uessing the future nearly 50 years ahead is a tough prospect. Will there still be anesthesia and surgery as we know it? Will “invasive” medical care be all about immunotherapies and injectable nanotechnologies or, at most, performing everything via percutaneous catheter-based procedures? Will anesthesia be artificial hibernation or “electroanesthesia?” Will anesthesia be conducted by intelligent robots who are only supervised by anesthesiologists? Who knows? But if surgeons are still cutting and sewing and anesthesiology still involves actual human beings pharmacologically putting patients into an intrinsically dangerous and unnatural state, we can expect major changes in the way that anesthesiologists — and indeed all health care personnel — are selected, educated, trained and maintained in their life-sustaining skills.

Realistic Low-Risk Training
At the present time, health care education begins with rigorous basic science courses yet leaves most clinical training to a relatively unsystematic apprenticeship process. The emphasis during clinical training is on individual knowledge and skill rather than on honing the performance of clinical teams. Once a clinician has completed graduate medical education, the required level of continuing education and training is often minimal and unstructured. By 2050 it will long have become commonplace for clinical personnel, teams and systems to undergo continual systematic training, rehearsal, performance assessment and refinement in their practices. For anesthesiology and other domains with high intrinsic hazard, simulation has a very important role to play. By using simulation, young trainees can be exposed to multiple episodes of high-risk, low-frequency events such as anaphylaxis, cardiac arrest or malignant hyperthermia and will be trained to manage these events in a systematic fashion. Furthermore, by using simulation, real patients do not have to provide the initial training experience.

A Sci-Fi Future
Simulation is a technique — not a technology — to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. “Immersive” conveys the sense that participants have of being immersed in a task or setting as they would if it were the real world. The ideal example of full immersion (currently fictional) would be the Star Trek “Holodeck” in which one literally cannot tell the difference between the simulated experience and real life. Although today and for the foreseeable future, simulations in anesthesiology and intensive care primarily use computer-screen and mannequin-based patient simulators, by 2050, simulation will almost certainly be conducted completely via virtual realities. These might be either the artificially created physical space of the Holodeck or the completely internal virtual realities envisioned in a host of science fiction novels and movies (e.g., the 1984 book Neuromancer or the 1999 movie “The Matrix”).

Regardless of the modality used to provide simulations, they will be used both for individuals and for teams, work units and whole organizations. Such exercises will be fully integrated into the routine fabric of health care delivery. Students will engage in simulations as a core part of their learning. Clinical trainees will be scheduled to undergo intensive simulation training as part of their expected responsibilities. Training will be performed not just for a fixed duration or number of cases but rather to specific criterion levels of competency for key aspects of knowledge, skill and behavior. Continuing education will be transformed into lifelong learning embedded within systems of care, taking part largely at the level of the clinical team rather than being solely at the discretion, time or cost of individual practitioners.

Simulation Limitations
Even in 2050, simulation will probably not entirely replace the apprenticeship system of supervised work on real patients. Unlike airplanes or nuclear power plants, we do not design and build human beings, nor do we receive the official instruction manual! Patient care is intrinsically more complex and requires more human empathy and connection than do other high-hazard activities that have used simulation. Simulation will be used for those activities for which it is best suited, but there will still be a time when each clinician performs key tasks on a living, breathing human being for the first time. By 2050 — unlike today — clinicians will have extensive experience under their belts when this time comes.

Detailed assessment of the performance of anesthesiologists and perioperative teams also will be a regular occurrence. Some evaluations will take place during real patient care; but with adverse anesthetic events still being uncommon but lethal, simulation will be key to evaluating individual and team responses to highly dynamic life-threatening situations.

Driving Force of the Future
The revolutions in training and testing will be implemented by a mix of agencies and methods that vary by country, region and specialty. ASA and the American Board of Anesthesiology will be major players, but perhaps an even bigger role will be played by hospitals (or their future successor organizations) and accrediting or regulatory bodies.

Ultimately we can expect the public to be the major underlying driving force for creating a medical system which can ensure that clinicians are trained and tested to the highest standards.

David M. Gaba, M.D., is Associate Dean for Immersive and Simulation-based Learning, Stanford University School of Medicine, Stanford University, Stanford, California.