Incorporating simulation into a residency curriculum

Education

CJEM 2010;12(4):349-353

Abstract

Résumé

Introduction

Education in emergency medicine requires the integration of a broad range of medical knowledge into a functional base of clinical knowledge. This knowledge base must be sufficient to drive both symptom evaluation and the pursuit of simultaneous diagnostic and therapeutic interventions.1 Traditionally, medical postgraduate learning occurs in 4 main contexts: bedside “apprenticeship,” self-directed reading, didactic classroom sessions and case conferences. Medical simulation has emerged as a potentially valuable tool for learning and demonstrating competency across the spectrum from individual procedures to complex team-based skills, including directing resuscitation. Simulation offers a risk-free environment for residents to learn under the direct supervision of expert faculty. Residents use newly acquired knowledge in simulations, allowing them to integrate it into their growing clinical knowledge base. When faced with the prospect of teaching with simulation, the educator must make decisions to ensure the technology is used effectively and efficiently with respect to the adult learning needs of residents. This article discusses our experience with the placement, planning and integration of simulation teaching into a residency curriculum.

Why Should I Use Simulation in My Curriculum?

Simulation can be expensive and resource-intensive. This necessitates a clear understanding of the educational goals of the overall residency curriculum so that simulation can be implemented effectively in combination with other teaching techniques that foster active adult learning.3,4 Learning goals and objectives for the residency training program should be examined to determine the potential role of simulation in meeting those objectives. Often, simulation is “added on” to an otherwise unchanged curriculum, focusing on a few small areas, such as specific procedural skills or advanced cardiac life support. One must understand the learning and evaluative capabilities of simulation, and other teaching modalities, relative to the learning objectives for the curriculum, mapping each objective to the best teaching method (Appendix). Simulation stimulates residents to apply knowledge in clinical care scenarios, allowing them to integrate new information in the context of what they already know. Faculty can observe the resident in this setting, evaluating performance gaps and giving immediate, grounded feedback. This can achieve a level of integrated learning not traditionally possible outside of the clinical environment.

Simulation is not a panacea, however. As adult learners, residents should have an opportunity to reflect on what knowledge they bring to the classroom. Seminars, literature reviews, small-group work, and lectures should be paired with simulations that permit residents to apply and integrate new knowledge in a clinically meaningful setting.2 Thus specific learning objectives, such as recognition and management of cardiac dysrhythmias, can be taught in a simulation “course” that includes an assortment of teaching modalities and simulations, forming a tapestry of teaching methods that address both knowledge acquisition and application in various contexts (Appendix). Learners can thus identify the leading edge of their current clinical knowledge and be prompted to seek feedback and new knowledge with the help of simulation.

How Often Can I Use Simulation?

Every residency curriculum has variable constraints that affect the implementation of simulation teaching. These include, but are not limited to, access to a simulation facility, design of simulation laboratories, classroom layout, availability of teaching faculty, educational budgets and a program’s overall educational mission. In the context of our curriculum, simulation courses comprise approximately 20% of the 250 annual teaching hours. We teach 16–17 courses per year, distributed among other teaching formats covering topics that are less amenable to simulation (e.g., endocarditis). In our block-format curriculum, we begin each year with cardiovascular emergencies and follow an annually repeated sequence of content areas (Box 1) to ensure consistent and predictable coverage of educational material. This format allows each incoming resident class, and rising classes, exposure to topics essential to clinical practice in order of their approximate clinical importance. We also conduct an intensive educational program for all interns entering our hospital, regardless of their service of origin, systematically training sterile technique, central line placement, defibrillation and myriad other procedures before the start of clinical rotations. The curriculum design we present has resulted from adapting our teaching methodology to the constraints of a 4-year academic residency, training 15 residents per year in a physical teaching space that includes a 4-room simulation laboratory and classroom. It is meant as an example, rather than an idealized form, of how to implement simulation education.

