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JOURNAL OF CLINICAL AND BIOMEDICAL SCIENCES
REVIEW ARTICLE
1
OPEN ACCESS
Received: 19.02.2023
Accepted: 07.09.2023
Published: xx xx xxxx
Citation: Ashokan B, Paul BJ, Saha P,
Domnic IS, Bhaskaran M.
Simulation-Based Medical
Education: A Boon for Medical
Students? - An Integrative Review. J
Clin Biomed Sci 2023; 13(3): 1-9.
∗
Corresponding author.
drbhaskarjpaul@gmail.com
Funding: None
Competing Interests: None
Copyright: This is an open access
article distributed under the terms
of the Creative Commons
Attribution License, which permits
unrestricted use, distribution, and
reproduction in any medium,
provided the original author and
source are credited.
Published By Sri Devaraj Urs
Academy of Higher Education, Kolar,
Karnataka
ISSN
Print: 2231-4180
Electronic: 2319-2453
Simulation-Based Medical Education: A
Boon for Medical Students? - An
Integrative Review
2
Ashokan Bhaskaran1, Paul Bhaskar Jyoti2∗, Saha Pijush3,
Domnic Inbaraj Susai4, Bhaskaran Mohana5
1Professor, Department of Surgery, College of Medicine, Shaqra University, Shaqra, KSA
2Associate Professor, Department of Obstetrics and Gynecology, College of Medicine,
Shaqra University, Shaqra, KSA
3Assistant Professor, Department of Obstetrics and Gynecology, College of Medicine, Shaqra
University, Shaqra, KSA
4Associate Professor, Department of Pharmacology, College of Medicine, Shaqra University,
Dawadmi, KSA
5Assistant Professor, Department of Microbiology, College of Medicine, Shaqra University,
Dawadmi, KSA
3
Abstract
4
Simulation is a synthetic representation of a real-world process with sufficient5
reliability to facilitate learning through contemplation and practice without6
the hazard, innate in a real-life experience. Nowadays, simulation is a useful7
accompaniment to medical education as pre-exposure to necessary clinical8
skills as exposure in the real clinical setting may be insufficient. Clinical skills9
and performance are considered core proficiency and are crucial to the10
professionals. This can enable the students to familiarize themselves with11
patient examination and hands-on- training by using models before coming12
across patients directly. Simulators are broadly classified into two broad13
categories: 1. High-fidelity Simulators and 2. Low-fidelity simulators. The fidelity14
of a simulator is decided by the extent to which it provides realism through15
characteristics. Simulation Based Medical Education (SBME) provides a safe16
environment for the students to acquire their psychomotor skill but is not17
necessarily better than other types of instruction as there is a high degree18
of variability between studies. SBME has been introduced in the health care19
field and now it is becoming one of the most popular teaching techniques for20
improving patient safety and care. It would be advantageous if it is included in21
medical curricula as it may proof boon for the young medicos.22
23
Keywords: Medical simulation; SBME; Simulators
24
25
J Clin Biomed Sci 2023;13(3):1–9 1
Ashokan et al., Simulation-based medical education
Background26
Simulation is a synthetic representation of a real-world pro-27
cess with sucient reliability to facilitate learning through28
contemplation and practice without the hazard, innate in a29
real-life experience1. Simulation is derived from the Latin30
word ‘Simulare’ which means to copy2Simulation is consid-31
ered at present a fundamental part of the contemporary med-32
ical education system, be it graduation or post-graduation.33
Nowadays, simulation is a useful accompaniment to medi-34
cal education as pre- exposure to necessary clinical skills as35
exposure in the real clinical setting may be insucient. A36
medical student is expected to acquire certain basic skills by37
the end of graduation and thereaer pursue learning skills38
throughout life even aer formal education is completed. A39
trainee is expected to learn patient-centered and process skills40
(teamwork, information management, self-directed learning,41
and patient advocacy) in their undergraduate curriculum. It42
is oen found that in a clinical area, a trainee does not get uni-43
form clinical exposure, thereby it is impossible to learn all the44
necessary skills (Friedman C, Purcell E, Swanson 1992).45
Besides issues like medico-legal issues, patient safety, and46
patient discomfort pose a serious threat to a trainee to practice47
and get suitable skills even if he gets a suitable patient to48
learn from. In the current situation, simulation provides an49
alternative environment to the real patient and trainees get50
an opportunity to learn a wide range of skills for mastering51
and practice with the achievement of specic learning goals52
and objectives. In such a situation learning can place in a53
dedicated teaching environment rather than in a patient care54
environment.3Clinical skills and performance are considered55
core prociency and are crucial to professionalism in medical56
