anesthesiologists have played a key role in development of mannequin simulators and contributed to the development of simulation programs for education , training and research . the first computer controlled mannequin simulator was simone manufactured by denson and abrahamson in 1960s , but it was too large and expensive to apply to medical education . in 1968 , gordon developed harvey , a high - technology cardiopulmonary simulator . harvey is capable of simulating auscultation sounds , blood pressure , arterial pulses , precordial impulses , normal heart sounds and murmurs . most medical students were able to demonstrate high objective structured clinical examination ( osce ) scores after training with the harvey simulator . an anesthetic drug physiology and pharmacology based computer simulation model , called gasman , was also developed . it was capable of showing anesthetic gas uptake , distribution and elimination . in the 1980s , high fidelity mannequin simulators emerged in clinical anesthesia training ( comprehensive anesthesia simulation environment [ case ] 1.2 ) for the purpose of teaching anesthesia crisis resource management ( acrm ) . many skill trainers for various procedures training such as epidural catheter insertion , central venous catheter insertion and fiberoptic bronchoscopy were also developed during this period . provides many lectures and workshops on simulation . the society for simulation in healthcare , an organization consisting of multi - disciplines in healthcare , has been organizing the annual international meeting on simulation for healthcare every january since 2004 , and has been publishing the official journal , " simulation in healthcare " , every other month since 2006 . high fidelity simulators have been widely used for training anesthesiology residents and medical students since the 1990 's . anesthesiology residents trained with simulators responded more quickly , performed better and deviated less from the accepted procedure . technical performance and ( meti ) was used as an effective teaching tool for airway management , ventilator care and hemodynamic management in critical care medicine . issenberg et al .   reviewed 109 studies on high fidelity simulation learning , and providing feedback ( 47% ) , repetitive practice ( 39% ) , curriculum integration ( 25% ) , range of difficulty level ( 14% ) , multiple learning strategies ( 10% ) , capture clinical variation ( 10% ) , individualized learning ( 9% ) , defined outcomes ( 6% ) and simulator validity ( 3% ) were suggested as features and uses of high - fidelity medical simulators that lead to effective learning . analyzed 609 articles from 10,903 , and searched evidence of the effect of simulation on health profession education . it was suggested that technology - enhanced simulation training in health professions education is consistently associated with significant effects on the outcomes of knowledge , skills , and behaviors and with moderate effects on patient - related outcomes compared to no intervention . the aim of this review was to introduce the necessities of simulation based training and education in the field of anesthesiology . simulation is a technique to replace or amplify real - patient experiences with guided experiences . these include mannequin simulators , human cadaver or animal models , computer - based simulation , haptic and/or virtual simulation , as well as simulation using standardized patients . simulation has been an accepted part of training , assessment and research in high - reliability organizations , such as aviation , nuclear power , and military . simulation - based learning has been used to shorten the gap that exists between the learning environment and the real clinical environment . many skill trainers have been developed to actualize real clinical site especially for novice anesthesiologists . utilization of simulatiors has many advantages for medical education [ 14 - 18 ] : 1 ) learning can be focused on the level of trainees with various levels of difficulties ; 2 ) learners can either learn the whole procedure process or just focus on certain tasks of the procedure ; 3 ) learners have the opportunity to repetitively practice in quick succession ; 4 ) learners learn in a safe environment where they can be allowed to learn from their mistakes rather than be rescued by their supervisor to keep the patient safe ; 5 ) simulators can provide objective evidence of performance , offering potential for their use for assessment , both formative and summative ; 6 ) simulation can provide practice on certain procedures such as cricothyrotomy , which is a critical life - saving procedure that is uncommon and rarely performed by anesthesiology residents . however , simulation also comes with some limitations , especially when using high - technology simulators . its high cost and the need for dedicated simulation rooms with audio - video system , separate debriefing rooms , simulation programs , trained faculty and staff are some of the barriers . various simulation programs are needed , because limited experience of simulation can guide heuristic approach based on their own experiences . there has been a growing trend for reduced medical training hours and decreased trainee exposure to clinical experience . this has led a question of whether there would be enough time for skills to be adequately learned through current training programs . in addition to the trend of reduced training hours and clinical exposure , medical simulation has gained importance in medical education , because there is a perceived need for greater accountability to the public health and an increasing emphasis on patient safety . therefore , medical education should follow the trend of outcome based , competency based , and individual learning to achieve these goals . many of the skills required in anesthesia practice should be acquired by exercises and experiences rather than traditional lectures . therefore , osce , problem - oriented learning ( pbl ) and clinical performance examination ( cpx ) were proposed as anesthesia education methods . medical simulation has grown significantly world - wide in medical education , and simulation - based medical education is now a very important part of anesthesia training programs . training with high - fidelity simulators helps learners to adhere better to the american society of anesthesiologists ( asa ) difficult airway management guideline . other researchers reported better cardiopulmonary resuscitation performance after simulation , reduction in costs and