. The machines monitoring his vital signs start beeping with urgency and the medical staff frantically try to stabilise him. Seconds later his vital signs return to normal and a voice says, ‘Let’s stop here!’. The medical staff step back and Leonardo lies still on the bed.

Fortunately, this is not a real operation. It is a sophisticated training exercise and Leonardo is a high fidelity simulated patient model on which medical trainees are practicing their skills. The simulated operation, including the patient’s vital signs, the steps the trainees took and in what order are all recorded in detail by the software linked to the simulated patient, allowing the trainees to review their work, learn from their mistakes and refine their skills. 

Uzbekistan’s Ministry of Health wants to modernise medical training to retain doctors in Uzbekistan

Uzbekistan’s health system faces many challenges common to lower middle-income countries. It has approximately 24 doctors per 10,000 people, which is significantly less than countries like the United Kingdom and Germany which have 30 and 44 respectively (WHO 2022). This shortage is exacerbated by emigration of doctors to other countries in search of better opportunities and pay. In addition, privately run hospitals compete with public hospitals for medical staff. Medical training institutes and the way they teach were shaped in communist times. As a part of its ongoing sector reforms and efforts to retain its medical staff in the country and in its public hospitals the Ministry of Health is intent on modernising their professional development to ensure that surgeons and physicians have access to up-to-date training opportunities. 

The Uzbek-German health project supports these efforts

Since March 2019 the Uzbek German health project, implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), has been supporting these modernising efforts. It is the aim of the project to systematically establish the use of minimal invasive procedures and diagnostic imaging in selected medical specialities. To this end, it has supported the revision of training curricula and modules and it has supported the use of simulators in undergraduate medical training and continued professional development. 

Two national medical training institutes have set up sophisticated simulation centres

This work is being led by the Tashkent Medical Academy (TMA) and the Centre of Development of Professional Qualification of Medical Professionals. They have established simulation centres where trainees can learn new skills or hone skills they already have. Both institutes have revised their training curricula to systematically include the use of simulation. They have acquired different types of simulators for trainees to use during their professional development: Physical simulators, models of body parts or of actual equipment that allow trainees to practise the use of surgical instruments and procedures; virtual patients that trainees can interact with on a touch screen and digital dummies like Leonardo which look like and respond with the typical symptoms of actual patients. The two institutes have also established masterclasses at which national and international experts provide a mixture of theoretical and practical training to trainees.

What do medical simulators offer? 

Medical simulation is the term used for all activities utilising simulation aides to replicate clinical scenarios (cf. Al-Elq, 2010). It allows medical trainees to practice their skills without putting patients at risks. Regular repetition of procedures and consultations with simulated patients allows medical staff to develop the ‘muscle memory’ they need for surgery and to make correct diagnostic and therapeutic decisions in their daily practice. The use of simulators in medical training has been shown to result in medical graduates making fewer mistakes, and in improving their clinical skills, communication skills and overall quality of care (ibid.).

Going digital – the next stage in medical simulation

Advances in digital technology have enhanced the utility of simulators as training tools. Electronic sensors can, for example, measure the accuracy of trainees’ use of a laparoscopic cutting tool or of the pressure applied during cardio pulmonary resuscitation (CPR). The steps trainees take and their clinical decisions can be monitored and fed back to them – providing valuable insights that support their active learning. Also, digital monitors can be used to simulate patients’ vital signs or health status, allowing trainers to present trainees with different scenarios to which they then need to respond appropriately. This type of experiential learning has been shown to be key in adult education (So et al 2019).

Leonardo – the perfect patient simulator

Dr Saidakhror Kariev is the Dean of Surgery at the Centre of Development of Professional Qualification of Medical Workers and the Coordinator of their Simulation Centre. The centre is responsible for all post graduate training of Uzbek doctors and nurses with higher education and attracts trainees from other countries in the region. Working as a surgeon and neurologist since 1993 Dr Kariev has seen a lot of changes in the way training is delivered. Before the Uzbek-German project started the Centre used simple dummies, i.e. anatomically accurate parts of the body such a female pelvis, to let trainees practise different procedures. With the support of the project, they acquired a digital patient simulator – Leonardo – and an attached laparoscopic simulator. On Leonardo, trainees can now practise anaesthetic injections and infusions, the treatment of oedema and respiratory tract problems, intubation of mouth, nose or oesophagus as well as pulmonary ventilation and a range of neurological procedures. The simulator breathes, blinks and has pupils that can dilate. Leonardo can even sweat. It is linked to a computer that acts as both a simulated patient monitor, showing vital signs or acting as a ventilator, and tracks the actions trainees take in addressing the medical scenarios they are presented with.

