Hi welcome back. Today, we're going to be talking about simulation. And so the intended learning outcomes for this section will be to understand the variety of simulations that are used in health professions education, and to define the necessary components of a well-constructed simulation. There may be a number of you in the audience who are very familiar with simulation and there may be some of you who have heard about it but don't exactly know what it is and so I'm going to create sort of broad strokes so that we all have an understanding of what simulations are, what they can do and how they can help us. So first, let's think about why are simulations useful? Well, they can be useful, because they're mainly a learner-centered activity that's experiential. So it helps the learner engage in confidence, competence and to develop the skills that are necessary to care for patients. The important piece there is that it's actually a safe way to do complicated scales or complicated procedures for all parties involved. So, not only for the patients but also for the learner. The other think that simulations are very useful for is creating a reproducible set of examples. So, you could set standards for a team. So, for instance, if you were interested in communication around how do you get a patient to the operating room in a timely fashion. You have created a simulated experience where sort of the same thing happens over and over and then you have a team that works that same situation so then they all have the same standard. you can think of, training for advanced cardiac life support. Again, there's sort of these standard techniques for how do you manage matricular fibrillation, how do you measure respiratory arrest, and so everyone who goes through that standardization will general perform the same way. The other thing that simulations are very helpful for, especially in skill training, is rare clinical scenarios, or procedures that you don't do frequently, or that require a fair amount of training. So for instance on labor delivery we may do shoulder distortion scenarios. Or, for some of the cardiac surgeons, some of their new techniques and their new technologies require practice as well as, sort of competence before you can actually transfer that to the patient. Again, we can talk about training and rehearsals, so what if we have a hazardous material situation? We can create a simulation so that people across all teams can learn how to respond to a hazmat situation. And the other thing that many of us use simulations for and find them actually very helpful are either informative assessments meaning, training and teaching and improving the learner's performance. Or, we're very familiar with summative assessments in the form of ASCIIs, etc. So your simulations can vary by the domain that you're trying to teach. So if you're using a skill domain basis, then you can think about task trainers When you break it down into how to insert an IV or we could talk about surgical trainers. So how do we do laparoscopy or how do you do [UNKNOWN]. Standardized patients are also a simulation around skill domain and you could think about skills of communication or for exam skills. Going onto yet another one of our domains. We could talk about Cognitive domains. So, many people are very familiar with using problem based learning sets or again patient based learning sets so you have a patient who presents with a standard complaint and then how do you simulate the work up or how do you simulate the care for that patient Many people are used to undergoing what we call tabletop exercises. So, for instance, again, for emergency situations, how do we deal with a power outage in the building or how might we deal with a medication shortage. And so you can create tabletop exercises that are written or problem based and then step through You know, what do we do. And depending on how people react in the situation you can actually have differing answers, or differing paths down the simulation to help them learn further. And then there's always the piece of the affective domain that is often the hardest to measure and the hardest to help teach. But simulations can help build sort of a social norm around teamwork, leadership, or communication. So what are the common elements that come in a simulation. What are the things that you really should make sure you have in all of your settings? So we're going to go through these one by one. But as you can see, we're going to talk about outcomes, fidelity, deliberate practice, the opportunity to reflect or debrief and then feedback on the experience. So what kind of outcomes are we looking for? Well, it depends. [LAUGH]. So the frustration there is that you actually do need clear metrics or rubrics. But what those metrics are or how you set up those rubrics is really going to depend on your intended outcome. So it's going to depend on things like; are you trying to measure how fast someone can do something, or the time that they spend on the task. Or are you trying to access the accuracy of their movements or the accuracy of the way they tie a knot or the way they treat tissue? Is it about communication skills? Are there specific rubrics for how information is transferred? Or are you actually looking at how people manage a patient care situation, and really, what you're worried about is the patient outcome. These skills that you create in the simulation should be transferable. Meaning that when the person goes through the simulation and works through the scenarios, that somehow they take away skills and abilities that can be transferred to a real-life situation. And that would get us into the idea fidelity in just a moment. The other thing that's important is that there are some sort of persistence or retention of the information, so its not just a sort of you are one and done kind of event that are really through this intentional practice and simulation you catually sort of reinforce things that you know, learn new things. And actually, can produce them later on. So I mentioned briefly fidelity. And let's talk about what fidelity is. So fidelity is really, sort of, how