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Simulation and the Family Medicine Physician: Current and future applications for technical skills training
1. Simulation and the Family Medicine
Physician: Current and future applications
for technical skills training
AnnualInternationalFamilyPracticeCongress
November 5, 2015
Deborah Rooney PhD
MEDICAL SCHOOL
UNIVERSITY
OF
MICHIGAN
Copyright 2015. All Rights Reserved.
3. My Background
• Medical education since 1991
• Nine years in surgical education
• PhD in Educational Psychology
• Director of Education and Research, Clinical
Simulation Center, University of Michigan (UMCSC)
7. Today’s talk: Simulation-based
education
o Brief history of developments that influenced
simulation
Simülasyonu etkileyen gelişmelerin kısa bir tarihçesi
o Examples of simulation-based training for
technical skills targeted toward Family Medicine
Teknik beceriler için gerekli olan güncel simülasyon bazlı
eğitim
o Projected trends in simulation-based training for
the family medicine physician
Simülasyon temelli eğitimde öngörülen akımlar
8. Simulation-based education is not
new
Sushruta, 2600 years ago
Used specific simulation models for procedural
simulation;
• Gourds, fruit, clay pots, leather pouch full of
“slime,” mud, or water, bamboo, wax on wood
• Included full size patient simulator for splinting
and ligature
• Suture training on the stem of a lotus lily, or cloth
17. Development & refinement of best practices
• Invention and proof of concept of specific
simulators, skills curricula
• Development of practical tools to support
learning and assessment in complex settings
• Application of educational theories
History of SBE* for technical
skills:
2000 to present
*SBE= Simulation-based Education
18. Educational Theory and Technical Skills:
Bloom
Bloom, based on Dave, R. (1967). Psychomotor domain. Berlin: International Conference of Educational Testing.
Higher order psychomotor skills
Lower order psychomotor skills
Watch instructor and repeat
(copy)
Complete task with verbal
instruction
Combine learned skills to
meet novel requirements
Apply automatic strategies
Perform with expertise
without assistance
Naturalization
Articulation
Precision
Manipulation
Imitation
GOAL
21. • M2 (second year medical students),
n=12
• Technical skills training prior to
clinical experience;
ü Central line (CVC) placements
ü Thoracentesis
ü Lumbar puncture
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
Addressing gaps: SBE preclinical
training
22. Training
• 3 x 2-hour sessions
• Lecture followed by hands-on practice
• 2-3 preceptors acted as coaches
Assessment
• Before, after, and 6-month follow-up
• Knowledge
• Attitudes related to Family Medicine
• Skills test after course and 6-month follow-up
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
Addressing gaps: SBE preclinical
training
23. Knowledge Test
• 9 item
• MCQ
Topics
• Contra/inidicatations
• Anatomy
Preclinical training: assessment
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
24. SBE preclinical training: improves
knowledge
Knowledge
Knowledge
Mean
Difference
P
(two-tailed)
Pre-course
Post-
course
1.18
0.007
Pre-course
Follow-up
1.17
0.012
Post-
course
Follow-up
0.18
0.34
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
Change in knowledge test scores
25. Skills Test
• Time
• Needle redirects (pokes)
• Ordered steps
Preclinical training: assessment
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
26. Steps = Insert spinal needle with stylet in place -> Check opening pressure ->
Obtain spinal fluid in tube -> Replace stylet -> Remove needle
Example Skills Test: Lumbar puncture
SBE preclinical training: skills
assessment
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
1 2 3 4 5
27. SBE preclinical training: improves skills
Kelley S, et al. Impacts of Electives in Family Medicine on Preclinical Medical Students. Society of Teachers of Family Medicine