practice for successful patient care. is can enable the57
students to learn themselves with clinical examination and58
hands-on- training by using models and simulators before59
examining the patients directly. Simulation-based medical60
education (SBME) has been introduced in the health care eld61
and now it is becoming one of the popular teaching modalities62
for rening patient safety and care4.63
e three objectives of SBME are:64
A. Executing a clinical skill.65
B. Practicing the clinical skill under observation.66
C. Performing clinical skills individualistically and self-67
assuredly.68
Maastricht university of Netherlands rst opened clinical69
skill laboratory in the year 1974. Over the last 25 years, the70
use of SBME and skill laboratories has seen a vast advance71
in medical education. e principle of “See one, Do one and72
Teach one” is still followed in certain countries. SBME is an73
educational interposition that links the gap between the “See74
one and Do one” in clinical practice to stress on psychomotor75
domain and to focus on the quality of medical care and the76
patient’s safety.77
e introduction of SBME is considered advantageous78
over the traditional style of medical education as it provides79
medical students and the” simulated patients”, a safe environ-80
ment to commit errors and to learn the right technical skills.81
Clinical simulation resembles a clinical scenario. It is one of82
the dierent modes in “health care education” that is usually83
oered to learn the competency and technical skills necessary84
to treat the patients to bring out a successful outcome.5
85
Implementation of clinical skill course86
e dierent skills that are to be instructed to pupils amid the87
early stage of their medical learning are recorded and each88
ability is applied within the skill lab. ey are classied as89
“Diagnostic skills, ‘Performing skills”, “Resuscitative skills”90
and “High delity skills”. e skills are instructed during91
the training session before the candidate performs it on the92
patient. e students are made to learn and practice repeat-93
edly so that aerward they are made to perform individually94
under the professional’s guidance and supervision. e train-95
ers instruct and insist on them constantly about the skills, the96
medical students can acquire the skill and perform them indi-97
vidually. Since the students are given repeated practice of the98
skills, they can perform on the patients independently with99
utmost condence. is enhances the learner to become a100
procient health care professional instead of acquiring only101
theoretical knowledge.6
102
e main benet is that clinical circumstances and103
outcomes of medical emergencies can be planned, can be104
detected and then can be replicated and at the same time105
understanding can be established. e particular clinical106
questions can be rehearsed by the students and can be107
replicated several times until they are satised and condent108
about the procedure. Here for training and understanding109
purposes, clinical circumstances are made so the practice of110
new competencies is possible without requiring a real patient111
role.7
112
Simulators113
Simulators are broadly classied into two categories: 1. High-114
delity simulators and 2. Low-delity simulators. e delity115
of a simulator is determined by the degree to which it116
oers realism over characteristics like visual signs, tactile117
characteristics, feedback abilities, and user interface with the118
learner.119
High-fidelity simulators120
ese simulators make use of lifelike constituents and121
apparatus to embody the job that the student should execute.122
It provides the learner with added real-life signals to engage123
them in a much more accurate interactive situation. Here124
learners are questioned to relate the correct intrusion or125
J Clin Biomed Sci 2023;13(3):1–9 2
Ashokan et al., Simulation-based medical education
operation to perform a surgical technique.126
1. (a) Scenario presented on PC (High tech)127
(b) Anesthesiology simulators (High tech)128
(c) Human patient simulators (High tech)129
(d) Plastic manikin computerized sounds and physi-130
ology skill assessment131
(e) Anesthesiology training applications132
(f) Minimally invasive surgery trainer (High tech)133
Surgical Trainers134
(g) Bronchoscopy Simulator: Used to demonstrate135
the art of using a bronchoscope. System con-136
tains bronchoscope replica. e device is intro-137
duced into a mechanical interface mimicking the138
patient. Encoders are incorporated on both ends139
the bronchoscope and mechanical interface to140
track the user’s actions.141
(h) High delity Surgical Suite: Teaches multiple142
tasks and advanced problem solving143
(i) Battleeld trauma using HPS: Leg amputation144
from landmine using Human Patient Simulator145
productively.8
146
Low-fidelity simulators147
ey utilize tools and apparatus that are inferior simulations148
