|Year : 2017 | Volume
| Issue : 1 | Page : 9-15
Simulation-based medical education: Using best practices and curriculum mapping to maximize educational benefits in the context of shift toward competency-based medical education
Thomas V Chacko
Department of Community Medicine, Believers Church Medical College, Thiruvalla, Kerala, India
|Date of Web Publication||16-Jun-2017|
Thomas V Chacko
Dean Medical Education, Believers Church Medical College, Thiruvalla, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chacko TV. Simulation-based medical education: Using best practices and curriculum mapping to maximize educational benefits in the context of shift toward competency-based medical education. Arch Med Health Sci 2017;5:9-15
|How to cite this URL:|
Chacko TV. Simulation-based medical education: Using best practices and curriculum mapping to maximize educational benefits in the context of shift toward competency-based medical education. Arch Med Health Sci [serial online] 2017 [cited 2018 May 27];5:9-15. Available from: http://www.amhsjournal.org/text.asp?2017/5/1/9/208217
| Introduction|| |
The present curriculum followed in many medical schools is mainly discipline based and knowledge intensive leading to information overload on students with less attention on skills required for the tasks they are expected to perform as health-care professionals. Thus, the graduates produced by this system are not job ready. Hence, medical schools in many countries have moved toward outcome-based curricula focusing the student learning experiences on acquiring competencies and attributes needed for attainment of stated graduate outcomes that would help them to become capable of discharging their job roles and professional activities to meet the health needs of the people. India is also moving toward attaining outcomes expected of Indian Medical Graduate (MCI Vision 2015). It is in this context that the need for simulation-based medical education (SBME) and the role that it plays to achieve the graduate outcome competencies needs to be understood better. In addition, after one is convinced about its need and its role, it is important to know what must be done to ensure and maximize the educational benefits of SBME.
| What Is Simulation-based Medical Education?|| |
In SBME, instead of using real patients, we use processes and teaching–learning methods including the use of “Simulated Patients” who are actors who act like a patient and/or use simulators which are devices and tools to replace the actual patient to help mimic a clinical encounter so as to provide a safe learning environment for the learner to do deliberate practice of health-care skills so that it then becomes safe for the patient and for the learner to practice the skills on real patients.
Clinical skills laboratories have been established in medical institutions as a facility for SBME. To facilitate SBME, skills laboratories have educational resources such as (1) plastic models for partial task training; (2) mannequin-type simulators (dummy type and high-fidelity type); (3) screen-based virtual-reality simulators; (4) live or inert animals including isolated organs; (5) human cadavers for surgical skills training; and (6) simulated or standardized patients to practice specific skills. There can also be a “full environment simulation” of clinical-or-service-delivery where learners can not only acquire technical skills but also nontechnical skills, such as professional team leadership, team work, communication, situation awareness, decision-making, and awareness of personal limitations.
| Simulation-based Medical Education: Its Place Within the Mbbs Curriculum|| |
Within the traditional apprentice-based curricular model that most medical schools in India are following, learning and acquisition of Medical Council of India's Graduate Medical Education-listed competencies is possible using a competency-focused curricular approach rather than a pure competency-based medical education model (where it is time independent and one exits the program only by attaining the targeted competency levels). In the competency-focused curricular approach (like what we seem to be moving toward), learning is focused around the identified competencies to be attained within the fixed time of the three phases of MBBS program where milestones to be achieved in the competency progression pathway are mapped out MBBS phase wise with the next milestone in the competency progression process getting addressed in the next phase and then during internship, etc., To make this possible, a further exercise of writing the competencies (which are descriptors of physicians) as Entrustable Professional Activities (EPAs) which are descriptors of professional work activities is needed. In teaching settings, written EPAs can help supervisors to decide when and for what tasks they can entrust trainees to assume clinical responsibilities. This step is needed so that it makes clinical sense to the trainer as well as helps learners get motivated to focus on the acquisition of knowledge required for the skill and do deliberate practice needed to gain mastery on that skill to make the graduate job ready (mastery learning).
