Simulation Based Medical Education

1. Simulation Based Medical Education Trevor Langhan PGY-4 Masters of Medical Education Candidate University of Calgary

2. Rounds Outline • Ethics of Simulation Based Medical Education • Uses of Simulation Based Medical Education • Procedural skill acquisition with simulation techniques • Local initiatives in Simulation Based Medical Education research

3. Medical Education “medical teaching must at some point use live patients to hone the skills of health professionals.” • Balanced with the obligation to provide optimal treatment and to ensure patient safety • Traditional apprenticeship model has learners receiving guided instruction during skill acquisition “see one, do one, teach one.”

4. Why Simulation? • 1999 Institute of Medicine report – • ‘to err is human’ • Highlighted the cognitive and technical errors in medical education • Patient safety became an important agenda item • Licensing and governing bodies challenged to improve physician confidence and patient safety

5. Ethical Themes of Simulation • Best standards of care and training • Error management and patient safety • Patient autonomy • Social justice – resource allocation “patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.”

6. 1. Best Standards • Best standard for patient care • First do no harm to patients • Using patients as learning instruments is only justified when all approaches to minimize risks have been taken • Simulation allows trainees’ first encounters with real patients to be at higher technical and clinical proficiencies

7. 1. Best Standards • Best standard for education • Responsibility of educators to provide clinicians with best training • Best standard for evaluation • Traditional evaluation focused on cognitive domain • With simulation can assess attitudinal and psychomotor as well

8. 2. Error management • Even with supervision it is inevitable that trainees cause preventable injuries • In clinical setting errors must be stopped promptly • In simulation errors may be allowed to progress • Errors can occur at any level in medical education • SBME has uses in UME, PGME, CME

9. 3. Patient Autonomy • Patients have the right to direct their own care • Historical reports of procedures or physical exam skills being practiced on: • Deceased • Drugged • Anesthetized

10. 4. Social Justice • Basic principle of distributive justice states: • Citizens equally share the risks of medical innovation, research and practice training • Most teaching institutions are urban and provide disproportionate care to the poor and under privileged • SBME may help equilibrate this imbalance

11. Simulation Based Medical Education • Simulation is a complimentary teaching method in the medical profession: “any educational activity that uses simultative aids to enhance medical educational message” “not to replace traditional methods, but to add to”

12. Resus Annie 1960 cadaver Anesthesia Sim 1986 Mannikins Task trainer Interactive 2000s Virtual Reality 1990 and now

13. SBME - uses • As described by Ziv: • ‘hands on’ uses to teach clinical skills • CME tool for practicing MDs • Teamwork training to enhance patient safety • Introduction of new technologies in safe manner • Ultimately may be used for assessment for licensing and certification • In broad range of situations • Traditional classrooms, home PC, simulation suites

14. What is Simulation? • Simulation is a technique – not a technology • Use in Medical Education is to: “replace or amplify real experiences with guided experiences that evoke or replicate aspects of the real world.”

15. What is Simulation? • Simulation is defined as: “the representation of the operation or features of one process or system through the use of another.” “the artificial replication of sufficient components of a real-world situation to achieve certain goals.”

16. What is Simulation? • Simulation is a representation of reality • How well does it represent actual clinical reality? • A question of fidelity

17. What is fidelity? “is the extent to which the appearance and behavior of the simulation match the appearance and behavior of the simulated system” “precision of reproduction, the extent to which an electronic device, for example, a stereo system or television, accurately reproduces sound or images”

18. A. Ziv’s definition of High Fidelity • Screen based simulator • May or may not interact • Procedural simulators (task trainers) • Static models with tactile cues • Realistic Patient Simulators • Virtual reality • Evolving technology • Combine virtual world with simulation +/- standardized patients to form microsystems

19. A. Ziv’s definition of Low Fidelity • Simple 3-D models • Animal models • Human cadavers • Realistic but lack physiologic response • Basic Plastic Manikin • Simple skills trainers • Physical exam teachers • Clinical skills teachers • Simulated or standardized patients • Best for clinical skills teaching

20. Low Fidelity • If simulation is a manifestation of reality • And some models have “low fidelity” • Or poorly mimic reality Can they make any difference? i.e. Do they change behavior?

21. Reviewed 40 consecutive charts in preceding 6 months • Intervention was a instruction of LP on manikin and proforma • Prospectively reviewed 25 next consecutive patient charts • Findings: • 4/12 clinical markers improved to 12/12 (p<0.01) • Improved charting • Change in behavior of junior staff • Limitations: • Hawthorne effect • No change in % of traumatic taps

23. What can be the effect of Low Fidelity training? • Are skills learned on ‘non-realistic’ or ‘non-interactive’ models not transferable to real clinical life? “Learning transfer is the application of skills and knowledge learned in one context to another context.”

