Obstetric simulation for medical student, resident, and fellow education

A Literature Study of Medical Simulations for Non-Technical Skills Training in Emergency Medicine: Twenty Years of Progress, an Integrated Research Framework, and Future Research Avenues

Medical simulations have led to extensive developments in emergency medicine. Apart from the growing number of applications and research efforts in patient safety, few studies have focused on modalities, research methods, and professions via a synthesis of simulation studies with a focus on non-technical skills training. Intersections between medical simulation, non-technical skills training, and emergency medicine merit a synthesis of progress over the first two decades of the 21st century. Drawing on research from the Web of Science Core Collection's Science Citation Index Expanded and Social Science Citation Index editions, results showed that medical simulations were found to be effective, practical, and highly motivating. More importantly, simulation-based education should be a teaching approach, and many simulations are utilised to substitute high-risk, rare, and complex circumstances in technical or situational simulations. (1) Publications were grouped by specific categories of non-technical skills, teamwork, communication, diagnosis, resuscitation, airway management, anaesthesia, simulation, and medical education. (2) Although mixed-method and quantitative approaches were prominent during the time period, further exploration of qualitative data would greatly contribute to the interpretation of experience. (3) High-fidelity dummy was the most suitable instrument, but the tendency of simulators without explicitly stating the vendor selection calls for a standardised training process. The literature study concludes with a ring model as the integrated framework of presently known best practices and a broad range of underexplored research areas to be investigated in detail.

Simulation-based training for embryo transfer for clinicians with differing levels of expertise: an application of the American Society for Reproductive Medicine Embryo Transfer Simulator

Objective

To compare the learning curve of clinicians with different levels of embryo transfer (ET) experience using the American Society for Reproductive Medicine (ASRM) Embryo Transfer Simulator.

Design

Prospective cohort study.

Setting

Single large university-affiliated in vitro fertilization center.

Patients

Participants with 3 levels of expertise with ET were recruited: "group 1" (Reproductive Endocrinology and Infertility attendings), "group 2" (Reproductive Endocrinology and Infertility nurses, advance practice providers, or medical assistants), and "group 3" (Obstetrics and Gynecology resident physicians).

Interventions

All participants completed ET simulation training using uterine cases A, B, and C (easiest to most difficult) of the ASRM ET Simulator. Participants completed each case 5 times for a total of 15 repetitions.

Main Outcome Measures

The primary outcome was ET simulation scores analyzed at each attempt for each uterine case, with a maximum score of 155. Secondary outcomes included self-assessed comfort levels before and after the completion of the simulation and total duration of ET. Comfort was assessed using a 5-point Likert scale.

Results

Twenty-seven participants with 3 different levels of expertise with ET were recruited from December 2020 to February 2021. For cases A and B, median total scores were not significantly different between groups 1 and 3 at first or last attempts. Group 2 did not perform as well as group 3 at the beginning of case A or group 1 at the end of case B. All groups demonstrated a decrease in total time from the first attempt to the last attempt for both cases. For case C, the "difficult" uterus, groups 2 and 3 exhibited the greatest improvement in total median score: from 0 to 75 from the first to last attempt. Group 1 scored equally well from first through last attempts. Although no one from group 2 or 3 achieved a passing score with the first attempt (80% of the max score), approximately 30% had passing scores at the last attempt. Groups 1 and 3 showed a significant decrease in total time across attempts for case C. Following simulation, 100% of groups 2 and 3 reported perceived improvement in their skills. Group 3 showed significant improvement in comfort scores with Likert scores of 1.71 ± 0.76 and 1.0 ± 0.0 for the "Easy" and "Difficult" cases, respectively, before simulation and 4.57 ± 0.53 and 2.4 ± 1.1 after simulation.

Conclusions

The ASRM ET Simulator was effective in improving both technical skill and comfort level, particularly for those with little to no ET experience and was most marked when training on a difficult clinical case.

Practice and expectations regarding simulation for residents in obstetrics and gynecology

BACKGROUND

Simulation now has an important role in theoretical and practical aspects of medical education and training.

METHODS

We performed an epidemiological, observational, multicenter study based on nationwide data collection. French obstetrics and gynecologic residents were invited to complete an anonymous survey.

RESULTS

We received 305 answers. The most frequently offered gynecology sessions were laparoscopy on pelvitrainer (76%) and pelvic ultrasound (60%) while the most frequently offered obstetric sessions were breech delivery (61%), shoulder dystocia (62%) and postpartum hemorrhage (68%) managements. Regarding session frequency, 29.1% of residents thought that one session per month would be ideal. Two hundred and sixty three residents (96%) considered that simulation-training sessions were beneficial. One hundred and thirty-six residents (49%) had an opportunity to repeat sessions and a majority of them (96%) found a daily benefit following a training simulation session.