real does the situation look. Right? Is this a high fidelity situation? Or a low fidelity situation And does it really matter. So many people are very familiar with sort of the high fidelity learning modules where you have a mannequin and a computer set up and you may even have IV drips that can measure the drip and the rate at which medication is being administered. And those are all wonderful scenarios and that's a very high fidelity situation. And, many people have simulations centers that they've build, and are using these types of centers. but there's a cost involved, and the question is, you know, does it matter? And do we really need all the bells and whistles? So I would argue that it actually depends on what you're trying to do. And some of my colleagues here at the University of Michigan, have taught out interns to perform Cesarian sections on watermelons. So you can imagine that the watermelons can simiulate a gravid abdomen. And if you place different types of tissue or sort of materials over the water melon rind then you consummate things like skin, sub cutaneous tissue, [INAUDIBLE] etc. I have also had other gynecological colleagues who use a papaya to actually simulate a uterus and you can see that when that is cut in half there is actually seed inside of it. You could simulate a hysteroscopy [INAUDIBLE] You could simulate, removing things with a polyp forceps. Again, so if you're creative, and you're clear on what you're trying to attain. You don't necessarily have to spend millions of dollars to get fidelity. Now, the challenge is that your learners will say, this is a papaya, this is not a uterus. And so their ability [LAUGH] to. Sort of agree with you and participate in the task is important as well. So again we're going to talk a little bit about high verses low, fidelity and some of the assumptions people make that high fidelity simulators, because the task is as similar or close to a real world situation as possible That those are somehow better or that the transference from the simulation to a real world scenario occurs more efficiently. I wnat to bring your attention to the artciel by Norman Dove and Grerson and I'm going to include the reference in the end Well what they did is they actually looked at about 24 studies, looking at high fidelity and low fidelity simulations, to see what the learning outcomes were. And what they noted was that many of the studies about high fidelity, or low fidelity trainers, were actually compared to no training at all. And so what that means is that when you have a no intervention group Your going to see impact on performance for both high fidelity simulations and low fidelity simulations. But in their review, when they compared high fidelity sims to low fideltiy sims, there really didn't seem to be much of an advantage between the two. Now again, I've talked about, sort of, everybody's buy in around a simulation. And there are many of us in the audience who had to participate in simulations, and it's pretty hard to dispent, sort of, suspend your. Disbelief or to sort of being engaged in the process. So sometimes if you go high with your simulation that actually is more realistic. So, last week I personally was involved in a simulation on our labor and delivery unit. Where we have A computerized laboring patient who's actually placed in a laboring room, and we all have pagers and different roles to portray, and we all got paged to the room for some sort of emergency and how we manage the communication between anestisia And our team, and the nursing team, and the OR's to get the patient to the operating room was the goal of the simulation. And while that simulation worked great, because it was insight to you, right? So it was on our labor and delivery unit. We were actually, you know, this is what we would normally do. We would get paged, and we'd get paged to a room. I still was very personally conscious of, you know, of "Am I making the right medical decisions? Is this what they're testing? You know, how do I know?" etc. And so, sometimes when a simulation can get too fancy, you may miss out on what the point is. The really important piece thing I think is to consider your cost. And definitely consider your access because just because it cost more or has more bells and whistles doesn't necessarily mean that its what you need in your situation. And there are obviously many of us watching all over the planet in a variety of situations and not all of us has access to computerized simulation. And so, the question then becomes well, what is your intended outcome. We could do a tabletop exercise. We could do a paper exercise. As long as you know what you're trying to measure or help people understand, you can create the intervention how it works best. People also talk about something called Progressive fidelity. So low fidelity is good for a novice learner. But an expert actually prefers high-fidelity because, again, they can't get past the fact of, you know, this is papaya that you're trying to have me learn how to do histrospocy on. As opposed to a novice who may say I've never held a histroscope before. I don't know what to do with the device. this makes sense to me. It's the safe environment. I can, sort of, you know, practice and make mistakes. And, and there's not going to a lot of high stakes involved. Again, lots of people are very, very creative. And use very easy to obtain items. So I've seen colleagues that have gone to the butcher shop and actually asked for specific scraps. you know, what's the difference? Really if you learn how to use cautery on an extra piece of animal, as opposed to a very expensive trainer. Or you go to a craft store, and see You know, are there items there that might fit your need. Different textures, different sizes, different ways to sort of craft something that looks like the task you're trying to attain. I've even seen radiologists who are masters at using gelatin in a box to help people with ultrasound training and, and embedding things in the gelatin to then figure out The depth and different assessments for gelatin. So again, there's a lot of very creative ways to do things. We talked