Medical simulation is widely used in postgraduate medical education. Mannequin simulation has proven effective at creating a learning venue for managing high-risk patient encounters, practicing invasive medical procedures, and experiencing the complexities of emergency resuscitation. Training in a simulated environment has the advantage over the “live” hospital setting in that the educational process can be more effectively tailored to the trainees while limiting risk to patients. It is not surprising that widespread adoption of this technology has occurred, such that nearly all US medical schools and major medical centers are equipped with training facilities. However, at present, simulated educational experiences are primarily adapted to interns, residents, and fellowship (postgraduate) education. Although true, the widespread availability of the technology has created opportunities for synergistic use of simulation centers among other groups. Medical students in their clinical clerkships represent one such group, and we have described previously a curriculum that had been initially piloted in this educational setting.1
However, many uncertainties remain regarding the sustainability of such curricula being incorporated into medical schools' programmatic goals and their overall educational value to the third-year medical student who may be experiencing hospital-based patient encounters for the first time. When one compares the educational necessities of a young medical student with those of a seasoned resident physician, the differences are striking. Although mannequin simulation provides a safe arena for the practice of “high stakes” scenarios, such encounters are far beyond the general comprehension of most third-year students. Similarly, although procedural techniques can be effectively practiced in a simulated setting, central line placement and other procedures are not core objectives of a typical internal medicine clerkship.
We and others have previously published descriptions of simulator-based curricula focused specifically on the educational necessities of medical students in their clinical years.1–5 Such simulated experiences are very different from those applied to resident physicians. In one simulated learning exercise at our institution, mannequin simulation was designed to facilitate the translation of physiologic and pathophysiologic principles learned in the first and second preclinical years of schooling, toward the understanding and care of sick patients during the third and fourth clinical years. This hypothesis was based on an observed needs assessment and grounded in plausible educational principles. Initial experience and student feedback with this simulated experience were highly positive.1 However, minimal data have been published that confirm the long-term experience of this intervention. Furthermore, the sustainability of such models has long been questioned, especially in light of the necessary faculty commitment, and the cost-intensive nature of these efforts. In part, because of these uncertainties, mannequin simulation has only partially penetrated into the standard clerkship curricula of most US medical schools.
In 2002, we introduced a mannequin simulation curriculum into our third-year internal medicine curriculum at the Brigham and Women's Hospital (BWH), a teaching affiliate of Harvard Medical School in Boston, MA. Following initial positive data describing student enthusiasm for the educational process, we sought to embed the curriculum as a formal piece of the 12-week clerkship. To date, >327 medical students have taken part in this experience, which remains ongoing. During a 6-year prospective investigation, we sought to collect data regarding students' experience with the simulator as an educational component of the 12-week clerkship experience. We also sought to assess the durability and sustainability for this effort. Below we describe the results of this investigation, and our recommendations for further continuation.
After initial success with our pilot effort,1 we fully incorporated the simulator experience into our third-year internal medicine clerkship. Small-group teaching sessions with our medical simulator would occur approximately once monthly. The primary objective of each session was to deliver an active educational experience that linked physiologic and pathophysiologic principles learned earlier in medical school (though at times poorly retained) to the evaluation and treatment of patients who might be encountered during an internal medicine clerkship. This article describes our simulator experience focused on cardiovascular ischemia, including acute right- and left-sided ventricular failure. The curriculum was delivered over 90 minutes and involved three separate mannequin simulations separated by 15-minute faculty-led discussions, as described previously (Fig. 1).1
We sought to determine whether the simulation experience positively influenced the internal medicine curriculum. Specifically, we assessed whether the teaching provided to the students during this simulated experience was duplicative of their clinical hospital encounters or fulfilled an important unmet need of delivering content exposure to core clerkship objectives. This was of great interest in light of the Liaison Committee in Medical Education's Standard ED-2 for accreditation where medical schools must define and ensure that students encounter specified types of patients and clinical conditions in their clerkship. If the student does not encounter these prespecified areas on the wards, one of the potential remedies suggested by the committee is a simulated experience.6 We also assessed whether this experience facilitated the synthesis, or reflective analysis, of the broader topic presented, in this case, physiologic principles of cardiovascular ischemia. Data were obtained through blinded surveying of the students at the completion of the simulator session and at the completion of the internal medicine clerkship. Faculty members were interviewed biannually for feedback regarding the effectiveness and sustainability of this effort.
