David Lee Gordon

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review*

Review date: 1969 to 2003, 34 years. Background and context: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. Objectives: Review and synthesize existing evidence in educational science that addresses the question, ‘What are the features and uses of high-fidelity medical simulations that lead to most effective learning?’. Search strategy: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the ‘grey literature’ were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. Inclusion and exclusion criteria: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. Data extraction: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. Data synthesis: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. Headline results: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: providing feedback—51 (47%) journal articles reported that educational feedback is the most important feature of simulation-based medical education; repetitive practice—43 (39%) journal articles identified repetitive practice as a key feature involving the use of high-fidelity simulations in medical education; curriculum integration—27 (25%) journal articles cited integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum as an essential feature of their effective use; range of difficulty level—15 (14%) journal articles address the importance of the range of task difficulty level as an important variable in simulation-based medical education; multiple learning strategies—11 (10%) journal articles identified the adaptability of high-fidelity simulations to multiple learning strategies as an important factor in their educational effectiveness; capture clinical variation—11 (10%) journal articles cited simulators that capture a wide variety of clinical conditions as more useful than those with a narrow range; controlled environment—10 (9%) journal articles emphasized the importance of using high-fidelity simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences; individualized learning—10 (9%) journal articles highlighted the importance of having reproducible, standardized educational experiences where learners are active participants, not passive bystanders; defined outcomes—seven (6%) journal articles cited the importance of having clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills; simulator validity—four (3%) journal articles provided evidence for the direct correlation of simulation validity with effective learning. Conclusions: While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.

Stroke training of prehospital providers: an example of simulation-enhanced blended learning and evaluation

Since appropriate treatment of patients in the first few hours of ischemic stroke may decrease the risk of long-term disability, prehospital providers should recognize, assess, manage and communicate about stroke patients in an effective and time-efficient manner. This requires the instruction and evaluation of a wide range of competencies including clinical skills, patient investigation and management and communication skills. The authors developed and assessed the effectiveness of a simulation-enhanced stroke course that incorporates several different learning strategies to evaluate competencies in the care of acute stroke patients. The one-day, interactive, emergency stroke course features a simulation-enhanced, blended-learning approach that includes didactic lectures, tabletop exercises, and focused-examination training and small-group sessions led by paramedic instructors as standardized patients portraying five key neurological syndromes. From January to October 2000, 345 learners were assessed using multiple-choice tests as were randomly selected group of 73 learners using skills’ checklists during two pre- and two post-course simulated patient encounters. Among all learners there was a significant gain in knowledge (pre: 53.9% ± 13.9 and post: 85.4% ± 8.5; p < 0.001), and for the 73 learners a significant improvement in their clinical and communication skills (p < 0.0001 for all). By using a simulation-enhanced, blended-learning approach, pre-hospital paraprofessionals were successfully trained and evaluated in a wide range of competences that will lead to the more improved recognition and management of acute stroke patients.

Skill Improvement During Emergency Response to Terrorism Training

Objectives. To assess the individual andteam skills acquired from an interactive training program to prepare emergency personnel to respond to terrorist acts. Methods. We developed a 16-hour, two-day, multimedia- andsimulation-enhanced course that places learners in realistic situations using the equipment required to respond to various chemical, biologic, radiologic, andexplosive acts of terrorism. Small-group sessions anddrills were conducted. Errors in skill performance were corrected immediately, andthen skills were repeated to achieve mastery. Participants included emergency medical technicians, paramedics, nurses, andphysicians. Team performance was assessed over four successive scenarios using a 100-mm visual analog scale. Individual learner skill acquisition was assessed with precourse andpostcourse evaluation of selected skills in a randomized sampling of consenting learners. Results. Nearly all teams achieved mastery of the required skills by the second assessment rotation. Individual learners demonstrated significant gains in the ability to emergently don personal protective equipment andadminister a nerve agent antidote kit. Conclusions. An interactive, simulation-enhanced curriculum of terrorism response training for emergency responders can produce significant, quantifiable individual andteam skill gain. Future studies should further address performance benchmarks for these newly acquired skills.

Development, implementation and outcomes of a training program for responders to acts of terrorism

Introduction. Responding to acts of terrorism requires the effective use of public-safety andmedical-response resources. The knowledge, skills andattitudes necessary to respond to future threats is unfamiliar to most emergency responders. Objectives. The purpose of this report to describe the development, implementation andevaluation of a multidisciplinary, interactive andsimulation-enhanced course to prepare responders to acts of terrorism. Methods. We used a 5-step systematic process to develop a blended-learning, simulation-enhanced training program. Learners completed a self-confidence questionnaire andwritten examination prior to the course anda self-confidence questionnaire, written examination andcourse evaluation when they finished the course. Results. From July 7, 2003 to March 8, 2005, 497 consenting learners completed the course. After course completion, learners demonstrated significant increases in their knowledge of terrorism response (t = −64.3, df = 496, p < 0.05) andtheir confidence in responding to terrorist events (t = −45.5, df = 496, p < 0.05). Learner feedback about the course was highly positive. Conclusions. We successfully implemented a two-day course for professionals likely to respond to terrorist acts that included scenario-based performance training andassessment. Course participants increased their knowledge andwere more confident in their ability to respond to acts of terrorism after participating in this course.

