Simulation is used in many different professions for training, and assessing knowledge and skills. Although medicine has been using some type of simulation for centuries, it was the aviation field that pioneered its use back in the 1930s. They led the way by training pilots in flight simulators to allow them a safe and controlled environment in which to practice maneuvers and flying in conditions that they could not otherwise experience. 

The first medical simulator was Resusci Anne, developed in the 1960s. It allowed individuals to practice prior to seeing critically ill patients. In the past 45 years, the number of publications per year on this topic has increased 80-fold and so have the number of fields that have embraced the use of simulation in the training of their professionals. It has become common place in universities and hospitals to have special facilities and equipment to train and assess staff and students. However, many audiology training programs have been slow to embrace the use of simulation in any form.

The key to simulation is that it allows the student to separate the equipment or test from the patient. In this way, it allows the student to practice and make mistakes in a safe environment without concern for patient comfort or risk (Barrows, 1993; Ziv et al, 2003). Manikins do not care how many times you need to repeat a procedure until you feel comfortable performing the test. Working with actors who portray patients’ means that you will not compromise patient care when trying to develop communication skills and other techniques. 

Simulation allows students to be able to learn a technique and practice it repeatedly until they feel comfortable and are prepared to be assessed on that skill. They can practice the same test on various pieces of equipment until they are proficient with that equipment. Most training programs do not have ready access to patients with a variety of disorders, such as acoustic neuroma, but they can through simulation. Parents will not allow you to practice on their newborn until you are competent conducting a threshold auditory brainstem response (ABR), but manikins do not complain. 

Simulation also allows the student to quantify their clinical skills through both self assessment and mentor assessment. Students can be taught a skill or learn it in a self-guided method, practice those skills, monitor their improvement through self assessment, and finally demonstrate proficiency in a mentor assessment all before putting hands on a patient.

Simulation in an Audiological Educational Model

Students can monitor incremental improvement in the skill (self assessment), and faculty can assess clinical proficiency in that skill (mentor assessment) and determine if remediation is required. An example of this is the use of an otoscopy trainer, which uses a self-guided method to enhance the student’s knowledge of a variety of conditions found in the ear canal and tympanic membrane. It provides information that the student can study to gain knowledge about the problem and visualize it through an otoscope in an ear simulator. Finally, it provides a self-assessment tool to determine if they are comprehending the material. Once they complete those tasks, the otoscopy trainer is utilized as part of a more comprehensive skills check or proficiency exam, in combination with a standardized patient, as a part of a mentor assessment.

Diagram model for simulation training in audiology
FIGURE 1. A model for the use of simulation training in audiology. Simulation can be used in both the education and assessment of clinical skills.

FIGURE 1 shows an educational model that utilizes simulation in a doctor of audiology (AuD) training program. This model combines the more traditional method of instruction and assessment with use of simulation. Didactic learning is enhanced with clinical skills learning and practice with simulation. The goal of this model is to produce competent audiology students who are prepared to move to the clinical portion of their training. An important step is the assessment and remediation of skills in which they are not competent. With the use of simulation, we can begin to determine those students who are not attaining the appropriate level of proficiency and develop strategies to remediate them so they can succeed. 

The use of simulation occurs in the gaining clinical skills section of the model and involves different types of simulation depending on the skill set that is being taught. It is also an integral component of the assessment component of the model. It is important to note the loop-backs, which indicate that this is not a single fix but a continuous flow until the student shows competency and exits through the traditional comprehensive exams.

Types of Simulation

There are two types of simulation that can be used in training—(1) simulation technology and (2) standardized patients. Both allow the learner to practice repeatedly until the skill is acquired. Simulation technology includes devices that allow the learner to practice a particular skill using a “life-like” replica or virtual computer program. 

Standardized patients (SPs) are individuals who are taught to portray a variety of conditions and disorders, interact with the learner, and provide them with feedback. SPs provide a safe and controlled learning and testing environment to prepare students to see real patients. They provide students with the same, consistent case each time, and, as a result, the faculty can be sure that all students practice the same skills. With every student having the chance to both learn and practice a clinical skill with a SP, they can also demonstrate that skill in the same situation, which can assist with assessing clinical skills. Thus, making for a fair exam or learning experience for everyone.

