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.

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. 

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)

Role of the attending physician in medical education

Recently JAMA published a short viewpoint on the role of the attending physician on ward rounds. This was brought to my attention from a great blog/website that highlights what’s new in the world of medical education.

In medical education there’s been quite a bit about different teaching methods and how to incorporate new approaches like simulation and case-based learning. But this viewpoint brings up an interesting perspective that we rarely consider…the role of our teachers and how it should change. While I didn’t agree with everything that authors mentioned, the concept is important to address.

In the article, the change from “older” to “younger” attendings was discussed and how it will impact trainees. The authors argue the hierarchy has disappeared and younger attendings are more comfortable helping trainees out with the workload. This works well given the increased emphasis on duty hour restrictions. Furthermore, the authors describe older physicians as more likely to teach at the bedside and less comfortable with technology.

I was surprised, however, to read how little attention was paid to the impact of technology on trainee education. To discuss the changing role of the attending must also include the changing methods that trainees learn. Attending physicians are no longer the fountain of knowledge they once were. Wikipedia has quickly taken over this role!  Trainees can easily access the opinions of 100 attendings with a quick glance on their smartphone. The experience of attendings in stating “I had a similar case and this is how I dealt with it” is arguably less important now as evidence-based medicine has become pervasive in medicine. Technology has augmented the trainees ability to find 10 articles about how to manage a particular condition, often drawing on the results of several studies – this is significantly more than an “experienced clinician” can provide. I write this understanding this may be provocative and subject to disagreement but sometimes controversy is good! What’s more is that some have used this article to prove the utility of apprenticeship. It’s difficult to imagine that in an era where competency-based education has been repeatedly shown to be superior to the “see one, do one, teach one” method, we still have to continue talking about it. More studies than I care to cite have demonstrated that its no longer good enough to have “done a procedure” as a surrogate for competence. There should be a uniform approach where trainees meet a minimum standard. They’ll have knowledge of complications and ideally even demonstrate this in a simulation (without having harm come to a patient). Finally, they’ll be assessed as they perform the skill in the clinical setting – all stakeholders benefiting including the patient, trainee and teacher.

A reply to the article mentioned above was posted by another group of authors who have addressed teaching by staff attending physicians. These authors conducted a survey that identified  “Sharing of attending’s thought processes” as among the most important attributes an attending physician could share during rounds. This highlights nicely how trainees are changing and as a result how staff physicians should re-focus their teaching.

Trainees can be effectively taught by flipping the classroom and learning on the web. 30 years ago this wasn’t possible but now with exponential growth of technology, learning can occur before actually seeing patients. However, what must be learned from experienced clinicians is their cognitive reasoning. Learning such a skill from the web or a textbook is much more difficult. Rounds or bedside teaching sessions should focus on how clinicians avoid biases in their decision making. Trainees should be taught early on how to think like an expert.

Attending clinicians must focus their efforts on training new doctors to think like they do – employing a sound approach to each clinical decision . And teaching faculty should be taught how to teach these skills.  In an era when trainee clinical time has become a scare commodity, efficiency becomes paramount. Teaching core content has become increasingly inefficient especially during precious clinical rounds when both the trainee & attending have access to patients!  Trainees have no shortage of information to diagnose and treat patients but they must be taught to use it. This is the new role of the attending physician in medical education.

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!

What’s the difference between a novice and an expert?


A new study published in Annals of Emergency Medicine helps us better understand the differences between an expert clinician (practicing >5yrs) and 1st year emergency medicine (EM) residents.

Using interviews and qualitative methodology they examined participant responses to a variety of situations and incidents. They performed cognitive task analysis (fancy words for what someone actually does when faced with decisions & situations).

While they found there’s considerable differences between the two groups, they were able to summarize the findings:

  1. Experts are able to extract relevant information from a large collection of irrelevant data
  2. Experts focus on assessing the nature of the situation and NOT comparing various course of action (this leads to faster decision making)
  3. Experts can rapidly alter their diagnostic direction or treatment plan with new/unexpected information; novices are unwilling to accept new information if it disrupts their diagnosis or plan
  4. Novices rely heavily on objective data independent of the patient’s context
  5. Experts maintain high levels of spatial, temporal & organizational systems awareness; novices struggle with the “big picture”

What is important from this study is that we learn how novices & experts think. By simply accepting that once “novices” get smarter and more experienced that they’ll think like experts is doing a disservice to our trainees. We must impart early on the approach to thinking and diagnostic reasoning while acknowleding that factual information and experience will come with time.

