Simulation-based medical education: an ethical imperative

Reducing Maternal Mortality and Severe Maternal Morbidity: The Role of Critical Care

Throughout most of the 20th century, the risk of maternal mortality in high resource countries decreased dramatically; however, this trend recently has stalled in the United States and appears to have reversed. Equally alarming is that for every reported maternal death, there are numerous severe maternal morbidities or near misses. Shifting maternal demographics (eg, obesity, advanced maternal age, multifetal pregnancies), with attendant significant medical comorbidities (eg, hypertension, diabetes, cardiac disease) and the increase in cesarean deliveries significantly contribute to increased maternal morbidity and mortality. This chapter focuses on the role of critical care in reducing maternal mortality and morbidity.

The Impact of Phone Interruptions on the Quality of Simulated Medication Order Validation Using Eye Tracking: A Pilot Study

INTRODUCTION

Order validation is an important component of pharmacy services, where pharmacists review orders with a focus on error prevention. Interruptions are frequent and may contribute to a reduction in error detection, thus potential medication errors. However, studying such errors in practice is difficult. Simulation has potential to study these events.

METHODS

This was a pilot, simulation study. The primary objective was to determine the rate of medication error detection and the effect of interruptions on error detection during simulated validation. Secondary objectives included determining time to complete each prescription page. The scenario consisted of validating three handwritten medication order pages containing 12 orders and 17 errors, interrupted by three phone calls timed during one order for each page. Participants were categorized in groups: seniors and juniors (including residents). Simulation sessions were videotaped and eye tracking was used to assist in analysis.

RESULTS

Eight senior and five junior pharmacists were included in the analysis. There was a significant association between interruption and error detection (odds ratio = 0.149, 95% confidence interval = 0.042-0.525, P = 0.005). This association did not vary significantly between groups (P = 0.832). Juniors took more time to validate the first page (10 minutes 56 seconds vs. 6 minutes 42 seconds) but detected more errors (95% vs. 69%). However, all major errors were detected by all participants.

CONCLUSIONS

We observed an association between phone interruptions and a decrease in error detection during simulated validation. Simulation provides an opportunity to study order validation by pharmacists and may be a valuable teaching tool for pharmacists and pharmacy residents learning order validation.

Addressing the growing opioid and heroin abuse epidemic: a call for medical school curricula

Substance abuse is a growing public health concern in the USA (US), especially now that the US faces a national drug overdose epidemic. Over the past decade, the number of drug overdose deaths has rapidly grown, largely driven by increases in prescription opioid-related overdoses. In recent years, increased heroin and illicitly manufactured fentanyl overdoses have substantially contributed to the rise of overdose deaths. Given the role of physicians in interacting with patients who are at risk for or currently abusing opioids and heroin, it is essential that physicians are aware of this issue and know how to respond. Unfortunately, medical school curricula do not devote substantial time to addiction education and many physicians lack knowledge regarding assessment and management of opioid addiction. While some schools have modified curricula to include content related to opioid prescription techniques and pain management, an added emphasis about the growing role of heroin and fentanyl is needed to adequately address the epidemic. By adapting curricula to address the rising opioid and heroin epidemic, medical schools have the potential to ensure that our future physicians can effectively recognize the signs, symptoms, and risks of opioid/heroin abuse and improve patient outcomes. This article proposes ways to include heroin and fentanyl education into medical school curricula and highlights the potential of simulation-based medical education to enable students to develop the skillset and emotional intelligence necessary to work with patients struggling with opioid and heroin addiction. This will result in future doctors who are better prepared to both prevent and recognize opioid and heroin addiction in patients, an important step in helping reduce the number of addicted patients and address the drug overdose epidemic.

Pre-departure Training for Healthcare Students Going Abroad: Impact on Preparedness

Background:

Many medical and nursing schools offer opportunities for students to participate in global health experiences abroad, but little is known about the efficacy of pre-departure training in preparing students for these experiences.

Objectives:

The primary aim was to identify characteristics of pre-departure training associated with participants’ reporting a high level of preparedness for their global health experiences. Secondary objectives included identifying students’ preferred subjects of study and teaching modalities for pre-departure training.

Methods:

A questionnaire was distributed to all medical and nursing students at our institution from 2013 to 2015. Questions addressed prior global health experiences and pre-departure training, preferences for pre-departure training, and demographic information.

Findings:

Of 517 respondents, 55% reported having a prior global health experience abroad, 77% of whom felt prepared for their experience. Fifty-three percent received pre-departure training. Simply receiving pre-departure training was not associated with perceived preparedness, but pre-departure training in the following learning domains was: travel safety, personal health, clinical skills, cultural awareness, and leadership. Perceiving pre-departure training as useful was also independently associated with self-reported preparedness. Students’ preferred instruction methods included discussion, lecture, and simulation, and their most desired subjects of study were travel safety (81%), cultural skills (87%), and personal health (82%).

Conclusions:

Incorporating travel safety, personal health, clinical skills, cultural awareness, and/or leadership into pre-departure training may increase students’ preparedness for global health experiences. Student perceptions of the usefulness of pre-departure training is also associated with self-reported preparedness, suggesting a possible “buy-in” effect.

Pre-departure Training for Healthcare Students Going Abroad: Impact on Preparedness

BACKGROUND

Many medical and nursing schools offer opportunities for students to participate in global health experiences abroad, but little is known about the efficacy of pre-departure training in preparing students for these experiences.

OBJECTIVES

The primary aim was to identify characteristics of pre-departure training associated with participants' reporting a high level of preparedness for their global health experiences. Secondary objectives included identifying students' preferred subjects of study and teaching modalities for pre-departure training.

METHODS

A questionnaire was distributed to all medical and nursing students at our institution from 2013 to 2015. Questions addressed prior global health experiences and pre-departure training, preferences for pre-departure training, and demographic information. Findings: Of 517 respondents, 55% reported having a prior global health experience abroad, 77% of whom felt prepared for their experience. Fifty-three percent received pre-departure training. Simply receiving pre-departure training was not associated with perceived preparedness, but pre-departure training in the following learning domains was: travel safety, personal health, clinical skills, cultural awareness, and leadership. Perceiving pre-departure training as useful was also independently associated with self-reported preparedness. Students' preferred instruction methods included discussion, lecture, and simulation, and their most desired subjects of study were travel safety (81%), cultural skills (87%), and personal health (82%).

