simulation - cord home page

Simulation For Simulation For Emergency Emergency Medicine Medicine

CORD Academic AssemblyCORD Academic AssemblyMarch 4March 4thth, 2006, 2006

Steve McLaughlin, MDSteve McLaughlin, MDEM Program DirectorEM Program Director

Medical Director ‘BATCAVE’ Simulation Medical Director ‘BATCAVE’ Simulation CenterCenter

University of New MexicoUniversity of New Mexico

Mary Jo Wagner, MDMary Jo Wagner, MDEM Program DirectorEM Program Director

Synergy Medical Education AllianceSynergy Medical Education AllianceMichigan State UniversityMichigan State University

ObjectivesObjectives

Describe the current state of Describe the current state of education and research in simulation.education and research in simulation.

List the various simulators, List the various simulators, mannequins and models available for mannequins and models available for emergency medicine training.emergency medicine training.

Discuss the strengths and weaknesses Discuss the strengths and weaknesses of each simulation modality.of each simulation modality.

List some of the best practice List some of the best practice examples for using simulation in EM examples for using simulation in EM residencies.residencies.

OutlineOutline

IntroductionIntroduction Spectrum of Simulation EquipmentSpectrum of Simulation Equipment Best Practice ExamplesBest Practice Examples Hands-on PracticeHands-on Practice

IntroductionIntroduction

““Simulation is the act of mimicking a Simulation is the act of mimicking a real object, event or process.”real object, event or process.”

““Simulation is a person, device or set Simulation is a person, device or set of conditions which present of conditions which present

evaluation problems authentically. evaluation problems authentically. The student responds to the The student responds to the

problems as they would under problems as they would under natural circumstances.”natural circumstances.”


CharacteristicsCharacteristics Cues and consequences are like realityCues and consequences are like reality Situations can be complexSituations can be complex Fidelity (exactness of duplication) is not Fidelity (exactness of duplication) is not

perfectperfect Feedback to users questions, decisions, Feedback to users questions, decisions,

and actions.and actions.

IntroductionIntroduction HistoryHistory

1928 Edwin Link develops first flight simulator – “Link 1928 Edwin Link develops first flight simulator – “Link Trainer”Trainer”

1960 Laerdal introduces first “Resusci-Annie”1960 Laerdal introduces first “Resusci-Annie” 1968 “Harvey” cardiology simulator 1968 “Harvey” cardiology simulator 1970 First power plant simulators1970 First power plant simulators 1973 First computer aided modeling of physiology1973 First computer aided modeling of physiology 1975 Standardized patients and OSCE’s introduced1975 Standardized patients and OSCE’s introduced 1988 First full body, computerized mannequin at 1988 First full body, computerized mannequin at

StanfordStanford 1989 ACRM – Anesthesia focused on patient safety and 1989 ACRM – Anesthesia focused on patient safety and

education movement at this timeeducation movement at this time 1990 Term Virtual Reality was introduced, Screen 1990 Term Virtual Reality was introduced, Screen

Based Simulators IntroducedBased Simulators Introduced

Link TrainerLink Trainer

HarveyHarvey

IntroductionIntroduction HistoryHistory

1990’s US IOM “To Err Is Human” report.1990’s US IOM “To Err Is Human” report. 1994 Boston Center for Medical Simulation1994 Boston Center for Medical Simulation 1993 First national/international simulation meetings MMVR1993 First national/international simulation meetings MMVR Late 1990’s Introduction of simulation into specialties like EMLate 1990’s Introduction of simulation into specialties like EM 1997 MIST VR Task Trainer1997 MIST VR Task Trainer 1998 AAMC MSOP1998 AAMC MSOP 1991-1993 a total of 30 articles on High Fidelity Simulation1991-1993 a total of 30 articles on High Fidelity Simulation 2000-1 Current generation of full body mannequins introduced 2000-1 Current generation of full body mannequins introduced

by METI and Laerdalby METI and Laerdal 2000-2003 a total of 385 articles on High Fidelity Simulation2000-2003 a total of 385 articles on High Fidelity Simulation 2005 Society for Medical Simulation2005 Society for Medical Simulation 2006 Simulation in Healthcare Journal2006 Simulation in Healthcare Journal


Why is this a valuable tool? Or is it?Why is this a valuable tool? Or is it? Learners can learn without risk to patient.Learners can learn without risk to patient. Learning can be focused without regard to Learning can be focused without regard to

patient care needs/safety/etc.patient care needs/safety/etc. Opportunity to repeat lesson/skill to mastery.Opportunity to repeat lesson/skill to mastery. Specific learning opportunitiesSpecific learning opportunities guaranteed. guaranteed. Learning can be done at convenient times.Learning can be done at convenient times. Performance can be observed/recorded.Performance can be observed/recorded.


Why is simulation important in Why is simulation important in medical education?medical education? Problems with clinical teachingProblems with clinical teaching New technologies for New technologies for

diagnosis/treatmentdiagnosis/treatment Assessing professional competenceAssessing professional competence Medical errors and patient safetyMedical errors and patient safety Deliberate practiceDeliberate practice


CORD Consensus ConferenceCORD Consensus Conference Simulation is a useful tool for assess Simulation is a useful tool for assess

competence. Especially patient care, IP skills competence. Especially patient care, IP skills and SBP.and SBP.

There is a lack of evidence to support the use There is a lack of evidence to support the use of simulation for high stakes assessment.of simulation for high stakes assessment.

Definitions of competence and tools to Definitions of competence and tools to evaluate performance must be developed evaluate performance must be developed and tested.and tested.

Scenarios and evaluation tools should be Scenarios and evaluation tools should be standardized.standardized.


ACGME ‘Toolbox of Assessment ACGME ‘Toolbox of Assessment Methods’Methods’ Simulation is ‘the best’, ‘second best’ Simulation is ‘the best’, ‘second best’

tool for assessing:tool for assessing: Medical proceduresMedical procedures Ability to develop and carry out patient Ability to develop and carry out patient

management plansmanagement plans Investigative/analytical thinkingInvestigative/analytical thinking Knowledge/application of basic sciencesKnowledge/application of basic sciences Ethically sound practiceEthically sound practice


LCME RequirementsLCME Requirements Allows simulated patients to count for Allows simulated patients to count for

student exposure to particular cases.student exposure to particular cases.

RRC RequirementsRRC Requirements Allows simulated procedures to count Allows simulated procedures to count

for program/individual totals.for program/individual totals. Very helpful for rare procedures.Very helpful for rare procedures.


Simulation is one toolSimulation is one tool(new, expensive and exciting)(new, expensive and exciting)

in our educational repertoire.in our educational repertoire.(Similar to lecture, case discussion, skill lab, MCQ, SP, etc.)(Similar to lecture, case discussion, skill lab, MCQ, SP, etc.)

OutlineOutline


Available Simulation Available Simulation EquipmentEquipment

Standardized PatientsStandardized Patients Improvised TechnologyImprovised Technology Screen Based SimulationScreen Based Simulation Task TrainersTask Trainers Low/Mid/High Fidelity MannequinsLow/Mid/High Fidelity Mannequins Virtual RealityVirtual Reality

Evaluating SimulatorsEvaluating Simulators

UsabilityUsability ValidityValidity

Face, Content, Construct, Concurrent, Face, Content, Construct, Concurrent, Predictive Predictive

TransferTransfer EfficiencyEfficiency CostCost EvidenceEvidence

Standardized PatientsStandardized Patients

Individuals trained to portray specific Individuals trained to portray specific illness or behavior in a realistic and illness or behavior in a realistic and consistent manner for the purposes of consistent manner for the purposes of teaching or assessment.teaching or assessment.

