Clinical Simulation in Family Medicine to address the ACGME Core Competencies Beth Anne Fox, MD, MPH Glenda F. Stockwell, PhD Martin Eason, MD, JD

“…budding and experienced musicians, actors, lawyers…clergy…would not consider engaging in these activities without some form of rehearsal….” Ingrid Philibert, editor ACGME Bulletin December 2005

Resident Morale  When a resident is in the clinic or wards, he or she knows that the care of the patient takes priority over education.  In the simulation lab, the resident knows that education is the only priority.

Objectives  Describe the utilization of clinical simulation to address the core competencies  Design a scenario for clinical simulation choosing participants, equipment, and personnel participating  List concerns regarding implementation or utilization of clinical simulation

Outline  Overview of Clinical Simulation (10 Min.)  Clinical Simulation in Family Medicine (10 Min.)  Small Group Participation (20 Min.)  Clinical Simulation (20 Min.)  Large Group Debriefing and Questions (20 Min.)

Overview of Clinical Simulation  History  Use in other residencies/professions  Anesthesiology  Surgery  OB/GYN  Pediatrics  Nursing  EMS  Pharmacy  Summary of capabilities

 Public demands for increased safety  Medical errors  Need for improved training, evaluation, and assessment  High cost of medical training  Decreased training time  Less exposure to uncommon events  Decreased availability of instructors Impetus for Simulation

Simulation in Family Medicine  Team and Leadership Building  Communication  History and Physical Examinations  Data Collection and Interpretation  Clinical Decision-Making  Procedures  Resource Utilization  Emergency Training

Scenario Components –The Recipe  Learning Objectives  Simulation Summary/Overview  ‘Patient’ Details  Labs and Additional Tests  Simulation Parameters  Participants  Expected Actions by Participants  Personnel/Props  Diagnostic Studies Needed  References  Competencies Addressed  Scenario Organization and Participant Instructions  Debriefing Goals and Objectives

Patient Care

Medical Knowledge  Acute coronary syndrome  Pulmonary embolus  Sepsis  Anaphylaxis  Acute respiratory failure

Interpersonal and Communication Skills

Professionalism

Systems-based Practice

Simulation Sessions  Involves a scenario with discrete objectives  May include varying procedural, cognitive, and behavioral objectives  All sessions are recorded for debriefing

Simulation Design  Objectives/Competency  Identification of participants  Determination of assessment criteria  Scenario sequence development  Debriefing

Things to think about….  What scenarios are important to your institution?  Do you have critical incidents that need improvement?  Are there trainee issues?  Are there specific experiences that need improving?  Are there specific skills/procedures which need developing?

 Cognitive  Decision making  Procedural competence  Crisis management  Role clarity  Asset management  Communication  Resources management  Professionalism What is the scenario objective?

Learning Objectives  What do you want the residents to come away with?  Writing them out helps you to create the scenario around them  Learning objectives also help determine the length and complexity of the scenario (materials, personnel, ancillary equipment)

Participants  Which residents/years?  Multiple levels of complexity?

Simulation Overview  Brief description of purpose of simulation and evidentiary basis for scenario  This serves as form of documentation for future users (like computer programming documentation)  History, examination, laboratory values for patient (make them realistic and consistent with your scenario)  This serves as the script if using a voice for the mannequin

Simulation Parameters  Parameters – initial settings for mannequin  VS, breath sounds, physical findings  Scenario Summary – the sequence of events that occur to the mannequin depending on the actions of the participants  Materials needed  Data sheets  Radiographs, ECG’s, etc…  Personnel needed  Ancillary equipment, props

Expected Resident Actions  Serves as a checklist for assessment  May be used as a summative evaluation tool  Can be formalized (e.g. checklist) or informal to be used as teaching points during debrief

Simulation Summary  Properly orient participants  Record if possible  Be ready for unpredictability  Be ready to improvise  Keep a lookout for hidden teaching moments

Orientation  Introduce role of instructors and purpose of exercise  Inform participants of role in exercise  Familiarize learners with equipment, environment, and limitations of simulation and ways to overcome limitations  Stress that this a learning exercise

Debriefing  Explain purpose of debriefing  Allow for reflective learning  Always make it a positive experience – there are no mistakes, just learning opportunities  Most important part of simulation  Allows residents to review actions, reflect, and receive and provide feedback  Validate participants’ concerns  Summarize learning points  Discuss reference sources

 Congestive heart failure  Post-partum hemorrhage  Anaphylactic shock  Neonatal resuscitation  Diabetic ketoacidosis  Trauma Sample Scenarios

Conclusion  Residents find simulation to be fun  Simulation can be important in fulfilling competency requirements  Creative attending physicians may enjoy the simulation exercises as much as the residents

Some final thoughts…..  You are limited only by your imagination  Involve everyone  The primary goal is LEARNING  HAVE FUN!!!!

Martin Eason MD, JD Assistant Professor Director, Center for Experiential Learning Quillen College of Medicine East Tennessee State University Beth A. Fox, MD, MPH Associate Professor Glenda Stockwell, PhD Assistant Professor Department of Family Medicine Quillen College of Medicine East Tennessee State University