1. Pal Bikramjit1, Kumar MV1, Nachiappan M1, Soe Htoo Kyaw2, Pal Sudipta3
The effectiveness of high fidelity simulation in undergraduate medical education
Pal Bikramjit1, Kumar MV1, Nachiappan M1, Soe Htoo Kyaw2, Pal Sudipta3
Professor, Dept. of Surgery, Manipal Medical College, Melaka, Malaysia
Professor, Dept. of Community Medicine, Manipal Medical College, Melaka, Malaysia
Lecturer, Manipal Medical College, Melaka, Malaysia

3. Introduction
Literature review
Methodology
Results
Findings
Limitations of the study
Conclusion
References

4. INTRODUCTION:
Benefits
Importance
Innovativeness
Usefulness
Purpose of the research
Research objectives

5. Introduction INTRODUCTION
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Introduction
INTRODUCTION
Simulation is not a technology but a technique
Replace or augment real experiences with guided experiences
Elicit or imitate substantial aspects of real world in a fully interactive manner [1]
Simulation is an all-inclusive term
encompasses interactive, as well as immersive activity
recreation of a part or whole of a clinical experience without putting the patients to the antecedent risks [2]

6. Benefits of Medical Simulators
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Benefits of Medical Simulators
To teach therapeutic and diagnostic procedures
To develop medical concepts
In decision making
Simulators have been developed for training procedures ranging from the basics such as blood draw, to laparoscopic surgery [3] and trauma care [4].

7. The importance of simulation in medical education
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
The importance of simulation in medical education
It basically animates the curriculum
It allows learners to try out and operationalize new knowledge
It helps in turning general concepts into practical skills and plan management
It imparts an emotional component to the experience
It firmly implants new information into memory [5]

8. Innovativeness of high fidelity simulation training solutions
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Introduction
Innovativeness of high fidelity simulation training solutions
Addresses the number of safety concerns
Reduces adverse effects on the patients
Replicates clinical case scenarios
Repetition of same scenario in a controlled environment
Allows practice without risk to patient

9. Usefulness of High Fidelity Patient Simulation [6]
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Usefulness of High Fidelity Patient Simulation [6]
To address increasing student enrolment
Faculty shortages
Limited clinical sites

10. Introduction Literature Review
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Introduction
Literature Review
1. According to a study conducted by Bjorn Hoffman - "simulation's ability to address skillful
device handling as well as purposive aspects of technology provides a potential for
effective and efficient learning” [7]
2. More positive information is found in the article by Kevin Kunkler who opined that, "medical
simulators can be useful tools in determining a physician's understanding and use of best
practices, management of patient complications, appropriate use of instruments and tools,
and overall competence in performing procedures” [8]

11. The effectiveness of high fidelity simulation in undergraduate medical education
3. It is now well recognized that high fidelity patient simulation (HFPS) encourages learning if it is facilitated in appropriate settings [9]
4. High fidelity patient simulators are extensively used to teach diagnostic as well as therapeutic procedures to develop medical concepts that help in decision making [10]

12. Benefits of Facilitated Simulation [11]
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education n
Benefits of Facilitated Simulation [11]
Encourages to explore emotions and question
Stimulates reflective thinking
Provides feedback
Ultimately reducing morbidity and mortality rates
Adds an emotional component to the experience that helps in implanting new information into memory [5]

13. The effectiveness of high fidelity simulation in undergraduate medical education
Current Scenario
According to the Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due primarily to medical mistakes during treatment [12]. CDC reported that in the United States, the medical mistakes represents 1.8% to 4.0% of all deaths [13]
A near 4% representation of deaths primarily related to medical mistakes is simply unacceptable in the world of medicine. Anything that can assist in bringing this number down is highly recommended and medical simulation has proven to be the key assistant