Simulation Technology

Many audiologists are familiar with simulation technology that has been in existence for decades and have acquired skills though them (e.g., Resusci Anne). They are defined in terms of their fidelity or the degree to which they approach reality and are ranked from low to high (Aebersold and Tschannen, 2013). Simulators with low fidelity are non-computerized manikins or models, mid-fidelity simulators use computer programs or video games, and high-fidelity simulators use computerized manikins. At Pacific University, we utilize a number of different types of simulation technology from low- to high-fidelity to assist with clinical skills training. Here are some examples of different types of simulation technology from each of the levels.

Low-Fidelity Simulation

Photos and checklist for EMI skill development
FIGURE 2. EMI skill development using low-fidelity technology. (A)  student preparing the material, (B) practicing the technique, (C) the manikin used for EMI practice, and (D) self-assessment tool for the students to determine if they are completing tasks appropriately.

Ear Mold Impression (EMI)—A low technology approach to teaching and assessing how students make EMIs is available. By using manikins, students can practice with or without faculty being present, as there are no safety concerns with the manikins. Use of this technology divides the task into different components and allows the students to learn and self-assess prior to being assessed by a mentor. Students receive instruction on the task, and are given a standard to work toward and a tool for self-assessment. 

Photos of cerumen management practiced using manikin heads
FIGURE 3. Cerumen management can be practiced using manikin heads and artificial cerumen. Various tools and illumination methods can be tried without concern for patient safety.

FIGURE 2 shows students practicing placing a block, mixing and inserting the material and the self-assessment tool for evaluating their product. When they are comfortable with how they are able to complete the skill and are satisfied with the final product, they proceed with a mentor assessment and then onto guided mentor assessment on “real” patients. Not all students are at the same level, and some need additional practice before being assessed on a skill. This technique allows the student to practice as much as is required before they move to the next level or to receive remediation if they are not competent.

A photo of a student self-learning otoscopy skills using the OtoSim otoscopy trainer.
FIGURE 4. A student self-learning otoscopy skills using the OtoSim otoscopy trainer.

Cerumen Management—Another example of low-fidelity technology is one that can be used with students who need to learn cerumen management techniques. With this simulation technology, students can practice unsupervised and become familiar with the different methods, visualization systems (i.e., loupes), and removal tools used in cerumen removal without needing to be concerned with patient safety. Utilizing artificial cerumen (, Forest Grove, OR), they can gain experience with different consistencies of cerumen prior to touching a patient. Mentor-assessment can be used to determine when they are ready for clinical experience. (See FIGURE 3.)

Mid-Fidelity Simulation

A close-up photo of a self-assessment quiz for middle ear conditions using the OtoSim otoscopy trainer.
FIGURE 5. A self-assessment quiz for middle ear conditions using the OtoSim otoscopy trainer.

Otoscopy—The OtoSim otoscopy trainer (OtoSim, Toronto, ON) is a computer-based trainer consisting of an artificial ear and otoscope to display hundreds of pictures of tympanic membranes with various pathologies. FIGURE 4 shows a student reviewing the training program to learn about different tympanic membrane and middle-ear pathologies, and then visualizing them through an otoscope. There are a number of training programs available showing different pathologies for the student to complete. 

When the student has completed an individual self-learning module, they are able to take a self assessment to determine their knowledge (FIGURE 5). They are able to spend as much time working through the different pathologies as necessary until they are comfortable with their knowledge, at which point they can be evaluated for this skill through a mentor assessment. The mentor has the ability to create an assessment tool that includes pictures that the student has not previously seen, which helps when evaluating concepts learned and not just rote memorization of pictures.

A screen capture of computer-based audiometer showing an air-conduction test for the left ear of this virtual patient.
FIGURE 6. A computer-based audiometer showing an air-conduction test for the left ear of this virtual patient.

