Hybrid Simulation…using patient actors to enhance simulation

I’ve gotten a bit behind in my posts mostly as I’ve just moved back from New Zealand but I’m hoping to get a few more regular posts. For those who’ve read this blog, you’ll know that I like to highlight innovative approaches to simulation. This post is mostly for those interested in medical simulation…hopefully providing some new ideas.

One of my interests is procedural skill acquisition and how simulation can be used to enhance learning. So when I came across this paper I thought it deserved mention. The authors, from the University of Toronto describe using “hybrid” simulation for teaching knee arthrocentesis among internal medicine residents. Residents went through a procedural skills curriculum where they received teaching and practice performing arthrocentesis. They had to interact with a standardized patient and explain risks/benefits of the procedure. Then they were evaluated on both technical & non-technical skills in a separate scenario. They demonstrated the feasibility of this approach and they showed high ratings of realism among trainees & standardized patients and it functions as a hypothesis generating study for if these acquired skills are translated to the clinical setting.

Great use of hybrid simulation for obstetrical scenario - live patient actor "giving birth". source: http://www.samuelmerritt.edu/hssc/task-trainers

Great use of hybrid simulation for obstetrical scenario – live patient actor “giving birth”. source: http://www.samuelmerritt.edu/hssc/task-trainers

Hybrid simulation is actually a pretty cool concept. For those are new to this, hybrid simulation combines patient interaction (using a standardized patient) with a bench model (or task trainer) that allows for procedural skill practice. The benefit of this technique is the learner gets to interact with a patient as if they’ll be the recipient of the procedure while also getting to master the technical skills of the procedure.

Using procedural competency as a goal in procedural training, hybrid simulation is an excellent method for integration into a training curriculum. In one definition of competency:

“it refers to a resident’s ability to safely prepare for, perform and navigate the complications of a procedure” (Mourad et al. J Gen Med 2010).

Hybrid simulation will allow the learner to manage each of these aspects. They practice how to prepare for the procedure (both technically and preparing the patient). This will include consenting the standardized patient to the risk and benefits. I think we often forget this key aspect and instead focus on the technical skill. Furthermore, hybrid simulation scenarios can also integrate complications and evaluate the learner as they manage both the technical and interpersonal issues that must be addressed.

Another group at the University of Ottawa has started using OSCEs as a method for evaluating procedural skills which also is quite innovative! I came across an abstract they recently presented and a quick google search revealed a manuscript that further outlines the integration of an OSCE for procedural skills. Definitely worth checking out.

In simulation, we spend thousands of dollars on advanced equipment that is designed to replicate real patient interaction. However, hybrid simulation shows us that we can enhance fidelity even more by using some imagination and combining a task trainer with a live actor.

Another example while I was in Auckland, I ran full trauma simulations with a live patient. At the helicopter base, we had an actor who had suffered a considerable trauma from a motor vehicle accident. Its very impressive to watch a team interact with a “real” patient compared to a manikin. There’s much greater concern with pain and emphasis towards communication of each management step – these are definitely lost during interaction with a manikin.

I think medical educators and those involved in curriculum design need to take the next step as we seek to improve procedural skill teaching in medicine – let’s start integrating live patient actors into our simulations. We’re starting to see that it’s feasible and that some considerable benefit can be ascertained. As we seek procedural competence, we cannot forgot the trainee should be evaluated for their ability to explain and work with a live patient throughout the procedure. Its not infrequent that trainees learn to perform a procedure but they have no idea the complication rate or even what can go wrong! Then when something does actually go wrong they haven’t thought about it. Integration of these  hybrid simulations will only enhance trainee skills and lead to improvements in patient safety – something we’re all working so hard to improve.

Information overload…staying up to date with new medical journal publications

As physicians, some of us love to read the latest journal publication while some of us don’t give a s@#!. Those in the latter category are more than happy to get the information at conferences or journal clubs in due time. There’s nothing wrong with these people…in fact, it could be argued this is a healthier approach than being addicted to your wireless device or computer waiting for the newest publication!

But for those of us who do get turned on by reading then talking about the newest publication the day it comes out “Epub ahead of print”, it can be a daunting task to stay up to date.

In our world where we’re exposed to up to the minute Twitter feeds, blog posts or push notifications, we can easily become overloaded and inundated with how to manage this information. The challenge is particularly difficult with journal publications. I admit, that I really enjoy reading the latest research data and while that doesn’t make me a bad person…it arguably makes me a less attentive husband (one woman’s opinion).