complications related to central catheter insertion by simulation training , higher scores in cardiopulmonary bypass weaning after simulation based learning   and superior non - technical skills in simulation training groups . simulation programs in anesthesia consists of , but not limited to , difficult airway management , lung separation , central venous catheter insertion , epidural block , hemodynamic monitoring , and so on [ 27 - 29 ] . another application of medical simulation in anesthesia education is the assessment of skills and competency . providing the opportunity to assess clinical performance in a scheduled , structured and standardized setting in conjunction with simulation based assessment may have the potential to be a valuable addition to the existing theoretical examination protocols in residency training . for example , can not intubate , can not ventilate ( cicv ) scenario was used for anesthesiologist assessment . trainees showed improvement in the second cicv scenario by debriefing them about airway management algorithms . situational stress , low familiarity with tracheal intubation instruments other than direct laryngoscopy and the lack of adherence to airway management algorithms are considered to be important causes for low scores . although simulation training is demonstrated to be of value in the acquisition of skills , its effect diminishes in the long run and showed no difference in performance of central venous catheter insertion between clinically trained residents and residents with additional simulation training . therefore , simulation acquired skills should be maintained by repetitive practice , constructive feedback and concrete assessment . in anesthesiology , simulation research has fewer limitations with regard to ethical aspects than basic or clinical research . simulation research has focused on the development of high fidelity simulators , the educational effects of combination of simulators , validity of educational tools such as global rating scale , application methods and so on . has some advantages , for example , trainees are familiar with the equipment and environment , can cooperate with their own team , and no need for additional space . the designing process is as follows : 1 ) review the process required to perform a procedure ; 2 ) establish the steps required to perform a procedure ; 3 ) develop a consensus on the sequence of the steps ; 4 ) identify major performance milestones required to perform a procedure ; 5 ) assure that trainees acquire the skills required for each step prior to advancing ; 6 ) define the common as well as serious failure modes ; and 7 ) design strategies that reduce the frequency of these errors . the designing process for scenarios are : 1 ) the scenario must include an opportunity for trainees to use judgments relevant to the training goals ; 2 ) the scenario must have high fidelity for the clinical environment ; 3 ) the scenario must include essential diagnostic and treatment skills required to manage the simulated condition ; 4 ) practice experts must agree on these essential diagnostic and treatment skills ; 5 ) an approach to evaluate , score and offer objective feedback must be provided following the scenario ; 6 ) the scenario needs a copious , easy and clear description ; 7 ) the scenario must include required skills embedded into the curriculum ; and 8) crisis events are included in the compressed timeline . it is well known that debriefing was first used to describe the account individuals gave on returning from a mission in the military . debriefing on an event or activity and subsequent analysis is essential in the process of learning . however , not everyone is naturally capable of analyzing , understanding and assimilating learning experiences on their own , particularly those included in highly dynamic team based activities . the attempt to bridge this natural gap between experiencing an event and making sense of it has led to the evolution of the concept of post - experience analysis called debriefing . elements of good debrief are the use of open ended questions , positive reinforcement , the use of cognitive aids , and good use of audiovisual capabilities . debriefing is performed according to the following process : 1 ) identifying the impact of the experience ; 2 ) identifying and considering the developed processes ; 3 ) clarifying the facts , concepts , and principles ; 4 ) identifying the ways in which emotion was involved ; and 5 ) identifying different views formed by participants . comprehensive checklists and global rating scales are frequently used . a greater level of involvement of simulation allows for more reliable assessment . a single prolonged and complicated scenario may offer more opportunities to demonstrate skills and non - technical skills , but scoring and assessment of the trainee is often challenging . decreased working hours during the training course , increased focus on patient safety and greater accountability is processed by the following 4 steps : 1 ) demonstration : show how to perform a procedure instead of using explanations ; 2 ) analysis : explains each step ; 3 ) understanding : trainee performs a procedure while trainer explains ; and 4 ) performance : trainee performs and explains the procedure . although animals and cadavers can be used to teach technical skills for medical students , utilization of simulators for technical skill training has become a major trend in recent years . simulation has been recognized as a useful method in acquiring technical skills because simulation fits well with the three - stage model of cognition , integration and automation . cognition is developing an understanding of the task , and being able to make a clear description and demonstration of the task . integration makes knowledge obtained from the cognition to be incorporated into learning the motor skills for the task . competence in procedural skills is achieved by a variable number of attempts in normal and pathological conditions , and depends on the quality of teaching , motor skills and aptitude of individual trainees . pre - trained novice can obtain proficiency without direct patient contact . if a learner reaches the level of automation in performing certain procedure , he or she can achieve additional abilities such as communication , teamwork and decision making . parts of anatomical area trainers have been used for procedural skill training instead of high fidelity full - scale computer based simulators . part of anatomical area trainers are widely used because it is less