Simulation-based Medical Education Research Articles

Use of a Novel Three-Dimensional Model to Teach Ultrasound-guided Subclavian Vein Cannulation.

Central venous cannulation is an essential skill in perioperative and critical care medicine. Ultrasound guidance is the standard of care for femoral and internal jugular vein access, with the subclavian vein being perceived to be less amenable to ultrasound-guided (UG) insertion, resulting in a lack of procedural competency and low cannulation rate. There is a paucity of resources and a lack of experience among staff physicians to effectively instruct trainees. Simulation-based medical education has the potential to help maintain high-stakes, infrequently performed skills and counteract possible unrecognized skill decline. We aimed to create a novel, low-cost, high-fidelity three-dimensional (3D) model for UG subclavian vein (UG-SCV) access with an accompanying curriculum to improve this important skill. A curriculum was created consisting of preparatory material reviewing UG-SCV access, followed by an in-person didactic lecture focusing on ultrasound use and management of complications and a deliberate practice session scanning volunteers and practicing UG vascular puncture on a 3D model. A qualitative usability test design was used to assess the validity of the curriculum in trainees with advanced vascular access skills (anesthesiologists). Participants were second-year anesthesia residents, anesthesia fellows, and staff physicians. Focus groups conducted after each session explored the face validity of the model and curriculum. By applying a usability design, the curriculum was optimized and finalized. Between September 2020 and February 2021, 28 participants tested the curriculum. The focus groups ensured that the curriculum achieved its objective, with iterative changes made after each session in a quality improvement framework Plan-Do-Study-Act approach. After the third cycle, minimal changes were suggested, and the curriculum and 3D model were finalized. An additional group of participants was used to ensure that no new input would help improve the curriculum further. A focused curriculum for enhancing skills in UG-SCV cannulation usinga novel 3D model was successfully implemented and validated through a usabilitytest design. This curriculum is better targeted for practitioners experienced incentral venous access to master a subclavian approach and maintain their skill level.

A randomised control trial study on the efficacy of high-fidelity simulation in enhancing knowledge

Introduction: The practice of high-fidelity simulation-based medical education has become a popular small-group teaching modality across all spheres of clinical medicine. High-fidelity simulation (HFS) is now being increasingly used in the context of undergraduate medical education, but its superiority over traditional teaching methods is still not established. The main objective of this study was to analyse the effectiveness of HFS-based teaching over video-assisted lecture (VAL)-based teaching in the enhancement of knowledge for the management of tension pneumothorax among undergraduate medical students. Methods: A cohort of 111 final-year undergraduate medical students were randomised for this study. The efficacy of HFS-based teaching (intervention group) and VAL-based teaching (control group), on the acquisition of knowledge, was assessed by single-best answer multiple choice questions (MCQ) tests in the first and eighth week of their surgery posting. Mean and standard deviation (SD) for the total score of MCQ assessments were used as outcome measures. ANCOVA was used to determine the difference in post-test MCQ marks between groups. The intragroup comparison of the pre-test and post-test MCQ scores was done by using paired t-test. The P-value was set at 0.05. Results: The mean of post-test MCQ scores were significantly higher than the mean of pre-test MCQ scores in both groups. The mean pre-test and post-test MCQ scores in the intervention group were slightly more than those of the control group but not statistically significant. Conclusion: There was a statistically significant enhancement of knowledge in both groups but the difference in knowledge enhancement between the groups was insignificant.

How Augmenting Reality Changes the Reality of Simulation: Ethnographic Analysis.