We need a strategic curricular approach that requires that we ensure learning opportunities for each of the identified competencies. For each of these competencies, students then need to engage in repeated cycles of deliberate practice, receive feedback, and make progress through the stages of unconscious incompetence (incompetent) to conscious incompetence (novice) to conscious competence (competent) and finally to unconscious competence (proficient ~ expert). The “10-year rule of necessary preparation” was recognized as necessary for experts in most domains to attain the highest level of performance by engaging in continuous deliberate practice (and not merely through years of experience alone). Hence, not all EPAs are to be reached to the level of proficiency at the graduate level except the most critical ones (like basic life support) and so they need to be stated as the milestones to be reached along the phases of UG and later internship (mostly reach up to advanced beginner and for some EPAs to competent level), and during residency (from competent to proficient) and progress further during higher PG specialization toward mastery and reach the level of expertise through conscious deliberate practice even after qualifying by engaging in continuing professional development for bridging the gap in the level of competencies needed for professional practice expected at expert level.
| The Need and Role of Simulation-based Medical Education in Making the Indian Medical Graduate Job Ready|| |
In the competency-focused curriculum transposed within the apprenticeship model of learning experience traditionally available in the institutional teaching–learning clinical environment in the wards and outpatient setting, it is challenged by the inherent shortcoming of the current MBBS curriculum where time for learning is fixed. This is compounded by shortage of appropriate cases for practicing the skills, by the unpredictability that these cases would be available for all students during their posting in the wards or outpatient department, inappropriateness of some cases like those in emergencies to be allowed for deliberate practice and receive immediate feedback and the valid concerns for patient safety. In most of these settings, focused competency-based medical education modality that requires dedicated faculty time to brief, supervise the process of practicing the learning of the correct steps in the right way as well as give immediate feedback on learner performance, score, and document progression is difficult.
All the above problems or challenges for competency-based/focused learning make a case for SBME to be a good supplement to the traditional apprentice-based learning system to ensure that none of the required skills are missed out.
To overcome the problem of clinical faculty not getting dedicated time for supervising student–patient encounters or deliberate practice sessions in skills laboratories, perhaps up to certain level of milestones at the MBBS graduate level for some EPAs, keeping in mind the large numbers, peer-assisted learning can supplement the process where the actual progression in acquisition of level of competency would need validation by faculty.
| Need for Simulation-based Medical Education to Prepare the Doctors for Licensure Examinations and Credentialing|| |
In the present times where concern about uniform standards and capabilities of graduates are being expressed and proposed to be mandatorily tested through national exit examinations and/or being made mandatory for licensure for practice (like in many countries in the West), it makes sense that medical schools must pay attention to ensure that the expected graduate competencies identified and listed as EPA required for carrying out professional tasks as well as leading teams for delivering health care in teams are practiced in simulated conditions and on simulators and internally certified so that the students become more confident to demonstrate the required skills and attributes at the national level testing for licensure as well.
| Maximizing the Educational Benefits of Simulation-based Medical Education|| |
Most of the EPAs which need performance of simple patient care task can be learned within the prevailing apprentice model under supervision using deliberate practice and immediate feedback in the ward and outpatient ambulatory setting, provided separate space and dedicated time are made available and student numbers are small. Simpler intervention procedures need simple simulation models that are available, but they are still costly if realism is to be achieved. Realism is needed for motivation to engage in repeated deliberate practice till competency level is to be reached before allowing them to do the procedure on the real patient in the interest of patient safety.
Sophisticated high-fidelity simulation systems are costly and are needed for higher specialty education. Acquiring such costly and advanced systems, however, sometimes takes away the attention and need for providing simpler models in sufficient numbers required for the number of MBBS students who are available during clinical rotations for learning some essential common procedures and this should not happen.
However, market forces and “prestige” associated with high-level investments in costly systems of simulation cloud the decision-making about the type of simulation facilities needed. And often after such costly decisions are made, administrators and decision makers feel that owning such “state-of-the-art” facility will take care of all the needs of MBBS students. This leads to gross underutilization of the facilities with money getting diverted to costly high-fidelity ones needed by specialists to the detriment of not making available simple facilities needed in larger numbers for the large number of MBBS students so as to address simple but essential skills including communication skills.