The authors suggest that “targeted and frequent exposure to critical situations translates knowledge into expertise and bridges the expert-novice gap in clinical decisionmaking”.

We need more research in this field so that we can modify our educational approaches. We should be teaching trainees early on how to think like an expert.

How do you use Twitter in medical education? A new article outlines “how to” tips

This past week I posted my first tweet.


I feel like an old man writing “how I walked uphill both ways to school in 5ft of snow”. For many of you, I’m sure I sound like I may have just recently adopted electricity and the wheel…but I figured I should join the masses and test out this “new” technology.

I’m not sure what’s taken me so long to move to the Twitterverse but part of me was still trying to figure out its utility. I guess I wasn’t so sure how I could use something such as Twitter…especially since all my entire impression of the technology was that it existed as a bulletin board for the latest celebrity breakups, hookups or feuds. I figured a few episodes of Entertainment Tonight should suffice as a Twitter replacement and I wouldn’t need this new technology…

However, I thought that there must be some way this can be effective within medicine…I’ve come across some physicians in Toronto who’ve started to use it. So before joining I followed along for a little bit to see how they used it. They often tweeted about new articles or cutting edge technologies…it seemed quite up to date and a great way to follow all that was new in medicine!

Then I came across a great article that was just published in Medical Teacher by a few medical educators in Calgary. They summarized 12 Tips for using Twitter in medical education. For anyone who teaches or is involved in medical education I highly recommend reading this paper. It provides practical reasons for Twitter and nicely summarizes how it has been described in the medical literature!

Not trying to steal the thunder of the authors but wanting to share a few of their tips…In the spirit of the wiki mindset which now pervades our consciousness, I’ve posted a few below. Enjoy!

I’ve picked the ones I thought were best and added a few comments or paraphrased the authors.

  1. Use a twitter account for a specific class or group: be sure to set some ground rules so that learners will have a framework for the discussion
  2. Use a live Twitter chat in your next lecture: I’ve been to a few lectures recently where this was done and it’s really quite interesting. What’s especially cool is if people from outside the classroom tweet a comment! The beauty is that they can be anywhere else in the world. If you’re using it for questions, it might be best to only open it up near the end of the lecture or at least only post it on the projector during a dedicated time as it may serve as distraction rather than an effective tool.
  3. Tweet key resources or new literature for your students to use and read: This is an excellent way to flip the classroom. Have them follow along and get them the material before class so that they can read it, digest it then come to class or academic day and discuss & analyze it. Or simply provide a resource for them to access the latest articles that you’re reading.
  4. Use twitter for real-time feedback: If you can make it anonymous this could be pretty cool. It could be posted in real-time at the end of the lecture or course. Though the logistics of creating anonymous usernames may limit its utility…unless they’re ok with identifiable responses.
  5. Maximize the power of Twitter with emphasis efficient communication: Twitter’s benefits include having only 140 characters to post high yield information. Use this to your advantage in teaching your students concise summaries for case presentations, etc…
  6. Twitter as a tool for self & group reflection:  I love this idea. I think it presents a novel way to gather feedback and one which many learners are comfortable using.
  7. Informal polls & quizzes: I think this is a good option though there may be a better app out there called Socrative which I’ve blogged about previously.
  8. Use it as subject for further study: There’s little out there regarding this topic and could be an outstanding resident research project! I definitely agree with the authors that further study is needed. Most importantly the authors specifically state that valuable studies would not compare Twitter to no intervention but rather evaluate how best to integrate this powerful technology.

I’m looking forward to seeing Twitter become increasingly used and studied within medical education! How will you use it?

Source: SE Forgie et al. Twelve tips for using Twitter as a learning tool in medical education. Medical Teacher 2012 [Epub ahead of print]

Sleep + Medical Residents = no change in patient outcomes?

