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Commentary: communication skills: how simulation training supplements experiential and humanist learning.

The Viewpoint article in this issue by Drs. Michael Hanna and Joseph Fins, "Power and Communication: Why Simulation Training Ought to Be Complemented by Experiential and Humanist Learning," is provocative on several levels. This Commentary focuses on three interrelated questions that emerge from the article's consideration of power dynamics in encounters with simulated patients: (1) To what extent do medical students "perform" (i.e., put on an act) in the context of teaching and assessment that involves simulated patients?; (2) How might medical educators increase the likelihood that students will apply to subsequent practice the core skills and strategies learned in their communication skills training?; and (3) How can different learning modalities complement one another in communication skills training? The Commentary articulates important differences in the application of simulated patients (i.e., teaching versus assessment), elaborates on the issue of power and authority, and then addresses each question noted above. In the process, it outlines some of the avenues through which interpersonal and communication skills are learned--or unlearned--in medical education.

Behavior↗

Simulation training in the obstetrics and gynecology clerkship.

OBJECTIVE: The purpose of this study was to determine the effectiveness of obstetrics simulator training for medical students by comparing measures of confidence in normal obstetrics skills of students with and without training. STUDY DESIGN: After a lecture on normal labor and delivery, 33 third-year students practiced their skills either on an obstetrics simulator (n = 17) or received no further formal instruction (n = 16). All students were asked to respond to surveys of their experience and confidence in performing obstetrics procedures. RESULTS: Students who practiced deliveries on the simulator were more likely to believe that they could perform most portions of a vaginal delivery with minimal supervision or independently than were students who did not receive simulator experience. Fifteen students (88%) who received simulator experience felt that they were ready to attempt a vaginal delivery independently or with minimal supervision compared with 2 students (12.5%) who received a lecture only (P < .001). CONCLUSION: Students who practiced deliveries on an obstetrics simulator report higher levels of confidence in their skills to perform vaginal deliveries.

Clinical Clerkship↗

Virtual environment-based training simulator for endoscopic third ventriculostomy.

A virtual environment-based endoscopic third ventriculostomy simulator is being developed for training neurosurgeons as a standardized method for evaluating competency. Magnetic resonance (MR) images of a patient's brain are used to construct the geometry model, realistic behavior in the surgical area is simulated by using physical modeling and surgical instrument handling is replicate by a haptic interface. The completion of the proposed virtual training simulator will help the surgeon to practice the techniques repeatedly and effectively, serving as a powerful educational tool.

Computer Simulation↗

Comparison of exercise variables measured during intensity of simulated training to variables at maximal effort in standardbreds.

The heart rate changes during routine training in a group of 8 actively racing Standardbreds were used to simulate the training work on a treadmill (ST) and indices of exercise compared to maximal effort (MAX) on the treadmill. The following parameters were recorded during treadmill work: heart rate, velocity, O2 consumption, respiratory and stride frequency, and stride length. Blood lactate concentrations were measured before and after each work test. Heart rate during simulated training was mean +/- s.d. 87.8 +/- 5.5% heart rate in MAX, one of the 8 horses working < 80% of maximal HR and 2 of the 8 horses working above 90% maximal heart rate. Mean +/- s.d. oxygen consumption during the ST was 75.1% +/- 8.4% MAX, but correlated poorly against percentage heart rate for individual horses (r2 = 0.02). At similar velocities for the ST and MAX, only respiratory frequency differed significantly (P > 0.05), being higher during the ST. Most horses worked at intensities based on heart rate consistent with proposed guidelines of 80-90% of maximal heart rate. However, in 3 of the 8 horses work intensity of insufficient or excessive amounts may have occurred.

Animals↗

Fundamentals of the model behind the COSMOS methodology used for team assessment in simulator training.

Team working is the basic way of working in the control rooms of hazardous technologies and therefore its quality is a safety-relevant issue. In addition to the technological competence it is also crucial for the crews to have the necessary communicational skills. During simulator training these skills can only be improved if the simulator use is embedded in an appropriate setting. To support this skill acquisition a computer-supported methodology called COSMOS (COmputer Supported Method for Operators' Self-assessment) has been developed. With its help more effective communication and more complete shared mental models can be fostered. This paper is a report on the psychological fundamentals and the mathematical model of the COSMOS methodology.

Communication↗

Functional endoscopic sinus surgery training simulator.