Are there any strategies for improving information intake and staying up to date with recent research? I don’t think this area is well taught in medical school or residency, partly due to the fact it’s a brand new method of information acquistion. Also, it’s rapidly changing with new sites and apps coming all the time.

I follow a few different journal topics including emergency medicine related, critical care, general medicine and medical education. Overall, this probably results in about 15-20 journals per month. I don’t read every article, nor do I read every abstract but I routinely read through table of contents or titles to make sure I’m staying up to date.

I’ve been thinking about this recently and while this post isn’t intended to be comprehensive, it does offer a few strategies that I’ve used to ensure I’m reading the newest evidence (any mention of a product/app below is only because I’ve found them helpful…I take no money from anyone). The following are in no particular order of preference. And if there’s an app or strategy I’m missing, please comment and I’ll add it to the post!

Here we go.

QxMD “Read”: I just started using this app and I really like it and I highly recommend it for any physician trying to keep up with the medical literature. And it’s FREE!  Anyways, it’s a Canadian company that “provides a single place to discover new research, read outstanding topic reviews and search PubMed“. It allows you to sign up through your library Proxy account and access PDFs for any medical journal that your library has available. If your university isn’t supported, email them, I believe they are really working hard to add new institutions. The key component for this app is the user can select which journals they want to receive regular updates from and easily access. Here’s a great review of the product.  For those using Android/non-Mac products I don’t think its available for any other platform than Apple (I only use Mac so I can’t confirm this).

Settings page for "Read"

Settings page for “Read”

Main interface used when reading articles

Main interface used when reading articles

Feedly: I also highly recommend this! and it syncs with GoogleReader which inexplicably is getting shut down. This program provides regular updates to any journal you wish to add to your list. The benefit to this approach is that it syncs well across platforms (both mobile and desktop) and it also houses all of your non-medical blogs and news sites. The difference between Feedly and QxMD is the latter offers a much easier route to read the PDF. Feedly simply provides you with the abstract then its up to you to figure out your own access method.

Screen Shot 2013-04-21 at 11.40.53 AM

Subscribe to a journal’s table of contents (TOC): Most journals allow you to provide your email so that every time a new volume is published, the TOC arrives in your inbox. This is how I started following journals though depending on the number of emails you receive (and the number of journals you follow), this process can easily overwhelm.

Example of "The Lancet" Table of Contents email

Example of “The Lancet” Table of Contents email

Subscribe to programs such as Journal Watch or InfoPOEMs (from Cdn Med Assoc): Essentially these organizations review the literature (typically 1-2 months behind) and send brief summaries of selected articles. This isn’t comprehensive and they’re not always free (e.g. Journal Watch) but it does help you find out about papers that maybe you wouldn’t have read. I use these methods then I download the article myself using my University library account. But it is a bit more labor intensive than Feedly or QxMD.

Follow an up to date medical blog. For those in emergency medicine/critical care, lifeinthefastlane.com is a must. The authors of this blog provide high quality, regular, up to date information about new publications that will interest EM physicians. Sign up to their LITFL review and they outline some of the newest journal articles out there. In addition, they link you up with all the most recent blog posts from around the EM world.

For those interested in medical education – I highly recommend a new blog “Medical Educator 2.0” that compiles medical education (and general education) related topics from sources around the world. Ali Jalali is a medical educator at the University of Ottawa (and happened to be a professor of mine in med school) and he puts together a very high quality site. If you subscribe then you’ll get regular emails when a new version/updates are posted.

Download each journal’s app: Great if you only read 1-2 journals but not sure how useful this is if you’re looking for regular updates from a broad range of journals. Here’s a list of journal apps for download.

Twitter: Either sign up and follow a journal’s twitter account (e.g. @EmergencyMedBMJ) or follow individuals that often retweet or post comments about new articles. This approach really maximizes the power of crowds and can make reviewing new articles much easier. On Twitter, you can also follow hasthtags like #meded and #FOAMed.

So those are a few strategies that I use. I welcome feedback and suggestions that I’ve missed. I’m happy to update this post with any ideas that you feel should be included.