Simulation-based medical education (SBME) provides key medical training for providers to safely and ethically practice high-risk events. Augmented reality (AR)-enhanced simulation projects digital images of realistic examination findings into a participant's field of view, which allows nuanced physical examination findings such as respiratory distress and skin perfusion to be prominently displayed. It is unknown how AR compares to traditional mannequin (TM)-based simulation with regard to influencing participant attention and behavior. The purpose of this study is to use video-based focused ethnography-a problem-focused, context-specific descriptive form of research whereby the research group collectively analyzes and interprets a subject of interest-to compareand categorize provider attention and behavior during TM and AR and providesuggestions for educators looking to delineate these 2 modalities. Twenty recorded interprofessional simulations (10 TM, 10 AR) featuring a decompensating child were evaluated through video-based focused ethnography. A generative question was posed: "How do the attention and behavior of participants vary based on the simulation modality?" Iterative data collection, analysis, and pattern explanation were performed by a review team spanning critical care, simulation, and qualitative expertise. The attention and behavior of providers during TM and AR simulation clustered into three core themes: (1) focus and attention, (2) suspension of disbelief, and (3) communication. Participants focused on the mannequin during AR, especially when presented with changing physical examination findings, whereas in TM, participants focused disproportionately on the cardiorespiratory monitor. When participants could not trust what they were seeing or feeling in either modality, the illusion of realism was lost. In AR, this manifested as being unable to physically touch a digital mannequin, and in TM, participants were often unsure if they could trust their physical examination findings. Finally, communication differed, with calmer and clearer communication during TM, while AR communication was more chaotic. The primary differences clustered around focus and attention, suspension of disbelief, and communication. Our findings provide an alternative methodology to categorize simulation, shifting focus from simulation modality and fidelity to participant behavior and experience. This alternative categorization suggests that TM simulation may be superior for practical skill acquisition and the introduction of communication strategies for novice learners. Meanwhile, AR simulation offers the opportunity for advanced training in clinical assessment. Further, AR could be a more appropriate platform for assessing communication and leadership by more experienced clinicians due to the generated environment being more representative of decompensation events. Further research will explore the attention and behavior of providers in virtual reality-based simulations and real-life resuscitations. Ultimately, these profiles will inform the development of an evidence-based guide for educators looking to optimize simulation-based medical education by pairing learning objectives with the ideal simulation modality.

Simulation-Based Education in the Artificial Intelligence Era.

Simulation-based medical education (SBME) has been widely implemented in skill training in various clinical specialties. SBME has contributed not only to patient and medical safety but also to undergraduate and specialist education in the healthcare field. In this review, we discuss the challenges and future directions of SBME in the artificial intelligence (AI) era. While SBME fidelity or methods may become highly complicated in the AI era, the fact is that learners play a central role. As SBME and clinical education are complementary, mutual feedback and improvement are essential, especially in non-technical skill development. For the development of sustainable SBME in the clinical field in the AI era, continuous improvement is needed by academia, educators, and learners.

The evaluation of stress during medical simulation: a feasibility study involving final-year medical students

Student stress is well-documented within the field of simulation-based medical education. However, current research is unclear as to what level of stress is optimal for an enhanced educational experience. This ambiguity may partly be due to the use of one or a small number of stress metrics in study designs. Our study will aim to evaluate the feasibility of measuring the human stress response during medical simulation, using a suite of techniques. Audiovisual (video spectacles), biochemical (serum cortisol and plasma metanephrine/normetanephrine), physiological (blood pressure, galvanic skin response and heart rate) and psychological (State-Trait Anxiety Inventory and Big Five Inventory-2) markers of stress will be monitored during two randomized medical simulations of differing complexities.

Man-O-War simulator: a Low-cost manikin for training on chest tube management.

Simulation-based medical education is becoming a cornerstone in health education. Simulators are commonly expensive and not available in developing countries. We propose a very low-cost simulator that any educator can realize. We describe here the steps to follow to develop this proposed simulator.

Virtual Reality Simulation for Suicide Risk Assessment Training: Prevalence of Adverse Effects.