Development of a Reliable Multimedia, Computer-Based Measure of Clinical Skills in Bedside Neurology

Purpose. This study reports the development of reliable multimedia, computer-based measures of bedside neurology skills. Method. A consortium of neurologists and medical educators (1) identified bedside skills and (2) created a computer-based test. Test-item stems were multimedia clips of standardized patients. Options appeared as text. Sixty-one junior medical students responded to these items. Results. The 77-item test yielded a reliability coefficient of 0.85. Subgroup item analysis resulted in reliability coefficients of 0.73 for the 20-question “pretest” (Test A) and 0.75 for the 20-question “posttest” (Test B). Conclusion. Two sets of test items were developed that can be used as outcome measures in studies that assess the effectiveness of educational interventions in bedside neurology.

A multicenter study to provide evidence of construct validity in a computer-based outcome measure of neurology clinical skills.

Background Using computer-based simulation to assess clinical skill—a key competence for medical trainees—enables standardization and exposure to a broad sample of physical findings. The purpose of this study is to provide evidence of construct validity for a computer-based outcome measure of neurology clinical skills. Method A total of 128 medical students and neurology residents at four institutions volunteered to take a 34-question computer-based test designed to measure neurology clinical skills. Subjects were classified into three groups based on level of training: novice, intermediate, and experienced. Results Overall performance increased with level of training. Question difficulty discriminated between groups as predicted. Twenty-six of 34 individual items discriminated between novices and more advanced learners. This test separated learners at different levels of training with a consistency of .92. Conclusion This study provided evidence of construct validity for a computer-based outcome measure of neurology clinical skills.

Bedside Cardiology Skills Training for the Physician Assistant Using Simulation Technology

&NA; Medical practice changes that limit patient availability and instructor time and advances in technology have led to a greater use of simulators and multimedia computers in medical education. These systems address the problem of inadequate bedside skills training and poor proficiency among all health‐care providers. While studies have shown their effectiveness among medical students, residents, and practicing physicians, none have focused on the physician assistant population—one that is becoming more responsible for conducting initial and follow‐up physical examinations. This report describes the use of “Harvey,” the Cardiology Patient Simulator, and the UMedic Multimedia Computer System at a workshop conducted at the 1999 Semiannual Meeting of the Association of Physician Assistant Programs. The participants in this study had a significant increase in their pre‐ to post‐test scores that measured their ability to identify common cardiac auscultatory events. Workshop participants were nearly unanimous in their feeling that they would like to use these tools as teaching and testing aids.

Lifelong quality improvement.

Medical education, for the individual doctor, is an ongoing process from the start of medical school until the doctor leaves practice at retirement. In addition, medical schools and postgraduate medical education institutions must continuously improve and develop the quality of their provision. Thus, we should focus on both the individual and the system. The theme of lifelong quality improvement in this year’s ‘State of the Science’ issue of Medical Education addresses both levels and clearly illustrates that to achieve lifelong quality improvement, there must be such a duality of focus.

Improvement in Paramedic Examination Skills Following a Stroke Course

P184 Introduction: The need to decrease time to treatment for acute stroke patients means that prehospital providers must play an increased role in their care. This is possible only if emergency medical services personnel are able to rapidly recognize and assess patients with neurologic syndromes. Purpose: To assess the performance of a focused neurologic exam by prehospital providers before and after participation in an interactive stroke course. Methods: We developed a 1-day emergency stroke course that consists of 2 hours of lectures and 6 hours of interactive instruction, including small-group sessions led by paramedic instructors as standardized patients (SPs) portraying 5 key neurologic syndromes: left hemisphere, right hemisphere, brainstem, cerebellum, and subarachnoid hemorrhage. We devised a 53-point skills checklist to evaluate paramedic performance of history, exam, management, and emergency department (ED) reporting during 2 pre- and 2 postcourse encounters with actors portraying one of 4 scenarios: left hemisphere stroke, right hemisphere stroke, right hemisphere seizure with postictal hemiparesis, and left hemisphere tumor with sudden worsening. Among the 53 total skills evaluated were 28 exam-related items, including traditional paramedic exam items such as pupil reaction, hand grasp, and foot strength and additional items from the Miami Emergency Neurologic Deficit (MEND) Exam. We randomly selected 46 of 281 learners to participate in the study. Results: Checklist scores for neurologic exam performance improved significantly. The precourse mean score for the 46 learners was 3.38 (12.1%) and the postcourse mean was 21.4 (76.4%) (p<.001). Conclusions: Paramedics significantly improved their performance of a focused neurologic exam after attending a stroke course utilizing paramedic instructors as SPs with key stroke syndromes. We conclude that prehospital providers can learn and perform a brief, focused neurologic exam after attending a 1-day stroke course that emphasizes hands-on instruction. We are continuing to evaluate the effect of the course on the history-taking, ED-reporting, and stroke-management skills of practicing paramedics.