Navigating the world of social media in clinical medicine

It’s great to see articles now about the impact and effects of social media in medicine especially in other specialities. This article titled “Social Media and Clinical Care” was just published in Circulation and deserves at least a brief review by any clinician who uses social media either to augment clinical care. It’s also encouraging to see this appear in the journal Circulation which has as a relatively high impact factor (around 14). Clearly the academic medical community and more importantly the general medical community is taking note of the importance of social media.

Whether you like it or hate it, I would argue we shouldn’t fight social media. It’s unlikely to disappear especially now with more than 1 billion smartphones on the planet.  Instead as clinicians we should use it in a way that helps us communicate with each other, with patients and ultimately improves care. That being said, social media does NOT equal good or better! (it can be ). We always strive to “do no harm” and social media in medicine should be no exception.

To borrow the Spiderman quote “with great power comes great responsibility“. The same applies to social media…in fact maybe I should try and coin my own modification “with great social media power comes great social media responsibility”! But as we increasginly engage in social media we must recognize it’s power…which is why we should continue to use it but also understand how it can be quite dangerous.

What this article does it outline the various ways that it can be used within clinical medicine. It also highlights the ethical challenges we face and provide some perspective using an ethical framework.  The great thing is that in the spirit of FOAM (free open access medicine) this article is free! Congratulations for Circulation for making this accessible to all.

Who should read this article?

  • Any clinician who has patients participating in social media as a source for medical advice
  • Any clinician who uses social media as a form of communication/education with other clinicians
  • Any clinician who engages with their patients through social media as a form of education
  • Any clinician looking for some good references of studies that evaluate the impact of social media within medicine/patients

Does this sound like all clinicians should read it? I would say unless you still think rotating tourniquets is the optimal method to treat heart failure, yes…you probably should at least give it a glance.

What I found interesting was the discussion about whether it’s appropriate to use specific patient cases on a blog. I haven’t taken up this practice, but I really do value reading other medical blogs when authors recount specific instances. It’s helpful to read these accounts – almost as if you’re speaking with a colleague about an interesting/challenging case…but now your colleague can be anyone in the world. Powerful stuff! But at the same time, I respect the issues of confidentiality that surround such discussions. What was interesting was the article quoted data that found

“medical educators…felt that writing a deidentified patient narrative using a respectful tone was never or rarely acceptable (61%)”

That is really quite high…61%! And impressively it was a “deidentified” patient described  using a “respectful tone”. I’m curious to know what others think but I personally don’t have a problem with it. I think it’s obviously better to have patient consent but what if the case was 2 years prior? Does that change anything? Pragmatically it would be hard to find that patient…and perhaps considerable learning can be achieved from the case. This is definitely a challenge for educators/clinicians in balancing the risks & benefits. More importantly, it doesn’t seem like our colleagues may support such actions!

The authors of this article outline some recommendations for physicians who have blogs/websites as well as those who engage in online social networks. None of these are revolutionary but they provide us with good reminders of how we can continue to uphold our commitment to improving patient care in an ethical manner.

Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013


Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013



Should the simulated patient die? Pros and cons to acting as the grim reaper

This post discusses a great article about death in simulation and the impact on learning. I’ve learned about the importance of this topic from @jameslhuffman, an ED physician with an interest in simulation. For those interested/involved in simulation, its importance is understated but probably moving forward we’ll hear more about.  I highly recommend that anyone who is regularly running simulations or involved in medical simulation check out this paper. I’ll review some of the highlights below.  This article follows the same topic that I wrote about a few weeks ago regarding the ethics (or impact of being unethical) of medical simulation.

Important to decide how much of a grim reaper you should be as a simulation facilitator

Important to decide how much of a grim reaper you should be as a simulation facilitator

The authors reviewed the literature for evidence about the impact of death during simulation and how it affects learners. I won’t discuss their methods as I really don’t think that’s the important message of the paper – it should be noted it’s simply a literature review rather than anything more detailed or comprehensive (e.g. systematic review or meta-analysis).

Who cares whether the simulated patient dies? Why does this even matter? These are two very reasonable questions and hopefully this review will help to shed some light on why some consideration should be made about the impact of the simulated patient’s life expectancy during the scenario!