14. Purpose of this research
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Introduction
Purpose of this research
Importance of simulation in training medical students are being recognized by academic institutions around the world
In spite of proven benefits, it has so far not been formally introduced as a part of curriculum in medical colleges in our settings
There are quite a number of studies on the use of high fidelity simulation
Most studies had a smaller number of subjects
Highlight of our study:
To explore the perception of medical students on the usefulness of HFPS
Large cohort of 347 participants in our study
We looked at several factors in the use of high fidelity patient simulation
Ultimate aim was to define how it may benefit the students in real life

15. Benefits of this research
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Benefits of this research
It is hoped that our students will be better prepared for tackling surgical emergencies including trauma as junior doctors
May enhance the importance of high fidelity patient simulation in undergraduate medical education and its inclusion in the curriculum in near future

16. To analyze the impact of stressors and its relevance
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Research Objectives
To evaluate the effectiveness of simulation-based teaching using a high fidelity simulator in acquisition of knowledge and practical skills, by student perception and performance
To analyze the impact of stressors and its relevance
To plan future teaching methodology based on the study outcomes

17. METHODOLOGY:
Type of study and design
Data collection
Assessment
Data analysis

18. Eligibility criteria for participants Inclusion criteria:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
METHODOLOGY
Type of study and General Design: Quasi-experimental time series design with pretest-posttest interventional study
Eligibility criteria for participants
Inclusion criteria:
Both male and female undergraduate (MBBS) final year students of Melaka- Manipal Medical College (MMMC), Malacca, Malaysia
Recruited during their surgical posting
Informed consent obtained
Exclusion criteria:
Students who declined for consent

19. Study period: October, 2015 to September, 2017 (24 months)
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Study population
Total number of students enrolled = 375
Number of students completed the course = 347 (92.53%)
Drop-out number = 26
Declined to participate = 2
Study area: Clinical Skills Simulation Lab of MMMC
Study period: October, 2015 to September, 2017 (24 months)
Intervention: METIman Pre-Hospital HI-Fidelity Simulator (Serial number: MMP-0418), CAE Healthcare, USA was used for the simulation sessions

20. Data Collection Procedure
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Data Collection Procedure
Pilot study involving 50 students to explore the time management, feasibility,
 acceptability and validation of the questionnaires prior to the main study
The students were allocated into groups
Each group consisted of 12 to 15 students
Further divided into three teams of 4 to 5 students
Pre-brief:
students made aware about the confidentiality of the high fidelity simulation sessions
the ethical issues involved
shown the environment and the functions of the simulator to avoid stress caused by ignorance of the technology used
assured that the program was not part of the evaluation process for the surgical curriculum

21. Methodology: First day
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Methodology: First day
Self-assessment of initial background knowledge (Pre-test) about surgical emergencies & trauma care and stressor assessment
Briefed about the simulation sessions and expected learning outcomes
Interactive lecture on ATLS protocol for management of trauma and surgical emergencies like hypovolemic shock due to hemorrhage (gastrointestinal bleeding, hematuria), head injury, tension pneumothorax, hemothorax and burns

22. Each team then participated in trauma simulation session
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
First day (contd.):
Three teams in the group were assigned three different scenarios which were chosen randomly from the conditions mentioned above
Each team then participated in trauma simulation session
Allocated time for each simulation session:
Pre-brief (10 minutes),
Simulation (20 minutes) and
Debriefing (20 minutes)
Post-test I

23. The same team had participated in the simulation of the same scenario:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
The same team had participated in the simulation of the same scenario:
(i) after 1 week (second simulation session) followed by Post-test II
(ii) at weeks (third simulation session) followed by Post-test III
To test their short to medium term retention of knowledge and practical skills
Final debriefing
Feedback
Subsequent sessions

24. The effectiveness of high fidelity simulation in undergraduate medical education
The progress in applied knowledge, psychomotor skills, confidence and stress reduction was assessed individually for each participant
Standardized five point (1 to 5) Likert scale questionnaire was developed for Pre-test and Post-tests
Ordinal scale (1 to 5) used by the participants to rate the degree of perception
Another set of questionnaires is designed to obtain participant feedback after each session on the relevance and usefulness of the simulation experience and usefulness of briefing and debriefing
ASSESSMENT