CONCLUSIONS

Incorporating travel safety, personal health, clinical skills, cultural awareness, and/or leadership into pre-departure training may increase students' preparedness for global health experiences. Student perceptions of the usefulness of pre-departure training is also associated with self-reported preparedness, suggesting a possible "buy-in" effect.

Mock ECHO: A Simulation-Based Medical Education Method

Problem: This study was designed to develop a deeper understanding of the learning and social processes that take place during the simulation-based medical education for practicing providers as part of the Project ECHO® model, known as Mock ECHO training. The ECHO model is utilized to expand access to care of common and complex diseases by supporting the education of primary care providers with an interprofessional team of specialists via videoconferencing networks. Intervention: Mock ECHO trainings are conducted through a train the trainer model targeted at leaders replicating the ECHO model at their organizations. Trainers conduct simulated teleECHO clinics while participants gain skills to improve communication and self-efficacy. Context: Three focus groups, conducted between May 2015 and January 2016 with a total of 26 participants, were deductively analyzed to identify common themes related to simulation-based medical education and interdisciplinary education. Principal themes generated from the analysis included (a) the role of empathy in community development, (b) the value of training tools as guides for learning, (c) Mock ECHO design components to optimize learning, (d) the role of interdisciplinary education to build community and improve care delivery, (e) improving care integration through collaboration, and (f) development of soft skills to facilitate learning. Outcome: Mock ECHO trainings offer clinicians the freedom to learn in a noncritical environment while emphasizing real-time multidirectional feedback and encouraging knowledge and skill transfer. Lessons Learned: The success of the ECHO model depends on training interprofessional healthcare providers in behaviors needed to lead a teleECHO clinic and to collaborate in the educational process. While building a community of practice, Mock ECHO provides a safe opportunity for a diverse group of clinician experts to practice learned skills and receive feedback from coparticipants and facilitators.

Low-cost three-dimensional printed phantom for neuraxial anesthesia training: Development and comparison to a commercial model

METHODS

Anonymized CT DICOM data was segmented to create a 3D model of the lumbar spine. The 3D model was modified, placed inside a digitally designed housing unit and fabricated on a desktop 3D printer using polylactic acid (PLA) filament. The model was filled with an echogenic solution of gelatin with psyllium fiber. Twenty-two staff anesthesiologists performed a spinal and epidural on the 3D printed simulator and a commercially available Simulab phantom. Participants evaluated the tactile and ultrasound imaging fidelity of both phantoms via Likert-scale questionnaire.

RESULTS

The 3D printed neuraxial phantom cost $13 to print and required 25 hours of non-supervised printing and 2 hours of assembly time. The 3D printed phantom was found to be less realistic to surface palpation than the Simulab phantom due to fragility of the silicone but had significantly better fidelity for loss of resistance, dural puncture and ultrasound imaging than the Simulab phantom.

CONCLUSION

Low-cost neuraxial phantoms with fidelity comparable to commercial models can be produced using CT data and low-cost infrastructure consisting of FLOS software and desktop 3D printers.

Simulation-based education: A narrative review of the use of VERT in radiation therapy education

Simulation has a long history in medical and health science training and education. The literature describing this history is extensive. The role simulation plays in many health disciplines has evolved, as has the focus of the literature around it. The Virtual Environment for Radiotherapy Training (VERT) system is a relative newcomer to radiation therapy education and, similar to the literature around radiation therapy (RT) education, is still in its infancy. This narrative review sets the scene of simulation-based education within the health sciences and considers the lessons learned from published work on VERT to date. The evidence suggests that future inquiry involving VERT should explore different ways in which VERT can be used to contribute to the skillset required by the radiation therapist of tomorrow.

Investigating the impact of moulage on simulation engagement - A systematic review

BACKGROUND

Simulation Based Education (SBE) is used as a primer for clinical education in nursing and other health professions. Participant engagement strategies and good debriefing have been identified as key for effective simulations. The environment in which the simulation is situated also plays a large role in the degree of participant engagement. Various cues are staged within simulations to enhance this engagement process. Moulage techniques are used in current-day simulation to mimic illnesses and wounds, acting as visual and tactile cues for the learner. To effectively utilise moulage in simulation, significant expense is required to train simulation staff and to purchase relevant equipment.

OBJECTIVE

Explore the use of moulage in simulation practice today and its influence on participant engagement.

DESIGN

Using a systematic process to extract papers, we reviewed the literature with a critical-realist lens.

DATA SOURCES

CINAHL Complete, ERIC, Embase, Medline, PsycINFO, SCOPUS, Web of Science, Proquest, Science Direct and SAGE.

REVIEW METHODS

10 databases were systematically reviewed using the keyword "moulage" to answer the question "How does the authenticity of moulage impact on participant engagement?". 1318 records were identified prior to exclusion criterion were applied. 10 articles were targeted for review, following exclusion for English language and publication between 2005 and 2015.

RESULTS

The resulting 10 papers were assessed for quality using the Medical Education Research Study Quality Instrument (MERSQI). The majority of papers were situated in dermatology teaching, with only one nursing paper. Study participants were both undergraduate and postgraduate. Most of the studies were undertaken at a university setting. No papers comprehensively addressed whether the authenticity of moulage influences learner engagement.

CONCLUSIONS

Results were limited, yet clearly outline a widely held assumption that moulage is essential in simulation-based education for improved realism and subsequent learner engagement. Despite this, there is no clear evidence from the literature that this is the case, suggesting that further research to explore the impact of moulage on participant engagement is warranted. A number of recommendations are made for future research.