OBJECTIVE/HYPOTHESIS: To determine the efficacy of a haptic (force feedback) device and to compare isosurface and volumetric models of a functional endoscopic sinus surgery (FESS) training simulator. STUDY DESIGN: A pilot study involving faculty and residents from the Department of Otolaryngology at The Ohio State University. METHODS: Objective trials evaluated the haptic device's ability to perceive three-dimensional shapes (stereognosis) without the aid of image visualization. Ethmoidectomy tasks were performed with both isosurface and volumetric FESS simulators, and surveys compared the two models. RESULTS: The haptic device was 77% effective for stereognosis tasks. There was a preference toward the isosurface model over the volumetric model in terms of visual representation, comfort, haptic-visual fidelity, and overall performance. CONCLUSIONS: The FESS simulator uses both visual and haptic feedback to create a virtual reality environment to teach paranasal sinus anatomy and basic endoscopic sinus surgery techniques to ear, nose, and throat residents. The results of the current study showed that the haptic device was accurate in and of itself, within its current physical limitations, and that the isosurface-based simulator was preferred.

Computer Simulation↗

Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study.

OBJECTIVES: Computer-based colonoscopy simulation (CBCS) is being utilized in endoscopy training without supporting evidence that it improves patient-based colonoscopy performance. The goal of this pilot study was to determine if CBCS training improves gastroenterology (GI) fellows' patient-based colonoscopy skills. METHODS: Competency at colonoscopy among 4 novice GI fellows who completed a 6-h CBCS curriculum was compared with 4 novice fellows who were not CBCS-trained. Measurements of competency were rendered by supervising faculty by recording "insertion time,""depth of unassisted insertion,""independent procedure completion,""ability to identify endoscopic landmarks,""inserts in a safe manner,""adequately visualizes mucosa on withdrawal," and "responds appropriately to patient discomfort" with each colonoscopy. RESULTS: Simulator-trained fellows outperformed traditionally trained fellows during their initial 15 colonoscopies in all performance aspects except "insertion time" (pp < 0.05). Simulator-trained fellows inserted the endoscope significantly further and reached the cecum independently nearly twice as often during this early training period. Three parameters ("depth of insertion,""independent completion," and "ability to identify landmarks") demonstrated a continued advantage out to 30 colonoscopies. Beyond 30 procedures, there was no difference in the performance of the two groups. CONCLUSION: In this pilot study, a 6-h CBCS curriculum provides an early training advantage by enhancing competency at the early stages of patient-based colonoscopy. These advantages are negligible after approximately 30 patient-based procedures. CBCS-enhanced training may allow faculty to be more efficient with their colonoscopy practice.

Clinical Competence↗

Cognitive versus technical debriefing after simulation training.

BACKGROUND: Recent literature describes "cognitive dispositions to respond" (CDRs) that may lead physicians to err in their clinical reasoning. OBJECTIVES: To assess learner perception of high-fidelity mannequin-based simulation and debriefing to improve understanding of CDRs. METHODS: Emergency medicine (EM) residents were exposed to two simulations designed to bring out the CDR concept known as "vertical line failure." Residents were then block-randomized to a technical/knowledge debriefing covering the medical subject matter or a CDR debriefing covering vertical line failure. They then completed a written survey and were interviewed by an ethnographer. Four investigators blinded to group assignment reviewed the interview transcripts and coded the comments. The comments were qualitatively analyzed and those upon which three out of four raters agreed were quantified. A random sample of 84 comments was assessed for interrater reliability using a kappa statistic. RESULTS: Sixty-two residents from two EM residencies participated. Survey results were compared by technical (group A, n = 32) or cognitive (group B, n = 30) debriefing. There were 255 group A and 176 group B comments quantified. The kappa statistic for coding the interview comments was 0.42. The CDR debriefing group made more, and qualitatively richer, comments regarding CDR concepts. The technical debriefing group made more comments on the medical subjects of cases. Both groups showed an appreciation for the risk of diagnostic error. CONCLUSIONS: Survey data indicate that technical debriefing was better received than cognitive debriefing. The authors theorize that an understanding of CDRs can be facilitated through simulation training based on the analysis of interview comments.

Cognition↗

Effect of simulator training on driving after stroke: a randomized controlled trial.

BACKGROUND: Neurologically impaired persons seem to benefit from driving-training programs, but there is no convincing evidence to support this notion. The authors therefore investigated the effect of simulator-based training on driving after stroke. METHODS: Eighty-three first-ever subacute stroke patients entered a 5-week 15-hour training program in which they were randomly allocated to either an experimental (simulator-based training) or control (driving-related cognitive tasks) group. Performance in off-road evaluations and an on-road test were used to assess the driving ability of subjects pre- and post-training. Outcome of an official predriving assessment administered 6 to 9 months poststroke was also considered. RESULTS: Both groups significantly improved in a visual and many neuropsychological evaluations and in the on-road test after training. There were no significant differences between both groups in improvements from pre- to post-training except in the "road sign recognition test" in which the experimental subjects improved more. Significant improvements in the three-class decision ("fit to drive," "temporarily unfit to drive," and "unfit to drive") were found in favor of the experimental group post-training. Academic qualification and overall disability together determined subjects that benefited most from the simulator-based driving training. Significantly more experimental subjects (73%) than control subjects (42%) passed the follow-up official predriving assessment and were legally allowed to resume driving. CONCLUSIONS: Simulator-based driving training improved driving ability, especially for well educated and less disabled stroke patients. However, the findings of the study may have been modified as a result of the large number of dropouts and the possibility of some neurologic recovery unrelated to training.