The authors outline a few concerns that have been described regarding simulated death:

  • Stressful situations including death may negatively affect learning and memory, as a result the scenario may not achieve its predefined learning objectives
  • Death during simulation may instill negative feelings among learners about simulation (e.g. “every time I do a simulation, the patient dies…I don’t ever want to participate in that again!”)
  • Death of a simulated patient may overtake the other objectives of the scenario and may occupy most of the debriefing 
  • Inability to maintain an environment of psychological safety – learners lose trust in the instructors if too many unexpected and difficult situations occur thus detracting from learning

I think all of these are very reasonable concerns and should be considered when designing a simulation scenario however, I don’t believe (nor do the authors of this review) that death in simulation should be abandoned. It clearly has a role as death in real life is inevitable and we should train and practice how to manage it. In addition, trainees must be exposed to scenarios where regardless of the therapies implemented the patient will inevitably die. This happens almost every day for clinicians involved in acute care medicine.

What I liked about this review is that the authors included some recommendations for educators to consider when designing a scenario.

First, they defined 3 types of simulated death:

  1. Death expected by both the facilitator & the learner – include discussion about end-of-life
  2. Death expected by the facilitator & unexpected learner – may include a planned respiratory arrest that the learner must attempt to manage
  3. Death unexpected by facilitator & the learner – this involves the learner administering a fatal drug or failing to recognize a fatal condition

Depending on what type of death occurs may dictate the implications for debriefing. The following are recommendations that the authors make based on a combination of evidence and experience but in general, they’re quite reasonable. In planning for a death during simulation here are some considerations:

  • Ensure the instructor is prepared for the discussion
  • Ensure the participants have a pre-briefing session that includes mention of the possibility that the simulated patient may die 
  • Simulated death should probably not be used with novice learners
  • Scenarios for advanced learners should include simulated death if clinically appropriate
  • Simulated death shouldn’t be used for punishment (e.g. death shouldn’t occur if a participant administers a noncritical drug) – death should only occur when the learner’s actions lead to a life-threatening consequence in real-life
  • A de-briefing after a simulated death is essential – it must safely address the factors  that led to the patient death with discussion about team dynamics & medical management
  • Acknowledge participant emotions associated with death 

In my opinion, most important however is simply to acknowledge that death during simulation isn’t without consequences. The impact on learners is relatively unknown given the lack of evidence. But we should consider how much stress we place on the learners as it may positively or negatively impact their learning.

Hopefully these considerations will be helpful in evaluating the sim patient’s life expectancy! I found it extremely useful and I acknowledge that the paper is better than any summary I can provide. Here’s the reference below for the article

Simul Healthc. 2013 Feb;8(1):8-12. doi: 10.1097/SIH.0b013e3182689aff. To die or not to die? A review of simulated death. Corvetto MA, Taekman JM. 

A little bit more about the benefits of In-situ simulation. It’s time we practice where we work

In-situ simulation has become increasingly popular and just recently there’s some evidence that it’s achieving the holy grail of simulation…simulation resulting in improved patient-centered outcomes. Intuitively it makes sense that more practice will make us better and probably practice within the exact place that we work, will be good too! Look at an Olympic downhill skier…they train several days in advance of their race on the exact same course as the race. Why? So that they can gain a better understanding about where every difficult turn is located or how they should navigate through a particularly challenging section. I mean, for such a high risk setting, why wouldn’t you practice where you work? Well I think the same can extend to resuscitation medicine. We should practice where we work! And at the very least, it won’t hurt us…and it will probably help. And maybe, just maybe it will benefit our patients too. 

This study was just published in Resuscitation. It’s a prospective study that implemented in-situ simulation in a pediatric setting with their emergency response team and they studied several clinical outcomes in a pre-post study design.

Their results included that after in-situ simulation, deteriorating patients were recognised more promptly and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). Furthermore there were additional trends (though not significant) towards decreased morbidity & mortality – which warrants further investigation.

The authors also note some key features of their team training & human factors considerations that may have contributed to the success of this intervention. Each of these 5 factors are EXTREMELY important for successful in-situ simulation:

(1) Regular training for all team members (4–10 times/year depending on rotation).

(2) Training in real clinical roles in real clinical environment.

(3) Key decision makers (paediatric registrars and charge/deputy charge nurses) from all wards participate in team and team training, building capacity to deal with evolving critical illness on the wards, even if the team as such is not called.

(4) Senior medical and nursing staff from many departments are team trainers – enabling trainers to address issues identified in clinical practice during team training and to facilitate acceptance of team and team training across traditional departmental boundaries

(5) Senior clinical and managerial staff support team and team training (willingness to respond early to calls from team; protected training time).

Finally, I’ve included the study abstract if you’re interested.

Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. U. Theilen et al.  vol 84 (2):218-222

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.


Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.


Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.

There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).


These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.

Cricothyroidotomy – considerations for teaching & simulation

Earlier this week I posted about the integration of a cric task-trainer at ARHT. I’ve decided to follow this up with some general evidence about cricothyroidotomy training.

The data regarding technique selection for cricothyroidotomy exists primarily in the context of simulation. It would be impossible to run a trial to compare techniques in real patients given the rarity of the scenario. In general, there are two types of techniques: 1) open or surgical cricothyroidotomy 2) percutaneous or needle cricothyroidotomy. I tend to favor an open technique (and maybe with a bougie)  given the simplicity but there is some evidence to support the needle method. There is a nice  Below is a brief outline of some evidence-based considerations for anyone involved in training clinicians for cric performance.

Needle vs. Open

  • Randomized trial of emergency physicians performing surgical and percutaneous cricothyroidotomy on cadavers. Time to first ventilation was significantly longer using the surgical technique (108 seconds vs. 136 seconds) while there were significantly more injuries to surrounding structures using the open technique (6 thyroid vessel injuries vs. none)
  • Authors concluded results tend to favor percutaneous technique
  • I’m quite surprised that time was shorter with the percutaneous technique – interesting result!

Alternative techniques

Time to Completion 

  • Highly dependent on when the timer starts but regardless everyone agrees time is important! And less is more!
  • 40 seconds was achievable in one study – time to skin palpation to first ventilation when all equipment was laid out
  • 95 seconds (mean) was recorded in another study as time from first grasping cric equipment to first ventilation

Number of times to achieve competence

  • Debatable whether experience = competence
  • Performance times plateau after 4 attempts (using a manikin)
  • Very little evidence to support number of times needed especially since all evidence is manikins or cadavers

Room for improvement as an inter-disciplinary approach

  • Several studies show that often it’s the surgeon performing cricothyroidotomies in emergent settings (article 1, article 2
  • This has important training implications – we should be training as a trauma team and incorporating the trauma team during in-situ simulation
  • EM teachers & educators must also be aware of this issue and work with surgeons so that they understand cricothyroidotomy is completely within the scope of practice for EM physicians (or anyone who performs RSI)

Some High Quality Learning (FOAMed)

The time for checklists in medicine…is NOW!

I have written about checklists in medicine before, but in light of a recent publication in the New England Journal of Medicine, I was inspired again to write about it.

One of the leading advocates for checklists in medicine is Atul Gawande. His book “The Checklist Manifesto” is an excellent read for anyone interested in the topic and definitely well written for the lay-person. Notably he’s also the senior author on this randomized trial just published in NEJM. And while the NEJM is often busy publishing some questionably biased and often pharma-funded studies, this one deserves attention. But before I discuss more about the trial…I digress…

Just this week, while we were flying I observed something quite interesting. Typically when we fly in the helicopters, our pilots ask our crewman for landing checks. At which point the crewman will go through the checklist with the pilot answering appropriately. We were out on a job and the crewman was busy in the back of the machine so the pilot read the checklist himself. After each item on the list, the pilot would answer himself….basically talking to himself. I remember asking a pilot about the value of a checklist for both their critical and non-critical procedures. He told me that by doing a checklist, he could concentrate on the variables that may arise and not worry about forgetting something small or routine. This is interesting…

I can’t remember the last time I’ve seen a physician read off a checklist, answering to themselves that all everything required is present and functional.  In medicine, we have this idea that if we can’t remember everything then it’s a sign of weakness. We don’t use checklists. In our minds “checklists are for losers” (not sure who I’m quoting here). But this idea that we must remember everything during a critical event is unique to medicine. Obviously I’m not advocating that we shouldn’t commit anything to memory but why bother trying to remember mundane items when we should be concentrating on “owning the resuscitation” (A term coined by Cliff Reid from resus.me).

We should instead focus on identifying why the patient is crashing or what might make this particular intubation difficult. We should NOT be trying to remember whether we’re missing anything… “ok…so I have the BVM, suction, tube…anything I’m missing? Of course! We need RSI drugs!”…this is a useless conversation and waste of time. By using a checklist the cue for RSI drugs will happen and the focus can be on more important things like ensuring the patient is well positioned, critically evaluating the cause for clinical deterioration – then the clinician can focus on real problem solving.