Used in classroom setting, or without Used in classroom setting, or without knowledge in clinical settingknowledge in clinical setting

Especially useful to teach and assess Especially useful to teach and assess communications and professionalism communications and professionalism competencies in a standardized method.competencies in a standardized method.


Initially started in the 1980’sInitially started in the 1980’s Now - Association of Standardized Now - Association of Standardized

Patient Educators Patient Educators http://www.aspeducators.org/sp_info.hthttp://www.aspeducators.org/sp_info.ht

mm Required Clinical Skills testing for all Required Clinical Skills testing for all

studentsstudents USMLE Part II CS examUSMLE Part II CS exam

Univ of South Florida standardized patient


StrengthsStrengths Can consistently reproduce clinical Can consistently reproduce clinical

scenario for standardized testing of scenario for standardized testing of learnerslearners

Ability to assess rare conditions not Ability to assess rare conditions not otherwise reliably seenotherwise reliably seen

Patients trained to provide objective & Patients trained to provide objective & accurate feedbackaccurate feedback

Can use in real settings (arrive at office/ED Can use in real settings (arrive at office/ED as ‘real’ patient for realistic environment)as ‘real’ patient for realistic environment)


WeaknessesWeaknesses Little research on effectivenessLittle research on effectiveness

Most studies are from preclinical medical school Most studies are from preclinical medical school educationeducation

Few studies done with residents or practitioners Few studies done with residents or practitioners and nearly all have small numbers (15-50)and nearly all have small numbers (15-50)

Cost to pay & time to teach standardized Cost to pay & time to teach standardized patientspatients

Quality of experience heavily dependent Quality of experience heavily dependent upon training of the patient and scenarios upon training of the patient and scenarios developeddeveloped

Improvised TechnologyImprovised Technology Models made of easily available itemsModels made of easily available items

Closely mimic human tissueClosely mimic human tissue Allow for near replica of actual procedural stepsAllow for near replica of actual procedural steps

Generally used for instruction of Generally used for instruction of proceduresprocedures

Commonly used examplesCommonly used examples Slab of ribs to teach insertion of chest tubesSlab of ribs to teach insertion of chest tubes Pigs feet or head for suturing practicePigs feet or head for suturing practice

Other examples in the literatureOther examples in the literature Jello for vascular modelJello for vascular model Lasagna for split skin graft harvestingLasagna for split skin graft harvesting

Animal ModelsAnimal Models

Improvised Technology – Improvised Technology – Educational TheoryEducational Theory

Cognitive process for learning a Cognitive process for learning a procedureprocedure Understanding of indications, Understanding of indications,

contraindications & complications contraindications & complications Knowledge of equipment used for procedureKnowledge of equipment used for procedure Step-by-step knowledge of technical Step-by-step knowledge of technical

procedureprocedure Identifying anatomical landmarks and ‘tissue Identifying anatomical landmarks and ‘tissue

clues’ clues’ E.g. “pop” when entering dura or peritoneal E.g. “pop” when entering dura or peritoneal

cavitycavity

Improvised Technology – Improvised Technology – Educational TheoryEducational Theory

Improvised Technology Improvised Technology Useful to teachUseful to teach

Knowledge of equipmentKnowledge of equipment Step-by-step knowledge of procedureStep-by-step knowledge of procedure Some ‘tissue clues’Some ‘tissue clues’

Less useful forLess useful for Anatomical landmarksAnatomical landmarks

““Greatest predictor of procedural Greatest predictor of procedural competency … was the ability to competency … was the ability to sequentially order procedural steps”sequentially order procedural steps”Chapman DM et al Open Thoracotomy Procedural…Ann Emerg Med 1996; 28:641.Chapman DM et al Open Thoracotomy Procedural…Ann Emerg Med 1996; 28:641.

Improvised TechnologyImprovised Technology

StrengthsStrengths Cheap!!!Cheap!!! Made easily available at all sitesMade easily available at all sites Easy to duplicate for repetitive use or Easy to duplicate for repetitive use or

numerous usersnumerous users Minimal instructor education neededMinimal instructor education needed Ability to create models otherwise not Ability to create models otherwise not

availableavailable Resuscitative ThoractomyResuscitative Thoractomy


WeaknessesWeaknesses Almost no research on effectiveness Almost no research on effectiveness Less ‘real-life’ experience, therefore Less ‘real-life’ experience, therefore

stress factor removedstress factor removed Often does not duplicate most difficult Often does not duplicate most difficult

aspect of procedure (E.g. obese patient)aspect of procedure (E.g. obese patient) Static devices , therefore useful for Static devices , therefore useful for

specific procedures only, not actively specific procedures only, not actively changing clinical scenarioschanging clinical scenarios

Examples – Vascular Examples – Vascular modelmodel

A = Sock skinB = Film canister for supportC = Foam curler connective tissueD = Straw vessel

Examples – DPL modelExamples – DPL model

A = Fine fabric peritoneumB = Foam connective tissueC = Shower curtain skinD = PVC pipe intestinesE = Umbilicus marking

Examples – Lumbar Examples – Lumbar puncture modelpuncture model

A = Box spinous processB = Film canister lateral massesb = Lid of film canisterC = Foam curler connective tissueD = Dural “pop” from packing bubblesNot seen – pillow muscular layer

Examples – Thoracotomy Examples – Thoracotomy modelmodel

A = Shower curtain skinB = Foam connective tissueC = Laundry basket rib cageD = ClipsE = Packing air bag lungsF = Ice cube tray spineG = Plastic bag pericardium with tape phrenic nerveH = covered football heart with holeI = Tubing esophagus with NG in placeJ = Tubing aorta

Examples – Thoracotomy Examples – Thoracotomy modelmodel

Screen Based SimulationScreen Based Simulation

Desktop ComputerDesktop Computer Strengths – low cost, distance Strengths – low cost, distance

learning, variety of cases, improving learning, variety of cases, improving realism, self guidedrealism, self guided

Weaknesses – procedural skills, Weaknesses – procedural skills, teamwork skillsteamwork skills


Laerdal MicrosimLaerdal Microsim www.www.AnesoftAnesoft.com.com

ACLSACLS Critical CareCritical Care AnesthesiaAnesthesia SedationSedation NeonatalNeonatal

Task TrainersTask Trainers

Devices designed to simulate a Devices designed to simulate a specific task or procedure.specific task or procedure.

Examples:Examples: Lap simulatorLap simulator Bronch simulatorBronch simulator ““Traumaman”Traumaman” Artificial kneeArtificial knee


StrengthsStrengths High fidelity, good research on efficacy, High fidelity, good research on efficacy,

may have self guided teaching, metrics may have self guided teaching, metrics availableavailable

WeaknessesWeaknesses Poor haptics on most machines, Poor haptics on most machines,

expensive, focus on single task, not expensive, focus on single task, not integrated into complete patient careintegrated into complete patient care

Low Fidelity MannequinsLow Fidelity Mannequins

Features:Features: Static airwaysStatic airways +/- rhythm generation+/- rhythm generation No/minimal programmed responses.No/minimal programmed responses.