Virtual reality (VR) simulation is changing the landscape of simulation-based medical education. Immersive VR allows users to interact with a computer-generated environment and digital avatars using a VR headset and controllers. However, current literature regarding the use of immersive VR simulation in psychiatric medical education is sparse. This study describes its use and considerations regarding tolerability. At a mental health hospital in Canada, two immersive VR suicide risk assessment (SRA) case simulations were developed. These simulations have participants interview VR patients to characterize their suicide risk, offering a novel and safe way to engage healthcare providers in SRA training. Regarding user tolerability of these VR simulations, the Simulator Sickness Questionnaire (SSQ) was administered to participants after the simulation to characterize any motion sickness symptoms experienced. Of the 22 participants in this study, the overall SSQ scores demonstrated good tolerability of the VR SRA, with the majority of participants reporting no or minimal simulator sickness symptoms. Moreover, the majority of participants reported being satisfied with this training and that the VR SRA simulation enhanced their learning experience. These study findings are novel, given the current dearth of data regarding the use of immersive VR in simulation-based psychiatric medical education. Further studies exploring the educational effectiveness of VR SRA in simulation-based psychiatric medical education are indicated.

Utilizing simulation to improve pre-hospital medical care for paediatric seizure

Paediatric patients represent 5–15% of emergency medical services (EMS) transports in the US, yet true paediatric emergencies are rare. Management of these cases remains a common area of discomfort for pre-hospital providers. Previous studies have shown that simulation-based medical education is a useful tool to enhance patient safety in paediatrics. Simulation is an ideal modality to evaluate cognitive, technical and behavioural skills in low frequency, high-stakes events for healthcare providers. We hypothesize that using a deliberate practice model with simulation through a 6-month longitudinal curriculum will improve performance among pre-hospital providers treating paediatric seizure patients. A prospective observational education study design of a 6-month longitudinal simulation curriculum was executed. The performance of each two-member fire-based crew was analysed during three separate simulation events. The Thirty-nine pre-hospital providers completed at least some portion of the curriculum. There was an improvement in provider reported self-efficacy scores across all questions, as well as improvement in pre- and post-test knowledge scores. While the total number of critical actions completed did not vary significantly between simulations, there was improvement in several action items including end-tidal carbon dioxide use, application of oxygen, checking of medication dosage and administration of correct benzodiazepine dose. A simulation-based curriculum on the management of paediatric seizure for EMS providers improved self-efficacy, knowledge and performance of various critical actions in simulated settings.

Building low-cost simulators for invasive ultrasound-guided procedures using the V-model

The use of medical simulators for training technical and diagnostic skills has rapidly increased over the past decade. Yet, most available medical simulators have not been developed based on a structured evaluation of their intended uses but rather out of expected commercial value. Moreover, educators often struggle to access simulators because of cost or because no simulators have been developed for a particular procedure. In this report, we introduce “the V-model” as a conceptual framework to illustrate how simulator development can be guided by the intended uses in an iterative fashion. Applying a needs-based conceptual framework when developing simulators is important to increase the accessibility and sustainability of simulation-based medical education. It will minimize the developmental barriers and costs, while at the same time improving educational outcomes. Two new simulators for invasive ultrasound-guided procedures are used as examples, the chorionic villus sampling model and the ultrasound-guided aspiration trainer. Our conceptual framework and the use cases can serve as a template for future simulator development and documentation hereof.

Psychological safety and intellectual bravery in simulation-based medical education

Simulation-based medical education (SBME) is known as a powerful instructional technique for teaching health-care students. Simulation has become an integral part of medicine and health-care teaching in few institutes in India, and there are certain challenges instructors/facilitators face on a regular basis. Psychological safety and intellectual bravery are some of these challenges. Timely recognition of these issues and implementation of a long-term solution may be useful to improve the experience of simulation-based learning and ultimately deliver better care to real-life patients. In this article, we discuss these specific challenges and the role of a simulation instructor in making learning environment safe for the participants in SBME.

Teaching Accuracy Through Repeated Gamified Echography Training (TARGET): Assessment of an Ultrasound Skill Simulator in Teaching Ultrasound-Guided Needle Placement, a Prospective Observational Study.