CONCLUSION

Simulation programs were extremely popular among the surveyed residents. To improve OBGYN resident training, simulation should be an integral part of residency programs.

The impact of Covid-19 on simulation-based learning of gynecology and obstetrics skills

Simulation-based learning can be defined as a modern learning and training method. The pan-European curriculum for training in obstetrics and gynecology PACT (Project for Achieving Consensus in Training) incorporates medical simulation and recommends its urgent implementation in the national residency programs of individual countries. The current Covid-19 pandemic presents challenges to the medical community. During the first wave of the pandemic, Italy was the most severely affected EU country, whereas during the second wave Slovenia was among those most affected. The severe limitations of the lockdown and post-lockdown led to significant changes in all healthcare organizations and, consequently, also training activities in obstetrics and gynecology. Limitations on training during the Covid-19 pandemic may have severely impacted the opportunity to learn basic clinical and surgical skills. A potential strategy for overcoming these limitations was offered by simulation activities, which allowed trainees to receive basic training in our discipline and prevented an additional "lockdown" of their learning and development of skills. This type of simulation training will be of paramount importance, considering the paradigm shift caused by the Covid-19 pandemic in lifestyle and healthcare activities.Abbreviations: ACOG: American college of obstetricians and gynecologists; EBCOG: European board and college of obstetrics and gynaecology; ICU: intensive care unit; OR: operating room; PACT: project for achieving consensus in training; PUI: patient under investigation.

Readiness: Utilizing bundles and simulation

Postpartum hemorrhage is an important contributor to maternal morbidity, and is one of the most common worldwide causes of preventable maternal mortality. Preventing significant morbidity and mortality from postpartum hemorrhage necessitates preparedness on both a unit and patient level. Our objectives are to define a bundle, to review the elements of the Council on Patient Safety in Women's Healthcare Obstetric Hemorrhage Bundle and to highlight simulation-based training opportunities, focusing on readiness for this significant obstetric emergency.

To the Point: The expanding role of simulation in obstetrics and gynecology medical student education

This article, from the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC), provides educators with an overview of the use of simulation in undergraduate medical education in the field of obstetrics and gynecology. Simulation plays an important role in the education of medical students. Students are increasingly serving as clinical observers and providing less direct patient care. Simulation can help standardize education and ensure quality and comparability across an enlarging educational environment. This article summarizes the expanding role of simulation in undergraduate medical education in obstetrics and gynecology and its effect on important learner outcomes such as confidence, knowledge, skills, workplace behaviors, and translation to patient care.

Impact of a Multidimensional Technical Skills Training Session Before Obstetrics and Gynaecology Clerkship Rotation on Performance and Exposure

OBJECTIVE

This study sought to assess the impact of an obstetrics and gynaecology (OBGYN) multidimensional technical skills training session on medical student self-perceived confidence, objective performance, clinical exposure, and interest in OBGYN.

METHODS

OBGYN clerkship students were divided into control (i.e., traditional curriculum) and intervention (i.e., additional pre-rotation simulation training in vaginal delivery, suturing and knot tying, speculum and bimanual examinations, and intrapartum cervical examination) groups. Both groups underwent an objective structured clinical examination (OSCE) after the rotation and completed pre- and post-rotation questionnaires to assess confidence, clinical exposure, and interest in OBGYN. The primary outcomes were self-reported confidence and OSCE scores, and the secondary outcomes were clinical exposure and interest in OBGYN.

RESULTS

A total of 148 students participated. Both groups reported least confidence with vaginal delivery and cervical examinations before the rotation. There was improved self-confidence across all skills after the rotation, with the intervention group demonstrating greater improvement for vaginal delivery (3.36 vs. 3.10; P < 0.05) and cervical examination (3.14 vs. 2.86; P < 0.05). The intervention group also demonstrated a trend towards higher OSCE scores for all skills, but only speculum and bimanual examinations reached statistical significance. The intervention increased exposure from "0 to 5" to "6 to 10" for vaginal delivery and suturing. There was no difference in interest in OBGYN between the two groups.

CONCLUSION

A technical skills training session before OBGYN clerkship is feasible and has the potential to increase students' confidence, OSCE performance, and hands-on procedural exposure. The optimal combination of skills to be included still needs to be defined.

Medical students and midwives - How do they view each other?