Setting and Population
We provided simulator-based teaching sessions to a total of 327, third-year Harvard medical students assigned to complete their core internal medicine clerkship at the BWH, Boston, MA, during a 6-year period (2002–2009). Sessions were conducted using a mannequin patient simulator maintained on the campus of Harvard Medial School (Human Patient Simulator Medical Education Technologies, Inc., Sarasota, FL). This simulator is a computer-controlled mannequin that replicates human physiology in real time. Its features and capacities have been described previously.1
More than 95% of the students had prior experience with the patient simulator as part of coursework completed during their first and second years of medical school, though none had participated in a curriculum similar to that used in this analysis. Teaching groups comprised three to four students taught by one faculty and one technician both trained in the use of the mannequin simulator. The 90-minute session occurred at varying points in the students' 12-week internal medicine clerkship and was additive to the current clerkship curriculum, which was otherwise unaltered.
A nearly identical simulator experience was provided to each cohort of students during the 6-year period. The session was directed at understanding the pathology and pathophysiology of cardiovascular ischemia, as described in detail previously.1 Each 90-minute session involved six components, including an introductory case of acute congestive heart failure, two cases of acute cardiac ischemia [anterior myocardial infarction (MI) and inferior MI], and three interspersed faculty-lead discussions (Fig. 1). The final discussion reviewed data from all three cases and sought to exploit the differences in clinical presentations and treatment response. Specifically, this involved an iterative, active discussion that sought to have students recollect prior physiologic principles and explain why the same clinical diagnosis could lead to differing experiences. For example, two cases of MI were presented, one representing an inferior infarct, whereas the other an anterior infarct. Focused questioning sought to force the students to explain different clinical presentations (eg, heart rate 39 bpm when an inferior MI vs. 100 bpm when an anterior MI) despite the same clinical diagnosis MI and same cellular process (myocyte ischemia). No advanced preparation was assigned to the students before attending this exercise. Students were not graded on their knowledge or performance during the exercise, though attendance was mandatory for a passing clerkship evaluation.
At times, a second simulator teaching experience was offered to some students based on specific requests. In such settings, different physiologic principles were targeted, such as mechanisms of hypoxia for example. Because only a portion of students received extra instruction, this article describes the findings specific to the simulation of acute cardiac ischemia, which was universally delivered to all Harvard medical students rotating in the medicine clerkship at our hospital.
Through the 6-year effort, four different faculty members were involved with this simulator curriculum and one technician. Faculty members were not additionally compensated for this teaching commitment, but rather this effort was incorporated into their salaried time already financed toward medical education efforts. Faculty members alternated their role in delivery of the sessions.
Two student surveys were constructed to assess this teaching process. The first survey was introduced at the initiation of the simulation pilot effort (2002) and focused on student perception and evaluation of the learning process. This survey was applied to all students during 6 years. The second survey was developed and initiated following analysis of the initial simulation pilot study. The second survey sought to assess whether this educational experience was additive or duplicative to the students standard clerkship curriculum and how this simulated experience may affect the clerkship learning process. This survey was applied to all students participating in this curriculum from July 2004 onward, which comprised 259 students, or about 80% of the cohort. All surveys were delivered to students in a blinded fashion and were batch analyzed.
Simulator faculties were interviewed biannually by the lead author (E.K.A.) to seek feedback on past experiences in a qualitative fashion. This was done in a structured fashion to assess the education tool from a development and modification standpoint, as well as to assess sustainability during a 6-year process.
This investigation was reviewed and exempt from continuing oversight by the investigational review board.
With the exception of data obtained from interviews and open-ended questioning, data were quantitatively analyzed and presented in descriptive format. In both surveys, students were encouraged to include free text commentary, and these comments were transcribed and coded by topic for analysis.
We also analyzed whether students' prior exposure to MI and their perception of increased value from the simulator correlated with the timing of the students' internal medicine clerkship within the academic year (first quarter to fourth quarter) using an analysis of variation.
During the 6-year study period, we documented limited medical student exposure to “live” hospitalized patients with a MI, despite “myocardial ischemia” representing a core clerkship objective. Only 109 (42%) of 259 students questioned on this topic had participated in the care of a patient with an anterior MI, whereas 54 students (21%) had participated in the care of a patient with an inferior infarction (Fig. 2). Only 40 students (15%) had the opportunity to participate in the clinical care of both types of MI, with 19 of 40 (48%) such students reporting their clinical exposure to these two types of infarction separated by more than 1 month. Students were also asked to provide details regarding exposure to didactic teaching of myocardial ischemia during their 12-week internal medicine clerkship. Two hundred one of the 259 students (78%) reported having a didactic teaching session focused on myocardial ischemia. Even in this setting, only 43 of these students (21%) reported that the prior didactic session effectively compared or contrasted the pathophysiologic principles of different types of MI (Table 1). Thus, the simulation exercise provided the only exposure to the core curriculum topic of MI for 22% of students. Furthermore, for 85% of students, this single simulation exercise provided the only means of clinical exposure to multiple but variable presentations of this single illness.