Delivering Bad News: Attitudes, Feelings, and Practice Characteristics Among Speech-Language Pathologists

PURPOSE

The purpose of this study was to examine the attitudes, feelings, and practice characteristics of speech-language pathologists (SLPs) in Israel regarding the subject of delivering bad news.

METHOD

One hundred and seventy-three Israeli SLPs answered an online survey. Respondents represented SLPs in Israel in all stages of vocational experience, with varying academic degrees, from a variety of employment settings. The survey addressed emotions involved in the process of delivering bad news, training on this subject, and background information of the respondents. Frequency distributions of the responses of the participants were determined, and Pearson correlations were computed to determine the relation between years of occupational experience and the following variables: frequency of delivering bad news, opinions regarding training, and emotions experienced during the process of bad news delivery.

RESULTS

Our survey showed that bad news delivery is a task that most participants are confronted with from the very beginning of their careers. Participants regarded training in the subject of delivering bad news as important but, at the same time, reported receiving relatively little training on this subject. In addition, our survey showed that negative emotions are involved in the process of delivering bad news.

CONCLUSIONS

Training SLPs on specific techniques is required for successfully delivering bad news. The emotional burden associated with breaking bad news in the field of speech-language pathology should be noticed and addressed.

Education and Training in Pediatric Cardiac Critical Care

Pediatric cardiac critical care is a new and emerging field. There is no standardization to the current education provided, and high-quality patient outcomes require such standardization. For physicians, this includes fellowship training, specific competencies, and a certification process. For advanced practice providers, a standardized curriculum as well as a certification process is needed. There is evidence that supports a finding that critical care nursing experience may have a positive impact on outcomes from pediatric cardiac surgery. A rigorous orientation and meaningful continuing education may augment that. For all disciplines and levels of expertise, simulation is a useful modality in the education in pediatric cardiac critical care.

Patients with chronic conditions: simulate to educate?

Simulation in healthcare in an way to train professionals but it is not yet use commonly to train patient or their caregivers. Recently, it has been suggested to extend simulations to patients with chronic conditions. Simulations could help patients and caregivers to acquire psychosocial and self-management skills. This approach proved to be effective for the training of healthcare professionals, but its transferability to patients needs to be evaluated. Already, several questions arise. However, by considering simulations as pretexts for debriefing, they enable patients and professionals to assess a concrete situation, implying voluntary and reflexive learning processes. Thus, video recording should be assessed for its role in patient metacognition, defined as knowing about knowing. A taxonomy for simulations dedicated to patients, like that already developed for healthcare professionals, should be considered. Although practical constraints must be identified and addressed, they should not be the primary issue guiding research. The transferability of simulation as an educational technique from professionals to patients and caregivers should be investigated essentially in order to provide a significant benefit to patients.

Learning outcomes evaluation of a simulation-based introductory course to anaesthesia

OBJECTIVE

An increased number of errors and reduced patient safety have been reported during the incorporation of residents, as this period involves learning new skills. The objectives were to evaluate the learning outcomes of an immersive simulation boot-camp for incoming residents before starting the clinical rotations. Airway assessment, airway control with direct laryngoscopy, and epidural catheterization competencies were evaluated.

MATERIAL AND METHOD

Twelve first-year anaesthesiology residents participated. A prospective study to evaluate transfer of endotracheal intubation skills learned at the simulation centre to clinical practice (primary outcome) was conducted. A checklist of 28 skills and behaviours was used to assess the first supervised intubation performed during anaesthesia induction in ASA I/II patients. Secondary outcome was self-efficacy to perform epidural catheterization. A satisfaction survey was also performed.

RESULTS

Seventy-five percent of residents completed more than 21 out of 28 skills and behaviours to assess and control the airway during their first intubation in patients. Twelve items were performed by all residents and 5 by half of them. More than 83% of participants reported a high level of self-efficacy in placing an epidural catheter. All participants would recommend the course to their colleagues.

CONCLUSIONS

A focused intensive simulation-based boot-camp addressing key competencies required to begin anaesthesia residency was well received, and led to transfer of airway management skills learned to clinical settings when performing for first time on patients, and to increased self-reported efficacy in performing epidural catheterization.

Modeling Touch and Palpation Using Autoregressive Models

OBJECTIVE

The human haptic system uses a set of reproducible and subconscious hand maneuvers to identify objects. Similar subconscious maneuvers are used during medical palpation for screening and diagnosis. The goal of this work was to develop a mathematical model that can be used to describe medical palpation techniques.

METHODS

Palpation data were measured using a two-dimensional array of force sensors. A novel algorithm for estimating the hand position from force data was developed. The hand position data were then modeled using multivariate autoregressive models. Analysis of these models provided palpation direction and frequency as well as palpation type. The models were tested and validated using three different data sets: simulated data, a simplified experiment in which participant followed a known pattern, and breast simulator palpation data.

RESULTS

Simulated data showed that the minimal error in estimating palpation direction and frequency is achieved when the sampling frequency is five to ten times the palpation frequency. The classification accuracy was for the simplified experiment and for the breast simulator data.

CONCLUSION

Proper palpation is one of the vital components of many hands-on clinical examinations. In this study, an algorithm for characterizing medical palpation was developed. The algorithm measured palpation frequency and direction for the first time and provided classification of palpation type.

SIGNIFICANCE

These newly developed models can be used for quantifying and assessing clinical technique, and consequently, lead to improved performance in palpation-based exams. Furthermore, they provide a general tool for the study of human haptics.

Engagement and learning in simulation: recommendations of the Simnovate Engaged Learning Domain Group

Background

Health professions education (HPE) is based on deliberate learning activities and clinical immersion to achieve clinical competence. Simulation is a tool that helps bridge the knowledge-to-action gap through deliberate learning. This paper considers how to optimally engage learners in simulation activities as part of HPE.

Methods

The Simnovate Engaged Learning Domain Group undertook 3 teleconferences to survey the current concepts regarding pervasive learning. Specific attention was paid to engagement in the learning process, with respect to fidelity, realism and emotions, and the use of narratives in HPE simulation.