25. For Knowledge Assessment:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
LIKERT SCALE
For Knowledge Assessment:
1 – Very Poor, 2- Poor, 3 – Average, 4 – Good, 5 - Excellent
For Simulation Assessment:
1- Strongly Disagree, 2 - Tend to disagree, 3 - Neither agree or disagree, 4- Tend to agree, 5 - Strongly Agree
For Stressor Assessment:
1 - No Stress, 2 - Low stress, 3 - Moderate stress, 4 - High stress, 5 - Maximum Stress
LIKERT SCALE

26. Microsoft Excel was used for data entry
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Data analysis
Microsoft Excel was used for data entry
SPSS software (SPSS Inc. Released PASW Statistics for Windows, Version Chicago: SPSS Inc.) for data analysis
Descriptive statistics such as frequency and percentage for categorical data, mean and standard deviation for total score of knowledge, simulation assessment and stressor assessment
Median, 1st quartile (Q1) ad 3rd quartile (Q3) were calculated for each individual item

27. P-value <0.001 was considered to be statistically significant
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Data analysis (contd.)
One-way repeated measure ANOVA with Bonferroni post hoc analysis was used to determine the statistically significant difference in total scores
Friedman test was used to determine the statistically significant difference in individual items
We checked content and face validity of all assessments
For internal consistency, we calculated Cronbach’s alpha coefficient. It was (knowledge), (skills), (stressor) and (feedback)
P-value <0.001 was considered to be statistically significant

28. RESULTS:
Knowledge assessment
Simulation assessment
Stressor assessment
Feedback assessment

29. The effectiveness of high fidelity simulation in undergraduate medical education
Results
Knowledge assessment:
Mauchly's test of sphericity indicated that the assumption of sphericity had been violated, χ2(5) = , p <0.001
Greenhouse & Geisser was used to correct the one-way repeated measures ANOVA
The total score of knowledge was statistically significant increased over time, F(2.48, ) = , p <0.001
Total score of knowledge assessment progressively increased from 7.99 (SD 3.2) at Pre-test to (2.84) at Post-test III

30. A one-way repeated measures ANOVA
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Results: Knowledge Assessment (Total score) *
Table 1:
A one-way repeated measures ANOVA
* Significant
Assessment
Knowledge Assessment (Total score)
Mean (SD)
P-value
Pre-test
7.99 (3.28)
<0.001*
Post-test I
11.66 (2.92)
Post-test II
12.52 (2.89)
Post-test III
13.33 (2.84)

31. The effectiveness of high fidelity simulation in undergraduate medical education

32. Results: Knowledge Assessment (Pairwise comparison)
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Results: Knowledge Assessment (Pairwise comparison)
Table 2:
Pairwise comparison
of knowledge assessment
(total score) with Post-hoc
Bonferroni adjustment
Between Pre-test
And Post-tests
Assessment
Knowledge Assessment
Mean difference
(95% confidence interval)
P-value
Pre-test
Post-test I
-3.66 (-4.23, -3.10)
<0.001*
Post-test II
-4.52 (-5.16, -3.89)
Post-test III
-5.33 (-5.99, -4.67)
-0.86 (-1.36, -0.35)
-1.65 (-2.15, -1.18)
-0.81 (-1.24, -0.39)

33. Knowledge Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 3: Knowledge assessment (individual item) - Friedman test. * Significant
Knowledge Assessment Item
1 – Very poor, 2 – Poor, 3- Average, 4 – Good,
5 - Excellent
Knowledge
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
ATLS protocol for management of acute trauma
2.0 (1.0, 2.0)
2.0 (2.0, 3.0)
3.0 (2.0, 3.0)
<0.001*
The management of Hypovolemic Shock
3.0 (3.0, 3.0)
The management of Tension Pneumothorax
The management of Head Injury
1.0 (1.0, 2.0)
The management of Burn Injury
2.0 (1.0, 3.0)