compared to a true medical environment. ey typically pro-149
vide to perform isolated techniques such as knot tying, prac-150
ticing dissection, intravenous line insertion, instrument man-151
agement and hand-eye coordination in endoscopic instru-152
ments.153
1. (a) Low-tech Simple 3-D organ models: ese are154
simple organ models made of plastic or cotton.155
(b) Hands-on Suture Simulator (Low tech): ese156
are static models also known as ‘Bench Models’. A157
wide variety of models includes, ‘knot tying train-158
ers, ‘Models for dissection and suturing’, ‘abdom-159
inal opening and closure trainers’, ‘episiotomy160
repair trainers’, ‘anal sphincter repair trainers’ and161
‘urethral sling procedure trainer’.162
(c) IV Trainer to Augment Human Patient Simula-163
tor (Low tech): Augmented with an inexpensive164
IV trainer for scenarios involving heavy bleeding.165
ese models may be reused for frequent practice166
of a certain clinical task. is includes ‘synthetic167
skin pads’ for suture practice, ‘synthetic arms’ for168
practicing IV cannulations, and the ‘Upper body169
torso’ for practicing airway skills.170
Basic mannequin (Low tech)171
1. (a) Full body mannequin: Patients are represented172
physically by mannequins. In advanced man-173
nequins by incorporating electronic devices phys-174
iological responses may be generated. ey can175
operate by providing the physical conditions like,176
heart and lung sounds, pulse rate, Blood pressure,177
pupil dimension and voice command etc. ese178
can provide training for personal tasks and for179
team-based learning.180
(b) Dummy type: ese are used for diagnostic pro-181
cedures and basic skills. ey simulate the phys-182
ical structure of patients. Various skill training is183
provided using these models in the earlier days.184
Human cadavers simulated185
ey deliver a realistic prototype for surgical skill exercises186
without involving the actual patient’s role. is is a better187
simulation model compared to others but evidence of the188
apprentice’s performance using the cadaver model is still not189
being documented.190
Realistic procedural simulators/Video Box191
Trainer192
Simulate various endoscopic surgical skills and techniques193
using original surgical instruments as well as equipment, with194
video monitors and cameras. “e Box Trainer” is an excellent195
mechanism for training eye-hand coordination, camera196
handling, suturing techniques, grasping mechanisms, point-197
to-point movements, cutting and clipping, and coordinated198
movements with small objects. Suturing skills may as well199
be performed using conventional sutures with needles. An200
essential feature of the “Box Trainer” is that it provides the201
trainee with the sensing of the equipment on the surface of202
the tissue and the pressure to close and open the instrument203
which is sensory feedback.204
Realistic interactive patient simulators205
ese standardized patients are made to play the role of a206
real patient. Clinical history can be obtained and a physical207
examination can be performed.208
Virtual reality/Surgical simulators209
Virtual reality is the knowledge that permits an operator to210
act together with a computer-simulated setting, whether it is211
real or ctional. Recent virtual reality settings are primarily212
graphical images that are exhibited either on a computer213
screen or through a specic stereoscopic display. It also214
incorporates haptic systems that combine tactic information,215
which is in form of force feedback. Alongside simulators make216
a recording and save actual data on individual execution on217
specic tasks time taken to achieve the task, the economy218
of hand motion, agility, and instrument path span. Example:219
Lap-Sim system.220
J Clin Biomed Sci 2023;13(3):1–9 3
Ashokan et al., Simulation-based medical education
Miscellaneous221
1. (a) Hybrid simulators222
A hybrid simulator combines a simulated patient with a223
“subtask trainer” to acquire clinical skills. Model wounds224
can be demonstrated on standardized patients, allowing225
participants to simultaneously learn clinical techniques,226
professional behaviors, and related communication skills227
Similarly, keeping a stethoscope over a simulated subject228
could be used to assess clinical signs such as cardiac murmurs229
and irregular breath sounds.230
Designing a Simulation Programme231
Firstly, learning objectives are dened followed by feedback232
from the faculty members and trainees are obtained. Best-233
suited simulators are identied. e preparatory phase con-234
sists of arranging infrastructure, procuring the simulators,235
maintenance, funding, and manpower.10
236
Preparation of blueprint: is is prepared for the training237
session by specifying textbooks, international guidelines and238
checklists. e number of trainers is allocated based on the239
students’ strength and the type of the skill to be taught. e240
resource persons have to be trained based on the total training241