Hence, MCI Expert group for undergraduate medical education in its document “Academic Staff Training and Learning Enhancement Strategies for Capacity Building in Medical Education” (2010) recommended that, for adopting the above-mentioned contemporary education technologies, faculty development programs in teacher training, skills training, training for patient simulation center, and e-learning resource center are needed. To avoid burdening the medical colleges administering the MBBS program with costly advanced systems and equipment, it has recommended and classified skills laboratories for various levels of competence and variety of skills for undergraduate, postgraduate, and subspecialty training:
- Level 1 training facility mandatory for all medical colleges: Basic surgical skills, basic life support skills, procedural skills, normal labor management, and conduct of delivery. Interns should have a mandatory Level 1 certification before they get licensure
- Level 2 training desired in each medical college or in collaboration with regional centers: Advance life support, basic laparoscopic skills, neonatal and pediatric resuscitation skills
- Level 3 facilities–to be available in regional skills training centers and above: Microsurgical skills, advanced laparoscopic skills, human patient simulator for anesthesia.
So, at the MBBS level, for ensuring all EPAs needed for the graduate to be job ready, curricula must be planned in such a way that all listed competencies are addressed in a systematic process of curriculum mapping [rubric in [Table 1] to identify what appropriate learning experiences are needed for each of those competencies with the skill part of the EPA alone requiring deliberate practice sessions within dedicated time slots within the traditional clinical learning settings as well as in facilities where simulated patients, mannequins, and advanced high-fidelity systems each directed to different skills and different levels of expertise needed.
|Table 1: Curriculum matrix as a tool to plan the learning experiences for acquiring expected competencies and plan optimal use of simulation-based medical education|
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| Maximizing Educational Benefit Using Medical Simulation Technology|| |
Based on critical review of literature on SBME covering the years 1969–2003 and from 2003 to 2009, McGaghie et al. as well as the systematic review on features and uses of high-fidelity medical simulations by Issenberg et al. have led to evidence-based identification and proposal of features and best practices for effective simulation-based medical education.
| the 12 Features and Best Practices for Effective Simulation-based Medical Education|| |
Knowledge of results of one's performance and feedback on performance that is constructive is the most important feature of SBME that is essential to promote effective learning. Source of feedback could be built in to the simulator, given by the instructor in real time or done as a debriefing by viewing a video of simulation-based educational activity. What is important is that it should be immediate, formative (purpose being to improve), and done as a debriefing. Salas et al., 2008, recommend the best practices in feedback debriefing: “it must be diagnostic, team members must be educated about the art and science of leading team debriefs, focus on a few critical performance issues during the debriefs, support feedback with objective indicators of performance, record conclusions made and goals set during debriefing to document progress for reference during the next debriefing.” There is evidence that “educational feedback slows the decay of acquired skills and allows learners to self-assess and monitor their progress toward skill acquisition and maintenance.”
2. Repetitive/deliberate practice
For professional skill improvement toward expertise, deliberate practice is important. It requires highly motivated learners with good concentration, engagement with a well-defined learning objective or task at an appropriate level of difficulty and requires focused repetitive practice that leads to precise measurements that help in providing objective feedback from teachers or peers or trainees themselves who monitor their progress in learning. Skill repetition in practice sessions gives learners opportunity to correct errors and polish their performance and helps make their skill demonstration effortless and automatic and to reach mastery level and then move to another task. The practice “dose” is to be determined by the learner's needs and not by the instructor's demands.
3. Curriculum integration
SBME, being one of the approaches to produce job-ready graduates, should not be an extraordinary or stand-alone activity. It should be built into the learner's routines and required training schedules of educational events and planned curricular learning experiences designed and directed to achieve outcome competencies and grounded in the ways learner performance is evaluated. This is important because SBME can only complement clinical education and cannot be a substitute for training grounded-in patient care in real clinical setting. Since deliberate repetitive practice for acquiring skills is optimally possible in the SBME mode, for specific skills requiring repetitive practice, medical education using simulations must be a required part of the overall curriculum since optional curricular portions do not arouse learner interest.