Strengths: Low cost, reliable, easy to Strengths: Low cost, reliable, easy to use, portableuse, portable

Weaknesses: Limited features, less Weaknesses: Limited features, less interactive, instructor requiredinteractive, instructor required

Low Fidelity MannequinsLow Fidelity Mannequins

ExamplesExamples

Mid Fidelity MannequinsMid Fidelity Mannequins

Relatively new class of mannequins, Relatively new class of mannequins, often used for ACLS training.often used for ACLS training.

Features:Features: Active airways – ETT, LMA, CombitubeActive airways – ETT, LMA, Combitube Breathing/pulses, rhythmsBreathing/pulses, rhythms Basic procedures – pacing, defibrillationBasic procedures – pacing, defibrillation Some automated response and Some automated response and

programmed scenariosprogrammed scenarios

Mid Fidelity MannequinsMid Fidelity Mannequins

Strengths:Strengths: Active airways, somewhat interactive, Active airways, somewhat interactive,

moderate cost, moderate portabilitymoderate cost, moderate portability Weaknesses:Weaknesses:

Semiskilled instructor, limited advanced Semiskilled instructor, limited advanced procedures (lines, chest tubes)procedures (lines, chest tubes)

High Fidelity High Fidelity MannequinsMannequins

Mannequin with electrical, pneumatic Mannequin with electrical, pneumatic functions driven by a computer.functions driven by a computer.

Adult, child and newborn modelsAdult, child and newborn models Features:Features:

Dynamic airways, reactive pupilsDynamic airways, reactive pupils Heart sounds, lung sounds, chest movementHeart sounds, lung sounds, chest movement Pulses, rhythms, vital signsPulses, rhythms, vital signs Abdominal sounds, voiceAbdominal sounds, voice CO2 exhalation, cardiac output, invasive CO2 exhalation, cardiac output, invasive

pressurespressures Bleeding, salivation, lacrimationBleeding, salivation, lacrimation


ProceduresProcedures O2, BVM, Oral/nasal airway, ETT, LMA, O2, BVM, Oral/nasal airway, ETT, LMA,

CricCric Pericardiocentesis, PIVPericardiocentesis, PIV Defibrillation, Pacing, CPRDefibrillation, Pacing, CPR Needle or open thoracentesisNeedle or open thoracentesis TOF, Internal gas analysisTOF, Internal gas analysis Foley placementFoley placement Reacts to medicationsReacts to medications

FeaturesFeatures

Laerdal vs. METILaerdal vs. METI

LaerdalLaerdal Instructor Instructor

programmed programmed physiology changesphysiology changes

WindowsWindows Terrific AirwayTerrific Airway ReliabilityReliability Ease of UseEase of Use Cost: 35-45KCost: 35-45K

METIMETI Physiology modeled Physiology modeled

to respond to to respond to interventionsinterventions

MacintoshMacintosh Drug RecognitionDrug Recognition Gas AnalyzerGas Analyzer Two Cost LevelsTwo Cost Levels

ECS: 45KECS: 45K HPS: >150KHPS: >150K


StrengthsStrengths Many dynamic responses, Many dynamic responses,

preprogrammed scenarios, widest preprogrammed scenarios, widest variety of procedures, most immersive.variety of procedures, most immersive.

WeaknessesWeaknesses Cost, procedures are not very realistic, Cost, procedures are not very realistic,

reliability, lack of portability, significant reliability, lack of portability, significant instructor training required.instructor training required.

MannequinsMannequins

Virtual RealityVirtual Reality

Advanced form of human-computer Advanced form of human-computer interactioninteraction Allow humans to work in the computer’s Allow humans to work in the computer’s

worldworld Environment understandable to usEnvironment understandable to us

Four necessary componentsFour necessary components Software Software Hardware Hardware Input devicesInput devices Output devisesOutput devises

Input and Output devicesInput and Output devices


Types of VR applicable to medicineTypes of VR applicable to medicine Immersive VRImmersive VR Desktop VRDesktop VR Pseudo-VRPseudo-VR Augmented realityAugmented reality

Immersive VRImmersive VR

Desktop VRDesktop VR

Pseudo-VRPseudo-VR

Augmented RealityAugmented Reality

OutlineOutline


ResearchResearch

Rapidly expanding body of literature Rapidly expanding body of literature since 2000.since 2000.

First issue of ‘Simulation in Healthcare’ First issue of ‘Simulation in Healthcare’ Jan 2006.Jan 2006.

Many articles on ‘look at what we did’ Many articles on ‘look at what we did’ level and data that says ‘everyone level and data that says ‘everyone thought it was nifty.’thought it was nifty.’

Focus on best practices in Focus on best practices in teaching/learning and assessment using teaching/learning and assessment using simulation.simulation.

Best Teaching PracticesBest Teaching Practices Screen based teaching with feedback is better than self Screen based teaching with feedback is better than self

study.study.

Schwid, H. A., G. A. Rooke, et al. Schwid, H. A., G. A. Rooke, et al. (2001). "Screen-based anesthesia (2001). "Screen-based anesthesia simulation with debriefing improves performance in a mannequin-simulation with debriefing improves performance in a mannequin-based anesthesia simulator." based anesthesia simulator." Teaching & Learning in MedicineTeaching & Learning in Medicine 1313(2): 92-6.(2): 92-6.

We measured the effectiveness of screen-based simulator training with We measured the effectiveness of screen-based simulator training with debriefing on the response to simulated anesthetic critical incidents. debriefing on the response to simulated anesthetic critical incidents.

The intervention group handled 10 anesthetic emergencies using the The intervention group handled 10 anesthetic emergencies using the screen-based anesthesia simulator program and received written screen-based anesthesia simulator program and received written feedback on their management, whereas the traditional (control) feedback on their management, whereas the traditional (control) group was asked to study a handout covering the same 10 group was asked to study a handout covering the same 10 emergencies.emergencies.

All residents then were evaluated on their management of 4 All residents then were evaluated on their management of 4 standardized scenarios in a mannequin-based simulator using a standardized scenarios in a mannequin-based simulator using a quantitative scoring system. quantitative scoring system.

Residents who managed anesthetic problems using a screen-based Residents who managed anesthetic problems using a screen-based anesthesia simulator handled the emergencies in a mannequin-based anesthesia simulator handled the emergencies in a mannequin-based anesthesia simulator better than residents who were asked to study a anesthesia simulator better than residents who were asked to study a handout covering the same problems.handout covering the same problems.

Best Teaching PracticesBest Teaching Practices Comparing simulation to other teaching modalities Comparing simulation to other teaching modalities

demonstrates some slight advantages.demonstrates some slight advantages.

Lee, S. K., M. Pardo, et al. Lee, S. K., M. Pardo, et al. "Trauma assessment training "Trauma assessment training with a patient simulator: a prospective, randomized study." with a patient simulator: a prospective, randomized study." Journal of Trauma-Injury Infection & Critical Care. Journal of Trauma-Injury Infection & Critical Care. 55(4):651-7, 2003 Oct.55(4):651-7, 2003 Oct.

Interns (n = 60) attended a basic trauma course, and were Interns (n = 60) attended a basic trauma course, and were then randomized to trauma assessment practice sessions with then randomized to trauma assessment practice sessions with either the patient simulator (n = 30) or a moulage patient (n = either the patient simulator (n = 30) or a moulage patient (n = 30). After practice sessions, interns were randomized a second 30). After practice sessions, interns were randomized a second time to an individual trauma assessment test on either the time to an individual trauma assessment test on either the simulator or the moulage patient.simulator or the moulage patient.