Results

This paper found that while many types of simulation exist, the current ways to categorise the types of simulation do not sufficiently describe what a particular simulation will entail. This paper introduces a novel framework to describe simulation by deconstructing a simulation activity into 3 core characteristics (scope, modality and environment). Then, the paper discusses how engagement is at the heart of the learning process, but remained an understudied phenomenon with respect to HPE simulation. Building on the first part, a conceptual framework for engaged learning in HPE simulation was derived, with potential use across all HPE methods.

Discussion

The framework considers how the 3 characteristics of simulation interplay with the dimensions of fidelity (physical, conceptual and emotional), and how these can be conveyed by and articulated through beauty (as a proxy for efficiency) as coexisting factors to drive learner engagement. This framework leads to the translation of deliberately taught knowledge, skills and attitudes into clinical competence and subsequent performance.

Preliminary evaluation of the efficacy of an intervention incorporating precision teaching to train procedural skills among final cycle medical students

Introduction

A lack of preparedness for practice has been observed among new medical graduates. Simulation technology may offer one means of producing competency. This paper describes the application of a simulation-based intervention incorporating precision teaching (PT), a method of defining target skills, assessing individual progress and guiding instructional decisions, which is used to monitor learning and the development of behavioural fluency in other domains, to procedural skills training. Behavioural fluency refers to accurate and rapid responding that does not deteriorate with time, is resistant to distraction and can be adapted into new, more complex responses.

Method

This study used a between-groups design to evaluate the efficacy of a simulation-based intervention incorporating PT for teaching venepuncture among 11 medical students. The intervention consisted of timed learning trials during which participants carried out the skill in pairs and received corrective feedback. Two control groups of 11 untrained medical students and 11 junior doctors were also included in the study.

Results

Intervention group participants required an average of five trials and 21.9 min to reach the criterion for fluency. The intervention group demonstrated significantly higher accuracy in venepuncture performance than either control group. Improvements persisted over time, did not deteriorate during distraction, generalised to performance with patients and performance of an untargeted skill also improved.

Conclusions

The outcomes of this preliminary study support the application of PT within medical education. The implications of these data for clinical and procedural skills training are explored and suggestions are made for further research.

[Learning how to learn for specialist further education]

The world of medicine is becoming from year to year more complex. This necessitates efficient learning processes, which incorporate the principles of adult education but with unchanged periods of further education. The subject matter must be processed, organized, visualized, networked and comprehended. The learning process should be voluntary and self-driven with the aim of learning the profession and becoming an expert in a specialist field. Learning is an individual process. Despite this, the constantly cited learning styles are nowadays more controversial. An important factor is a healthy mixture of blended learning methods, which also use new technical possibilities. These include a multitude of e‑learning options and simulations, which partly enable situative learning in a "shielded" environment. An exemplary role model of the teacher and feedback for the person in training also remain core and sustainable aspects in medical further education.

Designing in situ simulation in the emergency department: evaluating safety attitudes amongst physicians and nurses

BACKGROUND

This intervention study aimed to enhance patient safety attitudes through the design of an in situ simulation program based on a needs analysis involving thematic analysis of patient safety data and short-term ethnography. The study took place at an Emergency Department (ED) in the Central Region of Denmark. Research suggests that poor handover communication can increase the likelihood of critical incidents and adverse events in the ED. Furthermore, simulation is an effective strategy for training handover communication skills. Research is lacking, however, on how to use patient safety data and a needs analysis to the design of in situ simulation communication training.

METHODS

This is a prospective pre-post study investigating the interventional effects of in situ simulation. It used a three-pronged strategy: (1) thematic analysis of patient safety data consisting of reported critical incidents and adverse events, (2) a needs analysis based on short-term ethnography in the ED, and (3) pre-post evaluation using the validated Safety Attitudes Questionnaire (SAQ) and the Trainee Reactions Score.

RESULTS

Sixteen different healthcare teams participated composed by 9 physicians and 30 nurses. In the SAQ, participating staff scored their safety attitudes in six categories (n = 39). Two measures where significantly higher for the post-SAQ than those for the pre-SAQ: teamwork climate (p < 0.001) and safety climate (p < 0.05). The Trainee Reactions Score showed that the training was positively evaluated.

CONCLUSIONS

This study designed a feasible strategy for implementing in situ simulation based on a needs analysis of critical incidents and adverse events and short-term ethnography.

Impact of providing case-specific knowledge in simulation: a theory based study of learning

Background

Simulation-based education (SBE) has been lauded for its ability to help students recognise and react appropriately to common and rare circumstances. While healthcare professions have started to implement SBE into their curriculum, there is no evidence to suggest which educational theory is best for implementation. This study explores the usage of cognitive load theory (CLT) and the unified theory of emotional learning (UTEL).

Study design

A mixed methods ordered-allocation cohort study.

Methods

23 patient management teams were allocated into 2 groups. The first group received prior information about the simulation scenario; the second group did not. Each team had 1 student assigned to the role of doctor. The scenarios were filmed at time 1 (T1), time 2 (T2) and follow-up (F/U). The ‘doctor’ role was then graded with a validated checklist by a three-judge panel. The scores were evaluated to determine if prior information enabled better performance. Secondary analysis evaluated the role of gender on performance and also evaluated anxiety at the onset of the simulation.

Results

23 doctors were evaluated. There was no difference between groups in performance (t=1.54, p=0.13). Secondary analysis indicated that gender did not play a role. There was no difference in anxiety between groups at baseline (t=0.67, p=0.51).

Conclusions

Trends were observed, suggesting that when students enter a simulation environment with prior knowledge of the event they will encounter, their performance may be higher. No differences were observed in performance at T2 or F/U. Withholding information appeared to be an inappropriate proxy for emotional learning as no difference in anxiety was observed between groups at baseline. All trends require confirmation with a larger sample size.

Game theory and strategy in medical training

OBJECTIVE

This paper analyses how game theory can provide a framework for understanding the strategic decision-making that occurs in everyday scenarios in medical training and practice, and ultimately serves as a tool for improving the work environment and patient care. Game theory has been applied to a variety of fields outside of its native economics, but has not been thoroughly studied in the context of health care provision.

