Clinical Simulation
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Introduction
Most education occurs in real clinical care, though simulation and role play are used in increasing roles to teach principles and allow practice.
Funny cartoon (external link)
Role Play
Role play occurs when people act out a clinical situation. Often the teacher, or an actor, take on the role of the patient, while the learner plays the clinician.
Actual clinicial encounters provide powerful material for role plays.
Open role plays see the patient narrative flowing from the clinician's past experience, while a structured role sees the story unfolding in specific ways to cover specific teaching points.
Role play can be used to improve on specific aspects of their history and physical exam, especially with challenging patient types (eg anxiety, personality disorders, etc).
Role play can be anxiety-provoking for learners, but if is introduced properly, can rapidly represent a safe place for learning and experimentation. It also allows for immediate feedback.
http://www.cbc.ca/player/News/TV%20Shows/The%20National/ID/2283087844/
It is important to provide a clear ending to the role play.
Effectiveness of Simulation-Based Training
A critical care skills study done with internal medicine residents showed that first year residents, trained using simulation, performed better at the bedside of patients on mechanical ventilators, as compared with third-year residents not trained on simulators (Singer et al, 2012).
"The meta-analytic outcomes favoring SBME with DP are powerful, consistent, and without exception. There is no doubt that SBME is superior to traditional clinical education for acquisition of a wide range of medical skills represented in this study: advanced cardiac life support, laparoscopic surgery, cardiac auscultation, hemodialysis catheter insertion, thoracentesis, and central venous catheter insertion. We are confident that demonstrations of the utility and cost effectiveness of educational interventions featuring SBME with DP will increase as the technology is applied to other skill acquisition and maintenance opportunities in health care."
"A growing body of evidence shows that clinical skills acquired in medical simulation laboratory settings transfer directly to improved patient care practices and better patient outcomes. Examples of improved patient care practices linked directly to SBME include studies of better management of difficult obstetrical deliveries (e.g., shoulder dystocia), laparoscopic surgery, and bronchoscopy. Better patient outcomes linked directly to SBME have been reported in several studies using historical control groups that address reductions in catheter-related bloodstream infections and postpartum outcomes (e.g., brachial palsy injury, neonatal hypoxic-ischemic encephalopathy) among newborn infants. Such work suggests that traditional, clinical education is insufficient if the goal is skill acquisition and downstream patient safety." (McGaghie et al, 2011).
"A recent conference hosted by Harvard Medical School involving educational leaders from eight other U.S. medical schools concluded, “…investigation of the efficacy of simulation in enhancing the performance of medical school graduates received the highest [priority] score.” Enhancement of the traditional clinical educational model with evidence-based practices like SBME with DP should be a high priority for medical education policy and research (McGaghie et al, 2011)".
Aspects of Effective Simulation-Based Education
A 2013 meta-analysis has identified a number of best practices for simulations (Cook et al, 2013). These include:
- a range of difficulties and clinical variation
- repetition
- distributed practice
- cognitive interactivity
- multiple learning strategies
- individualized learning
- mastery learning
- feedback
- longer time
Cost
Most studies do not report cost (Zendejas et al, 2013).
Basic Procedural Skills
Lynagh et al. [26] concluded that skills laboratory training enhances procedural skills performance as assessed by simulation, though compared to standard or no training.
It appears that skills sessions can be taught by either faculty or med students (Weyrich et al, 2009).
This effect can be demonstrated regardless of whether the preceding skills laboratory training is lead by faculty staff or by trained medical students that serve as peer teachers [30], [31]. Yet, the transfer of procedural skills acquired in skills laboratories to actual clinical practice remains the subject of an ongoing discussion.
Resuscitation
Simulation-based training has been demonstrated to translate into improvement in patient outcomes (Wayne et al, 2008).
Resources and References
Biese KJ et al. 2009. Using screen-based simulation to improve performance during pediatric resuscitation. Acad Emerg Med. 16 Suppl 2:S71-5.
Cook D et al. 2013. Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis. Medical Teacher. e867–e898.
Individual case simulation online can improve knowledge and confidence, though not performance in scenario-based skills assessment (Biese et al, 2009).
Harder BN. 2010. Use of simulation in teaching and learning in health sciences: a systematic review. Nurs Educ. 49(1):23-8
Lee MO, Brown LL, Bender J, Machan JT, Overly FL. 2012. A medical simulation-based educational intervention for emergency medicine residents in neonatal resuscitation. Acad Emerg Med. 19(5):577-85.
Littlewood KE, Shilling AM, Stemland CJ, Wright EB, Kirk MA. 2012. High-fidelity simulation is superior to case-based discussion in teaching the management of shock. Med Teach. Nov 5.
Okuda Y, Bryson EO, DeMaria S Jr, Jacobson L, Quinones J, Shen B, Levine AI. 2009. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 76(4):330-43.
McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. 2011. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 86(6):706-11.
McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. 2010. A critical review of simulation-based medical education research: 2003–2009. Med Educ. 44: 50–63.
Norman G. 2012. Medical education: past, present and future. Perspect Med Educ. 1:6–14.
Singer BD, Corbridge TC, Schroedl CJ, Wilcox JE, Cohen ER, McGaghie WC, Wayne DB. 2012. First-Year Residents Outperform Third-Year Residents After Simulation-Based Education in Critical Care Medicine. Simul Healthc. Dec 7.
Tan SC, Marlow N, Field J, Altree M, Babidge W, Hewett P, Maddern GJ. 2012. A randomized crossover trial examining low- versus high-fidelity simulation in basic laparoscopic skills training. Surg Endosc. 26(11):3207-14.
- doesn't really seem to make a difference.
Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. 2008. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 133:56-61.
Weyrich P, Celebi N, Schrauth M, Moltner A, Lammerding-Koppel M, et al. 2009. Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial. Med Educ 43: 113–120.
Roy KM, Miller MP, Schmidt K, Sagy M. 2011. Pediatric residents experience a significant decline in their response capabilities to simulated life-threatening events as their training frequency in cardiopulmonary resuscitation decreases. Pediatr Crit Care Med. 12(3):e141-4.
Zendejas B, Wang AT, Brydges R, Hamstra SJ, Cook DA. 2013. Cost: the missing outcome in simulation-based medical education research: a systematic review. Surgery. 153(2):160-76.
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