Within randomized groups, mean trauma assessment test Within randomized groups, mean trauma assessment test scores for all simulator-trained interns were higher when scores for all simulator-trained interns were higher when compared with all moulage-trained interns.compared with all moulage-trained interns.

Use of a patient simulator to introduce trauma assessment Use of a patient simulator to introduce trauma assessment training is feasible and compares favorably to training in a training is feasible and compares favorably to training in a moulage setting.moulage setting.

Best Teaching PracticesBest Teaching Practices Simulation can be an effective replacement Simulation can be an effective replacement

for live practice for some skills.for live practice for some skills.

Hall, R. E., J. R. Plant, et al. Hall, R. E., J. R. Plant, et al. (2005). "Human (2005). "Human Patient Simulation Is Effective for Teaching Patient Simulation Is Effective for Teaching Paramedic Students Endotracheal Intubation." Paramedic Students Endotracheal Intubation." Acad Emerg MedAcad Emerg Med 1212(9): 850-855.(9): 850-855.

Paramedic students (n = 36) with no prior ETI training Paramedic students (n = 36) with no prior ETI training received identical didactic and mannequin teaching. received identical didactic and mannequin teaching. After randomization, students were trained for ten hours After randomization, students were trained for ten hours on a patient simulator (SIM) or with 15 intubations on on a patient simulator (SIM) or with 15 intubations on human subjects in the OR. All students then underwent human subjects in the OR. All students then underwent a formalized test of 15 intubations in the OR. a formalized test of 15 intubations in the OR.

When tested in the OR, paramedic students who were When tested in the OR, paramedic students who were trained in ETI on a simulator are as effective as students trained in ETI on a simulator are as effective as students who trained on human subjects.who trained on human subjects.

Best Teaching PracticesBest Teaching Practices Learner centered teaching with simulation.Learner centered teaching with simulation.

Gordon, J. A. and J. Pawlowski (2002). "Education on-Gordon, J. A. and J. Pawlowski (2002). "Education on-demand: the development of a simulator-based medical demand: the development of a simulator-based medical education service." education service." Academic Medicine.Academic Medicine. 7777(7): 751-2.(7): 751-2.

Using the simulator, we wanted to create a medical education Using the simulator, we wanted to create a medical education service-like any other clinical teaching service, but designed service-like any other clinical teaching service, but designed exclusively to help students fill in the gaps in their own exclusively to help students fill in the gaps in their own education, on demand. We hoped to mitigate the inherent education, on demand. We hoped to mitigate the inherent variability of standard clinical teaching, and to augment areas variability of standard clinical teaching, and to augment areas of deficiency.of deficiency.

Upon arriving at the skills lab for their appointments, students Upon arriving at the skills lab for their appointments, students would proceed to interview, evaluate, and treat the would proceed to interview, evaluate, and treat the mannequin-simulator as if it were a real patient, using the mannequin-simulator as if it were a real patient, using the instructor for assistance as needed. All students participated instructor for assistance as needed. All students participated in an educational debriefing after each session. in an educational debriefing after each session.

Customized, realistic clinical correlates are now readily Customized, realistic clinical correlates are now readily available for students and teachers, allowing reliable access to available for students and teachers, allowing reliable access to "the good teaching case.""the good teaching case."

Best Teaching PracticesBest Teaching Practices Cheap may be as good as expensive.Cheap may be as good as expensive.

Keyser, E. J., A. M. Derossis, et al. Keyser, E. J., A. M. Derossis, et al. (2000). "A (2000). "A simplified simulator for the training and evaluation of simplified simulator for the training and evaluation of laparoscopic skills." laparoscopic skills." Surg EndoscSurg Endosc 1414(2): 149-53.(2): 149-53. The purpose of this study was to compare a simplified The purpose of this study was to compare a simplified

mirrored-box simulator to the video- laparoscopic cart mirrored-box simulator to the video- laparoscopic cart system.system.

22 surgical residents performed seven structured tasks in 22 surgical residents performed seven structured tasks in both simulators in random order. Scores reflected precision both simulators in random order. Scores reflected precision and speed.and speed.

There were no significant differences in mean raw scores There were no significant differences in mean raw scores between the simulators for six of the seven tasks.between the simulators for six of the seven tasks.

A mirrored-box simulator was shown to provide a reasonable A mirrored-box simulator was shown to provide a reasonable reflection of relative performance of laparoscopic skills. reflection of relative performance of laparoscopic skills.

Best Teaching PracticesBest Teaching Practices Team behavior can be effected by focused simulation Team behavior can be effected by focused simulation

experiences.experiences.

Shapiro, M. J., J. C. Morey, et al. Shapiro, M. J., J. C. Morey, et al. (2004). "Simulation based (2004). "Simulation based teamwork training for emergency department staff: does it teamwork training for emergency department staff: does it improve clinical team performance when added to an existing improve clinical team performance when added to an existing didactic teamwork curriculum?" didactic teamwork curriculum?" Quality & Safety in Health Quality & Safety in Health CareCare 1313(6): 417-21.(6): 417-21.

ED staff who had recently received didactic training in the ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC) also received an 8 Emergency Team Coordination Course (ETCC) also received an 8 hour intensive experience in an ED simulator in which three hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. ED for one 8 hour shift.

Experimental and comparison teams were observed in the ED Experimental and comparison teams were observed in the ED before and after the intervention. before and after the intervention.

The experimental team showed a trend towards improvement in The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation showed no change in team behavior during the two observation periods (p = 0.55). periods (p = 0.55).

Best Teaching PracticesBest Teaching Practices Innovative use of two new technologies helps to Innovative use of two new technologies helps to

engage learners in a large group setting.engage learners in a large group setting.

Vozenilek, J., E. Wang, et al. Vozenilek, J., E. Wang, et al. (2005). "Simulation-based (2005). "Simulation-based Morbidity and Mortality Conference: New Technologies Morbidity and Mortality Conference: New Technologies Augmenting Traditional Case-based Presentations." Augmenting Traditional Case-based Presentations." Acad Acad Emerg MedEmerg Med: j.aem.2005.08.015.: j.aem.2005.08.015.

The use of two separate technologies were enlisted: a METI The use of two separate technologies were enlisted: a METI high-fidelity patient simulator to re-create the case in a more high-fidelity patient simulator to re-create the case in a more lifelike fashion, and an audience response system to collect lifelike fashion, and an audience response system to collect clinical impressions throughout the case presentation and clinical impressions throughout the case presentation and survey data at the end of the presentation.survey data at the end of the presentation.

The re-creation of the patient encounter with all relevant The re-creation of the patient encounter with all relevant physical findings displayed in high fidelity, with relevant physical findings displayed in high fidelity, with relevant laboratory data, nursing notes, and imaging as it occurred in laboratory data, nursing notes, and imaging as it occurred in the actual case, provides a more engaging format for the the actual case, provides a more engaging format for the resident-learner.resident-learner.

Best Teaching PracticesBest Teaching Practices

OrientationOrientation Introduction to sessionIntroduction to session

ExpectationsExpectations What is real/what is notWhat is real/what is not

Self assessmentSelf assessment DebriefingDebriefing EvaluationEvaluation

How To Best Use How To Best Use SimulationSimulation

Provide feedbackProvide feedback Give opportunities for repetitive practiceGive opportunities for repetitive practice Integrate simulation into overall Integrate simulation into overall

curriculumcurriculum Provide increasing levels of difficultyProvide increasing levels of difficulty Provide clinical variation in scenariosProvide clinical variation in scenarios Control environmentControl environment Provide individual and team learningProvide individual and team learning Define outcomes and benchmarksDefine outcomes and benchmarks

Best Teaching PracticesBest Teaching Practices

Best Assessment Best Assessment PracticesPractices

Simulation has some data to support its use as an Simulation has some data to support its use as an assessment modality.assessment modality.