expensive than full scale patient simulators . however , full scale simulators can simulate better in the settings of anesthesia clinical skill teaching which needs indispensable , quick and accurate performance at critical situation . hybrid simulation , a combination of a standardized patient who plays a role of assessing communication skills and a manikin simulator which assesses technical skills , is also useful in anesthesia procedural skill training . therefore , the development of more realistic simulation programs will provide more complex and higher quality education on both technical and non - technical skills . high fidelity simulators provide more realistic simulation environment and educational effects in comparison to simple part trainers . therefore , it is essential to facilitate high fidelity simulators and to replicate various simulation programs . non - technical skills can be defined as cognitive , social , and personal resource skills that complement technical skills , and contribute to safe and efficient task performance . adverse event data from anesthesia showed that non - technical skills play a key role in patient safety . a review of human factors and current use of behavioral markers , questionnaire survey , problems and concerns , observations in theatre , and interviews with consultant anesthetists to identify the non - technical skill underpinning their practice were undergone . for example , anesthesiologists and psychologists designed the anesthesia non - technical skills ( ants ) system using task analysis similar to the non - technical skills ( notechs ) system for pilots . non - technical skills are also applied in surgery , and assessment of surgical non - technical skills ( notss ) is becoming a training priority to develop in surgeons . notss is consisted of 4 categories , situation awareness , decision making , communication and teamwork , and leadership . such tools like notechs and notss may be helpful in the development of non - technical skill training in anesthesiology . such non - technical skills should be developed according to the regional and cultural environment . ants is a type of non - technical skill training tool consisting of 4 categories with each category having 3 to 5 elements . the four categories are task management , team working , situation awareness , and decision making ( fig . task management is the skill of management of resources and organization of tasks to achieve goals , be they individual case plans or longer term scheduling issues . it contains 4 elements , namely planning and preparation , prioritization , providing and maintaining standards , and identifying and utilizing resources . team working is the skill of working with others as a team , in any role , to ensure effective joint task completion and team satisfaction ; the focus is on the team rather than the task . it has 5 elements , namely coordinate activities with team members , information exchange , the use of authority and assertiveness , assessment of capabilities of team and self , and supporting others . situation awareness is the skill of developing and maintaining an overall dynamic awareness of the situation based on the perception of elements of the theatre environment ; that is , understanding what they mean and thinking ahead about what could happen in the near future regarding the patient , team , time , displays , and equipment . it has 3 elements , namely gathering information , understanding and recognition , and anticipation . decision making is the skill of making decisions to reach a judgment or diagnosis about a situation , or to select a course of action , based on experience or new information under both normal conditions and in time - pressured crisis situations . it has 3 elements , namely identifying , balancing risks and selecting options , and re - evaluation ( table 2 ) . for example , in the planning and preparation element of task management , good practices are communicate plan for case relevant staff , review case plan in light of changes and make post - operative arrangements for the patient . poor practices of planning and preparation are do not adapt plan in light of information , do not ask for drugs or equipment until the last minute , do not have emergency or alternative drugs available for the patient , and fail to prepare theater . ants is applied to simulators and in - theatre training to assess non - technical skills , to identify trainee 's competence , to give structured feedback , and to inform further training . the purposes of evaluation of non - technical skills are feedback , testing skills or licensing , the efficacy of nontechnical skills training programs and constructing databases and analyses . simulation has a potential to promote a new paradigm compared to traditional education tools . technical skills and non - technical skills such programs would be beneficial in training anesthesia teams working in the operation room . in conclusion , academic societies should develop simulation programs that are compatible with the international standards and periodic demand to achieve clinical competency and patient safety thorough medical education based on simulation .
many medical schools and hospitals throughout the world are equipped with a simulation center for the purpose of training anesthesiologists to perform both technical and non - technical skills . because induction , maintenance , and emergence of general anesthesia are critical to patient welfare , various simulation mannequins and tools are utilized for the purpose of training anesthesiologists for safer patient care . 
 traditionally , anesthesia residency training mostly consisted of didactic lectures and observations . 
 after completion of " traditional " training , anesthesia residents were allowed to perform procedures on patients under supervision . 
 however , simulation would be a more effective training tool for which to teach anesthesiologists the skills necessary to perform invasive procedures , such as endotracheal intubation , central venous catheter insertion , and epidural catheter insertion . 
 recently , non - technical skills , such as the anesthesia non - technical skills developed by anesthesiologists from aberdeen university , have been emphasized as an important training resource . 
 technical skills and non - technical skills can be learned by anesthesiology residents through a standardized and organized simulation program . 
 such programs would be beneficial in training anesthesia residents to work efficiently as a team in the operation room .