As concern mounts about resident sleep schedules and the potential impact on patient care, errors and all other potentially a bad things, studies have begun looking at the impact of sleep on residents. The challenge has been to correlate this with patient-oriented outcomes and this study suffers the same problem. Inadequately powered to assess whether the intervention of providing more sleep to residents would benefit patients.

sleep tweet

This study, just published in JAMA took about 100 internal medicine residents and randomized them to either a standard resident schedule which includes 30hr shifts or a protected sleep period (1230-0530). They looked at a whole list of outcomes but the primary one being “sleep time”. The also looked at alertness, numbers of sleepless nights, subjective “sleepiness” and also some patient outcomes likes readmission rates, ICU transfers and length of stay.

Now for the results

In a shocking twist of events…residents that were randomized to mandated sleep periods actually got more sleep! (vs traditional scheduled residents). I’m not sure why this is a surprise…they were forced to give their work cell phones to someone who would cover for them…I figure this is akin to testing whether an apple is more likely to fall to the ground in a place where gravity exists vs. a zero-gravity zone. What was actually interesting however, those residents with a “protected sleep period” of 5hrs still only got about 3 hours of sleep compared to 2hrs in the other group. Still not great…I can only imagine the size of a study required to show patient oriented outcomes when there’s only 1hr of sleep difference between groups.

In an outcome that was touted highly by the authors, the “mandated sleep” group resulted in residents being more alert the next morning. This was tested using a few fancy tests including sleepiness scales and psychomotor vigiliance (whatever that means!??!)

In conclusion…this study showed feasibility, increased amount of sleep, and more alert residents who got more sleep.

What we need to know however is how this impacts resident learning…did they miss any critical learning opportunities? What if these were surgical residents who would have missed a once-in-a-lifetime surgery? How much does this program cost? And really, we need to find out if patients are served better in such cases…that is the holy grail of this area of study. Another study which doesn’t quite provide us the answers we need.

Ironically I’m writing this at 1am…Anyways here’s the abstract

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns

Context  A 2009 Institute of Medicine report recommended protected sleep periods for medicine trainees on extended overnight shifts, a position reinforced by new Accreditation Council for Graduate Medical Education requirements.

Objective  To evaluate the feasibility and consequences of protected sleep periods during extended duty.

Design, Setting, and Participants  Randomized controlled trial conducted at the Philadelphia VA Medical Center medical service and Oncology Unit of the Hospital of the University of Pennsylvania (2009-2010). Of the 106 interns and senior medical students who consented, 3 were not scheduled on any study rotations. Among the others, 44 worked at the VA center, 16 at the university hospital, and 43 at both.

Intervention  Twelve 4-week blocks were randomly assigned to either a standard intern schedule (extended duty overnight shifts of up to 30 hours; equivalent to 1200 overnight intern shifts at each site), or a protected sleep period (protected time from 12:30 AM to 5:30 AM with handover of work cell phone; equivalent to 1200 overnight intern shifts at each site). Participants were asked to wear wrist actigraphs and complete sleep diaries.

Main Outcome Measures  Primary outcome was hours slept during the protected period on extended duty overnight shifts. Secondary outcome measures included hours slept during a 24-hour period (noon to noon) by day of call cycle and Karolinska sleepiness scale.

Results  For 98.3% of on-call nights, cell phones were signed out as designed. At the VA center, participants with protected sleep had a mean 2.86 hours (95% CI, 2.57-3.10 hours) of sleep vs 1.98 hours (95% CI, 1.68-2.28 hours) among those who did not have protected hours of sleep (P < .001). At the university hospital, participants with protected sleep had a mean 3.04 hours (95% CI, 2.77-3.45 hours) of sleep vs 2.04 hours (95% CI, 1.79-2.24) among those who did not have protected sleep (P < .001). Participants with protected sleep were significantly less likely to have call nights with no sleep: 5.8% (95% CI, 3.0%-8.5%) vs 18.6% (95% CI, 13.9%-23.2%) at the VA center (P < .001) and 5.9% (95% CI, 3.1%-8.7%) vs 14.2% (95% CI, 9.9%-18.4%) at the university hospital (P = .001). Participants felt less sleepy after on-call nights in the intervention group, with Karolinska sleepiness scale scores of 6.65 (95% CI, 6.35-6.97) vs 7.10 (95% CI, 6.85-7.33; P = .01) at the VA center and 5.91 (95% CI, 5.64-6.16) vs 6.79 (95% CI, 6.57-7.04;P < .001) at the university hospital.

Conclusions  For internal medicine services at 2 hospitals, implementation of a protected sleep period while on call resulted in an increase in overnight sleep duration and improved alertness the next morning.