Schwid, H. A., G. A. Rooke, et al. Schwid, H. A., G. A. Rooke, et al. (2002). "Evaluation of (2002). "Evaluation of anesthesia residents using mannequin-based simulation: a anesthesia residents using mannequin-based simulation: a multiinstitutional study." multiinstitutional study." AnesthesiologyAnesthesiology 9797(6): 1434-44.(6): 1434-44.

99 anesthesia residents consented to be videotaped during their 99 anesthesia residents consented to be videotaped during their management of four simulated scenarios on MedSim or METI management of four simulated scenarios on MedSim or METI mannequin-based anesthesia simulatorsmannequin-based anesthesia simulators

Construct-related validity of mannequin-based simulator Construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator assessment was supported by an overall improvement in simulator scores from CB and CA-1 to CA-2 and CA-3 levels of training. scores from CB and CA-1 to CA-2 and CA-3 levels of training.

Criterion-related validity was supported by moderate correlation Criterion-related validity was supported by moderate correlation of simulator scores with departmental faculty evaluations (0.37-of simulator scores with departmental faculty evaluations (0.37-0.41, P < 0.01), ABA written in-training scores (0.44-0.49, < 0.01), 0.41, P < 0.01), ABA written in-training scores (0.44-0.49, < 0.01), and departmental mock oral board scores (0.44-0.47, P < 0.01).and departmental mock oral board scores (0.44-0.47, P < 0.01).

Reliability of the simulator assessment was demonstrated by very Reliability of the simulator assessment was demonstrated by very good internal consistency (alpha = 0.71-0.76) and excellent good internal consistency (alpha = 0.71-0.76) and excellent interrater reliability (correlation = 0.94-0.96; P < 0.01; kappa = interrater reliability (correlation = 0.94-0.96; P < 0.01; kappa = 0.81-0.90). 0.81-0.90).


Task trainers appear to be a valid method for Task trainers appear to be a valid method for assessing procedural competence.assessing procedural competence.

Adrales, G. L., A. E. Park, et al. (2003). "A valid Adrales, G. L., A. E. Park, et al. (2003). "A valid method of laparoscopic simulation training and method of laparoscopic simulation training and competence assessment." competence assessment." Journal of Surgical Journal of Surgical ResearchResearch 114114(2): 156-62.(2): 156-62.

Subjects (N = 27) of varying levels of surgical experience Subjects (N = 27) of varying levels of surgical experience performed three laparoscopic simulations, representing performed three laparoscopic simulations, representing appendectomy (LA), cholecystectomy (LC), and inguinal appendectomy (LA), cholecystectomy (LC), and inguinal hemiorrhaphy (LH). hemiorrhaphy (LH).

Years of experience directly correlated with the skills Years of experience directly correlated with the skills ratings (all P < 0.001) and with the competence ratings ratings (all P < 0.001) and with the competence ratings across the three procedures (P < 0.01). Experience across the three procedures (P < 0.01). Experience inversely correlated with the time for each procedure (P inversely correlated with the time for each procedure (P < 0.01) and the technical error total across the three < 0.01) and the technical error total across the three models (P < 0.05). models (P < 0.05).


Multiple simulated encounters are needed to Multiple simulated encounters are needed to accurately assess resident abilities.accurately assess resident abilities.

Boulet, J. R., D. Murray, et al. Boulet, J. R., D. Murray, et al. (2003). "Reliability and validity (2003). "Reliability and validity of a simulation-based acute care skills assessment for medical of a simulation-based acute care skills assessment for medical students and residents." students and residents." AnesthesiologyAnesthesiology 9999(6): 1270-80.(6): 1270-80.

The authors developed and tested 10 simulated acute care The authors developed and tested 10 simulated acute care situations that clinical faculty at a major medical school expects situations that clinical faculty at a major medical school expects graduating physicians to be able to recognize and treat at the graduating physicians to be able to recognize and treat at the conclusion of training. Forty medical students and residents conclusion of training. Forty medical students and residents participated in the evaluation of the exercises.participated in the evaluation of the exercises.

The reliability of the simulation scores was moderate and was The reliability of the simulation scores was moderate and was most strongly influenced by the choice and number of simulated most strongly influenced by the choice and number of simulated encounters. encounters.

However, multiple simulated encounters, covering a broad However, multiple simulated encounters, covering a broad domain, are needed to effectively and accurately estimate domain, are needed to effectively and accurately estimate student/resident abilities in acute care settings.student/resident abilities in acute care settings.


Checklists scoring of videotaped performance can Checklists scoring of videotaped performance can have a high degree of inter-rater reliability.have a high degree of inter-rater reliability.

Devitt, J. H., M. M. Kurrek, et al. Devitt, J. H., M. M. Kurrek, et al. (1997). "Testing the (1997). "Testing the raters: inter-rater reliability of standardized anaesthesia raters: inter-rater reliability of standardized anaesthesia simulator performance." simulator performance." Can J AnaesthCan J Anaesth 4444(9): 924-8.(9): 924-8.

We sought to determine if observers witnessing the same We sought to determine if observers witnessing the same event in an anaesthesia simulator would agree on their rating event in an anaesthesia simulator would agree on their rating of anaesthetist performance. of anaesthetist performance.

Two one-hour clinical scenarios were developed, each Two one-hour clinical scenarios were developed, each containing five anaesthetic problems.containing five anaesthetic problems.

Video tape recordings were generated through role-playing Video tape recordings were generated through role-playing with recording of the two scenarios three times each with recording of the two scenarios three times each resulting in a total of 30 events to be evaluated. Two clinical resulting in a total of 30 events to be evaluated. Two clinical anaesthetists, reviewed and scored each of the 30 problems anaesthetists, reviewed and scored each of the 30 problems independently.independently.

The raters were in complete agreement on 29 of the 30 items. The raters were in complete agreement on 29 of the 30 items. There was excellent inter- rater reliability (= 0.96, P 0.001). There was excellent inter- rater reliability (= 0.96, P 0.001).


Validation that simulator performance Validation that simulator performance correlates with real practice.correlates with real practice.

Fried, G. M., A. M. Derossis, et al. Fried, G. M., A. M. Derossis, et al. (1999). (1999). "Comparison of laparoscopic performance in vivo "Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic with performance measured in a laparoscopic simulator." Surg Endosc 13(11): 1077-81; discussion simulator." Surg Endosc 13(11): 1077-81; discussion 1082.1082.

Twelve PGY3 residents were given a baseline evaluation in Twelve PGY3 residents were given a baseline evaluation in the simulator and in the animal model. They were then the simulator and in the animal model. They were then randomized to either five practice sessions in the simulator randomized to either five practice sessions in the simulator (group A) or no practice (group B). Each group was retested (group A) or no practice (group B). Each group was retested in the simulator and in the animal (final test). in the simulator and in the animal (final test).

Performance in an in vitro laparoscopic simulator correlated Performance in an in vitro laparoscopic simulator correlated significantly with performance in an in vivo animal model. significantly with performance in an in vivo animal model. Practice in the simulator resulted in improved performance Practice in the simulator resulted in improved performance in vivo.in vivo.


