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 1.Best standards of care and training 2.Error management and patient safety 3.Patient autonomy 4.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. Anesthesia Sim 1986 1990 and now Interactive 2000s Resus Annie 1960 Mannikins cadaver Task trainer Virtual Reality

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 1.Screen based simulator May or may not interact 2.Procedural simulators (task trainers) Static models with tactile cues 3.Realistic Patient Simulators 4.Virtual reality Evolving technology Combine virtual world with simulation +/- standardized patients to form microsystems

19. A. Ziv’s definition of Low Fidelity 1.Simple 3-D models 2.Animal models 3.Human cadavers Realistic but lack physiologic response 4.Basic Plastic Manikin Simple skills trainers Physical exam teachers Clinical skills teachers 5.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 fidelityHigh 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: 1.Develop a curriculum 2.Learners prepared with cognitive knowledge of procedure 3.Techniques then demonstrated with clarifying commentary 4.Learners then directly observed performing the skill 5.Repetition encouraged 6.Encourage learner self-assessment (reflection) 7.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 MaleFemaleTotalExcludedAnalysis FRCPC639-9 CCFP-EM314-4 CCFP81018117 GIM24615 3735 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 –3 rd year or above residents (n=10)

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

42. Correlation Matrix Expert Overall Impression Sum general confidenceCVC confidence Sum of Expert assessment scores Expert Overall Impression Pearson Correlation 1 Self-assessed General confidence Pearson Correlation.558(**)1 Sig. (2-tailed).000 Self-assessed CVC confidence Pearson Correlation.689(**).813(**)1 Sig. (2-tailed).000 Expert assessment scores Pearson Correlation.787(**).478(**).485(**)1 Sig. (2-tailed).000.004.003.000

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

44. Self-assessment Pre & Post HIC Paired Sample T tests Mean Std. Deviation 95% Confidence Interval of the Difference Sig. (p<0.05) General Confidence Pre & Post 2.543.033.591.50.000 CVC Confidence Pre & Post 6.774.498.325.23.000 Transfusion Medicine Confidence Pre & Post 2.061.232.481.63.000 Vasopressor Confidence Pre & Post 2.311.652.881.75.000 Intraosseous Line Confidence Pre & Post 3.232.264.012.45.000

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 1.Culture in medicine is resistant to change 2.Match educational goal & learner with appropriate model 3.Need to train the trainers 4.Quantitative testing and assessment to prove validity 5.Sustainable business model 6.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?

51. Experience Something happens! Reflection What happened? Generalization Why did it happen? Application Now do it! (Kolb: Experiential Learning -Experience as the Source of Learning and Development (1984)) Experiential Learning Cycle Theory

52. Learning in medical education is opportunistic Clinical expertise is a complex phenomenon No single theory can account for it’s acquisition Argues for a closer relationship between task based practice and clinical reality

53. Theory Procedural skill learning is a progressive process passing well defined stages General model that recognizes the interdependence of cognition and manipulative skill Cognitive stage Autonomous stage Associative stage

54. Theory Lev Vygotsky 1896-1934 –Russian psychologist –Most of his work with children and adolescent –Has some applicability to adult learning –Zone of Proximal Development: “place where guided learning takes place and where intervention by a teacher will have the greatest potential”

55. Theory ZPD model would have instruction preceding development Would then awaken and rouse set of functions in stage of maturing Modern educators use term “scaffolding” –Teacher provides help when needed, but fades into background when learner becomes independent –Apprenticeship model at heart of medicine

56. Legitimate peripheral participation –Newcomers to practice undergo absorption into a ‘community of practice’ –Learn from peers as well as tutors Royal Naval (Godden & Baddeley) Divers –Divers who learned new material underwater recalled it better in that context –Reverse true for out of water diver memory –? Importance of context

57. Kneebone argues for breakdown of artificial divide between simulation and patient care Envisions distributed learning along clinical workplace Explicit contextualization of learning Theory

58. Reliability Cronbach’s alpha: Results