METHODS

The paper discusses four of the most common 'games' and applies each to a scenario in medicine to provide new insight on the incentives and drivers for certain types of behaviour and a deeper understanding of why certain results are valued more strongly than others.

CONCLUSIONS

Using game theory as an integrative tool, in conjunction with good judgement and a sound knowledge base, trainees and physicians can work to better recognise where competing priorities exist, understand the motivations and interactions of the various players, and learn to adjust their approaches in order to 'change the game' when their preferred outcome is not the most likely one.

The Benefits and Risks of Being a Standardized Patient: A Narrative Review of the Literature

Standardized patients (SPs) are a widely used, valid, and reliable means of teaching and evaluating healthcare providers (HCPs) across all levels of training and across multiple domains of both clinical and communication skills. Most research on SP programs focuses on outcomes pertinent to the learners (i.e., HCPs) rather than how this experience affects the SPs themselves. This review seeks to summarize the current literature on the risks and benefits of being an SP. We reviewed the literature on the effects that simulation has on adults, children/adolescents, and medical professionals who serve as SPs, in addition to real patients (RPs) who are involved in teaching by sharing their medical histories and experiences. To collect the literature, we conducted two separate systematic searches: one for SPs and one for RPs. Following the searches, we applied standardized eligibility criteria to narrow the literature down to articles within the scope of this review. A total of 67 studies were included that focused on the outcomes of SPs or RPs. The benefits for those portraying SP roles include improved health knowledge and attitudes, relationships with their HCPs, and changed health behaviors. Negative effects of being an SP include anxiety, exhaustion/fatigue, and physical discomfort immediately following a simulation, but the literature to date appears to indicate that there are no long-lasting effects. These findings are consistent across age groups and the type of role being simulated. They are also supported by studies of RPs who are involved in medical education. Overall, the benefits of being an SP appear to outweigh the known risks. However, there are significant limitations in the current literature, and additional studies are needed to better characterize the SP experience.

General Anesthesia for a Posttonsillectomy and Adenoidectomy Bleed

INTRODUCTION

Providers at all levels should have some understanding of the pathophysiology and be able to manage such a patient in the operating room. In addition, any anesthetists providing pediatric care should be able to identify and understand the importance of other comorbid conditions in these patients. This simulation on posttonsillectomy and adenoidectomy hemorrhage in the pediatric patient presents a challenging case usually encountered in some form by most anesthesia residents during training. This simulation's objective is to challenge and further reinforce the knowledge of anesthesiology resident physicians who have completed 1 year of clinical anesthesia and at least 1 month of pediatric anesthesia.

METHODS

The simulation can be delivered in a single session of 1 hour or less. Materials in this simulation include a case template designed to provide facilitators with a general overview, a checklist of critical actions each learner should perform during the scenario, a brief summary to be provided to the learner to reinforce knowledge gained through the activity, and an evaluation form to assess the learner's view of the activity's educational value.

RESULTS

Learner comments were almost unanimously positive. All learners who returned surveys answered the questions "This simulation enhanced my understanding of how to manage critically ill patients in the perioperative period" and "The content was current and relevant to my practice" with either agree or strongly agree.

DISCUSSION

The module offers various points to practice troubleshooting skills in the management of difficult IV line placement as well as difficult airway management. In reality, this case could be modified in multiple ways, including management of a more severe hemorrhage with a much more hypovolemic patient.

Development of an Emergency Medicine Simulation Fellowship Consensus Curriculum: Initiative of the Society for Academic Emergency Medicine Simulation Academy

OBJECTIVES

There is currently no consolidated list of existing simulation fellowship programs in emergency medicine (EM). In addition, there are no universally accepted or expected standards for core curricular content. The objective of this project is to develop consensus-based core content for EM simulation fellowships to help frame the critical components of such training programs.

METHODS

This paper delineates the process used to develop consensus curriculum content for EM simulation fellowships. EM simulation fellowship curricula were collected. Curricular content was reviewed and compiled by simulation experts and validated utilizing survey methodology, and consensus was obtained using a modified Delphi methodology.

RESULTS

Fifteen EM simulation fellowship curricula were obtained and analyzed. Two rounds of a modified Delphi survey were conducted. The final proposed core curriculum content contains 47 elements in nine domains with 14 optional elements.

CONCLUSION

The proposed consensus content will provide current and future fellowships a foundation on which to build their own specific and detailed fellowship curricula. Such standardization will ultimately increase the transparency of training programs for future trainees and potential employers.

Simulation-based training in echocardiography

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

Building consensus for the future of paediatric simulation: a novel ‘KJ Reverse-Merlin’ methodology

Objectives

This project aims to identify guiding strategic principles to optimise simulation-based educational impact on learning, patient safety and child health.

Methods

Study participants included 39 simulation experts who used a novel ‘KJ Reverse-Merlin’ consensus process in the systematic identification of barriers to success in simulation, grouped them in themes and subsequently identified solutions for each theme.

Results

193 unique factors were identified and clustered into 6 affinity groups. 6 key consensus strategies were identified: (1) allocate limited resources by engaging health systems partners to define education and research priorities; (2) conduct and publish rigorous translational and cost-effectiveness research; (3) foster collaborative multidisciplinary research and education networks; (4) design simulation solutions with systems integration and sustainability in mind; (5) leverage partnerships with industry for simulation, medical and educational technology; (6) advocate to engage the education community, research funding agencies and regulatory bodies.

Conclusions

Simulation can be used as a research, quality improvement and or educational tool aimed at improving the quality of care provided to children. However, without organisation, strategy, prioritisation and collaboration, the simulation community runs the risk of wasting resources, duplicating and misdirecting the efforts.

Gaze entropy reflects surgical task load

BACKGROUND

Task (over-)load imposed on surgeons is a main contributing factor to surgical errors. Recent research has shown that gaze metrics represent a valid and objective index to asses operator task load in non-surgical scenarios. Thus, gaze metrics have the potential to improve workplace safety by providing accurate measurements of task load variations. However, the direct relationship between gaze metrics and surgical task load has not been investigated yet. We studied the effects of surgical task complexity on the gaze metrics of surgical trainees.