The increasing use of ultrasound in veterinary private practice and demand for skilled operators upon graduation has placed an increased burden on the ever-dwindling number of academic radiologists. Simulation-based medical education can help prepare for and consequently reduce this burden, allowing for the acquisition of clinical skills through deliberate practice in a safe, controlled, and low-stakes environment. Ultrasound-guided fine needle placement is the foundation for more advanced interventions such as ultrasound-guided fine needle aspirates and centeses. A reusable novel ultrasound skill simulator consisting of metal targets wired to a circuit and suspended in ballistics gel was created to teach ultrasound-guided fine needle placement. Forty-seven second-year veterinary students watched an instructional video and performed two ultrasound-guided fine needle placement skill tests on the simulator with a period of practice between. Significant improvement in time to task completion (p = .0021) was noted after the period of practice. The majority of student feedback was positive with 89% (42/47) indicating they would use the simulator again to practice and that it should be incorporated into the curriculum, 74% (35/47) indicating their basic skills, knowledge, and confidence using ultrasound improved using the simulator, and 55% (26/47) indicating they could now teach this skill to a peer. The authors suggest further development of this model for ease of manufacture and increased variation in difficulty, and veterinary curriculum incorporation for basic ultrasound-guided fine needle placement training.

Concurrent versus terminal feedback: The effect of feedback delivery on lumbar puncture skills in simulation training

Introduction Simulation-based medical education (SBME) is widely used to teach bedside procedural skills. Feedback is crucial to SBME but research on optimal timing to support novice learners’ skill development has produced conflicting results. Methods We randomly assigned 32 novice medical students to receive feedback either during (concurrent) or after (terminal) trialing lumbar puncture (LP). Participants completed pre- and post-acquisition tests, as well as retention and transfer tests, graded on a LP checklist by two blinded expert raters. Cognitive load and anxiety were also assessed, as well as learners’ perceptions of feedback. Results Participants who received concurrent feedback demonstrated significantly higher LP checklist scores (M = 91.54, SE = 1.90) after controlling for baseline levels, than those who received terminal feedback (M = 85.64, SE = 1.90), collapsed across post, retention, and transfer tests. There was no difference in cognitive load and anxiety between groups. In open-ended responses, participants who received concurrent feedback more often expressed satisfaction with their learning experience compared to those who received terminal feedback. Discussion and conclusions Concurrent may be superior to terminal feedback when teaching novice learners complex procedures and has the potential to improve learning if incorporated into SBME and clinical teaching. Further research is needed to elucidate underlying cognitive processes to explain this finding.

The Efficacy of High-fidelity Simulation-based Education in Enhancing Knowledge among Undergraduate Medical Students

Background: Medical education has experienced important changes in recent times. The concern for patient's safety is one of the key reasons for the change in medical curricula. Innovative instructional methods like simulation-based medical education (SBME) has evolved to address this problem. SBME has become an essential part of education and training for health professionals in many parts of the world. There are evidences that support that high-fidelity simulation (HPS) training has enhanced clinical knowledge among medical students.
 Aims: The objective of this study was to note the differences in the knowledge made by high-fidelity simulation-based medical education among undergraduate medical education.
 Study Design: It was a quasi-experimental time series study with Pre-test and Post-test interventions.
 Place and Duration of Study: Clinical Skills Lab, Faculty of Medicine, Manipal University College Malaysia, Melaka, between October 2015 and September 2017.
 Methodology: The study involved 347 final year undergraduate medical students. The participants were divided into groups during the simulation sessions and their knowledge was assessed individually with Multiple Choice Questions (MCQ) and also self-reported Pre-test and Post-tests. Paired t-test was used to determine the difference of MCQ scores between pre and post simulation sessions. One-way repeated measure ANOVA was performed to determine the significant difference in knowledge assessment of self-reported Pre-test and Post-test scores. P value < .001 was taken to be of statistical significance.
 Results: In the unpaired t-test, Post-test MCQ scores were higher than Pre-test scores but not statistically significant (P = .013). A one-way repeated measured ANOVA with Bonferroni post hoc analysis demonstrated that the total scores of the self-reported knowledge tests were significantly increased over time (P < .001).
 Conclusion: There is enhancement of knowledge as perceived by the students with self-reported knowledge tests but not statistically significant as revealed by the MCQ scores.