Audiometry—This mid-fidelity technology uses a virtual patient and audiometer to teach basic audiometric techniques including masking. There are different systems available including the AudSim Flex (, Florida) and Otis—the virtual patient (INNOFORCE creative solutions, Liechtenstein). These computer-based programs emulate diagnostic audiometers and allow the student to perform pure-tone air and bone conduction testing (FIGURE 6). The virtual patients have a variety of hearing loss patterns with type and degree of hearing loss. The program allows testing with and without the use of masking. 

For self assessment, the student can compare their results to the intended results set out by the program. This can also be used to assess a student’s ability to conduct an audiometric test, for use by the mentor to evaluate their readiness to test “real” patients.

High-Fidelity Simulation

Auditory Brainstem Response (ABR) and Otoacoustic Emissions (OAEs)—There is only one high-fidelity simulator available currently. This computerized manikin (Intelligent Hearing Systems, Miami, FL) allows students to conduct both ABR and OAE testing with any manufacturer’s diagnostic system. Students are able to practice making any evoked potential recording from neurodiagnostic testing to threshold estimation. They can practice picking peaks, measuring latencies, and determining the degree of loss using air conducted stimuli. Both transiently evoked otoacoustic emissions (TEOAEs) and distortion product otoacoustic emissions (DPOAEs) testing can also be competed with this manikin. 

A photo of a baby doll, Isao, the first computerized manikin for ABR and OAE testing and a screenshot of the results from a click ABR through the manikin.
FIGURE 7. (A) Baby Isao, the first computerized manikin for ABR and OAE testing. (B) The results from a click ABR through the manikin.

Students can practice each of the tests, complete a self assessment, and prepare for mentor assessment. We utilize this technology, in our clinical proficiency exam for newborn diagnostic hearing testing. FIGURE 7 shows the manikin and a test result for a neurodiagnostic test. The mentor has the ability to develop assessment tests that can assess any ABR or OAE test. 

Standardized Patients

Standardized patients (SPs) are defined as an actor or layperson trained to simulate or portray a patient’s condition in a realistic manner (Barrows, 1993; Furman, 2008). The terms standardized patient and simulated patient are often used interchangeably, although traditionally they had slightly different definitions (Barrow, 1993). Standardized patients are not volunteers or peers but trained individuals. Most programs require that their SP have a high school diploma, pass a criminal background check, a drug test, a physical examination, and have current immunizations. They must have a talent for acting and a desire to help train students to become more effective professionals. Large programs have SP of all ages, ethnicities, and physical characteristics, including hearing loss and balance issues.

A photo showing the interaction between a student and a standardized patient.
FIGURE 8. Interaction between a student and a standardized patient. Use of a room with video/sound system or observation room allows the mentor to evaluate and provide feedback to the student during the debriefing session.

Standardized patients are considered a mid-fidelity simulation technique and are used in most medical fields from nursing to medical students. FIGURE 8 shows a student interacting with a SP: the interaction between the student and an unknown “patient” enhances the experience more than use of a peer. Standardized patients allow students to practice communication skills with patients, practice dealing with difficult patients or in difficult situations; and review students own clinical behavior and terminology when communicating with patients. The use of SP improves counseling skills such as case history taking, ability to recognize and empathize with a client’s perspective, and general counseling skills such as “breaking bad news” (Gilmartin et   al, 2010).

Interactions with SPs help a student gain self-awareness of their own communication and clinical strengths and weaknesses, and their reactions to stressful situations (Shemanko and Jones, 2008). Debriefing from these sessions, whether self assessment or mentor assessment is a critical component of the use of SP. One evaluation tool to assess a simulated counseling session or interaction with a SP is the Audiologic Counseling Evaluation (ACE) (English et al, 2007). Use of this type of tool and a skillful  mentor with a positive attitude and constructive criticism can reinforce student learning.


The goal of simulation is for the student to incorporate the skills and lessons learned from the simulation experience and assessment/debriefing and apply them to their real-world clinical situations. Using an educational model for training audiologists that includes simulation, future students will be better prepared for clinical practice. The use of simulation serves to heighten the experience, develop and refine clinical skills, and to enhance students’ ability to interact with patients. Self assessment, feedback from mentors, and the opportunity for remediation will produce better-prepared audiologists.


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