A Multifaceted Educational Design Approach to Critical Care Rotation Improves Learner Confidence and Knowledge.

Abstract

Purpose: We developed a pilot elective to enhance the critical care training experience for medical students through integration of didactic, simulation, and experiential learning with the goal to increase student confidence in caring for patients with critical illness and advance knowledge and competencies within core critical care topics. Approach: We created and piloted a 4-week critical care elective for fourth-year medical students pairing clinical experience with didactic and simulation-based training. Students completed two 2-week intensive care unit (ICU) rotations in both medical and surgical ICUs. Students received 6 half-days of didactics focusing on: respiratory failure, ventilator management, shock, acid/base, and discussions at the end of life. Didactic sessions were coupled with simulation-based training to reinforce content through application and provide opportunity to build procedural skills. Medical knowledge was assessed via multiple-choice questions delivered before and after course completion. Course grades were determined through clinical evaluations by faculty/residents, written examination, and simulation assessment. Pre- and postknowledge assessment performance was compared between students enrolled in the pilot and traditional curricula. The traditional curriculum involved clinical experience without formal didactics or simulation opportunities, and course grades were determined by evaluations only. Outcomes: No students received passing scores of 70% on the precourse medical assessment in either curriculum group. The mean score on the postcourse knowledge assessment for the novel-curriculum students (N = 13) was 21.8/30 (72.8%), compared with the 17/30 (56%) for the students in the traditional curriculum (N = 6). No students in the traditional curriculum received a passing score on the postcourse assessment. Before the course, few students felt “comfortable” or “very comfortable” managing common ICU conditions (acute respiratory distress syndrome, 0%; undifferentiated shock, acute hypercarbic respiratory failure, and identifying need for mechanical ventilation, 33%; acute hypoxemic respiratory failure and cardiogenic shock, 50%; septic and hypovolemic shock, 83%). At completion, there was an improvement in the reported level of comfort; 100% of students reported feeling “comfortable” or “very comfortable” with all topics, save for cardiogenic shock at 83%. Comfortability levels remained high on subsequent evaluation 12 months post-course (6 months into trainee’s intern year). Discussion: A limitation of traditional critical care curricula is that it lacks structure designed to ensure exposure to core critical care topics. It relies on the randomness of patient’s disease states present during a given rotation. Incorporating scheduled didactics ensures consistent exposure to these topics regardless of the patient cases on service. A limitation of this study is the small sample size of both the novel-curriculum group and the percentage of traditional curriculum students undergoing written assessment. Despite the small sample size (N = 13), this pilot demonstrates feasibility of consistent delivery of core content via didactics and simulation coupled with experiential learning. Our results may suggest benefit in this multimodal approach compared with experiential learning alone; however, further research is needed. Traditional assessment relies solely on clinical impression which is biased and often fails to capture an actionable level of detail. Lack of objective measures of assessment impedes identification of areas for improvement at the trainee level as well as within a curriculum. The use of multiple methods of assessment allows for mitigation of bias and overcomes some of the limitations of a single method alone. 1 Simulation assessment allows for greater practical assessment of procedural competency than written assessment. Significance: With this novel pilot curriculum incorporating multiple educational strategies, students improved their confidence and knowledge in core critical care topics. By harnessing didactic and simulation training to complement the clinical experience, consistent delivery of core content is assured. Furthermore, evaluation is strengthened through use of knowledge assessment questions and simulation-based assessment as compared with traditional evaluations which are largely subjective. More research is needed to understand the impact when scaled to a larger group.