The Debriefing Assessment in Real Time (DART) tool for simulation-based medical education

BackgroundDebriefing is crucial for enhancing learning following healthcare simulation. Various validated tools have been shown to have contextual value for assessing debriefers. The Debriefing Assessment in Real Time (DART) tool may offer an alternative or additional assessment of conversational dynamics during debriefings.MethodsThis is a multi-method international study investigating reliability and validity. Enrolled raters (n = 12) were active simulation educators. Following tool training, the raters were asked to score a mixed sample of debriefings. Descriptive statistics are recorded, with coefficient of variation (CV%) and Cronbach’s α used to estimate reliability. Raters returned a detailed reflective survey following their contribution. Kane’s framework was used to construct validity arguments.ResultsThe 8 debriefings (μ = 15.4 min (SD 2.7)) included 45 interdisciplinary learners at various levels of training. Reliability (mean CV%) for key components was as follows: instructor questions μ = 14.7%, instructor statements μ = 34.1%, and trainee responses μ = 29.0%. Cronbach α ranged from 0.852 to 0.978 across the debriefings. Post-experience responses suggested that DARTs can highlight suboptimal practices including unqualified lecturing by debriefers.ConclusionThe DART demonstrated acceptable reliability and may have a limited role in assessment of healthcare simulation debriefing. Inherent complexity and emergent properties of debriefing practice should be accounted for when using this tool.

Development, implementation, and results of a simulation-based hands-on brachytherapy workshop for medical students

PurposeThe new Medical Licensing Regulations 2025 (Ärztliche Approbationsordnung, ÄApprO) require the development of competence-oriented teaching formats. In addition, there is a great need for high-quality teaching in the field of radiation oncology, which manifests itself already during medical school. For this reason, we developed a simulation-based, hands-on medical education format to teach competency in performing accelerated partial breast irradiation (APBI) with interstitial multicatheter brachytherapy for early breast cancer. In addition, we designed realistic breast models suitable for teaching both palpation of the female breast and implantation of brachytherapy catheters.MethodsFrom June 2021 to July 2022, 70 medical students took part in the hands-on brachytherapy workshop. After a propaedeutic introduction, the participants simulated the implantation of single-lead catheters under supervision using the silicone-based breast models. Correct catheter placement was subsequently assessed by CT scans. Participants rated their skills before and after the workshop on a six-point Likert scale in a standardized questionnaire.ResultsParticipants significantly improved their knowledge-based and practical skills on APBI in all items as assessed by a standardized questionnaire (mean sum score 42.4 before and 16.0 after the course, p < 0.001). The majority of respondents fully agreed that the workshop increased their interest in brachytherapy (mean 1.15, standard deviation [SD] 0.40 on the six-point Likert scale). The silicone-based breast model was found to be suitable for achieving the previously defined learning objectives (1.19, SD 0.47). The learning atmosphere and didactic quality were rated particularly well (mean 1.07, SD 0.26 and 1.13, SD 0.3 on the six-point Likert scale).ConclusionThe simulation-based medical education course for multicatheter brachytherapy can improve self-assessed technical competence. Residency programs should provide resources for this essential component of radiation oncology. This course is exemplary for the development of innovative practical and competence-based teaching formats to meet the current reforms in medical education.

Osteopathic Manipulation Skills Training: Past, Present, and Future

Abstract This article reviews the methods used to teach osteopathic manipulative treatment (OMT) from the inception of the profession in the 19th century through the 21st century. Past and current osteopathic literature contains very few references to psychomotor skills training methods used in the OMM lab. Faced with this paucity of information, suggestions for improving the traditional demonstration/imitation model of instruction are given. These suggestions are derived from the science of learning (SL), Simulation-Based Medical Education (SBME), Evaluation Science (EV), and insights gleaned from sim lab student assessment research. The future of osteopathic pedagogy is discussed in relation to advances in neuroscience, technology, and the need to preserve the uniqueness of the osteopathic profession. Kirkpatrick’s method of training evaluation is suggested as a paradigm for assessing curriculum changes and measuring goals set on departmental, college and professional levels.

Advanced Urology Boot Camp: A Simulation-based Curriculum to Enhance Fourth-year Medical Student Procedural Competency.

