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Simulation and the Family Medicine Physician: Current and future applications for technical skills training

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Deborah Rooney's, PhD, talk at the AHEKON Conference on November 5, 2015.

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Simulation and the Family Medicine Physician: Current and future applications for technical skills training

  1. 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.
  2. 2. Disclosures and conflicts of interest •  None (yok)
  3. 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)
  4. 4. UM Clinical Simulation Center (UMCSC)
  5. 5. 231523142305 UMCSC Spaces
  6. 6. UMCSC Utilization
  7. 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. 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
  9. 9. Simulation-based education is not Simulasyon bazlı eğitim yeni değil
  10. 10. n = 2 n = 690 History of Simulation-based Education
  11. 11. 1973 Dr. Gordon introduces “Harvey” History of Simulation-based Education
  12. 12. 1970s Standardized Pts History of Simulation-based Education1973 “Harvey”
  13. 13. 1980-90s Computers History of Simulation-based Education1973 “Harvey” 1970s Std Pts
  14. 14. 1990s Virtual Reality History of Simulation-based Education1973 “Harvey” 1970s Std Pts 1980s Computers
  15. 15. 1973 “Harvey” 1970s Std Pts History of Simulation-based Education 1980s Computers 1990s VR 1998 Standards
  16. 16. 2000 Error 1973 “Harvey” 1970s Std Pts History of Simulation-based Education 1980s Computers 1990s VR 1998 Standards
  17. 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. 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
  19. 19. Frequency Urgency (risk) urgency frequency urgency frequency (CVC, critical care) Current Trends: technical skills training ( PE, IV)
  20. 20. Address Gap Impact Pt Care Value ? Current Trends: technical skills training
  21. 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. 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. 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. 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. 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. 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. 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. 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. 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
  30. 30. Simulation to attract students to family medicine
  31. 31. What about impact to patient care? Ya hastaya etkisi?
  32. 32.
  33. 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. 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. 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. 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. 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
  38. 38. What about the future? Gelecekte neler olabilir?
  39. 39. Simulation System- based Trng & Assmnt Streamlined Trng & Assmnt Non- technical Skills Trng & Assmnt Projections
  40. 40. Simulation System- based Trng & Assmnt Streamlined Trng & Assmnt Shared Projections •  Increased incentives for system-level patient- safety initiatives •  Hospital safety officials interested in incorporating simulation in quality control cycles •  Interprofessional training is preferred
  41. 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. 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
  43. 43. Simulation Streamlined Trng & Assmnt Non- technical skills Authentic Trng & Assmnt Projections Costs associated with dedicated simulation resources •  Space •  Expertise •  Time
  44. 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. 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. 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
  47. 47. Simulation Non- technical skills Streamlined Trng & Assmnt Systems- based Trng. & Assmnt Projections •  “Overlooked” domains •  More complex skills (decision-making) •  Communication and professionalism
  48. 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. 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
  50. 50. Communication Skills: third-year medical students in Turkey
  51. 51. Final thoughts
  52. 52.       Deborah  Rooney,  PhD   dmrooney@med.umich.edu     teşekkür ederim Sorular ? Questions?

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