24. The authors have published a number of small studies touting the benefit of Low-fidelity simulation • Stating: “to ensure success with skill transfer need to identify the essential construct inherent to the relevant procedure” “low fidelity models can then be developed to fit the procedure”

25. Low fidelity High fidelity

26. 40 final year medical students • Assigned to low-fidelity, high-fidelity, didactic group • Trained to remove stone from mid-ureter • Performance measured on expert rating scale and time to completion • Hands-on far superior to didactic • No difference between low and high fidelity

27. Low Fidelity • If there has been some gain in procedural skill with low fidelity simulation • Is that skill retained? • Does the retention last as long as with Higher Fidelity training?

28. 18 surgical residents re-evaluated on high fidelity model 4 months after randomization to didactic vs. low vs. high fidelity training

29. Theory “to ensure success with skill transfer need to identify the essential construct inherent to the relevant procedure” • Has some cross over to Experiential Learning Theory • Not as clear in regards to generalizability and application “focus training on the process and ask trainees to suspend disbelief about the physical substrate” Theory

30. The developers of simulators are not driven by the same agenda as those who are using them • Ravert et al. (2002) literature search: • Quantitative studies on simulation – 513 references • 9 studies since 1980 met criteria • Of those 75% had positive effect of skill acquisition “we must not allow technology to drive the educational agenda but rather pursue the development of technology which will assist developing areas of identified training need”

31. STEPS: • Develop a curriculum • Learners prepared with cognitive knowledge of procedure • Techniques then demonstrated with clarifying commentary • Learners then directly observed performing the skill • Repetition encouraged • Encourage learner self-assessment (reflection) • Formative feedback imperative

32. Local Research and Work in SBME • Hemodynamic instability is a common clinical encounter in Emergency Medicine • Procedures and interventions require a confident skilled hand • Can’t delay a needed procedure in an unstable patient • By definition, resuscitation skills are not indicated in stable patients • ? How do junior learners (or CME docs) gain these skills?

33. Local Research and Work in SBME • Hemodynamic Instability Course (HIC) • Dr. Lord • Dr. Rigby • Dr. Walker • Dr. Dan Howes • Many local guest lecturers/facilitators

34. Methods • We undertook a prospective trial to assess the impact of a hemodynamic instability course. • Research Question: • Does Moderate Fidelity Simulation Training in Resuscitation Procedures Improve Residents’ Self-Assessed Competence? • Prospective convenience sample of 37 University of Calgary residents • Intervention: • 8 hour intensive simulation based training course on the management of hemodynamically unstable patients

35. Local HIC study

37. Methods • Survey questionnaire applied to each resident: • Scored a variety of self-assessment questions on a 5 point Likert scale • Pre-intervention • Post-intervention • Expert assessment during study on IJ placement station on manikin (OSCE format) • Statistical tests used: • Pearson’s correlation coefficient • Descriptive statistics (mean, range, SD) • Cronbach’s alpha (Reliability) • Paired sample T tests (compare pre and post)

38. Methods

39. Results • 2 Residents excluded from analysis • 1 GIM : did not have expert assessment station • 1 CCFP : did not complete the post-intervention assessment

40. Results • Participant demographics: • Age: mean 30.65 (range 25-44 years) • 72% were PGY 1 or 2 (27/37) • CCFP-EM and FRCPC residents • 3rd year or above residents (n=10)

41. Results • Cronbach’s alpha = 0.944 • Exceptional reliability Reliability

42. Correlation Matrix

43. Results • High Cronbach’s alpha = Reliable • Correlation Matrix provides criterion validity = Valid

44. Self-assessment Pre & Post HIC

45. Conclusions • Our data suggests that: • Simulation based procedural skill training can improve self-assessed procedural skill competence • In our sample, self-assessed competence was highly correlated to assessment by an ‘expert’ observer providing criterion validity to self-assessed skill • Simulation training allows repetition and practice in a safe environment without compromising patient safety

46. Limitations • Local study – may not be externally valid • Intensive 8 hour session may be the difference, not the act of simulating the procedure • Known biases in Likert scales: • ‘central tendency bias’ • ‘acquiescnce response bias’ • ‘social desirability bias’ • Unsure of ‘Knowledge Transferability’

47. Future Directions • Will apply the self-assessment instrument to residents again in April 2007 for assessment of ‘retention of knowledge’ • Presentation at CAEP • Manuscript preparation • HIC will be touring to Western Canadian sites to promote rural MD training and CME

48. SUMMARY - Pitfalls of SBME • Culture in medicine is resistant to change • Match educational goal & learner with appropriate model • Need to train the trainers • Quantitative testing and assessment to prove validity • Sustainable business model • Prove cost reduction to health care with minimizing medical error

49. Summary • Reviewed Ethical reasons to pursue SBME • Defined simulation and fidelity • Examined current research and learning theory of procedural skills simulation education • Listed advantages to SBME • Briefly listed potential pitfalls

50. Questions?