The simulator-based teaching session was successfully added to the BWH Internal Medicine clerkship without disruption to the remaining teaching and educational activities. The 90-minute activity was delivered to two student groups in succession approximately once a month. This model was continually sustained during the last 6 years. Although the curriculum was slightly modified based on faculty and student feedback, no major change in content or education delivery occurred during this time. Of the 327 medical students who participated in the simulated experience during 6 years, >99% of the students reported the educational exercise as “useful” to their learning. Two hundred ninety-five students (90%) rated the overall quality of the exercise as “excellent” (the highest option). Students overwhelmingly felt that the simulator should be a routine part of the internal medicine clerkship (310 students, or 95%). Two hundred twenty-four students (69%) requested three or more simulator sessions be provided to each student per 12-week clerkship.
When directly compared, 148 students (74%) found the simulator session “more valuable” than the prior didactic session (Table 1). Eighty-eight students expanded qualitatively on this opinion, reporting that they found the hands on experience of the simulator superior (42%), the simulator made material easier to remember (28%), and the simulator made it easier to compare different scenarios (20%), among other comments (Table 2).
Students were also asked to comment on means to improve the simulation exercise. Open-ended and qualitative feedback was provided by 182 students. These data reflected a desire for more (or longer) sessions (39%), additional topics to be taught and/or technical modifications be made to the sessions (26%), and the request for more didactic time and feedback incorporated into the sessions (9.7%) among other comments (Table 3).
Students were asked to specify the “most valuable” portion of the simulator exercise. One hundred seventy-eight (69%) of 259 students surveyed on this question reported the iterative discussion at the completion of the 90-minute session as “most valuable.” The individual cases of myocardial ischemia (the inferior MI simulation or the anterior MI simulation) were ranked “most valuable” by 57 students (22%). Occasionally, some students ranked multiple portions of the simulation as “most valuable.”
The timing of the clerkship during the academic year had no statistical influence on students' assessment of whether the simulator was more valuable than a traditional didactic lecture (F = 0.43, P = 0.73). Interestingly, the students' reports of clinical exposures to myocardial ischemia also did not significantly vary based on the time of the clerkship within the academic year. For example, involvement with clinical cases of inferior MI were reported by 22% of students in the first quarter, when compared with 17% in the second and third quarters and 27% in the fourth quarter (F = 1.15, P = 0.32). Students also reported consistent experience with anterior MI across academic quarters (F = 0.45, P = 0.72).
Interviews of clerkship faculty participating in this simulator exercise provide insight into factors contributing to its sustainability. After initial attempts to modify the number of students per session, as well as the frequency of delivery and its timing during the 12-week clerkship, all faculty agreed that the following concepts were optimal: (a) three to four students participate per simulator session, (b) delivery of the simulation exercise occur about once monthly, during which two separate groups would participate (ie, two, 90-minute sessions), and (c) sessions should be staggered through the 12-week clerkship. Because teaching in the simulator requires at least two faculty/technicians to deliver, it was also commented on that the simulator exercise was increasingly effective after the same faculty/technicians had worked together at least three times prior. Faculty acknowledged that about 10% of students would also display full understanding of the pathophysiologic differences being simulated. In this setting, it was necessary to modify the group discussion session to avoid prematurely closing the thinking process or reducing the efficacy of a step-by-step analytic reasoning process. The latter was felt most important by the faculty. In such cases, the faculty would acknowledge the students understanding of the situation but redirect the discussion of the group to allow for all students to equally benefit. Overall, faculty found the simulation exercise enjoyable and felt it added to the clerkship curriculum.
We describe the first long-term experience using mannequin simulation as part of an internal medicine clerkship. The utility of simulation has been reported for procedural, high-risk, and team-based training;7–9 however, few data have previously described the efficacy of this educational tool incorporated longitudinally within the confines of a medical clerkship. Our data confirm widespread support for mannequin simulation, expressed by the students themselves. The majority of students desired three or more simulator-based learning sessions per clerkship. Pedagogically, our data also confirm that simulation is vital toward expanding the delivery of core clerkship objectives and facilitating higher learning. Only 47% of students had participated in the care of a “live” patient with a MI during their 12-week clerkship. Only 78% reported receiving didactic teaching on the subject. Thus, for 22%, the simulation exercise provided the sole exposure to this core objective material. Furthermore, only 15% of students participated in the care of two cases of MI with different clinical presentations. Even when this topic was presented and compared in small-group didactic sessions, the students perceived greater value from the efficient delivery of multiple cases during the simulator exercise and the comparative discussion which followed the simulation. Thus, these data demonstrate the ability of mannequin simulation to improve both content delivery and to promote comparative analysis within a traditional internal medicine clerkship. This effect was apparent during 6 years and remains financially and logistically sustainable.