Accidents, Traffic↗

Virtual training simulator--designer of EEG signals for tutoring students and doctors to methods of quantitative EEG analysis (qEEG).

Within the framework of the system for computer diagnostics of EEG (qEEG) NeuroResearcher 5.2 is created virtual training simulator--designer of EEG signals and models multidimensional neurodynamic systems of the brain. It is intended for tutoring with minimum engaging of mathematical formulas of doctors and students to comprehension of essence of mathematical methods (classical correlation and spectral analysis and newest methods of multi-dimensional analysis of neurodynamic systems of the brain), which are successfully used for quantitative EEG (qEEG).

Computer Simulation↗

Improving patient safety by using interprofessional simulation training in health professional education.

Modern medicine is complex. Reports and surveys demonstrate that patient safety is a major problem. Health educators focus on professional knowledge and less on how to improve patient care and safety. The ability to act as part of a team, fostering communication, co-operation and leadership is seldom found in health education. This paper reports the findings from pilot testing a simulated training program in interprofessional student teams. Four teams each comprising one medical, nursing, and intensive nursing student (n = 12), were exposed to two simulation scenarios twice. Focus groups were used to evaluate the program. The findings suggest that the students were satisfied with the program, but some of the videos and simulation exercises could be more realistic and more in accordance with each other. Generally they wanted more interprofessional team training, and had learned a lot about their own team performance, personal reactions and lack of certain competencies. Involving students in interprofessional team training seem to be more likely to enhance their learning process. The students' struggles with roles, competence and team skills underline the need for more focus on combining professional knowledge learning with team training.

Education, Medical, Graduate↗

[Simulator training in anesthesia. Applications and value].

Simulation has gained an important role in medical education and continuing education in the field of anaesthesia and emergency medicine. This article gives background information on how full-scale simulators are applied in medical education as well as in continuing education for advanced anesthesia and scientific applications. Acceptance of training seems enhanced by inclusion of the human factor aspect, since this has proven to be a major source for the development of critical situations in our specialty. Furthermore, drawbacks of the simulators available and the current training availability in Germany is described.

Anesthesiology↗

Virtual reality flexible sigmoidoscopy simulator training: impact on resident performance.

BACKGROUND: Flexible sigmoidoscopy, a core skill for the primary care physician, requires learned hand-eye skills that can be difficult to master during residency training. With recent advances in virtual reality simulation technology, simulated flexible sigmoidoscopes are available to family medicine residents for training before their initial and subsequent live patient examinations. The purpose of the study was to determine whether a virtual reality flexible sigmoidoscope simulator would improve the hand-eye skills and various performance parameters in a live patient. METHODS: Residents were assigned to a control (n = 5) or experimental group (n = 5) in which the experimental group trained on a virtual reality sigmoidoscopy simulator before their first sigmoidoscopies on live patient volunteers. After the initial live patient sigmoidoscopies, both control and experimental groups trained on the simulator so that it was possible to evaluate presimulator and postsimulator training effects on live patient performance and to compare speed and skill between the groups at different levels of training. RESULTS: Training on the virtual reality simulator produced substantial improvements in examination times and hand-eye skill measures. After 6 to 10 hours of training on the simulator, the experimental group achieved significantly faster insertion times to 30 cm (119 versus 357 sec, P = 0.03), 40 cm (211 versus 518 sec, P = 0.03), and a shorter mean length of examination (323 versus 654 sec, P = 0.01). There was also significant improvement of hand-eye skill measures of the experimental group in directional errors (1.6 versus. 8.6, P < 0.01), percentage of colon visualized (79 versus 45 percent, P = 0.02), and viewing quality of examination when compared with the control group's initial performance on live patients. Resident survey findings after the study confirmed the trainee's perception of the benefit of the simulator training. CONCLUSIONS: This study shows the value of virtual reality simulator training for accelerating the development of the hand-eye skills to perform adequate sigmoidoscopy.

Clinical Competence↗

Virtual reality arthroscopy training simulator.