4. Outcome measurement
Measurement of trainee competence progression is important. Learners are more likely to master key skills if outcome benchmarks are defined and appropriate for their training level prior to the simulator exercise. Defining the benchmarks to be reached by a trainee is important to measure the effectiveness of SBME. Besides, observational ratings of trainee progress are also subject to inter-observer biases and so need rater training and calibration. Defining the criteria for correct performance of activities within a professional task helps in reducing inter-rater variability and so also the reliability of self-reports or reports by peers.
5. Simulation fidelity and simulator validity
There needs to be a close match between educational goals and simulation tools. Simple task trainers and devices that mimic body parts are enough for procedural skills such as suturing, lumbar puncture, and intubation. Complex clinical events training such as response to simulated hospital “codes” require more advanced systems including life-like full body mannequins. Haptic virtual reality simulators help surgeons and interventionists to acquire skills that are too dangerous to practice on real patients. A high degree of realism or fidelity provides an approximation of complex clinical situations, principles, and tasks and is essential to help learners increase their perceptual skills and to sharpen their responses to critical incidents. Although it is important to note that the desired outcome should be matched with the appropriate degree of fidelity, many competencies can be learned and mastered with relatively low-fidelity simulators.
6. Skill acquisition and maintenance
Without further deliberate practice in professional setting, skill acquired through SBME tends to decay post-SBME within 3–12 months depending on the specific skill acquired, the degree of skill learning, and the time elapsed since the last learning encounter. Hence, during the SBME training period, one needs to keep the above variables in mind to determine the duration of SBME the novice or advanced beginner must go through. Helping learners master skills at increasingly difficult levels slows their deterioration of skills over time.
7. Individualized mastery learning
The key benefit of competency-based medical education using deliberate practice is to attain mastery of the required professional skill. The goal of mastery learning is for all learners to achieve all objectives at mastery level. Since individuals learn at their own pace, it is important to individualize the learning experiences adapting to individual learning needs. Time taken to reach mastery level may vary from learner to learner. For ensuring that this mastery learning optimally happens, SBME should have the seven complementary features of mastery learning: (1) baseline diagnostic testing; (2) clear learning objectives sequenced as units with increasing difficulty; (3) engage in educational activities that help reach the stated objectives; (4) establishment of minimum passing standard test or checklist scores for each educational unit; (5) formative testing to determine unit completion set at a preset “minimum passing mastery” standard; (6) advancement to the next level unit upon achievement of “at or above mastery” standard; (7) continued practice on an educational unit till mastery standard is achieved.
Using high-fidelity medical simulations, it is possible to achieve uniform educational outcomes despite different rates of learner educational progress.
8. Transfer to practice
The skills acquired in SBME laboratory settings must translate to real clinical settings. “Simulations capable of sampling from a broad universe of patient demographics, pathologies, and responses to treatment can increase the number and variety of patients that learners encounter. Boosting the variety of simulated patients seen by learners helps to standardize the clinical curriculum across educational sites” and makes the learner more confident and capable to transfer learning to practice.
This transfer of learning to practice must be observed and looked for as part of the SBME program evaluation. Deficiencies observed must be factored in to reengineer/redesign the SBME educational learning experience to make the SBME program more effective.
9. Team training
Patient care outcomes being influenced by team effort, care delivery teams must practice together using SBME. The eight evidence-based critical principles for effective planning, implementation, and evaluation of team training programs  are: (1) identify critical teamwork competencies and use these as a focus for training content; (2) emphasize teamwork over task work, design teamwork to improve team processes; (3) “one size does not fit all,” hence let the team-based learning outcomes desired and organizational resources, guide the process; (4) task exposure is not enough and so provide guided, hands-on practice; (5) the power of simulation being a great influencer, ensure training relevance appropriate to transfer environment; (6) feedback matters and so it must be descriptive, timely, and relevant; (7) go beyond learner reaction data to evaluate clinical outcomes, learning, and transfer of behaviors on the job, and (8) reinforce desired teamwork behaviors so as to sustain them through coaching and performance evaluation.