34. Results: Simulation Assessment
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Results: Simulation Assessment
Simulation assessment (as perceived by students):
Mauchly's test of sphericity indicated that the assumption of sphericity had been violated, χ2(5) = , p = 0.038
Greenhouse & Geisser was used to correct the one-way repeated measures ANOVA
The total score of was statistically significant increased over time, F(2.92, ) = , p <0.001
Total score of simulation assessment progressively increased from (5.19)
at Pre-test to (7.57) at Post-test III

35. A one-way repeated measures ANOVA with Bonferroni post hoc analysis
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Results: Simulation Assessment (Total score)
Table 4:
A one-way repeated measures ANOVA with Bonferroni post hoc analysis
* Significant
Assessment
Simulation Assessment (Total score)
Mean (SD)
P-value
Pre-test
30.12 (5.19)
<0.001*
Post-test I
52.75 (7.59)
Post-test II
52.19 (7.06)
Post-test III
52.35 (7.57)

36. The effectiveness of high fidelity simulation in undergraduate medical education

37. Simulation Assessment (95% confidence interval)
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 5:
Pairwise comparison
of simulation assessment
(total score) with
Bonferroni Post-hoc
adjustment
(as perceived by students)
* Significant
Assessment
Simulation Assessment
Mean difference
(95% confidence interval)
P-value
Pre-test
Post-test I
(-23.81, )
<0.001*
Post-test II
(-23.20, )
Post-test III
(-23.47, )
0.57 (-0.54, 1.68)
0.999
0.40 (-0.97, 1.67)
-0.16 (-1.26, 0.94)

38. Simulation Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 6: Simulation assessment (individual item) - Friedman test * Significant
Simulation Assessment Item
1- Strongly Disagree, 2 – Tend to disagree,
3 – Neither agree or disagree, 4 – Tend to agree,
5 – Strongly Agree
Simulation
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
The session level was appropriate to my present level of knowledge and experience
3.0 (2.0, 3.0)
3.0 (3.0, 3.0)
0.018
It encouraged my active participation
3.0 (3.0, 4.0)
<0.001*
The training session resembled a real life situation
It helps me to think quickly
Clinical management more easily learned
3.0 (3.0, 3.5)
0.470

39. Simulation Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 6 (contd.): Simulation assessment (individual item) - Friedman test * Significant
Simulation Assessment Item
1- Strongly Disagree, 2 – Tend to disagree,
3 – Neither agree or disagree, 4 – Tend to agree,
5 – Strongly Agree
Simulation
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
Repetition of the scenario during training is essential
3.0 (3.0, 4.0)
<0.001*
Pausing and teaching during simulation reduced the realism
2.0 (2.0, 3.0)
3.0 (2.0, 3.0)
2.0 (2.0, 2.0)
0.403
The training session was enjoyable
0.001*
The facilitator interfered too much during simulation -
1.0 (1.0, 2.0)
2.0 (1.0, 3.0)
0.092
Time for the scenario was adequate
3.0 (3.0, 3.0)
0.205

40. Briefing and De-briefing:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 6 (contd.): Simulation assessment (individual item) - Friedman test * Significant
Briefing and De-briefing:
1- Strongly Disagree, 2 – Tend to disagree,
3 – Neither agree or disagree, 4 – Tend to agree,
5 – Strongly Agree
Skills
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
Time for initial briefing was adequate
3.0 (3.0, 4.0)
3.0 (2.0, 3.0)
3.0 (3.0, 3.0)
<0.001*
Time for debriefing was adequate -
0.007
Debriefing helped me to learn better
0.225
The debriefing style was effective
0.296

41. The effectiveness of high fidelity simulation in undergraduate medical education
Table 6 (contd.): Simulation assessment (individual item) - Friedman test * Significant
Affective:
1- Strongly Disagree, 2 – Tend to disagree,
3 – Neither agree or disagree, 4 – Tend to agree,
5 – Strongly Agree
Skills
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
I want to have further sessions on the simulator
3.0 (3.0, 4.0)
4.0 (3.0, 4.0)
<0.001*
I feel that simulation is essential to train in trauma management -
Learning Outcomes:
I have achieved all my learning objectives
3.0 (2.0, 3.0)
0.110
Confident of managing trauma scenario in real life
2.0 (2.0, 3.0)

