Unexpected Collateral Effects of Simulation-Based Medical Education

Barsuk, Jeffrey H. MD, MS; Cohen, Elaine R.; Feinglass, Joe PhD; McGaghie, William C. PhD; Wayne, Diane B. MD

Purpose: Internal medicine residents who complete simulation-based education (SBE) in central venous catheter (CVC) insertion acquire improved skills that yield better patient care outcomes. The collateral effects of SBE on the skills of residents who have not yet experienced SBE are unknown.

Method: In this retrospective, observational study, the authors used a checklist to test the internal jugular and subclavian CVC insertion skills of 102 Northwestern University second- and third-year internal medicine residents before they received simulation training. The authors compared, across consecutive academic years (2007-2008, 2008-2009, 2009-2010), mean pretraining scores and the percent of trainees who met or surpassed a minimum passing score (MPS).

Results: Mean internal jugular pretest scores improved from 46.7% (standard deviation = 20.8%) in 2007 to 55.7% (+/-22.5%) in 2008 and 70.8% (+/-22.4%) in 2009 (P < .001). Mean subclavian pretest scores changed from 48.3% (+/-25.5%) in 2007 to 45.6% (+/-31.0%) in 2008 and 63.6% (+/-27.3%) in 2009 (P = .04). The percentage of residents who met or surpassed the MPS before training for internal jugular insertion was 7% in 2007, 16% in 2008, and 38% in 2009 (P = .004); for subclavian insertion, the percentage was 11% in 2007, 19% in 2008, and 38% in 2009 (P = .028).

Conclusions: SBE for senior residents had an effect on junior trainees, as evidenced by pretraining CVC insertion skill improvement across three consecutive years. SBE for a targeted group of residents has implications for skill acquisition among other trainees.

Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: A randomized trial

PMID:

 

22033049

CJ Schroedl, TC Corbridge, ER Cohen, SS Fakhran… - Journal of Critical Care, 2011

Abstract

Purpose

The purpose of this study is to determine the effect of simulation-based education on the knowledge and skills of internal medicine residents in the medical intensive care unit (MICU).

Methods and Materials

From January 2009 to January 2010, 60 first-year residents at a tertiary care teaching hospital were randomized by month of rotation to an intervention group (simulator-trained, n = 26) and a control group (traditionally trained, n = 34). Simulator-trained residents completed 4 hours of simulation-based education before their medical intensive care unit (MICU) rotation. Topics included circulatory shock, respiratory failure, and mechanical ventilation. After their rotation, residents completed a standardized bedside skills assessment using a 14-item checklist regarding respiratory mechanics, ventilator settings, and circulatory parameters. Performance of simulator-trained and traditionally trained residents was compared using a 2-tailed independent-samples t test.

Results

Simulator-trained residents scored significantly higher on the bedside skills assessment compared with traditionally trained residents (82.5% ± 10.6% vs 74.8% ± 14.1%,P = .027). Simulator-trained residents were highly satisfied with the simulation curriculum.

Conclusions

Simulation-based education significantly improved resident knowledge and skill in the MICU. Knowledge acquired in the simulated environment was transferred to improved bedside skills caring for MICU patients. Simulation-based education is a valuable adjunct to standard clinical training for residents in the MICU.

Keywords: Simulation training; Medical education; Medical intensive care unit; Clinical competence; Quality of health care

Medical Education Featuring Mastery Learning With Deliberate Practice Can Lead to Better Health for Individuals and Populations

 Pubmed ID: 22030671

McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. 

Medical education can lead to better health for individuals and populations when it has effective, evidence-based features and is delivered under the right conditions. Effective, evidence-based features include mastery learning (ML), deliberate practice (DP), and rigorous outcome measurement (ML and DP are both defined below). The right conditions include a committed and skillful faculty, curriculum integration and institutional endorsement, and health care system acceptance. Translation of medical education outcomes to measurable downstream effects on improved patient care practices and better health for individuals and populations is demonstrated by educational and health services research programs that are thematic, sustained, and cumulative.

ML is an especially stringent form of competency-based education where learners acquire essential knowledge and skill measured rigorously against fixed achievement standards without regard to the time needed to reach the outcome. Mastery indicates a much higher level of performance than competence alone, and evidence shows that ML leads to longer skill maintenance without significant decay. Educational outcomes are uniform in ML with little or no variation, whereas educational time varies among trainees.¹ In medical education, ML has been used chiefly for acquisition and maintenance of clinical procedural skills such as advanced cardiac life support (ACLS), thoracentesis, and central venous catheter (CVC) insertion. ML can also be used to acquire and refine cognitive and affective educational outcomes. The ability to engage a family in a difficult conversation about end-of-life issues is a clinical skill amenable to ML just like performance of a lumbar puncture. Work is now under way to evaluate these and other clinical mastery outcomes.

DP embodies strong and consistent educational interventions grounded in information processing and behavioral theories of skill acquisition and maintenance.² DP has at least nine elements: (1) highly motivated learners with good concentration, (2) well-defined learning objectives that address knowledge or skills that matter clinically, at an (3) appropriate level of difficulty for the medical learners, with (4) focused, repetitive practice of the knowledge or skills, that leads to (5) rigorous measurements that yield reliable data, which provide (6) informative feedback from educational sources (e.g., teachers, simulators) that promotes frequent (7) monitoring, error correction, and more DP that enables (8) performance evaluation toward reaching a mastery standard, and allows (9) advancement toward the next clinical task or unit. The goal of DP is constant skill improvement. Research shows that DP is a much more powerful predictor of professional accomplishment than experience or academic aptitude.

Medical education and evaluation research programs that incorporate ML and DP principles, and evaluate outcomes with measurement and methodological rigor, are beginning to show translational results in patient care practices and patient outcomes.³ Many of these educational programs use health care simulation technology as a curriculum driver. Examples of improved patient care include reduced complications and higher success rates at CVC insertion, improvement in laparoscopic surgical skill, better adherence to guidelines during ACLS team responses, and increased competence in several types of endoscopy. Better health for individuals and populations linked directly to medical education programs has been demonstrated through reduced rates of catheter-related bloodstream infections; reduced birth complications due to shoulder dystocia (brachial plexus injury), low Apgar scores, and infant brain injury from neonatal hypoxic–ischemic encephalopathy; and lower postsurgical complications among cataract surgery patients.³ Advancements in medical education, evaluated rigorously, can produce better patient health as judged statistically and clinically.

Powerful and effective medical education programs do not exist in a vacuum. They include not only such curriculum features as ML, DP, and reliable outcome measurement but also faculty and administrative commitment, curriculum support expressed as financial and human capital, and a health care system whose culture embraces professional competence evaluation in service of patient care quality and patient safety at all levels. Medical education programs are being recognized as complex service interventions that are affected by the context in which they are delivered. This context is highly variable but has a powerful role in determining the ultimate success of the program. A new, interdisciplinary academic field called implementation science, and the scholarly journal that bears its name, holds promise to teach the medical education community how to develop, launch, and sustain educational programs that improve health for individuals and populations.

Medical school and residency curricula must change to adopt a competency-based approach featuring structured learning experiences tied to assessments that yield reliable data. Research shows convincingly that ML and DP linked to competence assessment can improve health outcomes. Expansion of this model is needed to better prepare trainees for independent and group practice and to ensure competent medical care for patients and society.