best evidence practical guide on simulation in...
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Best Evidence Practical Guide on Simulation in Healthcare
Hyun Soo Chung, MD, PhD
Associate Professor, Department of Emergency Medicine
Director, Yonsei University Clinical Simulation Center
Yonsei University College of Medicine
Yonsei University Severance Hospital
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AMEE Best Evidence Practical Guide on Simulation in Healthcare
Ivette Motola, MD, MPHAssociate Professor of Emergency Medicine
University of Miami Miller School of Medicine
Director, Division of Prehospital and Emergency Healthcare
Gordon Center for Research in Medical Education
International Meeting on Simulation in Healthcare
January 13, 2015
Hyun Soo Chung, MD, PhDAssociate Professor
Department of Emergency Medicine
Yonsei University College of Medicine
Yonsei University Severance Hospital
Luke Devine, MD, MHPE, CHSELecturer
Division of General Internal Medicine
Mount Sinai Hospital
University of Toronto
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Learning Objectives
• Review an effective approach to curriculum integration of simulation in healthcare education.
• Explain the importance of feedback and deliberate practice to effective learning using simulation.
• Describe how a mastery learning model leads to skill improvement and retention.
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Overview
• Where are we now in simulation in healthcare education?
• Why this guide?
• A walk through the guide
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Where are we now in simulation in healthcare education?
• Please refer to Paul Phrampus lecture slides from yesterday’s keynote speech.
I am a Good Guy from
Pittsburgh !
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Why this guide? - Formula: Effective Use of Simulation
Training
Resources
Trained
Educators
Curricular
InstitutionalizationX X =
Effective
Simulation-based
Healthcare Education
Issenberg, SB. The Scope of Simulation-based Healthcare Education.
Simulation in Healthcare. 2006.
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SIMULATED ENVIRONMENTSimulators
CLINICAL ENVIRONMENT
Identify learning need
Simulatorbasedpractice
Reapply skill
Review
Further practice as needed
Patients
Clinical
supervision
Teachersupport
Continue
Why this guide? - Educational & Professional Context
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Why this guide?
International group of individuals, universities &
organizations committed to the promotion of
best evidence medical education
What are the features / uses of high fidelity simulations that lead to effective learning?
SB Issenberg et al. Medical Teacher 2005;27(1):1-28.
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Why this guide?
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Why this guide?
• Goal: To ‘operationalize’ the features from BEME into a practical, up to date guide for healthcare educators
• Provide information on current approaches relating to the day-to-day work of the healthcare educator
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Why this guide?- Sections
• Curriculum Integration• Feedback in Simulation• Deliberate Practice• Mastery Learning• Range of Difficulty • Capturing Clinical Variation• Individualized Learning• Approaches to Team Training• Future Directions of Education Using Simulation
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A walk through the guide
• Curriculum Integration• Feedback in Simulation• Deliberate Practice• Mastery Learning• Range of Difficulty • Capturing Clinical Variation• Individualized Learning• Approaches to Team Training• Future Directions of Education Using Simulation
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Curriculum Integration
• “The simulation experience must be planned, scheduled, implemented and evaluated in the context of the broader curriculum”
• Critical to the success and effectiveness of SBHE
• Most powerful outcomes are achieved by having an organized and systematic approach to the incorporation of simulation in an existing or new curriculum
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Curriculum Integration- Process
Plan
Develop
ImplementEvaluate
Revise
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Curriculum Integration- Examples
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Feedback
• Specific information given to a trainee about the comparison between observed performance and a standard, given with the intent to improve the trainee’s performance
• The “heart and soul” of simulation-based training
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Feedback
Without a post-event reflective process,
what the participants have learned is largely left to chance,
leading to a missed opportunity for further learning,
and making the simulation encounter less effective.