METHODS

We recorded the eye movements of 18 surgical residents, using a mobile eye tracker system, during the performance of three high-fidelity virtual simulations of laparoscopic exercises of increasing complexity level: Clip Applying exercise, Cutting Big exercise, and Translocation of Objects exercise. We also measured performance accuracy and subjective rating of complexity.

RESULTS

Gaze entropy and velocity linearly increased with increased task complexity: Visual exploration pattern became less stereotyped (i.e., more random) and faster during the more complex exercises. Residents performed better the Clip Applying exercise and the Cutting Big exercise than the Translocation of Objects exercise and their perceived task complexity differed accordingly.

CONCLUSIONS

Our data show that gaze metrics are a valid and reliable surgical task load index. These findings have potential impacts to improve patient safety by providing accurate measurements of surgeon task (over-)load and might provide future indices to assess residents' learning curves, independently of expensive virtual simulators or time-consuming expert evaluation.

Evaluating medical student engagement during virtual patient simulations: a sequential, mixed methods study

BACKGROUND

Student engagement is an important domain for medical education, however, it is difficult to quantify. The goal of this study was to investigate the utility of virtual patient simulations (VPS) for increasing medical student engagement. Our aims were specifically to investigate how and to what extent the VPS foster student engagement. This study took place at A.T. Still University School of Osteopathic Medicine in Arizona (ATSU-SOMA), in the USA.

METHODS

First year medical students (n = 108) worked in teams to complete a series of four in-class virtual patient case studies. Student engagement was measured, defined as flow, interest, and relevance. These dimensions were measured using four data collection instruments: researcher observations, classroom photographs, tutor feedback, and an electronic exit survey. Qualitative data were analyzed using a grounded theory approach.

RESULTS

Triangulation of findings between the four data sources indicate that VPS foster engagement in three facets: 1) Flow. In general, students enjoyed the activities, and were absorbed in the task at hand. 2) Interest. Students demonstrated interest in the activities, as evidenced by enjoyment, active discussion, and humor. Students remarked upon elements that caused cognitive dissonance: excessive text and classroom noise generated by multi-media and peer conversations. 3) Relevance. VPS were relevant, in terms of situational clinical practice, exam preparation, and obtaining concrete feedback on clinical decisions.

CONCLUSIONS

Researchers successfully introduced a new learning platform into the medical school curriculum. The data collected during this study were also used to improve new learning modules and techniques associated with implementing them in the classroom. Results of this study assert that virtual patient simulations foster engagement in terms of flow, relevance, and interest.

Death During Simulation: A Literature Review

INTRODUCTION

One of the goals of simulation is to teach subjects critical skills and knowledge applicable to live encounters, without the risk of harming actual patients. Although simulation education has surged in medical training over the last two decades, several ethically challenging educational methods have arisen. Simulated death has arisen as one of these challenging issues and currently there is no consensus regarding how to best manage this controversial topic in the simulated environment. The goal of this review is to analyze how simulated mortality has been used and discover whether or not this tool is beneficial to learners.

METHODS

In May 2016, the authors performed a literature search on both Pubmed and the Cochrane database using multiple variations of keywords; they then searched bibliographies and related articles.

RESULTS

There were 901 articles acquired in the initial search. The authors eliminated articles that were not relevant to the subject matter. After adding articles from bibliographies and related articles, the authors included the 43 articles cited in this article.

DISCUSSION

As a result, the authors of this article believe that death, when used appropriately in simulation, can be an effective teaching tool and can be used in a responsible manner.

Building and Participating in a Simulation: Exploring a Continuing Education Intervention Designed to Foster Reflective Practice Among Experienced Clinicians

INTRODUCTION

Engaging health professionals in the processes of first building and then participating in simulations has not yet been explored. This qualitative study explored the experience of building and participating in a simulation as an educational intervention with experienced clinicians.

METHODS

Pediatric rehabilitation clinicians, along with a patient facilitator and standardized patients, created simulations and subsequently participated in a live simulation. The educational content of the simulation was culturally sensitive communication. We collected participants' perspectives about the process from individual journal entries and focus groups. A thematic analysis of these data sources was conducted.

RESULTS

Participants described a process of building and participating in a simulation that provided: 1) a unique opportunity for clinicians to reflect on their current practice; 2) a venue to identify different perspectives through discussion and action in a group; and 3) a safe environment for learning.

DISCUSSION

The combined process of building and participating in a simulation stimulated reflection about the clinicians' own abilities in culturally sensitive communication through discussion, practice, and feedback. It provided a safe environment for participants to share their multiple perspectives and to develop new ways of communicating. This type of educational intervention may contribute to the continuing education of experienced clinicians in both academic and community settings.

Naval casualty management training using human patient simulators

BACKGROUND

Extended-evacuation or austere environments (e.g. naval, immature or depleted combat zones) are characterized by the lack of resources to facilitate medical evacuation in the "Golden Hour" from moment of injury. This may require the primary caregiver, often a relatively inexperienced general physician or EMT, to administer extended medical care in the field. We describe the Shipboard and Underwater Casualty Care and Sedation Simulation (SUCCeSS) program in the Israeli Navy, intended to train caregivers for extended prehospital intensive casualty care using high fidelity life-size simulation mannequins set up onboard corvettes or submarines during maneuvers, in maximally realistic conditions. Twenty two general physicians and EMTs in 12 teams were enrolled in the program in the years 2011-2013. Two to three hour long training sessions were headed by senior surgeons and anesthesiologists using flexible scripts enabling the mannequin operators to react to caregivers' actions and their consequences. Trainee evaluation was performed by the preceptors using semi-structured forms taking into account both critical treatment decisions and observation on the effects of actions taken. Trainees also completed self-report CRM (Crisis Resource Management) questionnaires before and after the sessions.