Simulation-based medical education continues to gain popularity as the clinical environment requires exemplary patient safety while simultaneously maximizing the learner's educational experience. There is a current lack of urology-focused medical student education curricula in the literature. Here, we present the findings of a didactic and simulation-based medical student advanced "urology boot camp" curriculum, which was designed for learners interested in pursuing careers in urology. Twenty-nine fourth-year urology-dedicated medical students completing their subinternship at our institution during the 2018-2019 academic year participated in an advanced hands-on simulation "boot camp," which taught both simple and advanced Foley catheter placement, manual and continuous bladder irrigation, and diagnostic cystoscopy. Knowledge acquisition was assessed through quizzes administered before and after completing electronic modules, and a post-simulation survey assessing learners' confidence in their knowledge and skill set, as well as their satisfaction with the curriculum. Medical students demonstrated significant gains in knowledge from pre-test (mean 73.7%) to post-test (mean 94.5%, P < .001), which was consistent across each simulation procedure. Participants self-reported significant improvement in confidence with the procedures from before to after the educational intervention (P < .001). Students also found the curriculum to be beneficial to their understanding of the subject matter (P < .001), would recommend this curriculum to other medical students (P < .001), and thought it better prepared them to meet expected ACGME (Accreditation Council for Graduate Medical Education) milestones (P < .001). Findings from our advanced "boot camp" simulation curriculum demonstrated successful gains in knowledge and confidence following learning modules and hands-on simulation, indicating that this type of educational intervention could be beneficial in improving exposure to skills and developing confidence prior to urology internship and junior residency.

Exploring the Frameworks, Needs, and Barriers of Interprofessional Education and Simulation in Emergency Medicine.

This manuscript focuses on interprofessional education (IPE) using simulation and its use between emergency department and emergency medical services personnel. It explores the theoretical frameworks behind IPE and applies them to simulation-based emergency medical services education. There is a notable lack of research on the use of IPE using simulation between these 2 professions. The need for IPE using simulation as well as barriers and recommendations to remove the barriers are discussed.

Visualisation Approaches in Technology-Enhanced Medical Simulation Learning: Current Evidence and Future Directions.

Technology-enhanced learning (TEL) has been proposed as an approach to minimise the healthcare workforce shortage preventing universal healthcare coverage. Simulation-based medical education is a well-established teaching method. Little is known about effective strategies to translate in-person medical simulation teaching into a virtual world. This work aimed to review the literature on approaches to visualisation in technology-enhanced medical simulation. A systematic search strategy was optimised using three databases: Embase, MEDLINE, and APA PsycInfo. Additional papers were identified through cross-referencing. The last date of this search was 3 January 2022. The articles were analysed qualitatively. The risk of bias was assessed using ROBINS-I and RoB 2 tools. The search yielded 656 results with 9 additional papers identified through cross-referencing. Following deduplication and exclusions, 23 articles were included in a qualitative synthesis of evidence. Offline and online computer-based modules with virtual patient cases or practical skills simulations were identified as the most prevalent clinical simulation teaching modalities. Visualisation approaches included text, images, animations, videos, and 3D environments. Significant heterogeneity of study designs with a moderate risk of bias was established. Based on the current data, the virtual patient scenarios should use natural language input interfaces enriched with video and voice recordings, 3D animations, and short text descriptions to make the patient management experience more lifelike and increase knowledge retention. However, there is no agreed framework for assessing the pedagogical value of these innovations. High-quality randomised controlled trials of TEL-based clinical simulation are essential to advance the field.

Perception, beliefs and attitudes towards simulation-based learning in health care students: Scoping review protocol

Existing studies on the perception of simulation-based medical education examine a wide range of topics, with correspondingly heterogeneous results. This scoping review aims to assess the scope of these empirical studies including a systematic description of the types and modalities of simulation that are used in simulation-based medical education and the methods used to study the perception of these simulations. Six databases will be searched for the purpose of this review: Scopus, Web of Science, MEDLINE/PubMed, Embase, PsycINFO/PsyARTICLES by EBSCOHost and Education Resources Information Center (ERIC). The data will be reported using quantitative analysis.