ABEM type assessment tools measure ABEM type assessment tools measure performance equally well in oral or simulation performance equally well in oral or simulation environments.environments.

Gordon, J. A., D. N. Tancredi, et al. Gordon, J. A., D. N. Tancredi, et al. (2003). (2003). "Assessment of a clinical performance evaluation tool "Assessment of a clinical performance evaluation tool for use in a simulator-based testing environment: a for use in a simulator-based testing environment: a pilot study." pilot study." Academic MedicineAcademic Medicine 7878(10 Suppl).(10 Suppl).

Twenty-three subjects were evaluated during five Twenty-three subjects were evaluated during five standardized encounters using a patient simulator.standardized encounters using a patient simulator.

Performance in each 15-minute session was compared with Performance in each 15-minute session was compared with performance on an identical number of oral objective-performance on an identical number of oral objective-structured clinical examination (OSCE) sessions used as structured clinical examination (OSCE) sessions used as controls. controls.

In this pilot, a standardized oral OSCE scoring system In this pilot, a standardized oral OSCE scoring system performed equally well in a simulator-based testing performed equally well in a simulator-based testing environment.environment.


There are many aspects of human There are many aspects of human knowledge/skills/attitudes to assess and the correct knowledge/skills/attitudes to assess and the correct tool must be used for each one.tool must be used for each one.

Kahn, M. J., W. W. Merrill, et al. Kahn, M. J., W. W. Merrill, et al. (2001). "Residency program (2001). "Residency program director evaluations do not correlate with performance on a director evaluations do not correlate with performance on a required 4th-year objective structured clinical examination." required 4th-year objective structured clinical examination." Teaching & Learning in Medicine 13(1): 9-12.Teaching & Learning in Medicine 13(1): 9-12.

We surveyed program directors about the performance of 50 We surveyed program directors about the performance of 50 graduates from our medical school chosen to represent the graduates from our medical school chosen to represent the highest (OSCEHI) and lowest (OSCELO) 25 performers on our highest (OSCEHI) and lowest (OSCELO) 25 performers on our required 4th-year OSCE. required 4th-year OSCE.

OSCE scores did not correlate with Likert scores for any survey OSCE scores did not correlate with Likert scores for any survey parameter studied (r < .23, p > .13 for all comparisons). parameter studied (r < .23, p > .13 for all comparisons). Similarly, program director evaluations did not correlate with Similarly, program director evaluations did not correlate with class rank or USMLE scores (r < .26, p > .09 for all comparisons).class rank or USMLE scores (r < .26, p > .09 for all comparisons).

We concluded that program director evaluations of resident We concluded that program director evaluations of resident performance do not appear to correlate with objective tests of performance do not appear to correlate with objective tests of either clinical skills or knowledge taken during medical school.either clinical skills or knowledge taken during medical school.


””Softer” competencies like professionalism can be assessed Softer” competencies like professionalism can be assessed with the aid of simulation technology.with the aid of simulation technology.

Gisondi, M. A., R. Smith-Coggins, et al. Gisondi, M. A., R. Smith-Coggins, et al. (2004). "Assessment of (2004). "Assessment of Resident Professionalism Using High-fidelity Simulation of Ethical Resident Professionalism Using High-fidelity Simulation of Ethical Dilemmas." Acad Emerg Med 11(9): 931-937.Dilemmas." Acad Emerg Med 11(9): 931-937.

Each resident subject participated in a simulated critical patient Each resident subject participated in a simulated critical patient encounter during an Emergency Medicine Crisis Resource encounter during an Emergency Medicine Crisis Resource Management course. An ethical dilemma was introduced before the Management course. An ethical dilemma was introduced before the end of each simulated encounter. Resident responses to that dilemma end of each simulated encounter. Resident responses to that dilemma were compared with a were compared with a

It was observed that senior residents (second and third year) It was observed that senior residents (second and third year) performed more checklist items than did first-year residents (p < performed more checklist items than did first-year residents (p < 0.028 for each senior class). 0.028 for each senior class).

Residents performed a critical action with 100% uniformity across Residents performed a critical action with 100% uniformity across training years in only one ethical scenario ("Practicing Procedures on training years in only one ethical scenario ("Practicing Procedures on the Recently Dead"). Residents performed the fewest critical actions the Recently Dead"). Residents performed the fewest critical actions and overall checklist items for the "Patient Confidentiality" case. and overall checklist items for the "Patient Confidentiality" case.

Although limited by small sample size, the application of this Although limited by small sample size, the application of this performance-assessment tool showed the ability to discriminate performance-assessment tool showed the ability to discriminate between experienced and inexperienced EMRs with respect to a between experienced and inexperienced EMRs with respect to a variety of aspects of professional competency.variety of aspects of professional competency.


The scoring/evaluation system chosen to assess The scoring/evaluation system chosen to assess simulated performance is critical.simulated performance is critical.

Regehr, G., R. Freeman, et al. (1999). "Assessing the Regehr, G., R. Freeman, et al. (1999). "Assessing the generalizability of OSCE measures across content domains." generalizability of OSCE measures across content domains." Academic MedicineAcademic Medicine 7474(12): 1320-2.(12): 1320-2.

Students' scores from three OSCEs at one institution were Students' scores from three OSCEs at one institution were correlated to determine the generalizability of the scoring correlated to determine the generalizability of the scoring systems across course domains.systems across course domains.

Analysis revealed that while checklist scores showed quite low Analysis revealed that while checklist scores showed quite low correlations across examinations from different domains correlations across examinations from different domains (ranging from 0.14 to 0.25), global process scores showed quite (ranging from 0.14 to 0.25), global process scores showed quite reasonable correlations (ranging from 0.30 to 0.44).reasonable correlations (ranging from 0.30 to 0.44).

These data would seem to confirm the intuitions about each of These data would seem to confirm the intuitions about each of these measures: the checklist scores are highly content-these measures: the checklist scores are highly content-specific, while the global scores are evaluating a more broadly specific, while the global scores are evaluating a more broadly based set of skills.based set of skills.


Learners are smart and will figure out the game.Learners are smart and will figure out the game.

Jones, J. S., S. J. Hunt, et al. Jones, J. S., S. J. Hunt, et al. (1997). "Assessing bedside (1997). "Assessing bedside cardiologic examination skills using "Harvey," a cardiology cardiologic examination skills using "Harvey," a cardiology patient simulator ." patient simulator ." Acad Emerg MedAcad Emerg Med 44(10): 980-5.(10): 980-5.

To assess the cardiovascular physical examination skills of To assess the cardiovascular physical examination skills of emergency medicine (EM) housestaff and attending emergency medicine (EM) housestaff and attending physicians. physicians.

Prospective, cohort assessment of EM housestaff and faculty Prospective, cohort assessment of EM housestaff and faculty performance on 3 valvular abnormality simulations conducted performance on 3 valvular abnormality simulations conducted on the cardiology patient simulator, "Harvey." on the cardiology patient simulator, "Harvey."

Forty-six EM housestaff (PGY1-3) and attending physicians Forty-six EM housestaff (PGY1-3) and attending physicians were tested over a 2-month study period. Physician responses were tested over a 2-month study period. Physician responses did not differ significantly among the different levels of did not differ significantly among the different levels of postgraduate training. postgraduate training.