10. High-stakes testing
Due to the standardization, fidelity, and reproducibility of SBME, apart from formative assessment following practice sessions to give feedback and improvement, SBME can be used for high-stakes assessment of student for certification that the student or health-care professional has attained the required level of competency (pass–fail decision) to be able to do it without risk to real patients. Such high-stakes assessment of students using SBME demands generation of highly reliable data that permit valid inferences about the competence of the health-care professional, should be acceptable to candidates and practicing professionals in the field with regard to patient safety, and should have systems in place for continuous refinement and quality improvement.
11. Instructor training
This is important since the above-mentioned essential features of SBME are important, “SBME is neither easy nor intuitive, and simulation experience alone is not a proxy for simulation instructor effectiveness” and so the instructors need to become aware of these issues and processes through training. Regarding this issue, McGaghie et al. reiterate that “faculty expertise in training with these devices, their motivation to succeed, the local reward system, and institutional support contribute significantly to the success or failure of SBME.”
12. Educational and professional context
Since SBME is expected to help the learner become job ready, the educational and professional context must be simulated (authentic) as well during the practice sessions. Schuwirth and van der Vleuten  second this when they state that “situations in which a candidate's competence is assessed should resemble the situation in which the competence will actually have to be used. SBME that ignores its educational and professional context for teaching, evaluation, or application in clinical practice is misdirected.” Furthermore, it must be noted that “high-fidelity medical simulations that capture or represent a wide variety of patient problems or conditions are more effective than simulations having a narrow patient range. This provides more 'contextual experiences' that are critical for gaining problem-solving skills.”
| Conclusion|| |
There is no doubt about the need for simulation in medical education in the competency-focused outcomes-based curriculum where competencies needed for the outcomes listed to be acquired by the Indian Medical Graduate are to be attained. However, SBME is only a supplement and does not replace the many educational methods and strategies in place in the traditional clinical setting for ensuring graduates become competent. After the learning experience using SBME to develop minimum level of competencies that are entrustable for safe care delivery, students need to further practice under supervision on real patients and service delivery systems in teams to learn to be part of and lead health-care teams in health-care delivery.
For the learners, simulation-based learning experiences built into the curriculum provide the ideal opportunity to practice patient care away from the bedside, applying the principles of adult learning and the principles of deliberate practice toward knowledge and skills mastery. Building SBME into the curriculum can be achieved using the tool of curriculum mapping which helps ensure that all expected EPAs needed for the job roles the graduate of the program are identified and addressed.
For the patients, having students and residents who have trained with simulation and developing a minimum competency level prior to clinical interaction with them makes them more willing to allow students to perform procedures on them after they have undergone simulation training.
For the institutions, pretraining in the simulator or simulated conditions prior to patient encounter addresses patient safety issues and makes them less defensive when faced by attempts by competitors driving the propaganda that “patients are being treated by students.”
There are various practical constraints and challenges that need to be overcome in implementing simulation training programs such as faculty time constraints, lack of faculty training, high cost of equipment, the high cost of equipment maintenance, and constraints for space needed for educational laboratories. As simulators do not replace good educators, faculty trained in solid educational principles and teaching techniques need to be identified and trained in simulation use and debriefing besides ensuring their availability in terms of some protected time away from their clinical responsibilities.
To overcome this SBME faculty-related challenge standing in the way of optimal availability of simulation-based learning for students and residents, institutions must properly reward educators through promotions and compensating them with protected time to teach and do further research and engage in periodic program evaluation in this area so that quality of the simulation-based training program and its effectiveness improves. Institutions must also prioritize simulation in their hospitals as per curricular needs through curriculum mapping using their own curriculum rubric, keeping in mind the facilities and opportunities available in the wards and ambulatory settings and identifying the EPAs that require pretraining on simulators before allowing them to practice on real patients.
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Conflicts of interest
There are no conflicts of interest.
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