hours of the session11 .242
Evaluation Phase: e student’s performance is evaluated243
based on their responses using a checklist. At the end of244
the session the drawbacks and strengths of the session is245
assessed12.246
Fig 1. Planning of a Clinical Session 13
Components of SBME247
e following are the essential components for a successful248
SBME program249
A.Training area and Debrieng room: It forms the area250
where the of the session is conducted from pre-lectures to the251
demonstration on the models.252
B. Simulators and equipment for training253
e usage of equipment also varies from simple plastic254
simulators to high-delity simulators with virtually assisted255
apparatuses. While using live organs and cadavers, a properly256
well-ventilated space for storage of cadaver is essential.257
C. Full-time faculty, instructor, and administrative sta258
Resource persons and administrative stas are essential259
for a successful simulation program. ey have a major role260
in maintaining equipment, scheduling the clinical sessions261
selecting and coordinating with learners.262
D. Educational content263
e content must include the learning objectives, the264
equipment, manual for using the equipment, the supporting265
supplies and the evaluation of the session. e content is266
designed in consultation with the personals in the clinical skill267
laboratory and the specialist in every department13.268
Benefits & limitations of269
simulation-based study270
Darla Brown once said, ”By making this doctor, I have not271
harmed my patients.” It oers a very safe and condent272
environment for both patients and learners. Medical students’273
knowledge and condence are reinforced through clinical274
skills lab work and simulation training making SBME, a275
valuable tool during the preclinical phase. e principles of276
adult active learning are reinforced and learners encounter277
a variety of clinical cases and rare situations. Simulation-278
based training integrates clinical and basic medicine. It279
also improves clinical outcomes, learning and training in280
appropriate clinical skills for medical students.14,15
281
Merits and Demerits of Medical simulation282
Merits283
1. Immersive and Experimental learning: e simulated284
events are believable enough to mentally connect the285
students, resulting in a unique learning experience. A286
high-delity simulator, can twinkle, inhale, talk, and287
make movements like an actual patient 16. A real patient288
can be simulated by high-delity Simulators in today’s289
world. ese types of simulated scenarios are strong290
enough to give pupils a unique learning experience.17.291
2. Better understanding of abstract concepts: e rst292
simulations in medical school can enhance your under-293
standing of fundamental perceptions in medicine such294
as pharmacology and physiology. ese replicated295
experiences help students appreciate intellectual ideas296
in basic science that are dicult to distinguish in nor-297
mal conversation18.298
3. Skill acquisition and maintenance: A signicant pro-299
portion of students showed better performance and300
management skills following simulation-based exer-301
cises than aer PowerPoint lectures19,20.302
4. Student satisfaction and condence: One of the exper-303
iments was teaching medical students how to man-304
J Clin Biomed Sci 2023;13(3):1–9 4
Ashokan et al., Simulation-based medical education
Table 1. Merits and Demerits of low and high-delity Surgical simulators
Simulator Description Measurement Advantages Disadvantages
Low delity
Bench models Static models, such as
knot tying and tissue
models for practicing
dissection and suturing
Direct observation Less costly Friendly
or made easy handi-
ness
No feedback to the trainee
from the model Need direct
observation for assessment.
Video box trainers Box with slits on the
anterior surface for
trocar insertion. make
use of true surgical
instruments including
cameras and video
screens.
Direct observation Use real surgical
instruments and
equipment. Provide
excellent training
for laparoscopy
because of sensory
feedback Moderately
expensive
Limited feedback Requires
direct observation for a full
assessment
High delity
Virtual reality stimu-
lators
A system that provides
a computer- simulated
environment to practice
surgical skills, consists
usually of laparoscopic
instruments and a desk-
top computer.
Performance is measured
fairly and data are stored
.so the learner can mon-
itor his/her progress. e
learner also can set the level
of diculty.
Objective Assess-
ment e learner can
practice at his/her
own pace.
Primarily visual experience,
few provide tactile informa-
tion. Expensive.
Procedural stimula-
tors
Virtual reality simula-
tors allow the learner to
learn the entire proce-
dure.
Direct observation Helps with basic sur-
gical skill acquisition
Enhances knowledge
and recognition of
anatomy and the
temporal sequence
of the procedure.