Housestaff and faculty had difficulty establishing a correct Housestaff and faculty had difficulty establishing a correct diagnosis for simulations of 3 common valvular heart diseases. diagnosis for simulations of 3 common valvular heart diseases. However, accurate recognition of a few critical signs was However, accurate recognition of a few critical signs was associated with a correct diagnosis in each simulation.associated with a correct diagnosis in each simulation.


Determine what you want to assess.Determine what you want to assess. Design a simulation that provokes Design a simulation that provokes

this performance.this performance. Observe/record the performance.Observe/record the performance. Analyze the performance using some Analyze the performance using some

type of rubric: checklist, GAS, etc.type of rubric: checklist, GAS, etc. Debriefing, feedback and teaching.Debriefing, feedback and teaching.

OutlineOutline


SummarySummary

Simulation is one toolSimulation is one tool(new, expensive and exciting)(new, expensive and exciting)

in our educational repertoire.in our educational repertoire.(Similar to lecture, case discussion, skill lab, MCQ, SP, etc.)(Similar to lecture, case discussion, skill lab, MCQ, SP, etc.)

SummarySummary Provide feedbackProvide feedback Give opportunities for Give opportunities for

repetitive practicerepetitive practice Integrate simulation into Integrate simulation into

overall curriculumoverall curriculum Provide increasing levels Provide increasing levels

of difficultyof difficulty Provide clinical variation Provide clinical variation

in scenariosin scenarios Control environmentControl environment Provide individual and Provide individual and

team learningteam learning Define outcomes and Define outcomes and

benchmarksbenchmarks

Determine what you want Determine what you want to assess.to assess.

Design a simulation that Design a simulation that provokes this provokes this performance.performance.

Observe/record the Observe/record the performance.performance.

Analyze the performance Analyze the performance using some type of rubric: using some type of rubric: checklist, GAS, etc.checklist, GAS, etc.

Debriefing, feedback and Debriefing, feedback and teaching.teaching.

OutlineOutline


ReferencesReferences Features and uses of high-fidelity medical Features and uses of high-fidelity medical

simulations that lead to effective learning: a BEME simulations that lead to effective learning: a BEME systematic review. Issenberg, McGaghie, Petrusa, systematic review. Issenberg, McGaghie, Petrusa, Gordon and Scalese. Medical Teacher, vol 27, 2005, Gordon and Scalese. Medical Teacher, vol 27, 2005, p 10-28.p 10-28.

Loyd GE, Lake CL, Greenberg RB. Practical Health Loyd GE, Lake CL, Greenberg RB. Practical Health Care Simulations. Philadelphia, PA. Elsevier-Mosby. Care Simulations. Philadelphia, PA. Elsevier-Mosby. 2004.2004.

Bond WF, Spillane L, for the CORD Core Bond WF, Spillane L, for the CORD Core Competencies Simulation Group: The use of Competencies Simulation Group: The use of simulation for emergency medicine resident simulation for emergency medicine resident assessment. Acad Emerg Med 2002;9:1295-1299.assessment. Acad Emerg Med 2002;9:1295-1299.

ACGME ResourcesACGME Resources www.acgme.org/Outcome/assess/Toolbox.pdfwww.acgme.org/Outcome/assess/Toolbox.pdf www.acgme.org/Outcome/assess/ToolTable.pdfwww.acgme.org/Outcome/assess/ToolTable.pdf Accessed on Feb 2Accessed on Feb 2ndnd 2006. 2006.

Additional ReferencesAdditional References1.1. Glassman PA, Luck J, O'Gara EM, Peabody JW. Using standardized patients to measure quality: Glassman PA, Luck J, O'Gara EM, Peabody JW. Using standardized patients to measure quality:

evidence from the literature and a prospective study. Joint Commission Journal on Quality evidence from the literature and a prospective study. Joint Commission Journal on Quality Improvement.Improvement. 2000; 26:644-653.2000; 26:644-653.

2.2. Owen H, Plummer JL. Improving learning of a clinical skill: the first year's experience of teaching Owen H, Plummer JL. Improving learning of a clinical skill: the first year's experience of teaching endotracheal intubation in a clinical simulation facility. Medical Education.endotracheal intubation in a clinical simulation facility. Medical Education. 2002; 36:635-642.2002; 36:635-642.

3.3. Pittini R, Oepkes D, Macrury K, Reznick R, Beyene J, Windrim R. Teaching invasive perinatal Pittini R, Oepkes D, Macrury K, Reznick R, Beyene J, Windrim R. Teaching invasive perinatal procedures: assessment of a high fidelity simulator-based curriculum. Ultrasound in Obstetrics & procedures: assessment of a high fidelity simulator-based curriculum. Ultrasound in Obstetrics & Gynecology.Gynecology. 2002; 19:478-483.2002; 19:478-483.

4.4. Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth.Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth. 1998; 45:130-2.1998; 45:130-2.

5.5. Schwid HA, Rooke GA, Ross BK, Sivarajan M. Use of a computerized advanced cardiac life support Schwid HA, Rooke GA, Ross BK, Sivarajan M. Use of a computerized advanced cardiac life support simulator improves retention of advanced cardiac life support guidelines better than a textbook review. simulator improves retention of advanced cardiac life support guidelines better than a textbook review. Critical Care Medicine.Critical Care Medicine. 1999; 27:821-824.1999; 27:821-824.

6.6. Rosenblatt MA, Abrams KJ, New York State Society of Anesthesiologists I, Committee on Continuing Rosenblatt MA, Abrams KJ, New York State Society of Anesthesiologists I, Committee on Continuing Medical E, Remediation, Remediation S-C. The use of a human patient simulator in the evaluation of Medical E, Remediation, Remediation S-C. The use of a human patient simulator in the evaluation of and development of a remedial prescription for an anesthesiologist with lapsed medical skills. and development of a remedial prescription for an anesthesiologist with lapsed medical skills. Anesthesia & Analgesia.Anesthesia & Analgesia. 2002; 94:149-153, table of contents.2002; 94:149-153, table of contents.

7.7. Gisondi MA, Smith-Coggins R, Harter PM, Soltysik RC, Yarnold PR. Assessment of Resident Gisondi MA, Smith-Coggins R, Harter PM, Soltysik RC, Yarnold PR. Assessment of Resident Professionalism Using High-fidelity Simulation of Ethical Dilemmas. Acad Emerg Med.Professionalism Using High-fidelity Simulation of Ethical Dilemmas. Acad Emerg Med. 2004; 11:931-2004; 11:931-937.937.

8.8. Schwid HA, Rooke GA, Michalowski P, Ross BK. Screen-based anesthesia simulation with debriefing Schwid HA, Rooke GA, Michalowski P, Ross BK. Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teaching & Learning in Medicine.improves performance in a mannequin-based anesthesia simulator. Teaching & Learning in Medicine. 2001; 13:92-96.2001; 13:92-96.

9.9. Gaba DM, Fish K.J., Howard S.K. Crisis Management in Anesthesiology. New York: Churchill Gaba DM, Fish K.J., Howard S.K. Crisis Management in Anesthesiology. New York: Churchill Livingstone; 1994.Livingstone; 1994.

10.10. Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y, Gaba D, et al. Emergency Medicine Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y, Gaba D, et al. Emergency Medicine Crisis Resource Management (EMCRM): Pilot Study of a Simulation-based Crisis Management Course Crisis Resource Management (EMCRM): Pilot Study of a Simulation-based Crisis Management Course for Emergency Medicine. Acad Emerg Med.for Emergency Medicine. Acad Emerg Med. 2003; 10:386-389.2003; 10:386-389.