How Do I Help My Residents Learn From Simulation?

Simulation requires the learner to suspend reality and perform in a fictitious environment. To optimize learning, residency leadership and simulation course directors must set clear expectations and motivation for both learners and faculty.3 Clear educational goals and objectives at the beginning of the session should engage the audience by establishing the need for active participation in the simulation exercises, highlighting why they are paired with the other teaching sessions within the course.

As residents gain real-world clinical experience as their training progresses, their need for case complexity increases. Simulation exercises should be designed with several difficulty levels to meet the differing educational needs of residents in different stages of training.4 Faculty may choose to segregate residents into groups by postgraduate year to facilitate teaching to these different learning needs. For example, a junior course may include a seminar on basic dysrhythmia recognition and therapies, procedure training in cardioversion and simulation cases involving simple tachydysrhythmia management. Senior residents may focus on more sophisticated differentiation between dysrhythmias, procedure training in transvenous pacemaker placement, and simulation cases involving dysrhythmia management in complex undifferentiated settings, such as thyroid storm or hypothermia. Alternatively, mixed resident groups can facilitate teaching and modelling between junior and senior residents. A senior resident may play the role of trauma captain with junior residents as part of the trauma team. At the end of the session, each resident would provide peer feedback in addition to the faculty’s expert opinion.

How Do I Help My Faculty Teach in Simulation?

Whether the intent is to teach a simple skill (e.g., lumbar puncture) or execute complex resuscitations, simulation requires that residents be divided into groups that permit participation and feedback. Our experience has shown that 4–6 residents per station allows for active participation of residents and individualized feedback by faculty. The need for small groups requires a significant commensurate increase in faculty teaching. Faculty may be reluctant to teach for fear that they lack sufficient knowledge on how to teach with simulation. Accordingly, faculty must be given appropriate preparation and guidance to teach in the simulation environment.4 Effective recruitment and continued participation of teaching faculty, or “facilitators,” requires a clear description of their teaching objectives and the simulation case scenarios. Course learning objectives must be written in language that focuses facilitators on evaluating residents’ knowledge application in addition to teaching the basic informational content of the case.3,4 The course director or the individual facilitators can use these objectives to plan the case scenario, organize supporting teaching materials (e.g., electrocardiograms, radiographs, laboratory reports) and structure their feedback on resident performance.4

As faculty become accustomed to the simulation teaching environment, more responsibility can be placed on them to assist with case design and debriefing content. Both the course director and the facilitators must ensure that they have in-depth knowledge of the specific content area, as the small-group format encourages discussion and questions by the learners, some of which may reach well beyond the core objectives of the session. Fortunately, these questions are comparable to those asked in the clinical environment, and faculty usually require minimal content preparation to manage these sessions.

Faculty facilitators should be trained in how to debrief residents after a simulation exercise, when knowledge gaps are identified and residents are primed to accept new knowledge.3,4 Effective clinical care relies on a variety of competencies, including medical knowledge, procedural skills, teamwork, communication and interpersonal skills.5,6 The richness of the simulation classroom allows observation of many of these fundamental aspects of medical expertise. The length and design of the debriefing session should therefore address more than just the medical knowledge applicable to the case.7 As much as possible, it should include resident self-evaluation and faculty evaluation of clinical performance in a structured format.7-9 Linking self-evaluation to faculty expert evaluation creates an opportunity for residents to understand the next step in their improvement10 by allowing residents to reflect on their own performance and take away individual learning issues.

How Do I Integrate Simulation into My Classroom?

Residency size, simulation laboratory design, teaching budget and faculty participation all play significant roles in the design of a simulation course. An ideal simulation would allow for one-on-one teaching in simulations, wherein a single resident performs under the critical eye of a faculty expert, and actors play ancillary staff roles such as paramedics, nurses, family members, consultants and others. Although essential for valid and reliable individual assessment of resident performance, the monetary and time cost of such a design is significant. Our classroom goals focus on learning and practising new concepts in bimonthly simulation courses that repeat yearly over a 4-year training program. With our classroom of approximately 45 residents, individual simulations are unachievable in our allotted course time of 3 hours, requiring that residents rotate in small groups through the stations.