Others have described short-term benefits of medical simulation on student education. A large meta-analysis concluded that the most important features of mannequin simulation was its ability to allow feedback during the learning experience, while also mandating an active learning experience by requiring direct student involvement. These activities are felt to slow the decay of knowledge and facilitate self assessment.10 A separate meta-analysis describes a strong association between mannequin simulation and achievement of standardized learning outcomes.11 In support, Winston and Szarek12 report the integration of the human simulator in a problem-based learning curriculum among 136 preclinical students, followed by improvement in student performance. Morgan et al.13 report a study of 299 medical students, who, after a single day of cardiac arrhythmia simulation, demonstrated improved scores on cardiac pharmacology testing. Multiple other studies also support the utility of medical simulation with specified learning objectives.3,13–16 The utility of the simulator as an education tool was consistently confirmed by medical students in previous studies.2–5,7,14–19 Our investigation supports these findings but demonstrates even greater power of mannequin simulation when viewed from the level of curriculum delivery.
For the first time, our data demonstrate that mannequin simulation is not just another means of delivering educational content. Rather, simulator curricula can be developed that focus on third year medical student educational needs and facilitate exposure to and comparison of illness otherwise not available by other traditional venues. Although core clerkship material concerning MI could be theoretically delivered to students by numerous means, our data demonstrate that simulation curricula overcame logistical hurdles of exposure to specific types of cases that existed within the hospital wards of the single institution in which we tested the program. Students preferred the simulation curricula, when directly compared with didactic sessions. Only 15% of students reported clinical encounters with both inferior and anterior myocardial ischemia on the wards. Even within this small minority, the cases were often separated by over 1 month. These facts alone demonstrate the limits inherent to clerkship learning and suggest the potential benefits of mannequin simulation.
Theories of higher education suggest that adult learning may occur by several basic steps. First, a learning experience must occur. Thereafter, the experience must be retained within the individual and remembered. Basic meaning is then applied to the experience by the learner him/herself. However, the fourth step is reached by some individuals and represents the highest level of learning. This fourth step involves reflection and comparative analysis of related experiences. This final step allows for the greatest understanding, as comparison often stimulates the need to explain similarities or differences between two or more experiences.20,21 Our data show that multiple experiences of similar illness can be difficult to deliver by traditional clerkship experiences. Furthermore, when they occur, there often exists a large time period between events and rarely are faculty available to assist the student in the process of comparative analysis. Mannequin simulation proved successful in addressing this limitation, at least for the single learning objective of MI.
Most research on medical simulation is limited to short-term research projects lasting <1 year in duration. There are few data describing long-term simulation curricula. Our data describe a 6-year prospective experience that remains ongoing. Beyond the pedagogical benefits noted above, simulation also proved logistically and financially sustainable at our institution. One faculty member was required to lead the effort and worked in conjunction with a simulator technician to deliver each experience. Although groups of three to four students were deemed optimal, this small size did not preclude feasible teaching to all students through the year. This educational experience occurred within a simulator center shared by numerous educators, thus reducing institutional financial cost through sharing of resources. Faculty feedback provides insight into the success of such a curriculum if other medical schools were to adopt this model.
We acknowledge limitations to this investigation. This study was undertaken at a single institution with a specific set of instructors and a simulation center, which was readily accessible. Although we believe our curriculum is widely adaptable to different institutions, various clerkship structures or logistical limitations at other schools may present unforeseen barriers. Second, we acknowledge that this investigation is not randomized nor does it demonstrate improvement in sustained learning. However, our prospective, quantitative data do effectively describe the fragmented exposure to illness often seen within a clinical clerkship. Building on theories of higher education, these findings nonetheless suggest that our simulator experience provided educational benefit by facilitating exposure to similar disease, while stimulating comparison and reflection. Finally, we note that all students participated in just one simulator experience throughout their 12-week clerkships. We are uncertain whether feedback would differ when three or more simulated exercises might be provided during the same period of time, as our students have requested. It is also possible that simulation could prove most effective for comparing cardiovascular illness, and thus application to other diseases would be suboptimal. However, we have no rational explanation for why this would be true.
In summary, we report a 6-year experience demonstrating the sustained value of a simulation curriculum within a third-year internal medical clerkship. Of 327 medical students, >99% reported the simulator experience valuable, and the majority desired repeated sessions through the clerkship. Mannequin simulation provided “live” exposure to core objective content not experienced on the hospital wards for nearly 50% of students. Furthermore, this educational experience seems important for facilitating direct comparison of illness and facilitating reflective analysis. This curriculum was additive to standard clerkship activities and proved logistically and financially feasible. Together, these findings demonstrate the flexibility of medical simulation to provide educational opportunities for medical students who are just beginning their clinical training.
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