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The 3 P’s of Feedback
Plan
•How & when
•Consistent with learning objectives of session
•Feedback checklists/tools for facilitators
•Leave time for “emergent” objectives
Prebrief/ Prepare
•Pre-event preparation of learners
•Rules and Expectations
•Learning objectives
Provide Feedback/
Debrief
•Ensure simulator feedback meets goals (physiologic, verbal, haptic)
•Feedback during session
•Post-event Debriefing
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Debriefing Models
• Plus/Delta
• Debriefing with Good Judgment (Reactions/Analysis/Summary)
• GAS (Gather/Analyze/Summarize)
• Crisis Resource Management
• TeamSTEPPS
• Korean model (?)
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“Typical” Korean Student
• Overly submissive & humble
• Forbearing or yielding passivity
• Learn not to ask any questions
• Poor student-teacher interaction
• Few active students (externship abroad)
• Culturally embedded in strict neo-confucianism & authoritarian hierarchy
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“Culture”
• Symbols
• Heroes
• Rituals
• Values
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Hofstede’s Cultural Dimensions
Helmreich RL. Culture at Work in Aviation and Medicine. 1998
Chung HS. Simulation in Healthcare. 2013
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Power Distance
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Power Distance
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During Debriefing…
• Negative feedback
• Scolding
• Learners favor feeding
You should
not make
that kind of
error!!
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Individualism-Collectivism
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Individualism-Collectivism
I hope this is
not a foolish
question?!
What might
the others
think of me?
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During Debriefing…
• Passive
• Quiet
• Overly conscious
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Uncertainty Avoidance
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During Debriefing…
• Teacher focuses on the errors
• Students refuse to accept differences and/or changes
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Chung HS. It is time to consider cultural differences in debriefing. Simulation in Healthcare. 2013
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Deliberate Practice
• Repetitive Practice + Rigorous Skills Assessment + Feedback
• Coined by Ericsson in instructional science research
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• Highly motivated learners• Identify well–defined task• Appropriate level of difficulty• Focused repetitive practice• Measurements that yield reliable data• Informative feedback• Opportunity to correct errors• Advancement to next level / skill
Acad. Med. 2004;79(Suppl):S70-81
Deliberate Practice
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Acad Med 2011;86:706-11.
Acad Med 2011;86:706-11.
Study N Population Competency Assessed Randomized Trials
1. Wayne, et al, 2005 38 IM Residents Advanced Cardiac Life Support
2. Ahlberg, et al, 2007 13 Surg Residents Laparoscopic choleystectomy
3. Andreatta, et al, 2006 19 Surg Residents Laparoscopic skills
4. Korndorffer, et al, 2005 17 Surg Residents Laparoscopic suturing
5. Korndorffer, et al, 2004 20 Med Students Laparoscopic camera navigation
6. Van Sickle, et al, 2008 22 Surg Residents Intracorporeal Suturing
Cohort Studies
7. Issenberg, et al, 2002 98 IM Residents Cardiology skills
8. Barsuk, et al, 2009 18 Neph Fellows Dialysis catheter insertion
9. Butter, et al 2010 108 Med Students Cardiac auscultation
Case-Control Studies
10. Wayne, et al, 2008 78 IM Residents Advanced Cardiac Life Support
Pre-Post Baseline Studies
11. Wayne, et al, 2008 40 IM Residents Thoracentesis skills
12. Barsuk, et al, 2009 41 IM Residents Central venous catheter insertion
13. Barsuk, et al, 2009 103 IM Residents Central venous catheter insertion
14. Stefanidis, et al, 2006 18 Surg &Residents Laparoscopic suturing
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Statistics for Each Study
Study Correlation and 95% CILower Upper
Correlation Limit Limit p-Value
0.81 0.70 0.88 0.0000.80 0.56 0.91 0.0000.67 0.40 0.84 0.0000.62 0.29 0.82 0.0010.52 0.17 0.75 0.0060.51 0.17 0.74 0.005