Working with a small group in a simulation, rather than an individual resident, presents challenges for the facilitator. Facilitators often define team roles and functions (e.g., team leader, airway, intravenous access, family and consult liaison, procedure resident) at the beginning of the simulation session, asking participants to take on roles not previously played. Residents can also define roles if this is a learning objective of the exercise. With defined roles, not all residents are equal, but all can participate in learning.4The facilitator should involve the individual participants as much as possible during the simulation by playing different roles of family, consultant, supporting staff and others to engage those who may have less active roles or are noted to fall by the wayside. Alternatively, facilitators may choose to divide residents into 2 groups, with one group observing the performance of the other to allow for peer evaluation. The constraints on teaching with simulation are unique for each program and require careful consideration to balance educational objectives with the reality of integrating simulation into a program’s individual curricula.

Planning for the flow of rotating resident groups through a sequence of simulation exercises requires careful planning and tight execution. During a 3-hour block of conference time, we typically divide the residents by postgraduate year (PGY), forming 2 groups (PGY1–2 and PGY3–4). Course directors may also choose to divide the groups across postgraduate years if their objectives include senior resident evaluation of junior resident performance or senior resident team leadership of junior residents. We teach a classroom seminar directed at knowledge acquisition for 90 minutes and use the other 90 minutes in the simulation laboratory to rotate groups of 4–6 residents through 3 stations of 30 minutes each. Adequate time is given for the simulation, debriefing and commute between stations.4 Thirty-minute stations allow 25 minutes of simulation and debrief time plus 5 minutes for commuting, which avoids residents or faculty feeling rushed. Typically, our junior residents (PGY1–2) have their seminar in the first 90-minute block to provide them with basic content knowledge and structure in preparation for the simulation stations during the second half of the course. The senior residents (PGY3–4) often begin with simulations and use the seminar session in the second half of the course to fill in learning gaps exposed by the simulation experiences.

Depending on the learning objectives for the course, patient simulations, procedural simulations and computer-based simulation programs can be used in the rotations as well as nonsimulation stations that involve other small-group learning formats (Appendix). The design of the stations is based on the learning objectives for the session and varies throughout the year based on the content (Box 1). Our simulation stations typically consist of 2 patient simulations and 1 procedural station. Depending on the topic to be covered, these stations may be substituted for computer-based simulations, small-group learning, mini-seminar, image/electrocardiogram review, oral board case or other teaching formats that fit into the 30-minute time frame.

Conclusion

Our understanding of the role of simulation in teaching residents is in its infancy.4,7 Simulation, like any teaching technique, requires informed implementation within a greater educational curriculum in ways that take advantage of its unique ability to facilitate guided application of new knowledge. It requires a commitment to review all learning objectives of a training program to ensure that each is mapped to the best possible learning method. If simulation is to be fully integrated into the learning environment, extensive reorganization of the resident didactic schedule is essential, with a willingness to disassemble and reassemble the entire curriculum, rather than simply looking for opportunities to add simulation into the existing curriculum and schedule. Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Using simulation as a regular teaching exercise requires an increased time commitment from teaching faculty and careful planning to facilitate flow of learners through teaching stations in ways that maximize learning time relative to commute time. When employed effectively, simulation offers a unique opportunity for residents to learn and apply knowledge under direct supervision in ways that complement the rest of the educational curriculum. Future research should address issues such as how multiple participants in a simulation exercise impact learning, how to best structure simulation debriefing, what role peer evaluation plays in learning, whether integrated simulation affects competency achievement, how curricula can meet individual learning needs identified by competency assessments and how the role of simulation in learning changes as residents gain more real-world expertise through clinical training.