42. Results: Stressor Assessment
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Results: Stressor Assessment
Stessors assessment (as perceived by students):
Mauchly's test of sphericity indicated that the assumption of sphericity had been violated, χ2(5) = , p <0.001
Greenhouse & Geisser was used to correct the one-way repeated measures ANOVA
The total score of stressors was statistically significant increased over time, F(2.824, ) = , p <0.001
Total score of stressor assessment progressively decreased from (SD 8.16)
at Pre-test to (9.59) at Post-test III

43. Results: Stressor Assessment (Total score)
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Results: Stressor Assessment (Total score)
Table 7:
A one-way repeated measures ANOVA with Bonferroni post hoc analysis
* Significant
Assessment
Stressor Assessment
(Total score)
Mean (SD)
P-value
Pre-test
27.41 (7.32)
<0.001*
Post-test I
25.98 (8.16)
Post-test II
24.92 (8.71)
Post-test III
24.54 (9.59)

44. The effectiveness of high fidelity simulation in undergraduate medical education

45. (95% confidence interval)
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 8:
Pairwise comparison
of stressor assessment
(total score) with
Bonferroni Post-hoc
adjustment
(as perceived by students)
Assessment
Stressor Assessment
Mean difference
(95% confidence interval)
P-value
Pre-test
Post-test I
1.43 (0.19, 2.66)
0.013
Post-test II
2.49 (1.17, 3.80)
<0.001*
Post-test III
2.87 (1.38, 4.36)
1.06 (-0.13, 2.25)
0.114
1.44 (0.15, 2.73)
0.019
0.38 (-0.82, 1.6)
0.999

46. Stressor Assessment Item:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 9: Stressor assessment (individual item) - Friedman test * Significant
Stressor Assessment Item:
1 – No stress, 2 – Low stress, 3 – Moderate stress, 4 - High stress, 5 – Maximum stress
Stressors
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
Difficulty in understanding the content
3.0 (3.0, 4.0)
3.0 (2.5, 4.0)
3.0 (2.0, 3.0)
3.0 (2.0, 4.0)
0.127
Need to do well (self-expectation)
4.0 (3.0, 4.0)
< 0.001*
Competition due to working in a team
0.001*
Shortage of time during training session
Feeling of incompetence in managing patient

47. Stressor Assessment Item
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 9 (contd.): Stressor assessment (individual item) - Friedman test * Significant
Stressor Assessment Item
1 – No stress, 2 – Low stress, 3 – Moderate stress, 4 - High stress, 5 – Maximum stress
Stressors
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
Death of the simulated patient
4.0 (3.0, 4.5)
4.0 (3.0, 5.0)
4.0 (3.0, 4.0)
0.001*
Conflict with other students
3.0 (2.0, 3.0)
2.0 (2.0, 3.0)
< 0.001*
Need to participate in scenario
3.0 (3.0, 4.0)
3.0 (2.0, 4.0)
0.016
Participation in debriefing
0.009
Not knowing my role in the team

48. Stressor Assessment Item:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Table 9 (contd.) : Stressor assessment (individual item) - Friedman test. * Significant
Stressor Assessment Item:
1 – No stress, 2 – Low stress, 3 – Moderate stress, 4 - High stress, 5 – Maximum stress
Stressor
Median (Q1, Q3)
P-value
 Post-test I
 Post-test II
 Post-test III
Lack of appreciation to my contribution in the team
4.0 (2.0, 4.0)
3.0 (2.0, 3.0)
< 0.001*
Stress as instructor is observing
4.0 (3.0, 4.0)
3.0 (3.0, 4.0)
Stress as fellow classmates are observing
3.0 (2.0, 4.0)
0.001*