Significant improvements in the speed and effectiveness of trainees’ learning

Dr Alisher Okhunov, Head of General and Paediatric Surgery at the Tashkent Medical Academy and Coordinator of their Simulation Centre, enthuses about the digital dummies for laparoscopic surgery and gynaecological procedures, and the interactive virtual patient simulator that the project provided to them. His post-graduate trainees use it to practise, for example, hernia and gall bladder operations and hysterectomies. His undergraduate students can engage with virtual patients on an interactive screen, practising their diagnostics skills, ordering tests and prescribing what they consider to be suitable medicines. All of this is tracked and scored digitally for trainers and trainees to jointly review and reflect upon afterwards.

Asked how his faculty and trainees had responded to the introduction of the simulators he pauses and then says ‘Wow!’. According to him, students, teachers and trainees have been completely taken with the many possibilities the simulators opened up to them. Before their introduction trainees learned mostly in theory how to carry out medical procedures. As a consequence, their learning was slower and less effective. The move from the classroom to practical training has, in Dr Okhunov’s view, resulted in significant improvements in trainees’ active learning and in their performance in all examinations. Through the high-fidelity simulators the Tahskent Medical Academy can now offer state of the art training opportunities to medical trainees, surgeons and physicians in Uzbekistan.

Trainees enjoy the simulation practice and grow in confidence

In an interview with them, two of the medical trainees, Gulshakhnoza and Rashid, agree with Dr Okhunov. They say that using digital simulators has given them the confidence they need for real life procedures and patient interactions. ‘For me as a postgraduate surgical trainee this type of practice is the most effective way to learn’, says Gulshakhnoza. She likes the way she can log into the simulator at any time it isn’t used by someone else and practise her skills without any assistance. She can get immediate feedback from the computer which helps her to continually improve her practice. Rashid, too, appreciates the opportunities he has had as a third-year medical trainee to use the interactive virtual patient. ‘This equipment breaks the usual mould of our studies and makes lessons more interesting’, he says. Also, both trainees like the addition of masterclasses with external experts to their training opportunities. These classes go into more detail on specific subjects or procedures. Both would like more time to practise with the digital simulators and more of these masterclasses.

Dr Kariev can see notable differences between the skills of trainees who have had the chance to use the simulators and those who have not. Previously trainees would go into real life surgeries with less confidence and take more time to carry out procedures. Now they can repeatedly practice those skills the quality of procedures has improved. His view is that patient outcomes have improved since the digital simulators have been in use though he concedes that this has not yet been studied. What is clear is that more trainees want to study at his institute, motivated by the opportunity to use the new simulators. Whereas in the past his department had to advertise to attract sufficient applicants they now have to turn some of them away. They have trained over 300 doctors using digital simulators since March 2021 and look forward to training many more.

Capacity in simulator maintenance is also being developed

Clearly, sophisticated digital equipment needs regular, high-quality maintenance. Each device is under warranty for 2 years from the suppliers. To ensure they last beyond this time, the project has provided training, including masterclasses, to the technicians responsible for keeping the equipment and software updated and in good working order. As part of the Uzbek-German cooperation the training institutes have committed to including maintenance costs for the equipment in their annual budgets. 

Positive feedback all around. What next?

In the current project phase, a group of master trainers has been cascading training on the use of simulators to training institutes across the country. All teachers, trainees and medical practitioners interviewed for this article were full of praise for the digital simulators and additional training opportunities the Uzbek-German project has provided. They are convinced that using them has improved the quality of the care they can provide to their patients. Cornelia Becker, GIZ team leader for the project, is glad about the positive response and confident that the Uzbek education system is benefitting from the increased focus on practical skills. German technical cooperation is happy to continue to contribute to this in the coming years.

Luke Boddam-Whetham, August 2022