11.11. Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. Demonstration of high-fidelity simulation Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. Demonstration of high-fidelity simulation team training for emergency medicine. Academic Emergency Medicine.team training for emergency medicine. Academic Emergency Medicine. 1999; 6:312-323.1999; 6:312-323.

Additional ReferencesAdditional References12.12. Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, et al. Simulation based Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, et al. Simulation based

teamwork training for emergency department staff: does it improve clinical team performance when teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?[see comment]. Quality & Safety in Health Care.added to an existing didactic teamwork curriculum?[see comment]. Quality & Safety in Health Care. 2004; 13:417-421.2004; 13:417-421.

13.13. Berkenstadt H, Ziv A, Barsuk D, Levine I, Cohen A, Vardi A. The use of advanced simulation in the Berkenstadt H, Ziv A, Barsuk D, Levine I, Cohen A, Vardi A. The use of advanced simulation in the training of anesthesiologists to treat chemical warfare casualties. Anesthesia & Analgesia.training of anesthesiologists to treat chemical warfare casualties. Anesthesia & Analgesia. 2003; 2003; 96:1739-1742, table of contents.96:1739-1742, table of contents.

14.14. Kyle RR, Via DK, Lowy RJ, Madsen JM, Marty AM, Mongan PD. A multidisciplinary approach to teach Kyle RR, Via DK, Lowy RJ, Madsen JM, Marty AM, Mongan PD. A multidisciplinary approach to teach responses to weapons of mass destruction and terrorism using combined simulation modalities.[see responses to weapons of mass destruction and terrorism using combined simulation modalities.[see comment]. Journal of Clinical Anesthesia.comment]. Journal of Clinical Anesthesia. 2004; 16:152-158.2004; 16:152-158.

15.15. Kobayashi L, Shapiro MJ, Suner S, Williams KA. Disaster medicine: the potential role of high fidelity Kobayashi L, Shapiro MJ, Suner S, Williams KA. Disaster medicine: the potential role of high fidelity medical simulation for mass casualty incident training. Medicine & Health, Rhode Island.medical simulation for mass casualty incident training. Medicine & Health, Rhode Island. 2003; 86:196-2003; 86:196-200.200.

16.16. Kassirer JPaK, R. I. Learning Clinical Reasoning. First ed. Baltimore, MD: Williams and Wilkins; 1991.Kassirer JPaK, R. I. Learning Clinical Reasoning. First ed. Baltimore, MD: Williams and Wilkins; 1991.17.17. Bond WF DL, Kostenbader M, Worrilow CC. "Using Human Patient Simulation to Instruct Emergency Bond WF DL, Kostenbader M, Worrilow CC. "Using Human Patient Simulation to Instruct Emergency

Medicine Residents in Cognitive Forcing Strategies". Paper presented at: Innovation in Emergency Medicine Residents in Cognitive Forcing Strategies". Paper presented at: Innovation in Emergency Medical Education Exhibit, SAEM Annual Meeting, . 2003; Boston.Medical Education Exhibit, SAEM Annual Meeting, . 2003; Boston.

18.18. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Academic Emergency Medicine.Academic Emergency Medicine. 2002; 9:1184-1204.2002; 9:1184-1204.

19.19. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them.Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them.[comment]. Academic Medicine.[comment]. Academic Medicine. 2003; 78:775-780.2003; 78:775-780.

20.20. Boulet JR, Murray D, Kras J, Woodhouse J, McAllister J, Ziv A. Reliability and validity of a simulation-Boulet JR, Murray D, Kras J, Woodhouse J, McAllister J, Ziv A. Reliability and validity of a simulation-based acute care skills assessment for medical students and residents. Anesthesiology.based acute care skills assessment for medical students and residents. Anesthesiology. 2003; 99:1270-2003; 99:1270-1280.1280.

21.21. Bond WF, Spillane L. The use of simulation for emergency medicine resident assessment. Academic Bond WF, Spillane L. The use of simulation for emergency medicine resident assessment. Academic Emergency Medicine.Emergency Medicine. 2002; 9:1295-1299.2002; 9:1295-1299.

22.22. Byrne AJ, Greaves JD. Assessment instruments used during anaesthetic simulation: review of published Byrne AJ, Greaves JD. Assessment instruments used during anaesthetic simulation: review of published studies. British Journal of Anaesthesia.studies. British Journal of Anaesthesia. 2001; 86:445-450.2001; 86:445-450.

23.23. Gordon JA, Tancredi DN, Binder WD, Wilkerson WM, Shaffer DW. Assessment of a clinical performance Gordon JA, Tancredi DN, Binder WD, Wilkerson WM, Shaffer DW. Assessment of a clinical performance evaluation tool for use in a simulator-based testing environment: a pilot study. Academic Medicine.evaluation tool for use in a simulator-based testing environment: a pilot study. Academic Medicine. 2003; 78.2003; 78.

Additional ReferencesAdditional References24. LaMantia J, Rennie W, Risucci DA, Cydulka R, Spillane L, Graff L, Becher J, et al.

Interobserver variability among faculty in evaluations of residents' clinical skills. Academic Emergency Medicine. 1999; 6:38-44.

25. Morgan PJ, Cleave-Hogg D, McIlroy J, Devitt JH. Simulation technology: a comparison of experiential and visual learning for undergraduate medical students. Anesthesiology. 2002; 96:10-16.

26. Schwid HA, Rooke GA, Carline J, Steadman RH, Murray WB, Olympio M, Tarver S, et al. Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study. Anesthesiology. 2002; 97:1434-1444.

27. Beaulieu MD, R. M., Hudon E, Saucier D, Remondin M Favreau R (2003). "Using standardized patients to measure professional performance of physicians." International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua 15(3): 251-9

28. Chapman DM. Rhee KJ. Marx JA. Honigman B. Panacek EA. Martinez D. Brofeldt BT. Cavanaugh SH. Open thoracotomy procedural competency: validity study of teaching and assessment modalities. Annals of Emergency Medicine. 28(6):641-7, 1996 Dec.

29. Cubison, T. C. S. and T. Clare (2002). "Lasagne: a simple model to assess the practical skills of split-skin graft harvesting and meshing." British Journal of Plastic Surgery 55(8): 703-4.

30. Davidson R, D. M., Rathe R, Pauly R, Watson RT (2001). "Using standardized patients as teachers: a concurrent controlled trial." Academic medicine : journal of the Association of American Medical Colleges 76(8): 840-3

31. Hance, J., R. Aggarwal, et al. (2005). "Objective assessment of technical skills in cardiac surgery." European Journal of Cardio-Thoracic Surgery 28(1): 157-62.

32. Maran, N. J. and R. J. Glavin (2003). "Low- to high-fidelity simulation - a continuum of medical education?[see comment]." Medical Education 37 Suppl 1: 22-8.

33. Nikendei, C., A. Zeuch, et al. (2005). "Role-playing for more realistic technical skills training." Medical Teacher 27(2): 122-6Clauser, B. E., S. G. Clyman, et al. (1996). "Are fully compensatory models appropriate for setting standards on performance assessments of clinical skills?" Academic Medicine 71(1 Suppl): S90-2.

34. Williams, R. G. (2004). "Have standardized patient examinations stood the test of time and experience?" Teaching & Learning in Medicine 16(2): 215-22

simulation - cord home page

Documents