Medical students from James Cook University who had completed their rotation in obstetrics, and midwives working in Cairns Hospital who had undertaken supervision of medical students in the birth suite, were invited to complete anonymous questionnaires on their views of their respective roles in the birth suite. Several issues were identified including increased medical and midwifery student numbers, and lack of communication between midwives and medical students. Increased cooperation and communication between medical and midwifery education providers is urgently needed to improve both student groups' learning experiences.

Internal Podalic Version and Breech Extraction: Enhancing Realistic Sensations in a Simulation Model

BACKGROUND

Experience with internal podalic version and breech extraction is diminishing, especially in the younger generation of obstetricians. Simulation training is essential to teach and maintain these skills.

INSTRUMENT

We present a mannequin-based simulation method that enhances realistic sensations during training.

EXPERIENCE

By positioning the fetal mannequin into a thin plastic bag filled with water, the impression of palpating, grabbing, and pulling the fetal feet through the plastic bag is similar to reaching feet through intact membranes. The unique approach of this realistic simulation model makes the experience fun and memorable, which contributes to the didactic value and success of the model.

CONCLUSION

The simulation model we present mimics the situation and sensation obstetricians experience while performing internal podalic version and breech extraction.

[Vaginal delivery in case of breech presentation: Impact of a service's incentive]

OBJECTIVES

The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices.

METHODS

A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared.

RESULTS

One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes.

CONCLUSIONS

This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.

Embryo transfer simulation improves pregnancy rates and decreases time to proficiency in Reproductive Endocrinology and Infertility fellow embryo transfers

OBJECTIVE

To design and evaluate an ET simulator to train Reproductive Endocrinology and Infertility (REI) fellows' techniques of ET.

DESIGN

Simulation model development and retrospective cohort analysis.

SETTING

Not applicable.

PATIENT(S)

Patients undergoing IVF.

INTERVENTION(S)

Simulation model evaluation and implementation of ET simulation training.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

The REI fellow and faculty evaluation responses (n = 19/21 [90%]) of the model demonstrated realistic characteristics, with evaluators concluding the model was suitable for training in almost all evaluated areas. A total of 12 REI fellows who performed ET were analyzed: 6 before ET trainer and 6 after ET trainer. Pregnancy rates were 31% in the initial 10 ETs per fellow before simulator vs. 46% after simulator. One of six pre-ET trainer fellows (17%) had pregnancy rates ≥40% in their first 10 ETs; whereas four of six post-ET trainer fellows had pregnancy rates ≥40% in their first 10 ETs. The average number of ETs to obtain >40% pregnancy efficiency was 27 ETs before trainer vs. 15 ETs after trainer. Pregnancy rates were similar in the two groups after 20 ETs, and collective terminal pregnancy rates were >50% after 40 ETs.

CONCLUSION(S)

Embryo transfer simulation improved REI fellow pregnancy rates in their first 10 transfers and led to a more rapid ET proficiency. These data suggest potential value in adopting ET simulation, even in programs with a robust history of live ET in fellowship training.

High-Fidelity Simulation Use in Preparation of Physician Assistant Students for Neonatal and Obstetric Care

PURPOSE

The study attempts to determine whether a simulation experience would increase physician assistant (PA) students' comfort level in caring for obstetric patients and assessing a neonate with an Apgar score.

METHODS

First-year PA students who are in the didactic phase of their education were asked to complete a questionnaire before and after a hybrid simulation scenario, in which they aided in estimating cervical dilation, delivering a neonate, and assessing the Apgar score of a neonate. The simulation included high-fidelity simulation for 2 portions of the experience and task-trainer simulation for the remaining portion of the experience. The questionnaire asked students to rate their comfort level before and after the simulation and provide information regarding their clinical experience level with obstetrics, gynecology, or pediatrics.

RESULTS

Comfort levels were significantly increased according to presession and postsession scores for each of the 3 portions of the simulation experience. Prior experience level did not affect the results of this group. Results indicate that regardless of experience, there was a statistically significant increase between presession and postsession comfort levels.

CONCLUSIONS

Simulation training in obstetric and neonatal assessment increases students' comfort level to perform these difficult tasks. Physician assistant programs that are not performing simulation currently, or have not used it to train in these specialty areas should consider doing so as part of their curriculum.

Assessment of Developmental Progress Using an Objective Structured Clinical Examination-Simulation Hybrid Examination for Obstetrics and Gynecology Residents

OBJECTIVE

The Test of Integrated Professional Skills (TIPS) is an objective structured clinical examination-simulation hybrid examination that assesses resident integration of technical, cognitive, and affective skills in Obstetrics and Gynecology (OBGYN) residents. The aim of this study was to analyze performance patterns and reactions of residents to the test to understand how it may fit within a comprehensive assessment program.