49. The effectiveness of high fidelity simulation in undergraduate medical education
Table 10: Descriptive statistics of feedback assessment at the end of training course
1 – Strongly disagree, 2 – Tend to disagree, 3 – Neither agree or disagree, 4 – Tend to agree, 5 – Strongly agree
Feedback Item
Median (Q1, Q3)
Could you get the best out of this training?
4.0 (4.0, 4.0)
Simulated training sessions better than didactic teaching
4.0 (4.0, 5.0)
I was able to participate actively
Debriefing is better after simulation
I would prefer a chance to correct wrong actions during a scenario
I would prefer a chance to correct wrong actions after a scenario
4.0 (3.0, 4.0)

50. FINDINGS:
Knowledge assessment
Simulation assessment
Briefing and Debriefing
Stressor assessment

51. The study showed that HFPS had made a difference
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Our main objective was to determine usefulness of HFPS as a teaching or learning tool for management of surgical emergencies
The study showed that HFPS had made a difference
in enhancing the knowledge and skills over time in management of trauma and surgical emergencies as perceived by our students
Learning and skills had significantly improved with each session of simulation
learners’ attitudes were supportive of simulation

52. The effectiveness of high fidelity simulation in undergraduate medical education
The study corroborates the findings of Wayne, Barsuk, O’Leary, Fudala, & McGaghie (2008) who showed that internal medicine residents had increased knowledge and skills using simulation technology and deliberate practice [14]
Participants in one study (Okuda et al., 2009) felt simulation based teaching was a reliable tool for assessing learners by providing good feedback on performance which was similar to our observation [15]

53. The effectiveness of high fidelity simulation in undergraduate medical education
In a study by Founds, Zewe, & Scheuer (2011), participants felt that high fidelity simulators can present simulations that were closer to real life situations which was similar to opinion of most of our students [16].
The study revealed that simulation sessions with high fidelity simulators encouraged active participation of students who need further sessions on simulation for better understanding of clinical problems and knowledge acquisition

54. The effectiveness of high fidelity simulation in undergraduate medical education
Findings
The finding in one of the main area of study: “Clinical management more easily learned” was not satisfactorily documented (p < 0.470). It showed that simulation did not always help in better understanding of management of clinical problems

55. Findings: Briefing and Debriefing
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Findings: Briefing and Debriefing
The time for briefing was adequate but participants felt that
Time for debriefing was inadequate and
Debriefing did not help them to learn better
This was an area of utmost concern to us as we concluded that there was a definite lacuna in our debriefing process
We planned to rectify our shortcomings and deficiencies in this matter

56. The effectiveness of high fidelity simulation in undergraduate medical education
Findings: Stressors
The drop in stress was significant at week II and III but flattened out in week IV which might be due to participants’ increasing adaptability to simulated atmosphere
This is similar to the findings by Lasater who reported that stress tend to decrease with continued practice [17]. Similarly, the study by Ghazali DA, Ragot S, Oriot D (2016) revealed that stress declined over time with the repetition of simulation sessions [18]. Fauquet-Alekhine P. et al. (2014) also observed that progressive simulation sessions helped to reduce stress of the students [19]..

57. “Seeing a patient die” is significantly more stressful [20]
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
The stressors showed significant drop in scores with repeated simulation sessions (p < 0.001) except in the category of “Death of a simulated patient”
The highest stressor score in our study was noted in “Death of the simulated patient”, which is similar to the finding by Lasater (2007) who reported that students experienced maximum stress during simulation in relation to the anticipation of an unexpected event [17]
“Seeing a patient die” is significantly more stressful [20]

58. The next two high stressor scores in our study were:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Findings: Stressors
The next two high stressor scores in our study were:
“Feeling of incompetence in managing patient”
“Need to do well (self-expectation)”
“Competition due to working in a team” showed moderate stressor score in comparison low score in Cato’s study [21].
The stressor score in the category “Participation in debriefing” showed moderate level all throughout the simulation training course

59. The effectiveness of high fidelity simulation in undergraduate medical education
Mary Louis Cato, in her study, had shown that the possibility of making a mistake during simulation sessions led to maximum stress followed by being observed on camera and performance in front of faculty and friends [21]
The same was observed in our study where the students perceived very high stress when the faculty and colleagues were present during the simulation sessions.