0.78 0.73 0.82 0.0000.61 0.29 0.81 0.0010.59 0.47 0.69 0.000
0.51 0.29 0.68 0.000
0.80 0.72 0.86 0.0000.79 0.70 0.86 0.0000.77 0.71 0.82 0.0000.71 0.55 0.83 0.000
0.71 0.65 0.76 0.000
Favors Traditional Clinical Education
Favors SBME with DP
-1.00 -0.50 0.00 0.50 1.00Overall Effect Size
Randomized Trials1. Wayne, et al, 20052. Ahlberg, et al, 20073. Andreatta, et al, 20064. Korndorffer, et al, 20055. Korndorffer, et al, 20056. Van Sickle, et al, 2008
Cohort Studies7. Issenberg, et al, 20028. Barsuk, et al, 20099. Butter, et al 2010
Case-Control Studies10. Wayne, et al, 2008
Pre-Post Baseline Studies11. Wayne, et al, 200812. Barsuk, et al, 200913. Barsuk, et al, 200914. Stefanidis, et al, 2006
Deliberate Practice Meta Analysis
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Mastery Learning
• Critical component of competency-based education
• Goal: All learners consistently achieve objective level of mastery performance
• Time: variable
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Mastery Learning
• Model:
• Establish assessment and minimum passing standard;
• Baseline assessment;
• Clear objectives, units in increasing difficulty;
• Engagement in educational activity;
• Testing for mastery;
• Advancement to the next training level; or ongoing practice
• Essential Components
• Outcomes
• Increasing level of Difficulty
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Source: Barsuk JH, Cohen ER, Caprio T, et al. Simulation-based education with mastery learning improves resi
dents’ lumbar puncture skills. Neurology 2012; 79(2): 132-37. Reprinted with permission of Wolters Kluwer Heal
th.
Clinical skills examination (checklist) pre-and final posttest performance of 58 first-year simulator-trained i
nternal medicine residents and baseline performance of 36 traditionally trained neurology residents. Thre
e internal medicine residents failed to meet the minimum passing score (MPS) at initial post-testing. PGY
– postgraduate year.
Mastery Learning of Lumbar Puncture Skills
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Range of Difficulty and Clinical Variation
• Learning optimized with stepwise progression to increased levels of difficulty and complexity as mastery achieved
• Shift the learning curve
• Train for rare events
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So much complexity in the healthcare, thus too many
things to learn!
I have already worked 80 hours this week! No more
working for me!
Hospital is only interested in how many “profitable” patients I see!
And I get promoted through my research publication, not by
teaching a lot!
I do not have the luxury to devote my time to teaching!
I’m not just old, but have DM,
HTN, ESRD, MI, stroke, and have a forearm fracture!
Are you sure you can handle me?
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Range of Difficulty
• Cognitive load and complexity of intervention must be appropriate to learner level
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Level Population Tasks Example
11st year medical s
tudentIdentify finding “I hear a fourth heart sound.”
22nd year medical s
tudent
Correlate finding with und
erlying patho-physiology
“This fourth heart sound is cau
sed by an increased after-load
on the left ventricle.”
33rd year medical s
tudent
Generate a differential dia
gnosis
“Possible causes are aortic sten
osis, hypertension, etc.”
42nd year internal
medicine resident
Make a management decis
ion
“Order an EKG, consult a speci
alist, initiate medical therapy.”
Example: Cardiac Bedside SkillsThe University of Miami developed a multi-year cardiac bedside skill curriculum in
which the difficulty of each task increases with each stage of training.
Cardiac Finding: A simulator presents a fourth heart sound at the apex.
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Simulation as a Solution
• Medical error reduction and patient safety
• Learner-centered, individualized learning
• Outcomes-based education
• Needed exposure to range of clinical cases
• Studying human factors
• Supplant animal and live-tissue models (as technology & tissue fidelity continues to improve)
• Accreditation and Licensure
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Terima kasih
ありがとうございます
謝謝
Salamat po
धन्यवाद्
شكرا جزيل
MahaloThank you
Danke schon
唔該