It’s interesting that many of the HEMS services out there are using RSI checklists and yet few are used in EDs around the world. At our HEMS service, we use it because we work in often hectic conditions that can be quickly become uncontrolled situations with unstable patients…wait a second…that sounds remarkably like an ED around the world! So why not implement a similar protocol? A recent paper in J Trauma looked at a standardized approach to RSI in trauma…seems promising!

And as I mentioned above, the NEJM recently published a large randomized trial evaluating the use of checklists for high-fidelity crisis simulation in an operating room setting. The use of checklists resulted in a 75% reduction to adhere to critical steps in management. Most impressively, the difference in missing critical steps was 6% with checklists vs. 23% without checklists. That’s an absolute reduction of 17%! And a relative risk reduction after multivariate analysis of 28%. If there was ever a drug trial that showed similar results it would likely be put in the water (maybe fluoride?). But last time I checked, no one will be making much money by producing a checklist. And yet despite our inability to show much more than non-inferiority with new oral anti-coagulants (vs. warfarin), the increase in use is HUGE!

This figure below published in the article is impressive. It demonstrates how the same team behaved completely differently depending on the use of a checklist. Some of the instances where they failed to adhere to critical processes of care is unbelievable and certainly is NOT good for patient oriented outcomes! V.fib and no defib for 1.5min? WOW!

Prime example of how checklists can help during resuscitations! Published in NEJM

Prime example of how checklists can help during resuscitations! Published in NEJM

I agree that we should probably study the implementation of a checklist into emergency medicine…but we probably shouldn’t wait longer. Recent publications show adverse event rates (or near misses) of 10% during RSI in the ED. This is NOT acceptable. We can do better and we should do better. Time for checklists to become an integral part of our critical actions. We can assign the checklist to be administered by our resuscitation room safety officer (yes, another novel concept that also deserves consideration…check out Cliff Reid’s great blog post on the topic)


Not forgetting what you learned – how we can do better in medical education.

This blog posting was inspired by a tweet by @ARJalali (website: Medical Educator 2.0).

Remember that 10th grade history test? No.

Or that psychology exam in first year university? Probably not.

This propensity to forget what we’re learning has carried through to medicine and it appears that our same study habits that we adopted early in our educational careers really don’t serve us well. Cramming doesn’t work. Well, it does to pass the test but as we move into a field where we need to remember things for more than just a day, we need to have ways to learn better. We need to adopt techniques and integrate within our curricula improved methods for trainees to retain knowledge. You could argue that memorizing is less important with any fact just a “google” keystroke away. I agree. But we still need to retain information as it makes us more efficient during clinical situations, in emergent situations we MUST remember and finally it makes it easier to teach others.

Wouldn't you like a method to remember better, than just a few post-it notes?

Wouldn’t you like a method to remember better, than just a few post-it notes?

Psychologists have been interested in these concepts for decades and several interesting ideas have emerged. “Spaced education” – the idea that educational encounters which are spaced over time and repeated result in improved and more efficient learning. Contrast this to everyone’s favorite “Bolus education” which is found at conferences when you sit down for a 1 hour lecture and you expect to actually remember something. Or sit in front of that textbook for hours before the exam then as soon as you walk out of the exam…surprise…you don’t remember a thing!

A study by a urologist published in 2007, randomized medical students to receive this “spaced education” endeavor. This occurred by regular emails with short clinically relevant questions/scenarios followed by MCQ and a summarized “take-home message”.  There were 4 core topics for the urology curriculum at this medical school and half of the participants received 2 topics by “spaced education” while the other participants received the other 2 topics by space education.

The results? Spaced educational emails significantly improved composite end of year tests. With greater benefit for those who received the emails over a longer period (6-12 months).

Another, similarly designed study found that this could be done with consultants and residents. There were statistically significant improvements across a range of topics when learning included a “spaced education” model followed by testing on a cyclical basis. Most importantly 84% of participants wanted to engage in additional programs!

Brilliant! I love this idea! This is a similar concept that is occurring now doing with Twitter and FOAMed (Free open access medical education). Though spaced education is more formalized and contains an evaluative piece. The concept is the same however…deliver short bits of information to the learner on a regular basis. This will improve retention and their ability to self-assess performance.

Educators can easily utilize Twitter or other forms of social media to deliver a regular stream of information to learners which then ideally integrates an evaluative component. This evaluation part is more than just finding out what the learner knows…it functions as an additional learning tool!