This paper describes the result of the interdisciplinary cooperation of traumatologists of the Berufsgenossenschaftliche Unfallklinik (BGU) in Frankfurt am Main and a team of computer graphics scientists of the Franunhofer Institute for Computer Graphics in Darmstadt. We have developed a highly interactive training simulator system by means of computer graphics and virtual reality techniques.

Arthroscopy↗

Early exposure to haptic feedback enhances performance in surgical simulator training: a prospective randomized crossover study in surgical residents.

BACKGROUND: In the literature of skill acquisition and transfer of skills, it often is assumed that the rate of skill acquisition depends on what has been learned in a similar context (i.e., surgical simulators providing haptic feedback). This study aimed to analyze whether the addition of haptic feedback early in the training phase for image-guided surgical simulation improves performance. METHODS: A randomized crossover study design was used, in which 38 surgical residents were randomized to begin a 2-h simulator training session with either haptic or nonhaptic training followed by crossover after 1 h. The graphic context was a virtual upper abdomen. The residents performed two diathermy tasks. Two validated tests were used to control for differences in visual-spatial ability: the BasIQ general cognitive ability test and Mental Rotation Test A (MRT-A). RESULTS: After 2 h of training, the group that had started with haptic feedback performed the two diathermy tasks significantly better (p < 0.05, unpaired t-test). Only the group that had started with haptic training significantly improved during the last 1-h session (p < 0.01, paired t-test). CONCLUSION: The findings indicate that haptic feedback could be important in the early training phase of skill acquisition in image-guided surgical simulator training.

Abdomen↗

Web-based VR training simulator for percutaneous rhizotomy.

Virtual Reality offers great potential for surgical training--yet is typically limited by the dedicated and expensive equipment required. Web-based VR has the potential to offer a much cheaper alternative, in which simulations of fundamental techniques are downloaded from a server to run within a web browser. The equipment requirement is modest--an Internet-connected PC or small workstation--and the simulation can be accessed worldwide. In a collaboration between computer scientists and neurosurgeons, we have studied the use of web-based VR to train neurosurgeons in Percutaneous Rhizotomy--a treatment for the intractable facial pain which occurs in trigeminal neuralgia. This involves the insertion of a needle so as to puncture the foramen ovale, and lesion the nerve. Our simulation uses VRML to provide a 3D visualization environment, but the work immediately exposes a key limitation of VRML for surgical simulation. VRML does not support collision detection between objects--only between viewpoint and object. Thus collision between needle and skull cannot be detected and fed back to the trainee. We have developed a novel solution in which the training simulation has linked views: a normal view, plus a view as seen from the tip of the needle. Collision detection is captured in the needle view, and fed back to the viewer. A happy consequence of this approach has been the chance to aid the trainee with this additional view from needle tip, which helps locate the foramen ovale. The technology to achieve this is Java software communicating with the VRML worlds through the External Authoring Interface (EAI). The training simulator is available on the Web, with accompanying tutorial on its use. A major advantage of web-based VR is that the techniques generalize to a whole range of surgical simulations. Thus we have been able to use exactly the same approach as described above for neurosurgery, to develop a shoulder arthroscopy simulator--where again collision detection, and the view from the scope, are fundamental.

Computer-Assisted Instruction↗

[Simulator training in medicine and health care. A new pedagogic model for good patient safety].

Advanced simulation within medicine and health care is a rapidly growing field. Simulator based training can be applied in minimal invasive surgery, in endoscopic procedures as well as in anaesthesia and critical care management. At Huddinge University Hospital a center for advanced simulation of both endoscopic surgery and anaesthesia/critical care management is currently being set up. The objective is to focus on improved medical and health care training and thus improving patient safety by reducing medical errors.

Anesthesiology↗

Evaluation of the effect of a computerized training simulator (ANAKIN) on the retention of neonatal resuscitation skills.

BACKGROUND: Neonatal resuscitation knowledge and skills deteriorate after initial training. PURPOSE: To evaluate the effectiveness of a computerized simulator system (ANAKIN) as a means for boosting neonatal resuscitation knowledge, skills, and self-reported confidence beliefs. METHOD: A randomized pretest-posttest control group study design involving 60 3rd-year medical students. At a 4-month, post-training interval, experimental group was exposed to ANAKIN and control group to a training video. Both groups assessed at an 8-month, post-neonatal resuscitation training interval. RESULTS: Knowledge level for both groups decreased significantly at 4- and 8-month, post-training intervals despite booster exposure. Confidence level for both study groups increased significantly following booster exposure. However, no significant difference between study group skill levels at 8 months and no significant relation between neonatal resuscitation knowledge, confidence, or skills. CONCLUSION: Computerized simulator system was as effective as video for maintaining resuscitation skills of medical students, and students were very satisfied with experience of remote computer simulation training.

Adult↗