DESIGN

A retrospective, mixed methods review of the design and implementation of the examination, patterns of performance of trainees at different levels of training, focus group data, and description of use of TIPS results for resident remediation and curriculum development.

SETTING

OBGYN residents at New York University Langone Medical Center, a tertiary-care, urban academic health center.

PARTICIPANTS

OBGYN residents in all years of training, postgraduate year-1 through postgraduate year, all residents completing the TIPS examination and consenting to participate in focus groups were included.

RESULTS

In all, 24 residents completed the TIPS examination. Performance on the examination varied widely among individuals at each stage of training, and did not follow developmental trends, except for technical skills. Cronbach α for both standardized patient and faculty ratings ranged from 0.69 to 0.84, suggesting internal consistency. Focus group results indicated that residents respond to the TIPS examination in complex ways, ranging from anxiety about performance to mixed feelings about how to use the data for their learning.

CONCLUSION

TIPS assesses a range of attributes, and can support both formative and summative evaluation. Lack of clear developmental differences and wide variation in performance by learners at the same level of training support the argument for individualized learning plans and competency-based education.

Use of the Learning Curve-Cumulative Summation Test for Leopold Maneuvers Assessment in a Simulator: A Pilot Study

INTRODUCTION

Simulation enables medical students to practice clinical skills in a safe environment. Graduates in medicine must be able to correctly perform an examination on a pregnant woman using Leopold maneuvers. Learning curves-cumulative summation (LC-CUSUM) may help determine when the student has achieved a specific skill. Our objective was to perform the LC-CUSUM test regarding the ability of students to correctly carry out Leopold maneuvers; a pregnancy simulator was used, transferring the results to a clinical setting.

METHODS

Five medical students were trained to carry out Leopold maneuvers using the simulator. Each student performed maneuvers for 50 cases of different fetus positions; a LC-CUSUM was plotted for each student. Afterward, the students performed the Leopold maneuvers on 5 pregnant women.

RESULTS

Of the 5 students, 3 achieved a level of proficiency; the attempts needed for reaching this level were 13, 13, and 37, respectively. The other 2 students did not reach proficiency level. Of the students who became successfully proficient with the simulator, one of them attained a 100% success rate in pregnant patients, whereas the other two had success rates of 80%. The students who did not achieve a level of competency with the simulator had only a 60% success rate with patients.

CONCLUSIONS

Because of the differences observed between students in the number of attempts needed for achieving proficiency in Leopold maneuvers, we believe that each student should build his/her own learning curve. Achieving competency in carrying out Leopold maneuvers using the simulator could be transferable to patients.

A randomized controlled trial of birth simulation for medical students

OBJECTIVE

The objective of the study was to evaluate the effectiveness of a high-fidelity birth simulator (Noelle; Gaumard Scientific, Coral Gables, FL) compared with a lower-cost, low-tech, birth simulator (MamaNatalie; Laerdal Medical, Stavanger, Norway) in teaching medical students how to perform a spontaneous vaginal delivery (SVD).

STUDY DESIGN

Prior to the obstetrics-gynecology clerkship, students were randomly assigned to 2 groups. The MamaNatalie group (MG) completed 45 minutes of SVD simulation using an obstetrical abdominal-pelvic model worn by an obstetrics-gynecology faculty member. The Noelle group (NG) completed 45 minutes of SVD simulation using a high-fidelity, computer-controlled mannequin facilitated by an obstetrics-gynecology faculty member. The primary outcome was student performance during his or her first SVD as rated by supervising preceptors. Surveys were also completed by students on confidence in performing steps of a SVD (secondary outcome).

RESULTS

One hundred ten medical students (95% of those eligible) participated in this research study. The final postclerkship survey was completed by 93 students (85% follow-up rate). There were no significant differences in performance of SVD steps between MG and NG students as rated by preceptors. The SVD step with the least involvement by students was controlling the head (20.5% in MG, 23.3% in NG performed step with hands-off supervision). Delivery of the placenta was the SVD step with the most involvement (65.9% in MG, 52.3% in NG performed step with hands-off supervision). Baseline presimulation confidence levels were similar between MG and NG. On the immediate postsimulation survey of confidence, MG students were significantly more confident in their ability to deliver the abdomen and legs and perform fundal massage with hands-off supervision (P < .05) than NG students. Following the clerkship, MG students were significantly more confident in their ability to control the head and deliver the abdomen and legs (P < .05) than NG students.

CONCLUSION

MamaNatalie is as effective as Noelle in training medical students how to perform a SVD and may be a useful, lower-cost alternative in teaching labor and delivery skills to novice learners. Because birth simulation interventions involve both a simulation model and facilitator, research is required to further determine the effect of human interaction on learning outcomes.