a little bit about how cognitive complexity can really distract from the task. So if people are really engaged in the bells and whistles of you know, who's that man behind the curtain Making that noise with the, with the machine. then that may sort of, detract from what you're trying to train people to do. So, we're still thinking about common elements. We've talked about the intentional outcomes that you want with your simulation. We've talked about whether or not you need to do a high fidelity SIM or low fidelity SIM and when it may or may not matter. Another important piece of the simulation is the opportunity for the learner to engage in what we call deliberate practice. many of you may be familiar with the term deliberate practice by Dr. Ericsson and the references there, but basically Goal of deliberate practice is to develop an expert performance. So Dr. Ericsson talks about musicians or chess performers. Or you could talk about sports performers. Either way, they're all trying to create some sort of expert performance. And to do that, you have to practice, practice, practice. And what they do is they basically break down the desired task of their desired cognitive activity that they are trying to do and so components and they practice those components over and over and over so then they lik all of those components together into one smooth performance. Again, people talk about consciously practicing, and repeating and practicing, and repeating. And Dr. Ericsson talks about ten years or 10,000 hours of practice. The other piece about deliberate practice is that there's a conscious reflection and review. Or sort of a metacognitive moment about establishing those connections. Making memories and then developing automatically around the activities. So that also, then, requires the ability to have reflection or debrief after the simulation. So it's not enough to just put people in a situation where they can simulate Doing a procedure and can work on it on their own for four hours and keep trying and trying and trying again without the ability to then go back and say okay, what worked well, what didn't work well? And so to be able to reflect on the performance, people need to have purposeful review of their thoughts, the process that went on, and the outcomes. It needs to be a supportive environment right, its comfortable enough to be in a simulation when you think you are being judged or watched or if things don't go well. And so to be in an environment with the people who are in the situation with you and go through that performance to reflect on where the learners opportunities for improvement why. You also want to be able to debrief the team. Right, so there may have been miscommunications within the scenario. Perhaps I thought somebody was going to get the blood that we needed. And somebody else thought I was going to get the blood, well how did that happen? How did we miscommunicate? What, what do we need to do differently the next time? And that leads directly into sort of this notion of feedback. Now we will have a later session on feedback, but I want to touch just briefly. The important thing is that there's lots of ways to get feedback during a simulation. So there's something called haptics, which those of us who played video games sort of know that when you're playing a video game and And you get hit more, you hit something, it actually shakes, the video controller will shake back at you, and so haptics are sort of this tactile feedback that you may get when you're doing your procedure. So if you're trying to place a central line through plastic that doesn't feel like a person that may not give you the haptics that you need. It may be that you want sort sort of Situation that will give somebody enough feedback that they know that they've done something right, or that they've put the instrument in too far, etc. The other option for feedback involves engaging the participants or the observers. The patient can actually provide feedback, and I find that the standardized patients are often, especially when well-trained A very good source of feedback for the learner. In our high fidelity simulations the computers actually have an amazing amount of data and can measure all sorts of things again like flow rates or the amount of pressure that was applied to a certain area the time and task etc. so again depending of what your outcome is You may have a variety of Data points that help people understand their performance. Many people also video tape or audio tape the performance of the simulation, then they go back and watch themselves on video tape. I can promise you that, that is actually a fairly daunting thing to do, case in point but its very helpful to watch your own performance to recognize. You know, we did, there were a lot of movements that we didn't need to make. There were a lot of people coming in and out of the room that didn't necessarily need to happen. etc. Many people use checklists or global rating scales, we've talked about those in other sessions. So if you're doing a task trainer, then there may be specific checklists that you want that individual to attain. If it's a team training, then perhaps those are more global rating scales. But either way, there's some objective measure for what happened during the simulation so that people can get feedback and improve their performance later on. So, to summarize, we talked about how simulations can vary depending on which domain you're trying to cover. They can be high or low fidelity, and it depends on what you're trying to attain, and how closely you want the simulation to mimick the real world. It may also depend on the type of learner that you have. You may want your simulations to be summative or formative. But in either case you want to have those five crucial elements that we talked about which is having clear objectives. Having the ability to have deliberate practice to review to have fidelity and to have good feedback So here are those On-line resources that I recommend. Both of them are free and open on-line and so, they have a lot of informatioin about fidelity as well as simulation. See you soon.