60. The effectiveness of high fidelity simulation in undergraduate medical education
Presence of peers during simulation sessions may result in increased stress [22]
Boostel Radamés et al. (2018) study also showed that the participants in high fidelity patient simulation had increased perception of stress related to interpersonal relationships with patients, faculty and colleagues [20]

61. There was significant improvement in the following areas:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
There was significant improvement in the following areas:
ATLS protocol for management of Acute Trauma
The Management of Hypovolemic Shock
The Management of Tension Pneumothorax
The Management of Head Injury

62. The participants strongly agreed that:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
The participants strongly agreed that:
The session level was appropriate to their current level of learning
It encouraged active participation of the participants
Need further sessions on simulation for better understanding of clinical problems, knowledge acquisition and perfecting clinical skills
Simulation is essential to train in trauma management

63. Limitations of the study:

64. Limitations of this study
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Limitations of this study
The study was conducted on the information provided by students. There is a chance of selection bias due to volunteer nature of inclusion criteria
The participants' interpretation of the questions and subjective nature in reporting their perception may result in reporting bias
The study dealt with some variables like simulation course implementation, curricular integration, faculty expertise and student characteristics which might had influenced the findings

65. Limitations of this study
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Limitations of this study
The standard assessment for knowledge and skills with MCQ and OSCE respectively were not used. The findings were as perceived by the students during simulation sessions
Lastly, this is a single center study and only included the final year medical students and consequently the findings may not be applicable to other settings

66. Conclusion:

67. The effectiveness of high fidelity simulation in undergraduate medical education
Conclusion
Students’ favorable perception on high fidelity patient simulation in this study indicated that there is a valid need for its mandatory inclusion in undergraduate medical curriculum
Simulation based medical education may be helpful in preparing students to cope and respond more satisfactorily to stressful events in real clinical practice
It is hoped that this will translate into improved patient care and healthcare safety when these students progress as junior doctors further down their career path

68. Plan for future research study
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Plan for future research study
Encouraging results and students’ active participation in this study helped us to plan a Randomized Controlled Study:
“A prospective randomized controlled trial on the effectiveness of high fidelity simulation in undergraduate medical education in comparison to conventional educational methods”
It has started in October 2018 and the pilot study with 56 students has been completed. The main study is scheduled to start in March 2019 and will involve about 200 students

69. Declaration of Interest:
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Ethical Approval:
Duly taken from the IRB & IEC, Melaka-Manipal Medical College
Acknowledgements:
The final year MBBS students of Melaka-Manipal Medical College who had participated in this research project
The Faculty of the Department of Surgery
The lab assistants and technicians of Clinical Skills Lab
The Management of Melaka-Manipal Medical College
Declaration of Interest:
The authors have not received any funding or benefits from industry or elsewhere to conduct this study and have no conflicts of interest

70. References:

71. The effectiveness of high fidelity simulation in undergraduate medical education
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76. The effectiveness of high fidelity simulation in undergraduate medical education
Final year medical students participating in a simulation session at clinical skills lab of MMMC

77. Feedback and Evaluation or visit the kiosks next to registration
The effectiveness of high fidelity simulation in undergraduate medical education
The effectiveness of high fidelity simulation in undergraduate medical education
Feedback and Evaluation
Your kind feedback and evaluation are highly solicited
Please leave your feedback at
or visit the kiosks next to registration
Contact details: Dr. Bikramjit Pal; Professor of Surgery,
Melaka-Manipal Medical College, Malacca, Malaysia

78. The effectiveness of high fidelity simulation in undergraduate medical education

79. The effectiveness of high fidelity simulation in undergraduate medical education
Questions?