Animal Models Live animals Direct observation Real practice AvailabilityHigh cost Infec-
tion concerns Moral and
ethical concerns
Source: Hammoud. To the point: role of simulators in surgical training.9
Table 2. Skills learnt through clinical skill laboratory
Diagnostic Per rectal /vaginal exam. Abdominal/obstetrics exam visual acuity testing Documentation and certicate
of trauma diagnosis.
Performance Intramuscular, Intradermal, Intravenous, and subcutaneous injection Blood transfusion and Urinary
Catheterization Basic suturing, Basic wound care and bandaging Incision and drainage of supercial
abscess Basic fracture and dislocation management Eye irrigation, Instillation of eye medication, and
ocular bandaging
Resuscitative CPR in adults, children, and neonates Early management of trauma and trauma life support.
High delity Advance life support
age resuscitation during severe shock using simulation.305
e pupils claimed that it increased their degree of306
condence in handling circumstance aer a skill ses-307
sion21,22.308
5. Patient safety: Medical students cannot experiment309
on human subjects without previous practice skills.310
Exercise by simulation oers a safe atmosphere for311
training that does not endanger patients to risk by312
procedures accomplished by inexperienced trainees.23.313
6. Skill Training:314
(a) Rare event training: Simulation oers educators315
the capacity to deliver monitored training condi-316
tions under a selection of circumstances includ-317
ing unusual or high-risk circumstances24 .318
(b) Classroom-based training: Simulation-Based319
Medical Education is one method that allows320
students to understand educational uses in a321
J Clin Biomed Sci 2023;13(3):1–9 5
Ashokan et al., Simulation-based medical education
classroom. is can help out them realize the322
notions better than understanding in crowded323
hospital settings324
(c) Planning of training: Simulator-based medical325
training can be scheduled with predesigned clini-326
cal confronts rather than depend on random case327
accessibility25 .328
(d) Team training: Multidisciplinary team teaching329
and specic behavioral and interaction skills can330
be explained using simulated environments as331
it also oers educators a chance to examine332
participants26.333
(e) Analysis of training: Both students and instructors334
can review the instruction they received. e335
opportunity to review the training is unique336
for the organizers through the video and audio337
recordings of simulation circumstances.27 .338
(f) Training and retraining: Simulation-based train-339
ing permits learners to replicate processes as oen340
as required to x missteps and ne-tune their341
skills. It also permits for opinion and judgment of342
the act of individuals at the same level28 .343
7. Assessing performance: Simulators have been also344
suggested as an ideal instrument for the evaluation345
of learners’ clinical skills. is system allows the346
quantitative size of expertise, as well as replicates the347
same objective results29 .348
Demerits349
1. Incomplete mimicking of human system:Lots of data350
is gained from humans, not from instruments. Models351
and instruments can certainly not match humans352
entirely.353
2. Defective learning: Insuciently planned re-354
enactment can empower negative learning. Eg: if355
physical signs are missing within the re-enactment,356
understudies may neglect to check for these.357
3. Attitude of learners: Individuals will continuously358
consider a simulator in an unexpected way to actual359
life. Two common changes in demeanor can happen:360
(a) hypervigilance which causes over-the-top concern361
since one knows an occasion is almost to happen (b)362
careless conduct which happens since it is certain no363
human life is at stake30.364
4. Cost factor: Simulators especially the high delity ones365
are oered at signicant costs; both in terms of original366
purchase prices as well as maintenance charges. Hence,367
they are not reasonable for many teaching hospitals.368
5. Infrastructure: An educator-to- learner proportion of369
1:3–4 is perfect which isn’t attainable within the current370
restorative educational modules where each session371
comprises a bunch of 10–15 medical undergraduates.372
6. Technical diculties: Some physical ndings like skin373
color cannot be taught in simulators.374
7. Programming diculties: e simulation models have375
to be controlled by facilitators and simulation engineers376
in such a way as to reproduce a physiological reaction377
that may be required under specic conditions.378
8. Learner-specic teaching not possible.379
31
380
Fig 2. Millers Pyramid: e Eect of Implementing Innovative
Education Strategies31
Miller’s learning pyramid is oen mentioned as a guide to381
explain dierent stages of learning and skill gain. e rst382
two levels explain reasoning/cognitive aspects and the third383
fourth level refers to procedural skills. Obtaining knowledge384
and employing it happens under the rst two levels. In the385
third level, the procedural skills are executed, and the skill lab386
training takes place on the third level of Miller’s Pyramid.387