2015 Conference on Medical Student Education.
28. Performing the skills-based and hands-on procedures as part of
the course improved my;
knowledge
Mean 8.29 (SD 1.32)
confidence
Mean 8.09 (SD 1.58)
skill
Mean 8.23 (SD 1.50)
(1=strongly disagree, 10=strongly agree)
SBE Preclinical training: improves
attitudes
29. The course improved my perception of family medicine
ü Post mean 7.23 (SD 1.48)
ü Follow-up mean 7.37 (SD 1.66)
ü p=0.62
The course has led me to reconsider (or has reinforced my
interest in) family medicine as possible career option
ü Post mean 5.54 (SD 1.66)
ü Follow-up mean 5.94 (SD 1.96)
ü p=0.22
(1=strongly disagree, 10=strongly agree)
SBE Preclinical training: improves
attitudes
33. Improves patient outcomes: Central
Venous Catheter (CVC) placement in MICU
Sim-based, mastery training central line placement skills
in Medical ICU (MICU);
• Presentation with contra/indications for CVC
• Video demonstration of CVC IJ placement
• One-on-one instructor & trainee practice with
feedback
• Pre-post training assessment
Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation based mastery learning reduces complications
during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009 Oct;37(10):2697-701.
34. SBE improves patient outcomes:
Central Venous Catheter (CVC) placement
Sim-based, mastery training central line
placement skills in Medical ICU (MICU);
• Fewer needle passes
• Fewer arterial punctures
• Fewer catheter adjustments
Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation based mastery learning reduces complications
during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009 Oct;37(10):2697-701.
35. Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based
education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.
Follow-up research compared pre-post Catheter-Related
Bloodstream Infections (CRBSI) and potential cost-
savings for the hospital
-Cohen and colleagues
CVC placement in Medical
Intensive Care Unit (MICU)
36. Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based
education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.
4.2/100
MICU CVC CRBSI/adm.
0.42/100
MICU CVC CRBSI/ adm.
SBE CVC training improved infection
rates
37. • Training cost ~US$110,000 ( 319,000)
• Approximately 9.95 CRBSIs were prevented in MICU
patients/ CVCs in the year after intervention
• Each translated to US$82,000 ( 240,000) and 14
added hospital days
Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based
education for residents in a medical intensive care unit. Simul Healthc. 2010 Apr;5(2):98-102.
2M
SBE CVC training reduced costs
41. • Prepare for new EHR
• SBE sessions targeted provider/nurse pairs practicing delivery
of maternity care
• Triageà labor à complicationà postpartumà discharge
• Supplement to classroom/online
Systems-based training: EHR & Maternity
Care
193 individuals
64, 2-hr sessions x 4 weeks
Smith R, Hammoud M, Marzano D. (2014) University of Michigan
42. Results
• 100% participation
• Reduced anxiety toward EHR
• Operationalized knowledge
• Fostered teamwork
• Increased interest in SBE
36
25
23
125
92
OB Faculty
OB Residents
Midwives
Family Med
Faculty
Family Med
Residents
Nurses
Smith R., Hammoud M., Marzano D. (2014) University of Michigan
Systems-based training: EHR & Maternity
Care
44. • Using available web-based curriculum on computer
• Self-directed training and
assessment
• Addresses knowledge,
skills, attitude
Future Training: Streamlining
technical skills training with technology
45. Future training targeting
technical skills: retinal exam
• Originally developed for residents, soon to be
adapted by medical students (n=170)
• 3 weeks to teach retinal exam
skills
• 30 minutes/session = 85 teaching
hours
• Teaching commitment = 0
46. Future training targeting
technical skills: endoscopy
Residents;
• Family medicine
• IM-Gastroenterology
• Surgery
ü Self-directed learning
ü 24 hour access
ü Built-in assessment
48. End-of-Life
(Palliative) Care
Targeted Trainees:
• 2nd and 3rd year Family Medicine residents (n=30)
Learning Goals:
• Improve residents’ knowledge about symptoms
associated with dying process
• Improve residents’ ability to treat symptoms
• Improve residents’ communication skills with patient/
families
49. End-of-Life Care Program:
logistics
Intervention
• Presentation
• Clinical simulation
• 10 x 2 hour sessions
Pre-post assessment
• Knowledge
• Communication (social worker acting as family member)
• Comfort
Chiang C, Kelley S, & Petersen, K. Teaching End-of-Life Care to Resident Physicians Using Clinical Simulation.
Healthcare Professional education Day, University of Michigan, 2015