RESULTS

Success of the trainees correlated with an evaluation score above 72%. The mean overall CRM score for team leaders post exercise was 74.64%, an improvement of 10% over pre-exercise scores (p < 0.0001).

CONCLUSION

Caregiver self-perceived competence and self-sufficiency in treating casualties at sea was improved via high fidelity simulation in theatre using realistic naval casualty care situations. We discuss the relative strengths and weaknesses of our training program for the teaching of "NCM", or Naval Casualty Management, as well as the emergent concepts of the military extended evacuation environment.

Team-based clinical simulation in radiation medicine: value to attitudes and perceptions of interprofessional collaboration

Introduction

Simulation has been effective for changing attitudes towards team-based competencies in many areas, but its role in teaching interprofessional collaboration (IPC) in radiation medicine (RM) is unknown. This study reports on feasibility and IPC outcomes of a team-based simulation event; ‘Radiation Medicine Simulation in Learning Interprofessional Collaborative Experience’ (RM SLICE).

Methods

Radiation therapy (RTT), medical physics (MP) and radiation oncology (RO) trainees in a single academic department were eligible. Scheduled closure of a modern RM clinic allowed rotation of five high-fidelity cases in three 105-minute timeslots. A pre/post-survey design evaluated learner satisfaction and interprofessional perceptions. Scales included the Readiness for Interprofessional Learning Scale (RIPLS), UWE Entry Level Interprofessional Questionnaire (UWEIQ), Trainee Test of Team Dynamics and Collaborative Behaviours Scale (CBS).

Results

Twenty-one trainees participated; six ROs (28·57%), six MPs (28·57%) and nine RTTs (42·86%). All cases were conducted, resolved and debriefed within the allotted time. Twenty-one complete sets (100%) of evaluations were returned. Participants reported limited interaction with other professional groups before RM SLICE. Perceptions of team functioning and value of team interaction in ‘establishing or improving the care plan’ were high for all cases, averaging 8·1/10 and 8·9/10. Average CBS scores were 70·4, 71·9 and 69·5, for the three cases, scores increasing between the first and second case for 13/21 (61·9%) participants. RIPLS and UWEIQ scores reflected positive perceptions both pre- and post-event, averaging 83·5 and 85·2 (RIPLS) and 60·6 and 55·7 (UWEIQ), respectively. For all professions for both scales, the average change in score reflected improved IP perceptions, with agreement between scales for 15/20 (75·0%) participants. Overall, perception of IPC averaged 9·14/10, as did the importance of holding such an event annually.

Conclusions

Team-based simulation is feasible in RM and appears to facilitate interprofessional competency-building in high-acuity clinical situations, reflecting positive perceptions of IPC.

Pediatric Neurology Training in Canada: Current Status and Future Directions

Background:

Child neurology training in Canada has changed considerably over time, with increasing requirements for standardized teaching of the fundamentals of child neurology and the CanMEDS competencies. We sought to determine the current status of child neurology training in Canada as well future directions for training.

Method:

A web-based survey was sent to program directors (PD's) of active pediatric neurology training programs. General questions about the programs were asked, as well as about success at the Royal College of Physicians and Surgeons of Canada (RCPSC) exam, breakdown of rotations, views on CanMEDS roles and questions on the future of pediatric neurology.

Results:

9/9 PD's completed the survey. 96.5% of all trainees successfully passed their RCPSC exam from 2001-2006. Breakdowns of the number and type of rotations for each year of training were provided. All CanMEDS roles were deemed to be important by PD's and programs have developed unique strategies to teach and assess these roles. 92.6% of trainees chose to go into academic practice, with the most popular subspecialty being epilepsy. All PD's favour joint training sessions particularly for neurogenetics and neuromuscular disease. Overall, PD's suggest recruitment for future child neurologists at the medical student level but are divided as to whether we are currently training too few or too many child neurologists.

Conclusions:

This survey provides a view of the current state of pediatric neurology training in Canada and suggestions for further development of postgraduate training. In particular, attention should be given to joint educational programs as well as urgently assessing the manpower needs of child neurologists.

Assessment of performance measures and learning curves for use of a virtual-reality ultrasound simulator in transvaginal ultrasound examination

OBJECTIVE

To assess the validity and reliability of performance measures, develop credible performance standards and explore learning curves for a virtual-reality simulator designed for transvaginal gynecological ultrasound examination.

METHODS

A group of 16 ultrasound novices, along with a group of 12 obstetrics/gynecology (Ob/Gyn) consultants, were included in this experimental study. The first two performances of the two groups on seven selected modules on a high-fidelity ultrasound simulator were used to identify valid and reliable metrics. Performance standards were determined and novices were instructed to continue practicing until they attained the performance level of an expert subgroup (n = 4).

RESULTS

All 28 participants completed the selected modules twice and all novices reached the expert performance level. Of 153 metrics, 48 were able to be used to discriminate between the two groups' performance. The ultrasound novices scored a median of 43.8% (range, 17.9-68.9%) and the Ob/Gyn consultants scored a median of 82.8% (range, 60.4-91.7%) of the maximum sum score (P < 0.001). The ultrasound novices reached the expert level (88.4%) within a median of five iterations (range, 5-6), corresponding to an average of 219 min (range, 150-251 min) of training. The test/retest reliability was high, with an intraclass correlation coefficient of 0.93.

CONCLUSIONS

Competence in the performance of gynecological ultrasound examination can be assessed in a valid and reliable way using virtual-reality simulation. The novices' performance improved with practice and their learning curves plateaued at the level of expert performance, following between 3 and 4 h of simulator training.

Emulating Upper Limb Disorder for Therapy Education

Robotics not only contributes to the invention of rehabilitation devices, it can also enhance the quality of medical education. In recent years, the use of patient simulators and part-task trainers in the medical education field has brought meaningful improvements in the training of medical practitioners. Nevertheless, in the context of therapy training for upper limb disorders, trainee therapists still have to engage directly with the patients to gain experience of the rehabilitation of physical diseases. In this work, a high-fidelity part-task trainer that is able to reproduce the stiffness of spasticity and rigidity symptoms of the upper limb, such as those observed in post-stroke patients and Parkinson's disease patients, has been developed. Based on the evaluation carried out by two experienced therapists, the developed part-task trainer is able to simulate different patient cases and help trainee therapists gain pre-clinical experience in a safe and intuitive learning environment.