Instructors may wish to present optimally circumstances388
according to the abilities of dierent learners (Advanced389
tasks for procient students while basic tasks for new or390
slow learners). is individualized approach is not possible391
in simulation-based teaching. e acquisition of procedural392
skills from SBME doesn’t carry out the learning sequence393
of the medical students without learning the rst two394
levels of Millers Pyramid. Self-learning by students without395
understanding the rst two levels can tend to travel the wrong396
path with incorrect procedures and clinical skills.32,33
397
Simulation vs other intervention : Technology enhanced398
simulation shows small, statistically signicant benet for399
knowledge and skills outcomes. Anesthesia review showed400
moderate eects for satisfaction and skills, large eect for401
provider behavior, small eect for direct patient benet402
compared with non-simulation instruction. Negligible eects403
are noticed comparing simulation to alternative simulation404
interventions. Meta- Analysis showed inconsistencies in405
measurement of non-technical skills34 . Simulation based406
education is probably as good as (but is not necessarily better407
than) other types of instruction. ere is a high degree of408
variability between studies, suggesting that certain simulation409
interventions may be more eective in certain scenarios.35,36
410
J Clin Biomed Sci 2023;13(3):1–9 6
Ashokan et al., Simulation-based medical education
Clinical studies related to skill lab411
training412
Daniel et al., conducted a study with medical students (n413
85) from 2nd and 3rd year MBBS curriculum in which414
an audiovisual instruction followed by high delity man-415
nequins were provided during an Adult and child CPR train-416
ing session. Pretest and Post-test self-assessment question-417
naires were given. Simulation-based training improves the418
knowledge and skill of medical students37 .419
Hermann-Werner et al. (n94). organized a randomized420
controlled experiment among 4 group of students. One group421
was trained with TRAD model (Traditional See One, Do422
One) other group was trained with BPSL (Best Practice423
model). ese groups were monitored every 3 and 6 months.424
e study found that the BPSL group was advanced to the425
TRAD groups for several complex skills when examined both426
immediately and aer a follow-up period of three and six427
months.38 .428
Al Suwaidi et al. (n84) described the inuence of the429
simulation in acquiring clinical skills using “Kirkpatrick’s430
Evaluation Framework. IST group of students (n= 49) were431
oered “interactive learning tutorials” and the second group432
of students (n=35) were given simulation sessions to discuss433
the clinical vignette. Aer the session, the second group of434
students responded eectivity of the simulation session39 .435
Swami et al. (n24) divided into two groups of students.436
One group tested each other’s chests and the other group437
tested with their ‘SimMan’ model of high delity. e two438
groups then switched places and the groups switched subjects.439
ree tests were performed (pretest, mid- test, and post test).440
e study showed that knowledge and ability to perform441
chest exercises increased signicantly, as did students’ test442
performance and condence levels.40 .443
Conclusion444
Over the year’s models with Simulation machinery evolved445
along with medical procedures. It has gained rapid advance-446
ment in last few years beginning from part assignment train-447
ers to highly advanced computer-guided simulators with448
innovative technologies. More dicult devices have come449
into the market and Simulation is rened to a more advanced450
stage41. It has oered its hand in clinical practice and health451
care deliverance, particularly in the eld of patient protection452
and evaluation42 . As a part of professional learning, the Skill453
laboratory is taking place as an integral part of the medical454
curriculum oering both technical and non-technical skills to455
medical students43 . Medical professionals acquire knowledge456
and many skills such as professionalism, self-evaluation, man-457
agement, communication, and teamwork through SBME.458
With proper learning objectives, designing the clinical skill459
program with ecient teaching faculty and equipment, the460
SBME is a boon to medical students44 .461
Abbreviations462
SBME: Simulation-Based Medical Education463
Authors’ contribution464
Author 1 has reviewed the literature and prepared the465
manuscript. 2 gave signicant contributions to revising the466
text and bibliography, 3,4 & 5 signicantly contributed to467
revising the article.468
Acknowledgment469
e authors would like to acknowledge the ecient library470
sta of Shaqra university, Saudi online Digital library, the471
Administration & Dean and vice Dean of Shaqra university,472
and Skill Lab in charge of the College of Medicine for provid-473
ing logistic support. e authors express sincere gratitude to474
Mrs. Monami Chakraborty, Free2learn, UK, who checked the475
nal linguistic revision of this manuscript.476
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