Using virtual worlds for role play simulation in child and adolescent psychiatry: an evaluation study

Aims and method To develop and evaluate a novel teaching session on clinical assessment using role play simulation. Teaching and research sessions occurred sequentially in computer laboratories. Ten medical students were divided into two online small-group teaching sessions. Students role-played as clinician avatars and the teacher played a suicidal adolescent avatar. Questionnaire and focus-group methodology evaluated participants' attitudes to the learning experience. Quantitative data were analysed using SPSS, qualitative data through nominal-group and thematic analyses. Results Participants reported improvements in psychiatric skills/knowledge, expressing less anxiety and more enjoyment than role-playing face to face. Data demonstrated a positive relationship between simulator fidelity and perceived utility. Some participants expressed concern about added value over other learning methods and non-verbal communication. Clinical implications The study shows that virtual worlds can successfully host role play simulation, valued by students as a useful learning method. The potential for distance learning would allow delivery irrespective of geographical distance and boundaries.

Use of simulation-based education: a national survey of pediatric clerkship directors

OBJECTIVE

To document the prevalence of simulation-based education (SBE) for third- and fourth-year medical students; to determine the perceived importance of SBE; to characterize the barriers associated with establishing SBE.

METHODS

A 27-item survey regarding simulation was distributed to members of the Council on Medical Student Education in Pediatrics (COMSEP) as part of a larger survey in 2012.

RESULTS

Seventy-one (48%) of 147 clerkship directors (CD) at COMSEP institutions responded to the survey questions regarding the use of SBE. Eighty-nine percent (63 of 71) of CDs reported use of SBE in some form: 27% of those programs (17 of 63) reported only the use of the online-based Computer-Assisted Learning in Pediatrics Program, and 73% (46 of 63) reported usage of other SBE modalities. Fifty-four percent of CDs (38 of 71) agreed that SBE is necessary to meet the requirements of the Liaison Committee on Medical Education (LCME). Multiple barriers were reported in initiating and implementing an SBE program.

CONCLUSIONS

SBE is commonly used for instruction during pediatric undergraduate medical education in North American medical schools. Barriers to the use of SBE remain despite the perception that it is needed to meet requirements of the LCME.

Simulation Training in Health Care

In this chapter, we discuss the application of human factors and ergonomics to developing effective simulation training in health care. Simulation provides a safe, effective method for training and assessing human performance. In aviation, simulation-based training and assessment has been widely used, significantly improving safety. This progress would have been impossible without the involvement of human factors and ergonomics. Although aviation and health care have similarities, there also are differences that complicate the widespread implementation of simulation in health care.

Canadian Association of University Surgeons' Annual Symposium. Surgical simulation: the solution to safe training or a promise unfulfilled?

At its 2009 annual symposium, chaired by Dr. William (Bill) Pollett, the Canadian Association of University Surgeons brought together speakers with expertise in surgery and medical education to discuss the role of surgical simulation for improving surgical training and safety. Dr. Daniel Jones, of Harvard University and the 2009 Charles Tator Lecturer, highlighted how simulation has been used to teach advanced laparoscopic surgery. He also outlined how the American College of Surgeons is moving toward competency assessments as a requirement before surgeons are permitted to perform laparoscopic surgery on patients. Dr. Teodor Grantcharov, from the University of Toronto, highlighted the role of virtual reality simulators in laparoscopic surgery as well as box trainers. Dr. Peter Brindley from the University of Alberta, although a strong proponent of simulation, cautioned against an overzealous adoption without addressing its current limitations. He also emphasized simulation's value in team training and crisis resource management training. Dr. Chris de Gara, also from the University of Alberta, questioned to what extent simulators should be used to determine competency. He raised concerns that if technical skills are learned in isolation, they may become "decontextualized," and therefore simulation might become counterproductive. He outlined how oversimplification can have an "enchanting" effect, including a false sense of security. As a result, simulation must be used appropriately and along the entire education continuum. Furthermore, far more needs to be done to realize its role in surgical safety.

Virtual Reality Simulator

Background. The overriding importance of patient safety, the complexity of surgical techniques, and the challenges associated with teaching surgical trainees in the operating room are all factors driving the need for innovative surgical simulation technologies. Technical development. Despite these issues, widespread use of virtual reality simulation technology in surgery has not been fully implemented, largely because of the technical complexities in developing clinically relevant and useful models. This article describes the successful use of the NeuroTouch neurosurgical simulator in the resection of a left frontal meningioma. Conclusion. The widespread application of surgical simulation technology has the potential to decrease surgical risk, improve operating room efficiency, and fundamentally change surgical training.

[Bringing clinical simulation into anesthesiology and postoperative recovery care residency training]

This article describes the use of clinical simulations for training residents in anesthesiology and postoperative recovery care at Hospital Universitario Marqués de Valdecilla. A working group defined criteria for the competencies residents would acquire by means of simulation training, designed the scenarios to be used, and took responsibility for coordinating and funding the program. We used the platform of the Critical Events Training Center of the Marcelino Botin Foundation, now part of our center's virtual hospital. The simulation-based training modules include 4 activities in the residents' first year, 3 in each of the second and third years, and 4 in the fourth year; all center on acquisition of the identified competencies and take into consideration the time availability of residents and instructors and the budget. We have concluded that integrating clinical simulations into residency training is a challenge for educators, given that a large part of the benefit derived from this tool comes from complementing it with other instructional resources and adapting it to the syllabus. More studies are required to establish criteria to guide the integration of this tool into the curriculum in those areas of the specialty where it can work most efficiently; the effectiveness of the approach also needs to be assessed. Simulations facilitate training without putting patients at risk and provide residents with early exposure to situations that might otherwise be difficult to observe. This tool also encourages the practice of reflective clinical decision-making.